Reading · This is Motherhood

Hayden Panettiere died this week at 36. No cause of death has been determined as of this writing. What we do know is that she spent years fighting postpartum depression and addiction in public. Loudly. Vulnerably. She openly talked about it in interviews, in treatment programs, eventually in a memoir. She did the things we tell people to do. She spoke. She went to treatment. She went back. She got help. She admitted she wasn’t feeling like herself. She said the hard parts out loud that this wasn’t an ecstatic or happy time, she struggled bonding, she struggled. Period.

Lindsay Clancy is on trial for killing her three children and her defense argues postpartum psychosis. I’m not here to give my opinion on the court case. But prior to this incident, Lindsay spent several months in multiple hands of mental health care between inpatient treatment, outpatient providers, and even 2 calls to suicide hotlines. She begged for help from family, friends, providers, the ER. She was doing every single thing to get help. Her defense argues her providers were not communicating with each other and that the level of care she received did not match the level of risk she was actually at.

These stories are not the same story. The outcomes are vastly different. Both tragic.

What I cannot stop thinking about is how much these moms went through and did not get better. Both women were inside the system. Both were visibly struggling to the people around them. Both were reaching for something that was supposed to be there. Both had the resources for support. They said the right things. They begged for help. And yet were left without support and continued to struggle.

The question I can’t get past is what happened after they asked for help and why did they not get the treatment to help?

I am a Psychiatric Nurse Practitioner in perinatal mental health. I didn’t always specialize in this, and it was only after my first son was born at 28 weeks, and I realized, “Oh, I’m a mental health provider and this felt like a total shock to my system. Why is no one talking about how hard this really is? And if I can’t find support, how can anyone else?”

I know what it is to wonder when someone is going to notice I’m not okay. When someone will say “it’s okay, you don’t have to love every minute.” I know what it’s like to be asking for help and still be trying to figure out what the right next step is (I wrote about it here during my second postpartum)

I think the hardest part, at least in the US where I live, is that the answer is not going to be one thing. It is never one thing. We can have a thousand moms screaming for help, but without the right supports, nothing will change. There has to be a system there to catch them. And in too many places, it is not.

Here is what actually needs to change.

Fewer than 1 in 5 postpartum women are screened by a healthcare provider. The screening that does exist happens mostly at the six-week appointment — a visit that lasts, on average, twelve minutes (arguably two), and was designed to check a uterus, not assess a person. Most moms skip this appointment because they can’t get to it, they’ve already had to return to work, they don’t have someone to watch the baby, they have other kids at home etc. etc.. And even if they go, the screening that is done is by an OB, not by a mental health provider and frankly only tells moms they can have sex again.

I recently spoke to a friend of mine who’s an OB and she told me “we were never trained in postpartum. We were trained in treating the c-section recovery, but nothing more”.

Why are we not also assessing their mental health?

And why are we only checking in on them at six weeks?

Nearly 60% of women who developed depressive symptoms at nine to ten months postpartum did not show those symptoms at six weeks. We screen at the wrong time, by the wrong person and then stop asking entirely. The American College of Obstetricians and Gynecologists recommends screening at least three times during the perinatal period. Most providers do it once, if at all.

The Edinburgh Postnatal Depression Scale — the most widely used tool — does not screen well for anxiety, OCD, intrusive thoughts, psychosis, or birth trauma. We are using a tool designed in 1987 and calling it comprehensive maternal mental health care.

Companies like VillageFor are trying to change access to the EPDS so that moms can monitor their own symptoms. But again, this is a task that has to fall on a mom, who is leaking, sleep deprived, and most of the time, not a mental health provider.

More people need to be doing the asking. Not only OBs. Pediatricians see the mother at every well-child visit in the first year. Lactation consultants are with her in some of the most physically and emotionally vulnerable moments of early postpartum. Doulas. Primary care providers. Every trained professional who sees a mother in that first year is a potential checkpoint. Right now most of those checkpoints are empty. It is not their role to diagnose or treat, but to be someone that says, “How are you doing?” and not take “fine” as an answer.

