Portia Smith's most vivid memories of her daughter's first year are of tears. Not the baby's. Her own.
"I would just hold her and cry all day," Smith recalls.
At 18, Smith was caring for two children, 4-year-old Kelaiah and newborn Nelly, with little help from her abusive relationship. The circumstances were difficult, but she knew the tears were more than that.
"I really didn't have a connection for her," says Smith, now a 36-year-old motivational speaker and mother of three living in Philadelphia. "I didn't even want to breastfeed because I didn't want that closeness with her."
The emotions were overwhelming, but Smith couldn't bring herself to ask for help.
"You're afraid to say it because you think the next step is to take your children away from you," she says. "You're young and you're African American so it's like [people are thinking], 'She's going to be a bad mom.' "
Smith's concern was echoed by several women of color interviewed for this story. Maternal health experts say women often choose to struggle on their own rather than seek care and risk having their families torn apart by child welfare services.
Nationally, postpartum depression affects 1 in 7 mothers. Medical guidelines recommend counseling for all women experiencing postpartum depression, and many women also find relief by taking general antidepressants such as fluoxetine (Prozac) and sertraline (Zoloft). In March, the Food and Drug Administration approved the first drug specifically for the treatment of postpartum depression.
But those advances help only if women in need are identified in the first place — a particular challenge for women of color and low-income mothers, as they are several times more likely to suffer from postpartum mental illness but less likely to receive treatment.
The consequences of untreated postpartum depression can be serious. A report from nine maternal mortality review committees in the United States found that mental health problems, ranging from depression to substance use or trauma, went unidentified in many cases and were a contributing factor in pregnancy-related deaths. Although rare, deaths of new mothers by suicide have also been reported across the country.
"I was lying to you"
For many women of color, the fear of child welfare services comes from seeing real incidents in their community, says Ayesha Uqdah, a community health worker who conducts home visits for pregnant and postpartum women in Philadelphia through the nonprofit Maternity Care Coalition.
News reports in several states and studies at the national level have found that child welfare workers deem black mothers unfit at a higher rate than they do white mothers, even when controlling for factors like education and poverty.
During home visits, Uqdah asks clients the 10 questions on the Edinburgh Postnatal Depression Scale survey, one of the most commonly used tools to identify women at risk. The survey asks women to rate things like how often they've laughed or had trouble sleeping in the past week. The answers are tallied for a score out of 30, and anyone who scores above a 10 is referred for a formal clinical assessment.
Uqdah remembers conducting the survey with one pregnant client, who scored a 22. The woman decided not to go for the mental health services Uqdah recommended.
A week after having her baby, the same woman's answers netted her a score of zero: perfect mental health.
"I knew there was something going on," Uqdah says. "But our job isn't to push our clients to do something they're not comfortable doing."
About a month later, the woman broke down and told Uqdah, "I was lying to you. I really did need services, but I didn't want to admit it to you or myself."
The woman's first child had been taken into child welfare custody and ended up with her grandfather, Uqdah says. The young mother didn't want that to happen again.
Screening tools are not one-size-fits-all
Another hurdle for women of color comes from the tools clinicians use to screen for postpartum depression.
The tools were developed based on mostly white research participants, says Alfiee Breland-Noble, an associate professor of psychiatry at Georgetown University Medical Center. Often those screening tools are less relevant for women of color.
Research shows that different cultures talk about mental illness in different ways. African Americans are less likely to use the term depression, but they may say they don't feel like themselves, Breland-Noble says.
It's also more common for people in minority communities to experience mental illness as physical symptoms. Depression can show up as headaches, for example, or anxiety as gastrointestinal issues.
Studies evaluating screening tools used with low-income, African American mothers found they don't catch as many women as they should. Researchers recommend lower cutoff scores for women of color, because women who need help may not be scoring high enough to trigger a follow-up under current guidelines.
Bringing treatment home
It took Smith six months after her daughter Nelly's birth to work up the courage to see a doctor about her postpartum depression.
