After five months of maternity leave with her second baby, a daughter born on 26 March 2020, Pam Lins felt she was ready to return to work and start a new role. This was the first year of the pandemic, so she had to work remotely while simultaneously raising her newborn and a toddler.

Six weeks into her leadership position – about eight months postpartum – she finally admitted something was wrong.

“I had really bad anxiety. I had trouble sleeping, worrying about something that could happen to the kids. At work, I recognized that I would overreact to something that really wasn’t that big of a deal. I wasn’t able to think rationally, had trouble making decisions, and got hyper-worked up over certain things. I knew that wasn’t me,” she said.

She had dismissed what were hallmark symptoms of postpartum depression, among them a persisting sense of doom, overwhelm and mounting dread. It wasn’t until she began to receive feedback from her direct reports that she started to realize she needed help. “I hysterically broke down crying one day, and my husband sat me on the floor of our bedroom and said, ‘You need to go to the doctor,’” she recalled.

Lins, who is now 40 and works in corporate finance, was finally diagnosed. She told her boss that she had an emergency and took three days off work to take care of herself, resting and developing a treatment plan with her doctor. She began taking medication and reconnected with a therapist. “I do remember feeling relieved at the time that I could finally acknowledge that I needed help,” she said.

Before Covid, one in eight women experienced postpartum depression, but in 2020, that number soared to one in three. Doctors and researchers were forced to act quickly to support pregnant and postpartum women, and in doing so began to make overdue changes by increasing the integration of mental health care into the wider realm of maternal healthcare.

But four years on, what changed, and what progress remains?

A crisis made worse by the pandemic

While rates of postpartum depression are returning to pre-Covid numbers, it is still a significant crisis.

The CDC recently reported that 80% of US pregnancy-related deaths are preventable, with one in four maternal deaths stemming from mental health crises, including suicide or substance abuse overdoses. Historically, postpartum depression has been under-treated, despite a decade-long push by doctors and public health officials to create screening and adequate treatment measures.

Although perinatal mood disorders are among the most common complications that occur during pregnancy or in the first 12 months after delivery, they are still widely under-diagnosed. According to new data, 14.5% of pregnancies can cause a new episode of depression. Yet, as of 2021, less than 20% of pregnant and postpartum patients were screened for it.

Many medical organizations, including the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP), have pushed for routine screenings, but they aren’t consistently offered by providers.

This, coupled with a lack of access to healthcare, is contributing to a crisis that is soberingly unique to America.

Dr Clayton Shuman, associate professor at the University of Michigan School of Nursing and the lead author of two studies on the increased rates of postpartum depression and PTSD symptoms during the first year of Covid, said that although the US was starting to do better at removing stigma for mental health, “we have not really moved the needle much when it comes to perinatal mental health. Part of that has to do with the fact that perinatal illness is predominantly within the realm of women’s health.”

Women’s health has long been suffering the consequences of institutionalized medical sexism, which has led to diminished positive medical outcomes for women. The pandemic exacerbated these conditions to a critical level, with triple the level of postpartum depression and anxiety rates. A University of Michigan study found that a fifth of the women experiencing postpartum depression reported thoughts of self-harm. Suicidal ideation and self-harm were already on the rise in perinatal women before the pandemic.

The impact of Covid led to decreased rates in breastfeeding as many women, particularly during the first year of the pandemic, weren’t able to access lactation support. They also often experienced a lack of support from postpartum care, including missing out on the social celebrations that normally mark pregnancy and birth.

At the height of the pandemic, women like Lins found that every aspect of their birth experience was altered.

This, combined with the stress, isolation, and uncertainty of the pandemic, has led researchers such as Shuman to advocate for an immediate and robust change to women’s reproductive and mental health care.

Parenting life after six weeks

After birth, women typically have only two follow-up visits with their maternal care providers: the first at two weeks postpartum, then another at six weeks. This schedule leaves disconcerting gaps in care, including the diagnosis of mood disorders that range from the “baby blues” (which is not depression) to postpartum depression or, in more severe cases, postpartum psychosis, a rare medical health emergency.

