Letters from the Cocoon

1996 - “It’s dark here in my head Dr. P and my entire body is swollen. I spilled formula on the counter while trying to make a bottle and I burst into tears. I have a bladder infection, a newborn who seems to be a night owl, and we are graduates of 4 days in the NICU. Breastfeeding seems impossible, but I am scared to admit it all…”

1998 - “It’s dark here in my head Dr. P and I am so anxious, I think something bad will happen to my baby, what if I drop him off the back deck? I will keep that door closed and not go out there with him just in case. I have a two-year-old too who seems to demand my attention and I keep losing weight because it’s hard to eat, but I am scared to admit it all…”

2004 - “It’s dark here in my head Dr. P and I don’t know if I can do this anymore. I think this baby deserves a better mom than me, if this is how it’s going to be I don’t want to live anymore. I have to move back in with my mom and grandma while my husband takes care of our 8 and 6 year olds. I had kidney stone surgery 9 days after birth and I dread the daytime when I have to function, but I am scared to admit it all…”

I lived tightly curled in my cocoon three times and didn’t want to emerge into a mother. It was miserable there, it was dark and there were a lot of changes happening, surely I had made a mistake in becoming a mom, I was certainly going crazy. Like a caterpillar, my brain was digesting itself from the inside out and I was unable to see the metamorphosis happening. My hormones were riding a roller coaster, I was hanging upside down in my dark cocoon and I was never screened for Maternal Mental Health (MMH) issues.?

Screening for MMH issues is the first line of defense for new moms - it’s their chance to share their feelings, their mood, how overwhelming parenting is, how intrusive thoughts may take up a majority of their days and nights, and it will help give them words to match their experience.??

Below are some ideas for Providers to break down the MMH cocoon:

• Have a bigger conversation than “how are you feeling” to which most people answer “fine.” Instead, ask things like, “your son was in the NICU, that can be scary for a lot of people, how are you handling your experience?”?
• Use an approved and validated screening tool like the EPDS or PHQ-9, they can be lifelines
• Review the screening tool with the mom face-to-face
• Assure the mom that she is in a safe space to share
• Do not be dismissive - “of course you’re tired, you just had a baby” is not a helpful response
• Pay attention to the word ‘overwhelmed’ as that’s a common word mothers use to describe how they are feeling when they don’t understand what’s happening?
• List some common perinatal struggles and see if the mom connects with any of them - intrusive thoughts, breastfeeding issues, feeling scared, experiencing physical symptoms due to lack of sleep and eating issues, obsessively cleaning, etc.
• Have educational brochures, resources, and local information on hand to give to all moms regardless of screening score?
• Have a robust referral program to local mental health professionals and organizations
• Keep educating yourself and your office staff every two years on Perinatal Mental Health Issues
• Practice integrated care with other professionals as a best practice, contact a provider consult line or work with the Pediatrician
• Follow-up according to your policy and procedures manual
• Screen the soul too, screening algorithms can produce meaningful data and cutoff scores, but still completely miss a suffering person?

2022 - “It’s lighter here in my head Dr. P, but I dream of how different things would have been if I was screened and if we could have had a real conversation about my experiences. You asked me how I was feeling, and I replied with the usual ‘fine.’ The 15-minute appointment moved on to the physical aspects of birth, checking my episiotomy stitches, my high blood pressure, and our breastfeeding schedule. If only, if only you rolled your stool over to the head of the exam-room bed and took as much care with your MMH questions as you did with my healing body, I would have emerged from my cocoon much sooner and with greater ease.”?

I was not fine, I was a missed opportunity. This is a call to action for screening, conversations, provider education, and sharing resources.?

Lynn Ingram McFarland, MBA, PMH-C

Survivor (x3)