Even then, she encountered the typical barriers faced by new mothers: Therapy is expensive, wait times are long, and coordinating transportation and child care can be difficult, especially for someone struggling with depression.
But Smith was determined. She visited two different clinics until she found a good fit. After several months of therapy and medication, she began feeling better. Today, Smith and her three daughters go to weekly $5 movies and do their makeup together before each major outing.
But many mothers never receive care. A recent study from the Children's Hospital of Philadelphia found that only 1 in 10 women who screened positive for postpartum depression at the hospital's urban medical practice sites sought any kind of treatment in the following six months. A study examining three years' worth of New Jersey Medicaid claims found white women were nearly twice as likely to receive treatment as were women of color.
Noticing that gap, the Maternity Care Coalition in Philadelphia decided to try something new.
In 2018, the nonprofit started a pilot program that pairs mothers with Drexel University graduate students training to be marriage and family counselors. The student counselors visit the women an hour a week and provide free in-home counseling for as many weeks as the women need. Last year the program served 30 clients. This year, the organization plans to expand the program to multiple counties in the region and hire professional therapists.
It was a game-changer for Stephanie Lee, a 39-year-old woman who had postpartum depression after the birth of her second child in 2017.
"It was so rough, like I was a mess, I was crying," Lee says. "I just felt like nobody understood me."
She felt shame asking for help and thought it made her look weak. Lee's mother had already helped her raise her older son when Lee was a teenager, and many members of her family had raised multiple kids close in age.
"The black community don't know postpartum," Lee says. "There's this expectation on us as women of color that we have to be these superhero strong, that we're not allowed to be vulnerable."
But with in-home therapy, no one had to know Lee was seeking treatment.
The counselors helped Lee get back to work and learn how to make time for herself — even just a few minutes in the morning to say a prayer or do some positive affirmations.
"If this is the only time I have," Lee says, "from the time I get the shower, the time to do my hair, quiet time to myself — use it. Just use it."
This story was reported as a partnership between The Philadelphia Inquirer, for which Aneri Pattani reports, and WHYY. You can read the original version here.
RACHEL MARTIN, HOST:
At least 1 in 7 mothers suffer from postpartum depression. Left untreated, this can have serious consequences for both moms and babies. The burden on women of color is especially heavy. They are three times more likely to experience postpartum depression and are also less likely to get treatment for it. Nina Feldman at member station WHYY in Philadelphia has our story.
NINA FELDMAN, BYLINE: Santeno Adams is a talkative and precocious 2-year-old.
SANTENO ADAMS: Umbrella.
STEPHANIE LEE: Umbrella, right.
SANTENO: The rain.
LEE: Yes, the rain.
SANTENO: Rain and clouds.
FELDMAN: He's at home playing with his mom, Stephanie, Lee on their living room floor in Philadelphia. Santeno is Lee's second son - and he was a surprise. At 37, she thought she was done raising kids.
LEE: Like, I was busy. I was out. It's like - almost like I felt like, Stella (ph) got her groove back. I got my groove back.
FELDMAN: But even when she found out she was pregnant, Lee thought she could keep her momentum going.
LEE: I thought I was going to be able to work out until my ninth month and work up until my ninth month. Like, I was like, I'm going to be in labor at work.
FELDMAN: But about five months into her pregnancy, Lee had a procedure to prevent her from going into an unsafe, early labor. It forced her to stay on bedrest.
LEE: It was so rough. Like, I was a mess. Like, I was crying.
FELDMAN: Lee was stressed. She was worried about money and didn't feel like her friends or family understood what she was going through. The depression continued after Santeno was born, too, but Lee felt embarrassed to ask for help.
LEE: The black community don't know postpartum. It's like they look at it like, you need to be strong, girl. Like, my aunts and all them went through and had 5, 6, 7 babies and they are about 2, 3 years apart. Like, you only got one. And there's this expectation on us as women of color that, like, we have to be, like, these superhero - strong, that we're not allowed to be vulnerable. I'm not allowed to have postpartum because I'm black?