The end of the postpartum period is defined as six weeks post-birth in the majority of healthcare settings. But for many parents, including Lins, symptoms manifest well past this arbitrary date.

“There’s so much focus on the birth process itself, and on the early postpartum days,” said Dr Leena Mittal, a psychiatrist and the chief of the division of women’s mental health in the department of psychiatry at Brigham and Women’s Hospital in Boston. “The way healthcare is structured, you’re no longer perinatal after your six weeks postpartum visit. You’re supposed to go back to being a regular person. In fact, there are psychosocial and psychological adjustments and life changes that happen as one becomes a parent, [but] the focus then is so much on the baby.”

If women aren’t seeing their healthcare providers about emotional complications during the perinatal period, they do typically take their babies to the pediatricians. These visits provide a critical opportunity to expand care from the baby to the parents and offer mental health screening to parents regardless of gender. Some pediatricians have therefore become substitutes for family healthcare, on the frontline in detecting postpartum depression.

Logan children’s practice, in Kalispell, Montana, began to incorporate postpartum depression screening during well-infant checkups in 2020. In 2019, the AAP reported that roughly half of its providers offered maternal depression screening. But then Covid increased the feelings of isolation, anxiety and depression in many pregnant and postpartum individuals, which prompted the AAP to recommend that pediatricians conduct validated screening at each of the well-infant visits at one, two, four and six months to help improve diagnosis and referrals for treatment.

“There’s been this kind of wave right now of really leaning into mental health care as part of perinatal care, and it doesn’t just sit with mental health experts anymore,” said Mittal.

Dr John Cole, a pediatrician at Logan children’s, has noticed many positive results for postpartum depression since it instituted the screening tool four years ago. The reaction from parents had been fairly favorable, he noted. “I think the parents feel comfortable talking with us,” he said. “We just have a lot more touchpoints with mothers and fathers than they would otherwise have with their OB providers.”

Since the pandemic, his office has seen an uptick in cases – but what surprised him is the number of women and families who were already seeking treatment and support for it.

“It’s promising that many of these women have already spoken with their midwife or OB about this and are on treatments,” he said. The practice provides additional screening and recommendations for follow up treatment, and he says both men and women, especially new parents, should have a primary doctor to ensure that they are receiving regular healthcare checkups.

Disparities in care

While the majority of women are familiar with physical complications that can occur during pregnancy – such as gestational diabetes or pre-eclampsia – it can be hard for them to reach out for help when they struggle psychologically. Often, they just assume this is a normal, if difficult, part of new motherhood.

This was the case for Andrea Olmsted, who had two babies during Covid. “I’m an older mom and I felt like I should know more about this,” she said.

Olmsted, who is now 40 and runs her own public relations firm for the sustainable fashion industry, delivered her son on 3 March 2020 and experienced conflicting emotions: “I was super excited to be a mom. Meanwhile, we’re watching the news with Covid beginning to happen and feeling concerned,” she said. Olmsted remembers thinking: “What is going to happen to us?”

She wasn’t able to celebrate the birth of her first child outside of her home. California, where she was living at the time, entered lockdown on 19 March 2020. Her son was only a few weeks old and she entered into new motherhood feeling isolated and afraid.

She started to feel depressed from a lack of sleep. She had difficulties with breastfeeding and became very anxious as the news reported food shortages, including of infant formula. She and her husband also felt the financial burden of living on one income while she took unpaid leave from her job.

Social factors, such as financial insecurity, often affect mental health. Dr Allison Bryant, a maternal-fetal specialist and the chief health equity officer at the Mass General Brigham healthcare system, said where you live, where you work, and your relationship status influence your health.

“Just before the pandemic, we started to screen individuals intentionally for food insecurity, transportation insecurity, not because we had all the magic bullets, but maybe start to work on some of those things,” she said. “That certainly got exacerbated during the epidemic, so we started to be much more intentional about screening for those things, and ideally making some of those referrals to community health workers if available, or social workers.”

