Giving birth is a time of excitement and joy, but caring for a newborn — often on very little sleep — can lead to a roller coaster of feelings. For most people, these so-called “baby blues” disappear within a couple weeks.
But, sometimes, they don’t. In fact, 15 percent or more of those who give birth experience excessive crying, difficulty bonding with baby, withdrawing from family and friends, severe mood swings, and even thoughts of suicide — many of the signs and symptoms of postpartum depression or anxiety.
The first six weeks after birth can feel isolating for some patients, said Kelly Zafman, MD, an Obstetrics and Gynecology resident at the Hospital of the University of Pennsylvania (HUP). “The patient goes from having constant contact with an obstetrician while pregnant to no contact between delivery and six weeks,” usually the time for the first postnatal visit.
The American College of Obstetrics and Gynecology (ACOG) recommends that all new moms receive a postpartum depression screening sometime during the first six weeks after delivery. Identifying those at high risk — typically those with a history of depression or without support at home — is key to getting them the help they need. But symptoms don’t always appear so early. Indeed, postpartum depression can start at any time after giving birth, even up to one year, Zafman said.
In September 2020, Zafman began a study to determine how predictive early screenings — done during hospitalization and even before discharge — are in identifying who will develop postpartum depression. The participants, all of whom were patients at the Helen O. Dickens Center for Women, were screened pre-discharge. Those who scored high were screened at two and four weeks post-delivery. Preliminary results of this work — which Zafman presented at ACOG’s Annual Meeting in May — showed that the majority of patients who scored at higher risk on the initial screening continued to score high on later screenings.
But it also demonstrated the key role that technology can play in the process.
A “Penny” For Your Thoughts
Around the time Zafman initiated her study, Kirstin Leitner, MD, an assistant professor of Clinical Obstetrics and Gynecology at HUP, was already developing Healing at Home, a program to provide vital support for new moms at home, especially during the “fourth trimester” or those first six weeks after birth. She originally created the program for new parents with uncomplicated routine births wanting to go home early, an effort she pursued with a team as part of an Innovation Accelerator project with the Center for Health Care Innovation. The program’s texting service — a chatbot — allowed them to still remain connected with their care providers. To make communication easier, its automated chatbot, named Penny, used “natural language processing,” Leitner said. “That means patients can ask questions and receive answers in a natural way.”
Not only did the chatbot respond to questions but it also provided access to screenings, including a screening for postpartum depression that new parents were asked to complete at least twice, on the day of discharge and three weeks postpartum, helping to check in on how they are doing during the gap before the standard six-week postpartum checkup. Leitner collaborated with Zafman, providing access to “Penny” for her study’s patients to do their follow-up depression screenings via text message in the same way, but at different time points. “If patients have depressive symptoms, the chatbot alerts the provider who can call the patient,” Leitner said.
But, “even if someone hasn’t completed the screening but texts us ‘I’m crying or sad,’ we have the ability to reach out and do a screening.”
Currently, Penny access is offered to patients going home early after delivery but, longer term, once more staffing can support the program, “everyone will have access to the chatbot. It will be an ongoing resource, especially important for those with elevated scores,” Leitner said.
Her hope is that women at higher risk for postpartum depression “will benefit even more from resources such as the chatbot,” she continued, “but I want to emphasize: postpartum depression can impact all patients.’”
First Screening, Then Treatment
As part of her study, Zafman used the Edinburgh Postnatal Depression Scale (EPDS) to screen patients. It comprises 10 statements, ranging from “I have blamed myself unnecessarily when things went wrong” and “I have felt scared or panicky for no very good reason” to “The thought of hurting myself has occurred to me.” Patients rank their feelings for each of the 10 statements, from zero (no depressive thoughts) to three. These final total scores help identify those at potential risk for perinatal depression.
“Those with scores of nine to 12 or higher were screened weekly,” Zafman said. “But all patients who endorse having thoughts of self-harm met with psychiatry and the patient team to get them a safe plan and intensive follow up.”
Of the 1,200 patients who have completed the depression screening, nearly a fifth of patients were at risk, with 13 percent scored greater than nine and five percent greater than 12. But over 50 percent of those patients had no history of mental illness. “While we can identify risk factors,” she said, “until you ask people and assess symptoms, you don’t know how they’re feeling.”
Sometimes just screening alone or having a conversation is helpful, Zafman said. “New parents are so focused on the baby that they forget about themselves. Having time to think about how they’re feeling and assess symptoms, they realize ‘wow. I do feel anxious.’”
Connecting with a provider “can be helpful even without prescribing medication or therapy,” she added. “And we also educate patients about what to do if it gets worse.”
For patients who do have an elevated EPDS score at discharge, “in addition to the internal follow-up where they continue to get screenings, we reach out to their perinatal provider, asking them to schedule either a telehealth visit or an in-person appointment if needed,” Leitner said.
Standardizing care during key moments of childbirth and follow-up is a priority for Penn Medicine’s OB/GYN teams overall, as part of a broad system-wide effort to improve outcomes and reduce racial and ethnic inequities in maternal health. Standardization has been shown in other areas to make care and outcomes more equitable. Screening at discharge is now integrated into the checklist of patient milestones postpartum at HUP. “Our next goal is to make sure we standardize the follow-up,” Zafman said. “We want to make sure everyone gets the same resources.”