Perinatal Mood and Anxiety Disorders: What to Look for When Screening.

PMAD: The importance of screening early and often cannot be understated. Not only does it prevent suffering but offers an economic argument. In this episode, Lynn Ingram McFarland shares her expertise on how and why to screen for perinatal mood and anxiety disorders.

Transcript

Lynn McFarland: 0:02

Oh my gosh, he's the best thing that ever happened to me. But I had 345, months of horrible anxiety, intrusive thoughts, you know what? If I throw him off the balcony, you know what, if he doesn't wake up like all these horrible Welcome to perinatal and reproductive perspectives. This is a podcast where we empower birthing individuals, partners and health professionals with evidence based insights, holistic strategies and relatable stories. Hosted by a healthcare expert, this podcast fosters understanding equity and growth in perinatal and reproductive health. Here's your host, Becky Morrison gleed, we are so lucky today to have Lynn Ingram McFarland. She is the owner of Ingram screening. Welcome to perinatal and reproductive perspectives. Thank you for having me. Well, we are so excited to learn more about screening for perinatal mood and anxiety disorders. I just wanted to open it up for our audience to learn more of First, what is a pmad And why would we screen for them? Sure, a pmad is an acronym for perinatal mood and anxiety disorders. So I want to break that down for everybody. P stands for perinatal. That is the entire time frame from pregnancy through one year postpartum. The M is for mood, and that includes depression, bipolar one, bipolar two and psychosis. The A is for anxiety. And this has some subscales. So this is obsessive compulsive disorder, this is post traumatic stress disorder, general anxiety disorder and panic disorder. And then the D just stands for disorder in pmads, so that just means it affects everyday living and gets in the way of daily functioning. So what I listed were about eight specific pmads that are specific to the perinatal period. So I would just want everyone to know that we're not just talking about postpartum depression, we're not just talking about a six week follow up appointment. We're talking about pregnancy through one year. I think that's so important to point out, because oftentimes the assumption is it's postpartum depression, and there's so much more encompassed under the umbrella of perinatal mood and anxiety disorders. And just to back up a little bit of I know you and I have met a couple times at Postpartum Support international conferences, but I wanted our audience to really know you know the work that you're doing when I was, I think it was, I was circling around, meandering some of the posters, and, you know, you read a clinical story here, or maybe some research. But then I, I came across your, it is so it stood out to me in terms of, not only is she presenting this information, but somehow you've been able to operationalize it into a very meaningful screening. I think this might be our cue to open it up to you to explain more what, what does Ingram screening encompass? Sure, so I'll start with my personal story really quickly, because that is the genesis of Ingram screening. So Ingram is my Ingram is my middle name. That is a family name. So I came up with the term Ingram screening for my business model. So as a three time survivor of pmeds, I was never screened. And hence why I started this business. So this is very grassroots. I am not a clinician. I'm not a provider, not a counselor, a therapist. I am a mother with lived experience who designed a program around what I needed my providers to know when I was suffering, and that's the business model that I came up with. So what did I do is consult providers and offices and clinics on how to institute perinatal mental health screening programs, fantastic. Would you be willing to share a little bit more about your story? Oh, for sure. For sure. So I had my first baby in 1996 he was a surprise. When he was born. I had this sort of cognitive dissonance toward him, like when I looked at him, I was like, Oh, it's a baby. He's cute, but, like, you know, not the love of my life. I didn't have those feel good hormones, and I thought it was a horrible mother. I had depression, you know, I would cry when I spilled formula on the counter. I couldn't nurse, and I just had a really rough time. And nobody really asked me how I was and never screened. The second baby came in 1998 a little bit earlier than we had anticipated, and this time, pm ads presented themselves more as anxiety and less of depression. So I bonded right away with this baby, like, oh my gosh, she's the best thing that ever happened to me. But I had 345, months of horrible anxiety. Be intrusive thoughts, you know what, if I throw him off the balcony, you know what, if he doesn't wake up like all these horrible anxiety things, again, never screened. And at this point, I had a newborn and a two year old, so I fought through that my third pregnancy. We had our long awaited daughter in 2004 and bonded with her, but also heavy anxiety, OCD, some PTSD. So the whole premise of Ingram screening is that pedmads present different ways in the same person through different pregnancies, or they can. I mean, you don't have the same symptoms every time. And so my struggle, of course, became my strength. And I said, nobody's going to do this. You know, have this