Hope for mothers and babies at Bostons State House

Attending a meeting of Representative Ellen Story's Postpartum Depression Commission is always an uplifting experience. Talented, motivated, creative and hardworking people from a wide range of disciplines gather to figure out how to best address this significant public health problem. There are social workers, psychiatrists, pediatricians, obstetricians, health insurance industry representatives, and a range of others. There was a doula at the meeting this past week.

Representative Story told us about a pilot project based in two health centers. The project grew out of the recognition that mothers and babies are frequently at the office of a health care provider in the first weeks and months.  This model would capture a large number of families.   A person trained in working with mothers and babies together would be available for hour-long sessions for mothers in the postpartum period who are particularly stressed and overwhelmed.

Certainly if postpartum depression is identified, it is important to have a system in place to refer the mother for treatment. But the fact is that a mother who is struggling in the postpartum period is usually overwhelmed by the baby.  It is essential to bring the baby in to the work from the start. A person experienced working with both mothers and babies can listen to the mother while supporting her efforts to read the baby's signals and manage the normal challenges of sleep disruption, fussiness and feeding difficulties that come up in early infancy.

In my office at Newton-Wellesley Hospital's Early Childhood Social Emotional Health Program I have a special room for mothers and babies that has pastel rugs and soft chairs. It is quiet, private, and filled with light from a large window. One of my young clients called it a "feel better room." I think of it as what pediatrician/psychoanalyst D.W. Winnicott referred to as a "holding environment," where both mother and baby can feel safe, contained and understood.

It occurred to me at this meeting that perhaps we should aim to have a "feel better room" in every primary care office. True preventive mental health care starts in the newborn period. I am not saying that if things go wrong in the newborn period a child is destined for trouble. However, it is a time of rapid brain growth, and it is well known that the baby's brain grows in relationships with primary caregivers. With this model, we have the opportunity to set things right from the beginning.

A child psychiatrist at the meeting pointed out that "co-location" of mental health care in the primary care setting has run into trouble because of problems of economic viability. A pediatrician then brought in to the discussion the ACO (accountable care organization) model, whose intention is to promote preventive health care. He expressed concern that the needs of adults with chronic illness would overshadow the needs of children.

We know from a large body of research, particularly the ACE (Adverse Childhood Experiences) study, that true preventive care starts with promoting healthy secure relationships in the early years. This includes prevention not only in the realm of mental illness but also chronic physical illness such as asthma, diabetes, obesity and heart disease.

This model of investing in early relationships has been endorsed by nobel prize winning economist James J. Heckman. In a recent working paper, The Economics of Child Well-Being, he writes:

There is a growing interest in the well-being of children. Such interest is supported by recent evidence from both the biological and the social sciences, which points to the importance of the early years in shaping the capabilities that promote well-being across the lifecourse. It is now recognized that human development is a dynamic process that starts in the womb. Capabilities interact synergistically to create who we are and what we become. The foundations for adult success and failure are laid down early in life... 

Prevention is more cost effective than remediation. As implemented, most adolescent and adult remediation programs are ineffective and have much lower returns than early childhood programs that prevent problems before they occur... High quality early interventions that alter early life conditions are effective ways to promote well-being and human flourishing across the life cycle.

If the ACO model is really going to fulfil its aim of preventive care, then we would do well to find a way to make it "economically viable" to have "feel better room," staffed with professionals trained in work with mothers and babies, in every primary care office in the country.

I hope that the pilot program Representative Story referred to will serve to provide evidence for what the abundance of research already shows us will likely be a very good idea.