MHM Magazine

that opportunities for many kinds of care arise during pregnancy and the postpartum period. The first step is to come to some kind of understanding with yourself that you can recognise a problem that needs addressing and to have confidence in your ability to address it. But in medicine, a very political discipline, there are many obstacles. Does it meet the “standard of care”? What if a non-standard-of- care solution to a diagnosis provides some patients with better outcomes than the prescribed approach? A physician can still be sued for practicing outside the standard of care even if the results are better than they would be with the professionally sanctioned approach. Here in the United States, I would see my patients in as many prenatal and postpartum visits as they needed, even if insurance companies here wouldn’t cover the extra care. If patients had no insurance, I charged them what I was paid for a claim, which was always a fraction of what was billed. As an independent physician, I could do this. TREATING THE WHOLE FAMILY I always made it a practice to see moms, dads, and children during the prenatal course of visits. It’s a great opportunity to pick up on family dynamics. These are things I looked for in these family visits: • Do the parents respect each other and their children? • Is there pre-existing depression in family members, putting all at risk for more depression? • Are family members loyal to each other? • Are expectations unrealistic? Is there an attitude of “This is not what I expected”? • Are there signs of obsessive- compulsive disorder? There will be many times parents can’t control everything. Babies need to eat and sleep, but not always at the “right” time. The ability of parents to work together to help each other is effective and important in preventing PPD. Indeed, fathers can get PPD as well, but it usually shows up later than in mothers, and the cause is typically that they feel left out with the new baby. On the other hand, if I noticed a father appeared to be the better caretaker in a family, I could recommend the mother work and the father stay home and care for the children. I’ve seen this done successfully. There are simply times that the caretaker roles are better reversed. In 1999 I delivered quadruplets, now adults. When I interviewed the family last year, it was clear that dad was a major caregiver. He proudly reported that he changed an estimated 7,000 diapers a month. Neither parent expressed any discontent with this arrangement. MORE CARE IS BETTER CARE Because I owned my practice, I could be led by my conscience in providing the care needed. I saw everybody at one week or less postpartum. Insurance companies in the United States limit postpartum visits to one at six weeks because that’s when “the uterus should have involuted.” Note the concern for the uterus, not the mom or her mental state. As mentioned above, obstetricians are not supposed to treat psychiatric illness. Many countries have unlimited postpartum care for the first year after a child’s birth — and they have better outcomes all around for the health of families. With unlimited prenatal and postpartum care, depression could be identified early, when it’s most treatable. Sometimes I was a little surprised by who got depression, but all patients knew they could come in or call me at any time. I was fortunate to have been able to develop a good working relationship with a psychiatrist whom I could speak with whenever needed. We talked about symptoms and treatment. If anxiety was an issue, we started the patient on Ativan. If depression was present, we most often used venlafaxine, a serotonin- norepinephrine reuptake inhibitor (SNRI). I found that to be most useful because it helped resolve depression and problems with motivation. I didn’t much care for the selective serotonin reuptake inhibitors (SSRIs) because while taking them, the patients were perfectly happy doing nothing but sleeping, eating, and watching TV. On the other hand, venlafaxine not only managed the depression, but also motivated the mom or dad to take care of the baby. ACKNOWLEDGING PARENTS’ LIMITS There are also mothers or fathers who either don’t know their limits or won’t admit to having them. I explained to my patients that it’s normal to sometimes get to their wit’s end. Sometimes they might feel like shaking or otherwise hurting their baby to get the baby to stop crying. We all have limits. However, we need to know our limits, own them, and be adult enough to put the baby down without taking our frustration out on the infant. For those who live in close proximity to their extended families, they can turn a child over to another adult when they have reached their limits. Even the most sophisticated health systems in the world frequently lack the ability to provide needed care. Therefore, it’s up to individual doctors to identify their patients’ needs and find a way to treat them. In the case of PPD, it could save lives. References available upon request BIO About: An obstetrician and maternal mortality expert, “Rural Doc” Alan Lindemann, M.D. teaches women and their families how to create the outcomes they want for their own personal health and pregnancy. A former Clinical Assistant Professor at the University of North Dakota, he is currently a clinical faculty member available to serve as preceptor with medical students in rural rotations. In his nearly 40 years of practice, he has delivered around 6,000 babies and achieved a maternal mortality rate of zero! Learn more at LindemannMD.com. MHM 16 | MENTALHEALTHMATTERS | Issue 4 | 2021