happen after me. So I'm going to invent this business, and I'm going to teach providers how to treat these mothers and birthing people. Well, I love that you've been able to figure out how to refocus and create something and pass the baton to this new generation of birthing individuals. I mean, what a gift to create something new from a really tough three time experience. And you know, thinking about the 90s of I want to accentuate for the audience that this organization, Postpartum Support International, for example, was founded in the 80s. It's a very new space. And even just juxtaposing the psi conference from a few years ago to more recently, it has just expanded. And I think that's the beauty of the work that you're doing and others that through these grassroot efforts, we are really creating something beautiful and changing the resource, not only resources, but screening, I mean something that at the front end is so important, diagnostically, so we know what type of treatment does This person need, what type of resources, and it's often under resource, under supported as as you know, but again, just what a beautiful way to recreate meaning. Yeah, thank you. And screenings really underutilized because the return on investment is from insurance companies. The reimbursement rate is so low it's about two to $7 per screen. And so when we're talking about that versus all the other things that go on at an OB appointment or midwifery appointment or pediatric appointment, you know it's really minimized. Screening is very minimized. And also, no one profession wants to take responsibility for the mental health of a parent. So the OB at six weeks. The pediatrician says that's not my mom's not my patient, the midwife. So we have doulas in there, and so nobody's taking responsibility. No one profession. They all boot it to the next person, which is why integrated screening across disciplines is so important. And I would go a step further even with what I hear is this internalized experience of the mother or the parent, is, if I disclose this number one, what does that mean? Am I going to have CPS show up at my front door and really the fear and stigma that goes along with it that prevents them? And another thought I'm having is, how do we restructure for professionals, for providers to buy in if they're not incentivized financially? What are some other incentives of can we lean on ethical care? Can we lean on, you know, we want mothers and parents and individuals to be healthy, yes. So I think the first thing we need to lean on, because it's not a big money maker, and that's the way our health care system runs, is that, you know, doctors and providers take an oath to do no harm, and so when we're not screening, we're losing a lot of people. People are slipping through the crack cracks, like myself. So I was a white, middle class woman with health insurance, a great OBGYN and private practice, and I still slip through the cracks. And so how do we sort of create like you said, this urgency of like, this needs, this needs to get done, and that is part of my business model. So that is the whole education and training piece. And there's 30 specific questions that that I go through offices with, and they kind of come up with their policies and procedures manual from there, which is really sort of the the topper, the top of the cake, there's their policies and procedures manual. So it walks through like, who's screening? How are we screening? How is it being scored? What does our care pathway look like? So we walk through all of that, and what is the best way for providers, physicians, paraprofessionals, to set that up. How do they sure? They just, they just contact me. So I also have sales reps across the United States. I have about 10. Sales Reps so far that are selling the business model, that are helping me get into offices and clinics, but most of the time, just through my website, there's an about us, there's a Contact Us, and more information on what we do. I was browsing your website, and it's is so well organized. One of the sections I was I was looking at was speaking to the crisis of pm ads, can you share with the audience a little bit more about really, this urgency you're talking about and importance? Yes. So pmeds are considered a public health crisis. According to the Centers for Disease Control, roughly 4 million people give birth in the United States each year, and following the prevalence rates that we know about PMETs, which is about 20% that means about 800,000 out of the 4 million will suffer, and only 20% will receive treatment, and that's only 160,000 so that leaves about 600,000 or 75% of people who have to give birth every year, unidentified and untreated yearly. So screening can help mitigate these numbers, and that's why we say screen early and screen often. So it is a public health crisis, and really quickly, the difference between baby blues and postpartum depression is the onset and the the duration of it, so anything after two weeks is not considered the baby blues anymore, and and then anything after two weeks is considered something depression that needs a little bit more assessment. I think that's a helpful stat for our audience, because often, oftentimes, it's assumed, well, you know, I'm two days postpartum, but to normalize those first two weeks are bumpy and can be very emotional and challenging. But if you are still having symptoms a few weeks postpartum, those