The screening also needs to last longer than six weeks. Postpartum is not six weeks. Postpartum is the first year at minimum, and for many mothers it extends well beyond that. We need routine check-ins at two weeks, six weeks, two months, and six months, and we need them to be standard — not something that happens if a mom is lucky enough to ask.

Getting screened and getting diagnosed are not the same thing. A positive screen is supposed to open a door. Too often, it doesn’t.

About 75% of women who need treatment for a perinatal mood disorder never receive it. More than half of pregnant women with depression still never get treated for it, even after someone has identified it. (CDC) Part of that gap lives between the referral and the appointment — between the provider who flags something and the mom who is then expected to call a stranger, explain her history, navigate her insurance, and schedule an intake while she is barely keeping it together. The referral is not care. It is a direction. The direction often leads nowhere and leaves a mom with one more task to do, that if she’s depressed or overwhelmed, will probably make it hard to do herself.

There is also a diagnostic problem. Many perinatal presentations are genuinely complex. They aren’t what we learn in the textbook, but then again, postpartum depression isn’t even in the DSM. On top of that, changes happen so quickly in the field that even providers who are trained, it’s challenging to stay on top of it. I was trained on perinatal psychiatry in 2023, and even what I was taught then about postpartum psychosis is no longer the standard.

Postpartum psychosis is not severe postpartum depression — it is a psychiatric emergency with a distinct presentation that sometimes can include delusions, hallucinations, mania, paranoia, and confusion. Postpartum OCD is consistently missed or mistaken for something else. Birth trauma isn’t even asked about, so moms don’t realize why their kids birthday might be hard.

If the provider in front of a mother cannot identify what she has, she cannot be treated for it.

What is part of the record in the Clancy case — and what I cannot dismiss as a clinician — is that she was seen by multiple providers. She was medicated. She was admitted. Her defense argues her care was fragmented and that no one was holding the full picture. Her doctors testified they did not observe mania or psychosis at the time of her evaluations. Whether that is accurate, and whether the standard of care was met, we still don’t have a clear picture of. What is not in dispute is that a woman was inside the mental health system, touching it at multiple points, and still ended in catastrophe. That demands an honest look at what touching the system actually means and where do women fall through the cracks.

Treatment is not the same as the right treatment. And the right treatment requires far more than most moms are currently getting.

Medication, when it is indicated, often requires time that postpartum mothers do not have. The first medication may not be the right one. The path to the right treatment can take months. All done outpatient while they still have to take care of kids, go back to work, and navigate the stressors that led them to feeling this way in the first place.

For postpartum psychosis specifically, the window for intervention is narrow and the consequences of missing it are catastrophic. A woman who is discharged after one inpatient day because she cannot demonstrate a current safety plan is not a woman who has been helped. She is a woman who has passed the minimum threshold on the day she happened to be assessed. There are only three perinatal-specific inpatient psychiatric programs in the entire United States. Three. There are twenty-five partial hospitalization programs nationwide. (Postpartum Support International) When the highest level of care a postpartum mom in crisis could need is available in only three places in the country, “get more help” is not an instruction. It is an impossibility for almost everyone who needs it.

Effective treatment also requires continuity that the current system does not reliably provide. When a mother moves between providers — from her OB to a general psychiatrist to an emergency department and back — what travels with her is her own account of what happened. Her history, her medications, what she disclosed and to whom. Everyone is treating the part of her they can currently see. The whole person gets lost in the handoffs and the bigger picture is forgotten about.

Hayden Panettiere described going to treatment, getting sober, coming home, and still having postpartum depression. Lindsey also got treatment, was meeting with providers, was asking for help. Access to treatment is not the same as receiving the right treatment for what you actually have. It’s not the same as feeling heldduring the journey.

Even if we screen more, train better, and diagnose more accurately — none of it works if a mother cannot get through the door.

Ninety-six percent of women of childbearing age in this country live somewhere without enough maternal mental health providers to meet the need. (Policy Center for Maternal Mental Health) That’s not a gap. That’s almost everyone. Across the country, 1,119 counties have no OB-GYN at all. (March of Dimes)

Access to perinatal mental health care in this country is largely a function of where you live and what you can pay. Rural areas have almost none. Waitlists for providers with perinatal specializations in cities can stretch for months. Insurance covers some services but rarely covers the ones that would catch things earliest — doulas, lactation consultants, pelvic floor therapists, perinatal mental health specialists. The services we categorize as optional or supplemental are often the ones that keep mothers from deteriorating to the point of crisis.

