Postpartum depression on the rise, especially for women of color, during COVID-19 pandemic
Los Angeles — When Altagracia Mejía learned she was going to be a mother, happiness flooded her heart.
She picked out a crib. She took photos of her growing belly and redecorated her bedroom. She held a gender-reveal party on Zoom.
But her bliss didn't last long.
Perplexing feelings of anxiety and doubts that she ever could be a fit mother for her baby crept into her head during pregnancy while living in her small one-bedroom apartment. And while the Panorama City resident tried to brush away her uneasiness, those feelings seized her again after she gave birth to her daughter, Alexa, in the middle of the pandemic, on Sept. 8, 2020.
By the time Mejía's daughter was around 2 months old, the 26-year-old mother's episodes of anxiety and irritability had darkened into thoughts of suicide.
"In my most lucid moments, I ask myself over and over again what is happening to me," said Mejía, who immigrated to the United States from El Salvador four years ago in hopes of putting the poverty and violence of her homeland behind her. "I am supposed to be happy, resplendent and full of energy, but nothing is as they paint it on television or social networks.
"For society, especially for Latinos," she continued, "it is unforgivable for a woman to feel sad or have thoughts of death at this moment that is supposed to be the happiest of her life."
Mejía suffers from postpartum depression, a severe form of clinical depression related to pregnancy and childbirth. Symptoms include severe mood swings and deep despondency as well as impulses that can impel a mother to harm herself or her child.
Last week, Sandra Chico, the 28-year-old mother of three children found dead in an East Los Angeles home, was arrested on suspicion of murder and is being held on $2-million bail, L.A. County Sheriff's Department officials said Tuesday.
In an interview with the Times, Elizabeth Chico said her younger sister had exhibited symptoms of postpartum depression following the birth of her youngest child about a month ago. "All that stress, all that anxiety, it takes over you," she said.
Although the California Department of Public Health has not released figures on the number of women with postpartum depression since 2018, experts say that an increase in calls from women asking for help from local nonprofit organizations, along with lengthening hospital waiting lists, indicate that postpartum depression cases may have increased dramatically over the course of the COVID-19 pandemic.
Women of color continue to be among the most affected, in part because many do not have health insurance or their insurance covers little or no therapy, said Misty Richards, one of the directors of the Maternal Outpatient Mental Health Services program at UCLA. Evidence suggests that some Latina mothers may hesitate to seek help because of stigmas associated with mental illness, as well as cultural expectations surrounding motherhood and the traditional roles of women in Latin societies.
In addition, many of those afflicted are not being screened for postpartum depression, despite California's maternal mental health bill, AB 2193, which went into effect on July 1, 2019, and requires that obstetricians and gynecologists screen mothers for these conditions during and after pregnancy and ensure that they get any needed treatment.
The most recent available CDPH statistics, from 2018, indicated that 1 in 5 California women suffered from postpartum depression during or after giving birth, which translated to 100,000 cases a year. The report also states that: "Black and Latina women experience the highest percentage of depressive symptoms of all racial/ethnic groups during both the prenatal and postpartum periods."
According to the CDPH: "Disparities are particularly evident for prenatal symptoms of depression, which are twice as common for Black (19.9%) and Latina (17.1%) women compared to white (9.5%) and Asian/Pacific Islander (10.3%) women."
Richards, of the UCLA clinic, said that she has seen a 30% increase in postpartum depression cases since the pandemic started. She expressed particular concern for low-income women of color who are disappearing into the cracks of an inaccessible healthcare system.
She estimates that she sees 15 women a week, or about 700 cases a year. If the clinic is full, as has been the case since the beginning of the pandemic, she refers mothers to other affordable clinics and nonprofit organizations.
"A single 90-minute visit to the reproductive psychiatrist in California costs $500 to $800 if you don't have health insurance," said Richards, who currently has a 15-day waiting list for treating patients. "That money cannot be paid by a low-income person."
Responding to the pandemic, the California Department of Health Care Services implemented a Provisional Postpartum Care Extension programon Aug. 1, 2020, that allows Medi-Cal eligible mothers who are diagnosed with a maternal mental health condition to remain eligible for assistance for up to one year after giving birth — 10 months longer than the normal 60-day period of post-pregnancy care.
However, in order to get help, mothers must be diagnosed with postpartum depression, and many health experts are not even aware of the existence of the program, which will expire Dec. 31.
Medi-Cal, the service that pays for more than 50% of all births in California, would have covered mental aid assistance for Mejía, but her condition was never detected, she said.