screenings can be extremely helpful. Oftentimes, that's would be at the pediatrician's office or at the OB and through there is a certification called the pmhc perinatal mental health professional certified. And I know I have that credential you as well, and that provides that extra layer of training for professionals on perinatal mood and anxiety disorders. Just so folks, if you're looking for someone to support you, you can search whether you're on Psychology Today or some other platform to see, does that provider have that extra layer of credentialing? Yes, exactly. I want to point out to people that sometimes providers, and especially in the labor and delivery units, they are afraid to screen early. They're afraid to screen in the hospital. They're afraid to screen in the first two weeks because they feel like they'll they'll pick up on postpartum depression when it's really not. And the guidance from psi and other maternal mental health leadership and the Policy Center on maternal mental health, the guidance is to screen anyway, because it's really more about the conversation that they're having. So screening is just an assessment. It's not diagnostic. Very important to know. So what's happening in the hospital when they're giving the EPDs and the mother may score high, but this opens the chance for a conversation like this is common. Postpartum blues will last two weeks. They peak at days three to five. You know, if you have any symptoms after two weeks, you know, contact us, and then it also shows the patient or the mom, what the tool looks like. So if they see it again, they're not surprised. I think exposure that speaks beautifully to number one, these screenings exist, and even if you're not symptomatic. Now, right? That individual might say, in three minutes, should I revisit that or ask to be screened again simply because they know it exists. You use the acronym. But can you explain to listeners what the Edinburgh is, and speak to some of the other screenings that you use. Yes, the Edinburg the EPDs, is the Edinburgh postnatal depression scale. And to be honest with you, it's not my favorite screening tool, but it's become the industry standard. And before I tell you a little bit about it, I just want to let people know that it was formulated like 40 years ago and created with cisgender white women birthing people in mind. And so it's, it's outdated in a lot of things, and people have problems with the questions and that aren't clear. And when they say, you know, like I've been feeling, you know, down for no good reason. Parents are saying, well, do I not have a good reason, you know, or do I have a good reason? And so when it's not explained to them, it's it's kind of not the best screening tool, but that is the industry standard. Unfortunately, when it's used correctly with conversation, it can be very effective, but there. At least 27 other screening tools that I work with in my business, and then, yeah, there's at least 27 so of course, the other common one is the patient health questionnaire, which is the PHQ nine. I like the PHQ four because the PHQ four has two questions on anxiety and two on depression. So it's a really good first step tool. Like, what's the next best step? Are we going to go for a general anxiety disorder, a gad seven, or are we going to go for the PHQ nine? So this is what I train and educate people on. Like, what's the next best thing to do? What's the best tool to use? So the problem with using the EPDs as a blanket tool is we're missing a lot of people. We're missing a lot of anxiety. We're missing bipolar. Thank you for accentuating that and the four. I mean, it has four questions, the PHQ nine will have nine just so we see some of these acronyms and numbers. People are like, what is the PHQ nine? What does that mean? But you also highlight something that is important for professionals too to know this can capture very quickly and for questions anxiety and depression, and the importance of incorporating questions for bipolarity or psychosis, which is treated As an emergency. And while these tools are wonderful and can provide good data for how we can best support these individuals. They are not perfect, correct, and we can continue to create and develop better ways to screen. Yes, we can, and also there are best practice is, if somebody screens positive for depression on the PDS, the best practice is to give them the mood disorder questionnaire, which is called the MDQ, the acronym, and that's for bipolar. And that's because bipolar is the great imposter of depression, because people seek help in their in their depressive states. And so it mimics, mimics depression, so sort of those, those nuances and screening like that is what I teach people to work with. But there's also a city birth trauma scale that's really good about birth trauma. There's health related social needs. There's a perinatal grief scale, which is great for stillborn abortion, termination for medical reasons, miscarriages, those kind of things. There's a postpartum distress message measure. You know, 2020 mom. Now the Policy Center for maternal mental health has a psychosis Symptoms Checklist. So there's just so many different things that we could be using to screen and yet we just blanket the EPDs without any conversation. And the real problems that I'm seeing in clinics is that a screening tool is put on a clipboard in the waiting room with all other paperwork, and