By EMILY JOHNSON
Imagine you’re an executive at a large health system in a major metropolitan area. One morning, you wake up to a missed call and a voicemail from your PR leader. It’s urgent: one of your employees–who was also a patient and a member of the organization–has unexpectedly died by suicide. Their family is furious.
You follow up and learn that this wasn’t just any employee. It was a young leader you had worked with only a few months ago. You had regular meetings with them and had been serving as a mentor. You had been impressed by this young person’s drive, enthusiasm, analytical skills, and ability to build relationships. You believed they were on the path to being a strong leader in health care. But not anymore. Now, seemingly out of nowhere, they are gone.
You’re shocked. You’re devastated. You’re confused. You demand an immediate safety review to understand what happened and why.
The patient safety team moves quickly to investigate, and they discover that the patient was a young woman who had given birth to her first child just two weeks ago at one of your hospitals.
During her pregnancy she had disclosed to her primary OB that she was beginning to have panic attacks. The OB offered to start her on an antidepressant, but the patient declined. No referrals were placed. Red flag.
She delivered her baby after a 30+ hour labor culminating in postpartum hemorrhage. Anxiety was noted several times throughout her hospital stay. Her notes from labor say “patient acutely anxious and requesting “to be done.” Her discharge notes state “Difficulty coping with anxiety for past 1-2 weeks. Has been affecting her ability to bond with baby.” Red flag.
She was seen by a social worker, who shared with her a packet of information about postpartum depression. This person recalls the patient asking her “which of the numbers should I call if I need help immediately?” Red flag.
She presented back at the ED the day after her initial discharge with additional hemorrhage concerns. Her notes say “Patient is anxious, tearful, arriving in the ED hypertensive at 140/90, tachycardic in the 120s.” She was discharged with blood pressure medication. Red flag.
You learn that her husband tried calling the behavioral health department to make his wife an appointment, only to be told that the soonest they could get her in would be 6 weeks. He pressed and asked if there were exceptions for urgent OB patients and was told no. Red flag.
In the week leading up to her death this patient had been in contact with 3 OBs, a pediatrician, and a lactation consultant, saying things like “I am afraid of everything” and “I can’t eat or drink.” She had a positive EPDS flagging thoughts of self-harm. Big, bright, unmistakable red flag.
Phone records show that one night she tried calling the behavioral health appointment scheduling line, which was given to her by multiple providers as a 24/7 crisis line, at 2am. Red flag.
Her notes from the last time she was seen in the clinic state “she is not eating, vomits any food she eats and has diarrhea. She reports sleeping at most 4 hours a day.” She walked out of that appointment with only a prescription for hydroxyzine, which is similar to Benadryl. Red flag.
At 5:30am the next morning, her husband woke up and found that she was not in the bed. He looked over and saw that the baby was still sleeping peacefully in the bassinet. He panicked. He knew in his gut that something was wrong.
He found her curled up on the floor of their bathroom next to an empty bottle of antidepressants, which she had been prescribed for the very first time on the day she delivered her baby. It was too late, she was gone. His partner of 8 years, the mother of his 15-day old baby, was gone.
You read the report, and you are fuming. How did this happen? We are an organization that prides itself on providing comprehensive care. We have an active mental health awareness campaign. We have implemented universal postpartum depression screening for new moms.
You reach out to the family and share that you are unbelievably sorry to learn of this young woman’s passing. You share that you will always remember her as a kind, passionate person who made an impact during her short tenure with the organization. You promise them that you are going to do everything in your power to ensure it never happens again. That is the only thing you can say or do that means anything to this family.
Later that same day you set up an emergent meeting to debrief the situation with your leaders. You delegate interim responsibility for maternal mental health to one of your leaders, recognizing that the safety report demonstrates several process failures that stemmed from punting the patient back and forth between different teams, with nobody taking ultimate responsibility for the patient.
This leader commissions an urgent quality improvement project that leads to several recommendations for bolstering the safeguards for new parents.
This project finds that there is significant variation in perinatal mental health training and education among your dozens of OB providers, and that very few of the providers administering EPDS screens have received crisis response training to be equipped to respond in real time to individuals in distress. You identify several resources that offer this training, and you mandate it for all providers in your organization who regularly interact with perinatal women.
The project also finds that an FDA-approved medication for postpartum depression, Zulresso, has been on the market since 2019. Studies of this medication, which must be given in a hospital setting via IV, conclude that “it provides prompt and effective resolution of depressive symptoms” within a matter of days. Though postpartum depression is the #1 complication of pregnancy and childbirth, you find that very few of the OBs in your practice know about this medication, and there are no organizations in the state that administer it.
Fortunately, you learn that the company that makes Zulresso is also developing an oral formulation of the drug, expected to be approved by the FDA in just a few months. You begin making plans with the insurance arm of your organization to establish coverage criteria, and working with the clinical leaders of your care group to educate your OB and psychiatry providers about this extremely significant development in women’s health.
This QI project also finds that you have a handful of outpatient therapists trained in perinatal mental health, but you do not offer any higher levels of care for patients with severe symptoms. The current standard of practice is to just refer patients to the ED, though most providers surveyed acknowledge that they know that most women cannot or will not follow that guidance, given that they are trying to care for a newborn baby and perhaps other children 24/7.
With this mind, the leader that you’ve designated reaches out to leaders at other local organizations to get a better understanding of what maternal mental health resources exist in your community and how to help patients access them. They learn that just a few miles down the road, there is a partial hospitalization program for pregnant and postpartum mothers, designed to help patients with severe symptoms like the one you just lost. This program is one of only a handful in the country, and has published evidence demonstrating its effectiveness at reducing symptoms of anxiety and depression in pregnant and postpartum women.