Massachusetts, where Bryant practices, has recently instituted changes to encourage a wider range of support – from tackling racial inequities in healthcare to expanding maternal care access. As of 2023, the state insurance plan allows for doula coverage, as the state joined a handful of others across the country introducing legislation that certifies doulas and adds their care to insurance and Medicaid plans.

Studies have shown that doulas – birth professionals who tend to serve as a bridge between the patient and the doctor, provide evidence-based information and are trained to identify and support pregnancy complications – increase equity in maternal health outcomes. A 2016 University of Minnesota study showed that women with doula care had a 22% lower risk of preterm birth. Postpartum doulas also offer breastfeeding support and address maternal mental health issues, which evidence has demonstrated lowers the odds of postpartum depression.

According to the CDC, Black women are three times more likely to die from pregnancy-related causes than white women. Variations in quality healthcare, underlying chronic conditions, structural racism and limited opportunities for economic, physical and emotional health contribute to these alarming disparities. For pregnant Black women, having a doula is shown to bridge health inequities and improve birth outcomes, including a significant risk reduction in preterm birth and complications from a cesarean delivery.

But Bryant says there are still challenges in getting patients the care they need. “We’ve learned some things [during] the depths of the pandemic, but it does feel like people still have a lot of anxiety. The ability to get those individuals into referrals [for follow up mental health care] is also challenging. There’s even less ability to get people to care that they really need and deserve.”

‘There shouldn’t be any shame in reaching out’

Olmsted felt she had limited options for treatment: in 2020, it was challenging to find a mental health provider who accepted new clients. She found it difficult to express her feelings of grief, loss and confusion to anyone, even to her mother. When she tried to bring it up, her mother would refer to her own experience of raising children almost 40 years ago.

Olmsted’s experience isn’t uncommon. Shuman believes much more public health messaging is needed to educate people. “People don’t know what to do, and they don’t know what it is. They don’t understand what postpartum depression is. Yes, you’re happy you had a baby but at the same time, there are things that you can’t control. It’s not well communicated to the public,” he said.

Olmsted, who now lives in Spokane, Washington, to be closer to her family, is now in therapy and reports seeing a major difference in her outlook of life and day-to-day stress management. Her second pandemic baby recently turned two and she feels like the “fog of new motherhood” has begun to dissipate. She’s regaining her sense of self, especially the sparks of her creative energy. She’s found that seeking help has made a tremendous impact on her life.

Across the country, however, access to mental health care is still taxed by an increased demand for psychological services since the pandemic. The gap between demand and access is compounded by a shortage of mental health providers, the cost of services either covered by private insurance or out-of-pocket, and geographic disparities – many rural areas across the country lack critical services.

Although there’s still a need for enhanced mental health services, postpartum women can still find reliable treatment, which can include medication, by talking with their doctors.

Many mothers express safety concerns before taking medication, but Dr Cole insists that the medicines prescribed for postpartum depression are not dangerous to mother or baby. “It’s also safe to breastfeed while taking those and they are very effective at treating postpartum depression. We want to make sure parents are getting the best treatment,” he said.

With treatment, which ranges from medication and therapy to social connection, diet and exercise, postpartum can have an end-date. Left untreated, it can transform into generalized depression.

“Postpartum depression is normal and it happens to so many women,” said Olmsted. “It’s hard for people to understand, it’s hard for partners to understand, and it’s hard for the woman who’s experiencing it to understand. There shouldn’t be any shame in reaching out. It would have been helpful to find another mom that was potentially going through a similar experience where you could feel okay to verbalize things and not feel like I’m going to be judged, or am I a bad mom?”

• In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis counselor. In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org

• In the US, call or text Mental Health America at 988 or chat 988lifeline.org. You can also reach Crisis Text Line by texting MHA to 741741. In the UK, the charity Mind is available on 0300 123 3393 and Childline on 0800 1111. In Australia, support is available at Beyond Blue on 1300 22 4636, Lifeline on 13 11 14, and at MensLine on 1300 789 978

• In the US, call the National Maternal Mental Health hotline at 1-833-852-6262