I love babies. My decision to choose pediatrics and become a mother in residency was underpinned by this simple fact. As a baby doctor, I imagined my transition into motherhood would be elegant. I pictured myself breastfeeding, sleep training, and swaddling like a pro, using everything I’d learned to become a perfect mom.

Two days after my daughter, Iris, was born, I awoke to sunlight streaming through the bedroom window. I sat up, eager to check on my baby, and I felt like I’d been clobbered by an 18-wheeler. My head was throbbing and my ears were ringing. My eyes refused to focus, the outline of my daughter’s face fuzzy and unclear. Naturally, at this moment, the baby started to wail, demanding to be fed.

Within an hour, I was urgently readmitted to the hospital for postpartum preeclampsia. I received 3 days of intravenous (IV) magnesium and blood pressure management. Attempts to room in with my newborn were disastrous. The IV pole tethered to my arm prevented me from being able to lift her from the bassinet, and I was too weak to sit upright. Breastfeeding under these conditions felt like a cruel joke, the IV tubing kinking and alarming every few seconds. Instead, I watched my husband feed our baby formula in the shadow of endless “Breast is best!” posters. I felt like a failure.

After I was discharged, my body began to heal, but my feelings of inadequacy lingered. I continued to struggle with breastfeeding, each doomed latch leading to a spiral of shame. My swaddles fell apart; my lullabies were drowned by ear-piercing cries. As I reflected on my dreams of easing into motherhood, I felt a strong self-loathing. I was a pediatrician, after all. Wasn’t this supposed to be easier for me?

In medicine, we diagnose those difficult feelings I experienced after having an infant as the “postpartum blues.” If the symptoms persist longer than 2 weeks, the blues become a diagnosis of postpartum depression (PPD).1  Despite how isolated my own depression made me feel, the literature demonstrates that PPD affects ∼20% of mothers. In the wake of the coronavirus disease 2019 pandemic, this incidence appears to be rising even higher.2,3  Up to a third of mothers suffer from high subsyndromal depressive symptoms, meaning they do not technically meet the criteria for major depression but still report symptoms of dysphoric mood, inadequate support, and poor coping.4  Without a formal diagnosis, this population is less likely to receive recognition or services.

Studies suggest that up to 50% of cases of PPD go undiagnosed.5  I’ve seen this firsthand, having screened dozens of mothers in my clinic for PPD using the Edinburgh Postnatal Depression Scale.6  Unfortunately, those screenings too often go unheeded as but another piece of paper buried in a stack, receiving less than a cursory glance once unearthed. And, too often, the form was blank.

Given how common PPD symptoms are, this should have raised a red flag that my screening was inadequate. During these visits, I rarely paused to consider that these mothers were under enormous pressure to rush their own recoveries. How many of them had preeclampsia and experienced the horrors of a magnesium drip? How many had hemorrhages? Crash cesarean deliveries? Did they feel utterly desolate every time they failed to latch? Were they so exhausted they would empty their bank account for 8 hours of uninterrupted sleep? Even the most routine deliveries require weeks of physical and emotional recovery. Outside of risk stratifying the newborn, I had spent little time considering the mother’s experience.

Put differently: by failing these mothers, I’d failed their kids, too.

Research has shown that maternal depression affects development, rates of breastfeeding, and risk for nonaccidental trauma.1  Mothers with depression are also less likely to attend well-child visits, are more likely to use the emergency department, and are less likely to follow safety advice regarding car seats and sleep.1  Yet, we shouldn’t need data to tell us that a mother’s well-being is paramount to the health of her children.

Two of the biggest risk factors for PPD are low levels of social support and high levels of life stress.7  For me, returning from maternity leave meant enduring a crash course in life stress.

I juggled full resident clinical duties with raising my daughter, including night call and working 12 days without a break. I raced home after getting slammed with admissions at the hospital, attached to a portable breast pump with tubing that kept getting tangled in the steering wheel. I woke up at 4 am to read Dr Seuss aloud, terrified that my daughter, who was always asleep when I got home, wouldn’t remember me otherwise. I found dried spit-up on my scrub top and pacifiers in my pockets during rounds when I was looking for a pen.

Until I had my own child, I never noticed how thinly stretched new mothers seemed in the office. I always chose instead to focus on the tiny miracle they had just created. Now, I often recognize the desperation and sleep deprivation behind their smiles.

But recognizing a struggling mother is only part of the equation. Even when mothers are identified as having depressive symptoms, nearly 60% do not take up a referral to mental health services.8  An analysis of self-reported barriers to referral uptake by mothers with PPD cited inadequate time with the pediatrician and focus solely on the child during appointments.9 

These findings demonstrate that pediatricians must resist the impulse to rush visits with well-appearing newborns, as these are crucial opportunities to check in with families. Some institutions use a standardized treatment approach4  to managing PPD with improved outcomes.10  These institutions use a validated screening tool for PPD at the 2-, 4-, and 6-month visits. On the basis of the severity of their depressive symptoms, mothers are offered escalating amounts of follow-up and resources. These practices can be implemented in trainee clinics, too: treatment algorithms for PPD can be pasted on the wall right alongside the vaccine schedule. Accordingly, senior physicians and trainees alike should be empowered to increase visit frequency on the basis of positive PPD screens given the known impacts on newborn health5 , leveraging virtual visits to increase access for families with transportation barriers. And, in more complex cases, providers and trainees can collaborate with social work services and obstetrics and gynecology to provide referrals and resources if medication or psychotherapy is indicated. Importantly, any intervention must be balanced carefully with the needs of early postpartum mothers for rest.

My experience also highlighted barriers facing trainees who have children during residency. Family leave and pumping policies are not standardized across the board, so many resident mothers must advocate for themselves with inconsistent administrative support.11  Lack of standardized policies has ramifications, especially on rates of breastfeeding, the very practice we so vigorously recommend to all of our new moms. Indeed, data suggest that only 25% of trainee physicians meet their goal for breastfeeding duration, with 97% of those surveyed reporting at least 1 institutional barrier to breastfeeding.11  These barriers include long shifts without breaks, lack of pumping facilities, and short maternity leave. Transparent, standardized policies to give pregnant and breastfeeding mothers the breaks they need to keep themselves and their infants healthy should be the minimum standard. Mental health and lactation resources for residents should be abundant and easy to access. Administrators should also work with residents to meet their goals for family leave without extending training unnecessarily. The American Board of Pediatrics (ABP) policy states that, in addition to the 1 month of combined vacation, sick, and family leave allowed each year, a trainee may only take 8 weeks of leave from elective rotations without needing to extend their training.12  According to the ABP, the “total amount of leave time offered to the trainee is at the discretion of the institution.” In other words, those 8 weeks of leave are not guaranteed. In fact, the program must opt-in to allow residents who take parental leave to graduate at all. As experts in mother–infant well-being, the ABP misses an opportunity to lead by example and, instead, leaves resident mothers and their infants woefully undersupported.

When I started residency, I had thought that training to be a pediatrician would make me a better mother. Now, I think the opposite is true: Being a mom has taught me how to be a better pediatrician. Childbirth and motherhood are not for the faint of heart. Mothers deserve fierce advocacy from their pediatricians as we fight together to protect the babies we all love so dearly.

Dr Bruney was the primary author for this paper, conceptualized the manuscript, and the experiences detailed in the narrative are from her perspective as a trainee physician; Dr Sojar revised the manuscript and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLAIMER: The authors have indicated they have no conflicts of interest relevant to this article to disclose.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2022-059827.

ABP

American Board of Pediatrics

IV

intravenous

PPD

postpartum depression

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