You work with that organization to build a direct referral system to this program in the EMR, to make it easy for providers to get patients there when needed.
As awareness grows, so does the demand for this program. It quickly becomes clear that the community needs more access to these services, so you launch a campaign to raise money for a new intensive perinatal mental health program within your organization. You are shocked by the success of the campaign. Given the prevalence of these conditions, several big donors you work with have been personally touched by this problem and want to support the new program.
The young woman in this story is me. My name is Emily Johnson, and I work for a large nonprofit community health system. I earned my Master of Healthcare Administration three years ago, after which I did a year-long administrative fellowship where I worked closely with several of the health system’s top executives. This is the story of what happened to me after my son was born in 2023, and of how I slipped through not one, not two, but many different cracks in our care delivery system.
What makes my story different from the one I just shared is that my husband woke up. On the night that I finally broke, he found me in the nursery around midnight, having just gotten off the phone with the suicide hotline. He is a resident physician, and at the time he was beginning his final year of medical school. He knew the basics of what he needed to say and do.
He asked me if I was thinking of killing myself, and I nodded. He asked if I had a plan, and I said “no, but I am thinking about it. I am so scared. I don’t want it to hurt. It already hurts so much.”
He knew I would not go to the ED. He knew that the last time I went to the ED, it was clear to both of us that the ED is not designed or ready to see women who just gave birth.
Regardless, we had discussed this option after the latest doctor’s appointment. I had tearfully explained that I desperately wanted help, but I didn’t want to go to the ED because I knew they wouldn’t really know how to help me. And I knew I wouldn’t be able to bring my baby. Holding my baby was one of the only effective tools I had for reducing my anxiety, even if just slightly.
He asked me to take some of an old anxiety prescription we had in the house, to help me get to sleep and get through the night. I did this, and with the help of this medication I was able to get a few consecutive hours of sleep, which is the most I’d had in at least 24 hours. As soon as I fell asleep, he called my mom and shared what happened, and she came over immediately so that there would always be one person responsible for Julian, and one person responsible for me.
In the morning my mom called my aunt, an oncology nurse who lives in another state. She shared what was going on, how I had been acting, and what I had been saying. My aunt calmly stated that I needed to go to the ED and asked to talk to me.
When I talked to my aunt, she told me she knew I was hurting. She told me she knew I was scared. She told me that this is something that can happen to new moms, and that we would find someone who could help me, even if we hadn’t been able to find that person yet. And she told me that what I needed to do, for myself and for my family, was go to the ED. So I did.
After presenting to the ED I was admitted to an inpatient psychiatry unit, separated from my baby and my family each night. While also devastating, this inpatient stay bought my family time to research treatment options, since they were no longer juggling basic care of both me and Julian. This is when my mom discovered the Mother-Baby program at Hennepin Healthcare.
The earliest they could get me into the program was in 2 weeks, but they promised I could have my first perinatal psychiatry visit within a few days, and they would have me work with a therapist on a safety plan at that time. I’ll never forget that first appointment I had with their lead psychiatrist, who also founded the program. She was the first medical professional to tell me that she saw how much I was struggling, that she had seen this before, and that she had tools to help me right away, instead of in several months.
This is when the second big trauma began to set in. If you know how much I am suffering, and if this is as common as you are telling me it is, then why did so many people along this journey look at me and shrug their shoulders? What does that say about how much the world cares about new moms, and about me? And that is a trauma that is still with me today as I try to convince the people around me in healthcare to act on this problem.
I don’t share this story to vilify the health system I work for or the providers I saw. On the contrary, I have a lot of compassion for the caregivers I saw along this journey, because I know they work within an imperfect system. I share my story to shine a light on the very big, very real gaps in maternal mental health care that still exist in our healthcare system, so that we can address them and ensure that other women get the support they need during this critical time. As I hope you can see, it wasn’t one error, one gap that failed me – it was the entire process.
In graduate school, we learned about Just Culture– the idea that errors in healthcare are often the result of a combination of factors, and that safety incidents can be opportunities to learn and improve. In other words, the more we are willing to be open and honest about where the gaps are that can allow for bad outcomes, the better the chances that we will be able to correct them. But this is hard, as it requires us as healthcare leaders to shine the light on our shortcomings, which is often the opposite of what we want to do.
So I am doubling down on vulnerability, sharing my personal healthcare journey in hopes that it will inspire other leaders in healthcare, including my own, to be vulnerable in evaluating the current state of how we’re supporting women’s mental health throughout the perinatal period.
My call to action is for healthcare administrators to take a hard look at their current practices and honestly answer the following questions as a starting point:
- Who is responsible for maternal mental health outcomes at our organization?
- Is every woman screened for perinatal depression and anxiety?
- Are all of our providers aware of the treatment options available to women with postpartum depression, including but not limited to Zurzuvae (Zulresso’s successor)?
- Is every provider who screens for perinatal depression and anxiety equipped to respond to a woman in crisis when they encounter one?
- What is the hand-off process when a woman needs a higher level of care, and how do you ensure she isn’t left to figure it out on her own?
- Does evidence-based, higher level care for perinatal mental illness even exist in our community?
If the answer to any of these questions is ‘no,’ there’s work to be done—work that can dramatically improve outcomes for women, their babies, and their families. If we really care about maternal mental health, we will do something to address the gaps in care that exist today and ensure they get the support they need not just to survive, but to thrive. We do not need to wait for the next tragedy to occur to recognize that this is a crisis that deserves immediate attention. I am here, able to tell you now, and I want to make sure we are part of the reason that more women like me are still here, too.
Emily Johnson, MHA, is a healthcare strategist exploring the fine line between personal experience and professional responsibility in the world of healthcare leadership.