We need mental health providers embedded in OB offices and pediatric practices, where the mother is already showing up. The gap between a referral and an appointment is where a significant number of mothers get lost. We need care coordinators like Your PostParty to have someone be the care coordinator for all the services a mom can utilize, at her fingertips so she doesn’t have to coordinate it herself.

Co-located, integrated care removes that gap almost entirely. Some practices are already doing this. It works. It should be the standard.

We need warm handoffs — a real person, a next step that is activated on behalf of the mother rather than handed back to her to figure out. A woman in the middle of a postpartum mood disorder does not have the executive function to build her own care network from scratch. We keep designing systems that require her to.

Hayden had money, access, and celebrity. She described going to what she called an extremely expensive treatment program. Lindsay Clancy had clinicians and a hospital admission. Access is not sufficient. But the absence of access is disqualifying. The 75% of mothers who need treatment and never receive it are not failing to try hard enough. They are failing to find something that is available to them.

You cannot heal from birth while pumping in a bathroom stall at six weeks postpartum and while having to give her fresh, beautiful baby to someone else to take care of.

The United States is one of the only high-income countries in the world without guaranteed paid family leave. Most postpartum mood disorders peak between three and six months after birth — exactly when most American mothers have already returned to work. The timing is not incidental. It is a direct consequence of a policy decision that mothers’ recovery is a private responsibility, not a public one.

A mother cannot attend therapy if she has no leave to attend it. She cannot attend a day program if she has to decide between paying for that, or making her paycheck to pay for rent and food. She cannot rest — which is itself a clinical intervention — if rest is economically impossible. Paid leave is not a policy conversation that sits adjacent to maternal mental health. It is part of the clinical infrastructure. Without it, every other intervention becomes harder to access and harder to sustain. We keep building programs and pathways and then sending mothers back into the same conditions that made them sick.

I don’t have a clean answer to what comes next. I don’t think anyone does.

The change does not come from one place. It is not ACOG updating their screening protocols, though they should. It is not pediatricians adding a postpartum assessment at every well-child visit, though that too. It is not any single adjustment to a system that has been built, at nearly every level, around the assumption that the hard part of birth ends when the baby arrives.

The question I keep coming back to is not how we get more mothers to ask for help. They are asking. They have been asking. The question is whether the supports exist for them to get the help that they need.

About 600,000 mothers a year in the United States are affected by postpartum depression. Suicide and overdose account for nearly 25% of pregnancy-associated deaths, making mental health conditions one of the leading causes of maternal mortality. That is not a niche problem with niche solutions. That is a public health emergency being treated like an awareness campaign.

I am a provider who wants to figure this out for my clients. I am also a mother who sat in a NICU for two months and came home and discovered the hard part was not behind me. I wanted someone to figure it out for me, too. I know what it costs when the answer isn’t there.

I believe speaking about this helps. I believe knowing how to advocate — even though we shouldn’t have to — helps. I believe that every time a mother names what she is actually experiencing, it becomes harder for the system to pretend it isn’t happening.

But I want to be honest: naming it is not the solution. Advocacy is not the solution. They are what we do while we wait for the infrastructure to catch up.

To the mom who is pregnant, or thinking about getting pregnant, and scared of what postpartum might look like for her: I don’t know how to promise you the system will be there. I know that you deserve one that is. I know that what happened to Hayden and to the Clancy family is not what has to happen, and that the gap between where we are and where we need to be is made of specific, changeable things — screenings that don’t happen, diagnoses that get missed, treatments that aren’t coordinated, appointments that can’t be kept, leave that doesn’t exist.

None of that is inevitable. All of it can change.

It has to.

If this said something you’ve been trying to say — share it. Every time a mother names what the system is actually doing, it gets harder for the system to pretend it isn’t.

She Asked for Help. That Wasn't Enough.

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