"In my clinic, I filled out forms about how I felt, and even though they knew I had depression, they never gave me a positive diagnosis even after giving birth," she said.
While trying to navigate the labyrinthine U.S. medical system, Mejía felt isolated from friends and family. Fear of catching COVID-19, and shame over what she felt were her failures as a mother, kept her from seeking out others for comfort and support.
"Since I came to this country four years ago, I have worked as a babysitter," she said. "It was not possible to share that I could take care of other children, and not even be able to breastfeed my own daughter."
Because she couldn't afford a private specialist, Mejía, along with her husband of three years, Walberto Gochez, a maintenance worker, and her father, Marco Antonio Mejía, had to seek help on their own from Maternal Mental Health Now, a nonprofit that advocates for screening and treatment of prenatal and postpartum depression in Los Angeles County.
Eynav Accortt, a clinical psychologist at Cedars-Sinai Hospital, who treats women with anxiety and depression during pregnancy and postpartum (known as perinatal mood and anxiety disorders), said the pandemic has added a layer of complexity and isolation that could substantially increase rates of such cases.
"Women have been under more stress from the pandemic," she said. "They fear getting sick or their babies getting sick, they can't have home visits and this adds to the worries of the day, even if they aren't low-income."
According to Accortt, the Cedars-Sinai Reproductive Psychology Clinic received twice as many calls from women seeking help between January and April of this year, as it did during the entire previous year.
"About 11 patients who could have seen me for individual therapy, because I am in the network with their insurance company, were referred to other community providers, many of whom were already full," she said. "Right now, I have a three-week waiting list for a client to start individual therapy with me."
In 2020, about 6,500 women were screened for postpartum depression at Cedars-Sinai, and 300 to 500 who were at risk for perinatal mood and anxiety disorders were referred to local organizations for help. In addition, 150 other women obtained direct services such as individual therapy or support group aid from the Cedars-Sinai Reproductive Psychology Clinic.
Alondra Espinoza, 36, of East Los Angeles, is among those women whose postpartum depression was exacerbated by the pandemic. She was shocked after learning she was pregnant for the third time, in 2019, while raising her daughter, Jocelyn, now 15, and son, Isaiah, 11.
"During my pregnancy, I didn't want people to see me, I thought I was too old to start caring for a baby again," she said. "I started crying all the time and feeling irritated at the same time. As the months went by, I started to feel lonely, frustrated and desperate about what my future was going to be like. "
In January 2020, three months before giving birth, she had to stop working as a teacher's assistant because she suffers from sciatica.
In April 2020, Espinoza gave birth to Lexi, and by June, postpartum depression hit her harder when she learned that her husband, Jezreel, a building demolition worker, would have to return to work out of state.
"During the pandemic I couldn't go out, I was afraid that we would catch [the coronavirus] and I didn't know who to turn to," Espinoza said.
"My girl cried all the time, and I felt useless next to her," she continued. "I felt like she was freaking out. ... I wanted to get out of the house and run aimlessly, I wanted to disappear."
Like Mejía, Espinoza said, she was never diagnosed with postpartum depression despite filling out several forms at Garfield Medical Center in Monterey Park, where she gave birth.
"It took me about two months after giving birth to seek help on my own because I thought that asking for assistance was wrong," she said. "I believed that people would think that I am not a good mother and then social services would take away my children."
An employee of Garfield Medical Center, who did not want to be identified, said that since November 2019, the center has been screening all mothers before they return home with their newborns. "And if they screen high risk for postpartum depression, a social worker refers them to different resources," the employee said.
Regarding Espinoza's case, the employee said that there might have been a communication issue or "most likely she did not meet the criteria for high-risk postpartum."
"We only see the mothers for a short period of time, about four days, after the delivery," the employee said. "If they do not speak to us, we cannot catch them, we do not have a chance to help."
Emily C. Dossett, clinical assistant professor of psychiatry and behavioral sciences at USC's Keck School of Medicine, maintains that even though screening women for postpartum depression is now encoded in state law, "there is still a lack of resources available to do so, which puts doctors in a bad situation."
"If health experts are not aware of the postpartum screening laws or the [Provisional Postpartum Care Extension] law, and if there are not enough staff to refer women or therapists, there will always be mothers who will disappear into the cracks without any treatment," said Dossett, who since the pandemic began has seen a 25% increase in referrals from mothers in need of therapy.