that is completely inefficient. So I take myself back to when I was suffering and I'm sitting there in the office as I'm anxious and I can't eat and I'm nauseous and, you know, like, am I going to pass out? Absolutely and I'm looking at this, you know, if I were to look at this form, the EPDs, and it's got reverse scoring, and did I read the directions and it says the last seven days? Or do, what do they mean? Like, I mean, I there's no way I could have filled that out correctly. Absolutely not. And also I would have never admitted like, Oh, what if I throw my baby off the balcony? Like, I would have never admitted that to my pediatrician, because it was not a safe space. So the entire goal of my business model is to create safe spaces for moms like me to come in and have conversations and say, Hey, this is happening, and then for their provider to think, oh, intrusive thought, Okay, let's talk about this a little bit more and not call Child Protective Services. Absolutely, I think too something to point out that also happens, whether you're omitting it you might also minimize and so it's really not capturing, you know, the full symptoms. Or perhaps, you know there's a shame component or fear component, and so what can professionals do? Let's say you're in the OB your six week you know, postpartum check, and you know you're the provider. How do you have capture a more realistic picture of your patient, as opposed to just putting something on a clipboard and hoping for the best, right? So this is where face to face screening comes in, very important. So not on a paper, not online. A lot of people do it online in their offices and because it automatically scores for them, but to have a provider, and I just want to note point out, not just a provider. Anyone can screen, because it's not diagnostic. Diagnostic, it's just an assessment. So I'm talking the receptionist, you know, the nurse practitioners, the CNA, anybody in that office, because most tools can be self administered anyway. So. So it doesn't suck up all of the providers time, is what I'm trying to say. Because their complaint is they have 15 minutes. They're focusing on the physical manifestations of pregnancy, you know, mental health, not really on their radar. So to have somebody come in and first of all explain the tool like this is a mental health screening. We screen all of our patients, not just the ones we think, you know, we look our stuff are suffering. This is a standard best practice. Fill it out last seven days how you've been feeling, and then we can talk about it afterward. I mean, just a simple like that is perfect, because the moms know, oh, okay, they're aware of what's going on. And I can talk here. So don't, I don't want to put all the onus on the providers. Lynn, this is so wonderful too, because I'm even reflecting back. How could I improve my screening process? It's so easy to just click a few screenings and you know you want to review them before you see the person. But how often am I really having these face to face conversations, or making sure that we revisit these conversations of, how have you improved? What symptoms are persisting? How can we best support you? Just making a little bit more. I don't know, human is that the right word? Yeah, it's, it's really putting people over profits, if you're talking about the corporate world. And I tell you, most of my clients have been organizations that serve parents zero to three. So these are infant and toddler development programs, and they really wanted to institute screening because their providers were not for these people. So it's really just a vast, you know, it's a, it's a vast ocean of of who can screen and and all those. But yes, those are my zero to three parents or my have been my main consulting this work is just so important. I'm, yeah, I'm so glad that someone is in this space, you talked about a different types of screenings, and you mentioned one for birth trauma. Can you tell our listeners a little bit more about that screening? Yeah, the city birth trauma scale, yeah, yeah. That was that came from London. And there's one for the birthing person and the partner. Oh, fantastic. Yeah. And let me just read, if I may, hear a little, just a couple of these. So this is just about people's experience during birth, and it asks about potential traumatic events, the labor, the birth, whether they're experiencing symptoms, and then they just click their, their whatever they're experiencing the most. It's not super long. It's longer than the EPDs, but it doesn't have a name. But here, here's the first two questions, did you believe you or your baby would be seriously injured? Yes or no. You believe you or your baby would die? Yes or no. And then that's that's about during labor. Labor, some symptoms during birth, just do you have? Are you having recurrent unwanted memories of the birth or parts of the birth that you can't control? And then this is more of a Likert scale, and I'm happy to share this with anybody. You can actually download this for free on my website. Fantastic. Oh yeah, people can. Can check that out. But this is about flashbacks and getting upset when reminded of being reminded of birth, thinking something negative about the birth. And so those questions and the partner, the partner version is similar, but it says, Did you believe your partner or your baby would be seriously injured? Yes or no. So you know, do you believe