There’s A PPD Screening Problem In America, And Moms Know It

It’s a familiar memory for many moms in America: You’re six weeks postpartum and perched on an exam table, a sheet of tissue paper crinkling beneath your legs. It’s likely the first time you’ve been out of the house for anything besides a slow walk around the block since having your baby.

The clipboard in your hand asks you to get vulnerable:

“I have been able to laugh and see the funny side of things…As much as I always could / Not quite so much now / Definitely not so much now / Not at all.”

“I have been anxious or worried for no good reason…No, not at all / Hardly ever / Yes, sometimes / Yes, very often.”

“The thought of harming myself has occurred to me…Yes, quite often / Sometimes / Hardly ever / Never.”

The questions staring back at you are invasive and overly vague, and they come tied to a score. That number attempts to quickly quantify feelings so amorphous that you haven’t even been able to put them into words yourself, let alone measure them while waiting in a sterile doctor’s office.

But that’s what a postpartum depression (PPD) screening survey asks of you — to simplify one of the most confounding, emotional chapters of your life into a single number; to self-report the state of your mental health when your whole world has just flipped upside down.

What happens next can vary wildly. You could score just above the PPD threshold, and nothing more is mentioned. Maybe you’re handed a pamphlet with outdated resources. Maybe you’re one of the lucky ones whose doctor inquires more about how you’re doing or connects you with a mental health expert.

Maternal mental health conditions are the most common complication of pregnancy and childbirth, affecting 800,000 families each year and accounting for nearly 28% of pregnancy-related deaths in the U.S., according to the Maternal Mental Health Leadership Alliance.

Screenings are designed to help catch PPD problems before they become disasters. Yet, a whopping 50 to 70% of maternal mental health disorders go undiagnosed, per the Policy Center for Maternal Mental Health.

So, where are things going wrong? Here, moms and health care providers share the biggest flaws in the system, plus how you can make sure your own mental health doesn’t become just another note in your patient chart.

Postpartum Depression Screenings: The Point And The Problems

Maternal care had historically focused on physical recovery until the Edinburgh Postnatal Depression Scale (EPDS) was introduced in 1987 as the first reliable, self-reporting tool specifically designed to identify perinatal and postpartum emotional distress.

Since then, PPD screening policies and guidelines have become more common, largely thanks to recommendations from groups including the American College of Obstetricians and Gynecologists (ACOG) and the U.S. Preventive Services Task Force. The EPDS is one of several screening tools physicians can use, including the Patient Health Questionnaire (PHQ-9), which is a broader depression screening tool for the general population.

In a recent Reddit post, one mom shared her own experiences with PPD screenings, explaining that she selected “hardly ever” on a question regarding thoughts of self-harm, but was subsequently pressured by healthcare providers to change her answer to “never.” (The implication being that there would be specific actions taken if a patient expressed feelings of self-harm.)

She went on to say how the experience made the screening feel like a meaningless box to check, not an important part of her postpartum care. “Like, there's no point in answering honestly,” she wrote. “They're just going to…make sure they talked to you about depression, even if it's obvious that you're depressed. Nobody really cares.”

In the discussion that followed, moms shared their own experiences with PPD screenings, and their anecdotes highlight both a universal frustration with elements of the tests and the gaping disparities in subsequent support they received.

“My OB… said ‘oh, yeah, you failed. Maybe see a therapist’ and handed me a sheet directing me to the Postpartum International website,” wrote one commenter. “That was it.”

The timing of the screening can make a difference in accurately assessing a new mom’s mental health, too. “Symptoms [of PPD] often peak when the mother is six weeks to six months postpartum,” says Dr. Furr. “It’s often missed or misattributed as a ‘normal’ part of being a new parent if routine screening is not conducted.”

You might also be asked to complete the survey at your baby’s pediatrician appointments. The American Academy of Pediatrics (AAP) recommends new moms be screened for depression during their baby’s first month of life and again at a baby’s two-, four-, and six- month well visits.

“My daughter's pediatrician always goes out of his way to review my responses genuinely and with empathy. He made me feel so seen and appreciated when I was really struggling,” one mom wrote, highlighting a more supportive experience. “My son’s pediatrician still gently checks in with me about my PPA [postpartum anxiety] even though I gave birth almost three years ago,” replied another.