"Postpartum depression can occur shortly after delivery or even up to a year later," Dossett continued. "That's why we need more affordable support services because in my experience I believe that 80% of women with postpartum depression can be treated with therapies."
Norwalk resident Adriana Rangel did not have postpartum depression until two months after giving birth to Ivana on Nov. 13, 2020.
"As if there was a switch in my brain, suddenly I began to feel sad, exhausted, I did not want to eat, I did not even want to take off my pajamas," said Rangel, 31. "I was no longer the talkative, cheerful and outgoing woman that people knew."
When her mother died of COVID-19 in February, Rangel plunged further into depression and feared getting sick or making her daughter sick.
She subsequently was able to get help for her condition. She has private health insurance and pays $25 out of pocket for each weekly appointment to see a psychologist at Providence St. Joseph Hospital.
Mike Sherbun, executive director of the Providence Mental Health Clinical Institute, which is made up of 11 hospitals in Orange and Los Angeles counties, said that cases of postpartum depression have risen as much as 25% during the pandemic. He fears those figures are undercounted and may keep rising because they don't include women who don't seek help.
"These increases are just the tip of a mental health crisis in California," he said. "So our institute is in the process of opening more outpatient programs that can assist mothers with postpartum depression in Torrance and Tarzana."
Sherbun stressed that more laws are needed in California to cover all mothers, while current laws need to be enforced.
In the case of E.R., who asked not to disclose her full name, her OB/GYN did not tell her that she suffered from depression during pregnancy or after delivery until she, too, sought help on her own, she said. The Los Angeles resident, who gave birth in January, began to suffer from anxiety almost three months after her pregnancy began.
"I worked as a mental health case manager and even though I was scared of getting sick with COVID-19, I didn't want to stop working," E.R. said. "I heard from so many people who lost their jobs and couldn't pay their rent and didn't want to be in that situation. At the same time, I began to be scared by my future, the safety and stability of the baby, so I decided to work until the very moment I gave birth.
"I think working helped me a little bit not to think about depression and anxiety. However, once I had my baby, my mental health declined faster. I cried all the time. I fought with my husband.
"Part of my depression was also due to being isolated from my family and close friends. I come from a Latino family where we celebrate everything, and this time we couldn't because of the pandemic."
In the moments when she couldn't sleep, thoughts of ending her own life, or her child's, closed in on her.
"I thought that if she was dead, things would be better," she said. "What happens if I throw myself into a car or throw myself off a building?"
E.R. didn't confide in her family for fear that they would think she was crazy or that they would take her baby from her.
"In my family, with a mother from Mexico and a father from El Salvador, it is not normal for a mother to feel this way, or you just solve it yourself or you approach the priest to give you advice," she said.
E. R. asked her husband to accompany her to therapy groups, but he refused, wary of the stigma around mental health issues.
"Fortunately, he understands that I need help and has become more patient," E.R. said. "He also takes the baby with him when I have felt like I want a break. Having him on my side has helped me a lot."
Gabrielle Kaufman, clinical director of Maternal Mental Health Now, an organization that helps women with postpartum depression and advocates creating laws that benefit them, said there is still a lot to do at the state level.
"A couple of laws have been passed in the last three years to help this sector, but the pandemic has once again stalled us," she said. "If as health experts we do not follow current laws and do not advocate for more laws that protect mothers, we will have a mental health crisis that is going to leave a dent in the future."
Assemblyman Brian Maienschein (D-San Diego), the creator of the law to screen women for postpartum depression, acknowledges that new mothers need to be more aware of their rights .
"We want to remind [mothers] that experts should do postpartum screenings, and that they can ask for them if their providers don't," Maienschein said.
He added that "there is also a supplier problem. So a new law that I introduced to the Legislature in February will expand that group. After the diagnosis comes the next step, directing the mothers to the expert for treatment."
AB 935, the Mothers and Children Mental Health Support Act, would provide the consultation service through telehealth from private insurers and managed care organizations such as Medi-Cal to close gaps when there is a shortage of providers.
However, the bill will not be discussed until 2022.
For now, Mejía and Espinoza attend Maternal Mental Health Now groups. Rangel sees a psychologist at St. Joseph Heritage Hospital every week through her private health insurance. E. R. gets help in free therapy groups at Downtown Women's Center in Los Angeles.
"No mother has to suffer from postpartum depression alone," Mejía said. "Families must support their mothers so that there are no suicides, and in worse cases, even homicides. This mood disorder is real."