your partner or baby would die? Yes or no. So these are the similar questions, but for the partner, which is super, super effective. These, these, these are great conversation starters, because a lot of time there's more birth trauma than there's depression and anxiety. And how important to give space to the partner? How often times have I seen I'm thinking about a hemorrhage, or where the partner there's I'm hearing two things. Is there is a real threat to the baby or the birthing individual, and then the symptom piece. And again, oftentimes we're quick to dismiss the partner when they very much could have witnessed something highly traumatic, a threat to the baby to the birthing individual, and nobody's asking them any questions, correct. And one in 10 dads and birthing people suffer with P meds as well, and the rate goes up if some other suffering. So always screen the dads, the dad the EPDs is validated for dads, so is the PHQ nine for dads and partners. So we're talking about not just a birthing person. We're talking about everybody in that person's, you know, circle. So, you know the populations. We're talking about immigrant populations and the LGBTQ plus populations, and, you know, surrogacy and adoptive parents and all of those people should be being screened. Yes, and I've seen cases. I'm sure you have to where maybe one person has a has PTSD, maybe the the partner does, or maybe there's a combination of both, or even a family member. Yes, so I'm I'm really happy to hear that there's a separate screening tool for this, along with grief, along with the bipolarity, along with the psychosis and depression and anxiety, right? All all are important to screen for. Yeah, and these are important because if you use, if you give somebody EPDs, they don't score high, or scores looks like they're not suffering at all. It's this is where the conversations are coming in, and because they're still saying something's not right, even though I didn't score high on the EPDs, something's not right. And this is where your discernment on the screening tools has to go, because, like, Well, tell me a little bit more about this. Are we talking about, you know, anxiety, PTSD, trauma, so you can really kind of flush out the different pm ads in the system, and that's really important. And I also want to note that you don't just have to give one screening tool, like you can give the EPDs, if they don't score and it's and they're saying they feel bad, give them another tool. Give them the PHQ four, the nine, or give them the GAD seven. So you know you can, you can give them as many tools as they're willing, willing to take to kind of find this out, which is not the industry standard right now, it's, it's the blanket EPDs, and off you go. Yeah, and a word that you used was discernment, that this is not a binary necessarily, there is a sequential piece, but you do really have to use a level of discernment and triage of, okay, we've got all of these tools. How do we best use them for screening? Right? So this is sort of balancing out or or bridging this dichotomy between an algorithm and the human sitting in front of you, and so that's where the discernment comes in. So every screening tool has its own anatomy per se, and that is, you know, they have, they have a set number of questions they have. They're assessing different pm ads, they have different languages, they have sensitivity and specificity measures that are different for all of them, and so sort of that algorithm and that anatomy and those building blocks of the tool are very non personal. It is just literally math and calculating things. So bridging that gap to the person sitting in front of you takes discernment, and it takes looking at somebody and saying, you know, let's talk about this a little bit more, and also saying, well, it's not normal. It's very common, so that people don't feel ashamed. So I didn't know when I was suffering. I thought it was just me, of course. I thought it was just me. Thought I was a horrible mother. I thought it's because I had an anxiety order, you know, earlier in my life that, you know, I probably just wasn't cut out for this. And nobody told me that it was perfectly normal. And I think that would have saved me some, some months of suffering. You and I both I had untreated postpartum anxiety, and this is back in 2013 and I could have used screening and a pmhc and some medication. And so I think you and I share that in common, that we're trying to give something back, and that's probably part of our own healing as well. Is definitely making sure this doesn't happen to this next generation. So we're, we're in this together. Yes, exactly, yeah. And Ingram screening is turning eight this year, so I've started, I've been working at it for about eight years, and I'm just starting to break into into the field and make some headway. So it takes a lot of patience, because, you know, it's not, it's not of an of importance to a lot of providers and offices. So we're working on that. Yeah, when I started practicing in New Mexico, I was one of a handful. I'm now practicing in Virginia and Hawaii, but I'm with you. I mean this, I started private practice a decade ago, and I'm just now really starting to see, okay, this is, this is taking off, and this pmad work is a full time nation specialty, and let's, let's keep it moving. Yeah, but tell the audience a little bit more about who's studying this, these screenings, who, who