Access to perinatal mental health assessments also depends on where you live, explains Sarah Oreck, M.D., M.S., board-certified reproductive psychiatrist. “Some states have requirements that they should be screening, and other states don't,” she explains. “It's a very tricky landscape because everyone does it differently.”

In 2006, New Jersey became the first state to mandate PPD screenings and education for new mothers, as well as require providers to ask pregnant women about their history of depression. Today, only seven other states mandate some form of PPD screening: West Virginia, California, Florida, Oklahoma, Illinois, Louisiana, and Arkansas.

“I never filled these out at the pediatrician,” replied one parent. “They are optional and … it felt awkward to me because that is not my doctor and I don’t really want to discuss my mental health with them.”

Health care providers are well aware of some of these shortcomings of the screenings and protocols. “[The current standard] relies on self-reporting from the mother,” reminds Amanda Furr, M.D., chief medical officer at Zarminali Pediatrics. “Many new mothers and fathers may be embarrassed to report symptoms or be worried that they will be seen as a bad parent. The parent may feel overwhelmed and not take the time to reflect on their own well-being,” says Dr. Furr. To combat this, she sends patients the screening questions electronically before the child’s office visit, giving “mothers a chance to consider their own symptoms and answer without the pressure of juggling the kids, diaper bag, and stroller in hand,” she says.

BIPOC mothers may be at a particular risk because they are less likely to start and/or continue mental health treatment. Underreporting may be a contributing factor because the tests were not initially designed with them in mind, says Oreck. “How we even think about postpartum depression, as ‘oh, the woman's so sad’ — that's very Eurocentric. In other cultures, you have more anger, irritability, more somatic symptoms, including stomach aches or body aches.”

The individual questions are imperfect and narrow. “I hated those questions, so vague and misleading. Even when you do try to answer honestly, it's up for interpretation and feels leading to what they want to hear,” said another commenter. “Also, one major gap was that there were no questions at all about rage (at least, in my questionnaire), so it didn't pick up the alternative manifestation of PPD — I wasn't sad, I was angry — but it didn't register.”

Time constraints during appointments, discomfort among providers in asking probing questions, or uncertainty about recommended next steps may also contribute to the limited attention paid to maternal mental health, according to Dr. Furr.

The bottom line, as one mom put it, is that too ofen moms feel unseen after the baby is born.”

How To Speak Up When You Need Postpartum Mental Health Support

Even under perfect circumstances, a single questionnaire can only do so much. “A screening is just a screening, not a full diagnosis or description of every symptom that can occur,” says Dr. Furr. “If [patients] do not feel that the screening is capturing their situation or feelings, I advise mothers to put the screener down and talk about what they’re experiencing. As physicians, we know that every human is unique and screeners do not always give us the full picture of the person.”

Getting better postpartum care often requires demanding it, says Ana Velouise, L.M.F.T., perinatal mental health specialist at Well Parent Therapy, who suggests walking into each appointment with a goal in mind. Think: Getting a referral to a mental health provider or a prescription for an SSRI, she says. You may not be able to be that specific, but having a sense of what you need help with the most and staying focused on getting it can help.

If you’re expecting and already working with a therapist, make a plan for steps to take if you start feeling “off” postpartum, suggests Velouise. You might draft some scripts to use in the doctor's office when confronted with mental health questions or a screener. Preparing now can mean less emotional and mental labor later on, when you’re likely feeling compromised and overwhelmed.

And don’t be afraid to find another doctor. “If you don't feel heard or are not taken seriously, seek help elsewhere,” says Dr. Furr. “If you find yourself saying or thinking ‘something feels off’ or ‘I don’t feel like myself,’ that is enough to be taken seriously.”

Consider support systems outside of the exam room, too. “Having people who support and validate you outside of the doctor's office, even if it's not a professional, can help you get to that next step, whatever it might be,” says Velouise. (Virtual or IRL mom groups are an excellent option to consider. Put yourself out there.)

If your postpartum care felt less than in any way, it’s not you — it’s the system. Risk for maternal mental health disorders continues to rise, and the standard of care can’t seem to keep up.

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