FELDMAN: Underreporting of postpartum depression and the fear of being judged is pretty common for lots of women.
But 27-year-old Auriel Dickey says that as a black woman, she had another concern when she thought about asking for help.
AURIEL DICKEY: What color is it?
UNIDENTIFIED CHILD: Green.
FELDMAN: She also struggled with postpartum depression and was afraid her newborn daughter would be taken from her.
DICKEY: She's, like, so sweet and nurturing. Like, we'll - like, if she sees me a little sad, she'll say, what's wrong? And she'll grab my face and kiss it.
FELDMAN: After her maternity leave, Dickey went back to work. The separation felt overwhelming.
DICKEY: Sometimes I would be with my - talking to my boss and things and I would have, like, this impulse of, like, I quit, you know, just because to me, in that moment, it's like, my time here isn't worth me being away from her.
FELDMAN: That feeling lasted months. Dickey knew it was more than separation anxiety, but didn't dare utter the words postpartum depression.
DICKEY: I was scared 'cause just, like, what if they think I'm like a danger to us? Oh, wait, postpartum depression, doesn't that mean, like, you want to harm yourself and the baby? You know, like, that whole thing.
FELDMAN: Dickey says she worried that admitting she had depression would trigger a call to child welfare.
DICKEY: It's something that I've seen happen, like seen growing up, hearing stories of moms that, you know, like, they had their kid in, like, the most loving home and, like, for the slightest thing, now you're under investigation, you know. It just didn't seem like a risk I was willing to take.
FELDMAN: Her fears are warranted - research shows child welfare workers judge black mothers as unfit at a higher rate than white mothers, even when they have the same education and income level. It can also be harder to detect postpartum depression in women of color because they were mostly excluded when the screening tools were being created.
ALFIEE BRELAND-NOBLE: And so what we're stuck with is tools that weren't necessarily developed with these cultural nuances in mind.
FELDMAN: That's psychiatrist Alfiee Breland-Noble. She says screeners often ask questions using keywords like depression or anxiety. But different communities use different language.
BRELAND-NOBLE: So they'll say, I have the blues, I'm in my feelings, I don't feel right, something feels off. We have this old saying in - amongst southern African Americans where people will say, nothing ain't wrong, but something ain't right. You know what I mean? So it's just this uneasiness. So those are the kinds of things I've encountered with people where they will sort of talk around depression, but nobody really wants to say that what they have is a mental illness, like depression.
FELDMAN: Even if women of color show signs of depression, getting treatment means even more challenges.
Stacey Kallem is a pediatrician at the Children's Hospital of Philadelphia. During the baby's first year, she screens new mothers for postpartum depression at each visit. If signs point to a problem, Kallem offers them to mental health services. But once she had her own kid, she wondered, are the moms really going?
STACEY KALLEM: Literally just bundling up your child and leaving the house is an accomplishment in that immediate postpartum phase.
FELDMAN: Kallem did some research and found that in the six months after being diagnosed, only 1 in 10 mothers got any kind of treatment.
KALLEM: So first, you have to get yourself to the appointment. You have to arrange for childcare. And then on top of all that, you might have depression. I mean, of course, it's hard. Of course so many mothers aren't receiving services. The system isn't set up to be easy for them.
FELDMAN: Eventually, both the Philadelphia moms, Stephanie Lee and Auriel Dickey, were able to get treatment. Lee's counselor actually came to her house, so it felt private and easy.
LEE: I don't know if words can, like, really describe how much it really did help me. And I think there needs to be like a campaign of, like, a bunch of faces of women of color that look like us so they know, like, I went through it, too.
FELDMAN: Treatment for postpartum depression is effective. Talk therapy and antidepressants usually work. The hardest part for most new moms is getting the help. For NPR News, I'm Nina Feldman in Philadelphia.
MARTIN: This story was reported in partnership with Aneri Pattani of the Philadelphia Inquirer.
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