is giving space to the research to development. There are a couple of people that I know that are trying to rework the EPDs to make it more relevant. To today's world. I don't know their names. I know there's a couple other researchers and researchers in other countries that are coming up with screening tools for the African American population and bipoc populations. I know there's somebody else working on screening tools for LGBTQ plus populations. So a lot of that research is going on at the national level too. So I'm not, I kind of lean on the policy center for maternal mental health to keep me up to date on all those policies. But there are some, finally, some, after 40 years, somebody's trying to kind of rewrite the EPDs, fantastic. That's That's good to hear, and I didn't really know the back story. So thank you for shedding light on on the Edinburgh and its history, and really wanting to make it more inclusive to the bipoc community and other demographics that I mean, we really need to make sure that we are more inclusive. Yeah, and the the the other thing I'll say about the EPDs, because I don't want, I don't want people think I hate it, but when I spoke earlier about sensitivity and specificity, I just want to explain quickly that the sensitivity is the ability of a test to predict a true outcome. So, you know, the person has the disorder, and they score positive, and then sensitivity is the opposite. It is the ability to of a test to correctly identify people without the disorder, so it's a true negative. And so what happens with the EPDs is the sensitivity is kind of all over the place. The sensitivity for this, meaning it would be accurate, if the person has the disorder is 59% to 100% so that's quite, quite a range. The specificity, the true negative is 49% to 100% so there's so much, so much room in there, you know. So it's, it's really not, not my favorite, as opposed to the general anxiety disorder the GAD seven, it has 83% and an 84% sensitivity specificity. So it's really important that providers look at that as well. In order to make, like I said, the next best decisions, I want to look up the PHQ four for you, the sensitivity and specificity are really high. That's what it says. They're really high on them. So there are better tools than the APDS. Thank you again for shedding light on that. And again, we'll keep paying attention to these tools and screenings. And you know, it's it's a work in progress. It really is. Yeah, I feel more and more hopeful that some of these organizations, both nationally, internationally, privately, publicly, are taking a good look at these. It's so important, especially in the US we know maternal mental health is dire to say the least. What are the consequences of not screening? Can you point out a few different pieces around, what is this costing us? What are the consequences? Sure, so the cost of, oh, let me, I have this hang on, the cost of untreated pmeds, yes, training, obviously. I mean, the first thing that we're missing is suffering, of course. But other than that, it really affects and suffering, you know, not just for the mother and the baby, but we operate in systems. So this will incorporate partners and family members and work productivity and and and it goes beyond the nucleus, yes, so the cost of untreated pmeds, the top four are lost wages. So that's associated with pregnant birthing. People that are unable to work, they're too sick, and that was me. I was not able to work or drive, or underemployment, or underemployment. Yes, exactly. Number two is lower productivity in the workforce, because they're just trying to survive. They're going to work, they're just being robots. Number three is an increased reliance on public benefits. So need help. I know I, my family, was on the WIC program Women program in 98 for about six months because I was too sick to work, and we, you know, didn't have the money. So that's a big one. Number four is increased health care costs for treating worse maternal and child health. So when we let these things fester, we let them grow, it gets worse, and then it's more burden on the health care system. So those are the top four reasons, you know, for untreated pm ads and why screening can mitigate that. We can, we can stop that. There's no reason for that to be happening. So we spend about it costs about $14.2 billion a year, untreated P Mads in our in our economy. So this isn't just like you said in the nucleus, this is our society as a whole well. And I think you asked me. The Case for any insurance companies listening that it is more cost effective to treat at an outpatient level, if you can, than a partial hospitalization program or IOP or inpatient hospitalization, that if we can screen early and screen often, as you said, this can be a much more cost effective approach and prevent an unneeded suffering, right? We can enjoy postpartum and get treatment as soon as possible. Yes, is there anything else that you would want to really highlight or underscore for our listeners around these screenings and the work that you're doing. So not only do I consult provider offices and clinics and orgs, I have a two pronged approach, and that is some patient advocacy things that I have on my website. So I created some screen me rec cards. They're in English and Spanish. And what those are, they list the eight perinatal mood anxiety disorders on the front and on the back, there's a script for parents to write into their online portal or talk to their doctor about to advocate for their own screening. So I didn't have the words to explain what was happening to me. People say I'm just feeling really overwhelmed, and then they kind of leave it at that. So I really work on the patient advocacy side too. I try to get these rack cards into all of the offices that I work with, and it's just a reminder that parents can keep calling or sending messages to the provider's office until they receive what they need, and if one screening tool doesn't do it, you are able to ask for another screening tool. So that's that's really important to me. I also have a galaxy of motherhood card deck that is a journal and discussion prompt. It's a 78 amazing discuss discussion prompt that you can find on my website too. So a lot of organizations are using that in their therapy. And so I just a lot of you know, I'm kind of branching out into different things, but my main, my main priority is, is the consulting for the for the provider offices. But I know I wanted to touch on really quickly just how postpartum care is different in the United States, as opposed to like in China or in Europe, where they have such very different social structures and they take much better care of their parents and so, yeah, it's it's ridiculous. Here we're the only like high income nation that doesn't have a federally mandated paid maternity leave, paternity leave. You know, in China, they have a sitting month where the mom is just, you know, in bed or sitting relaxing, eating hot foods only somebody's taking care of everything. They're really being pampered. They have the dietary focus, some cultural restrictions. And then also in Europe, they have a lot of midwifery led care, which is different here than in the United States. So like the Netherlands and and Sweden, they have several home visits after the birth of their baby. They get several free home visits, which also United States doesn't do so. And Sweden offers about 480 days of paid parental leave. So there's just so many cultural differences. They just do it so much better than we do, which is, which is very sad. But, you know, we've taken a medicalized approach to birth, which has caused a lot more problems than probably good, well, sad, and by having these conversations, you know, the hope is that our voices will be heard and change will come from that of, what can we learn from these other entities, countries that are doing something right and well? And how can we do a better job and support our society a little bit better? And along with that, coming back to what you said as an advocate, and you also talked a little bit about this in the beginning of the episode. Is like mentorship. Maybe you're not a professional, but you're a survivor. And just to highlight, there are a lot of incredible peer mentors out there through different organizations, including Postpartum Support International, where folks who have been through pmads and have come out on the other side can provide us advocacy and mentorship. And I just want to make sure to highlight that as a survivor, that you have something so incredible to offer, just from the advocacy mentorship perspective and a business to you know, support providers, yeah, I want people to know that they're the expert of their own bodies. And so I know we trying to, we tend to fall into this hierarchy, like the doctor says, I'm okay, I guess I'm okay, and, you know, they know best. And I want people to realize that they're the expert they can be. Advocates for themselves, and I do a lot of speaking at things like the Portland doula association or a new moms group, and I tell them about the screening tools. And one of the new moms, she was crying, she said, I didn't know there was other tools other than the EPDs, or I didn't know there's other things besides depression, like she had no clue about it. So that's really part of of my work, too, is just being authentic in my story and just saying, Look, I almost lost my life, you know, in 2004 when I looked at my daughter, thought, God, she deserves better than this. I'm, you know, I'm a terrible mother, like she deserves better. And at that point, I have a six and a eight year old boy, you know. And now I look back on it, and I was like, that was just your anxiety, your depression, talking like that was not you, but the symptoms feel like who you are, and so that's why it's so hard for people to speak up, yes, and with help, the hope is that you will feel better. And other moms are experiencing this too. You're not alone, right? I think that's a wonderful, you know, piece to end on of hopefully that offers a little bit of hope and humanizing that some of us have been there and with treatment, you will feel well, correct, yeah. Well, thank you so much. Where can folks find you? My website's ingramscreening.com, they can email me at Ingram screening. Pmeds@gmail.com and on all my social media, they can just search Ingram screening, so Insta, Facebook, Tiktok, they can just like, find me there. Fantastic, truly, from one pmhc to another, thank you for the work that you're doing. I just hope to get the word out to the entire community and just keep rocking it. And I love the West Coast piece too. Hopefully I'll see you soon in New Orleans. That'd be awesome. Thank you so much. All right, thank you so much. Okay, bye, bye. 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