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Portia Smith’s most vivid memories of her daughter’s first year are of tears. Not the baby’s. Her own.

“I would just hold her and cry all day,” Smith said.

At 18, Smith was caring for two children, 4-year-old Kelaiah and newborn Nelly, with little help from the partner in her abusive relationship. The circumstances were difficult, but she knew the tears were more than that.

“I really didn’t have a connection for her,” said Smith, now a motivational speaker and mother of three living in Philadelphia. “I didn’t even want to breastfeed because I didn’t want that closeness with her.”

The emotions were overwhelming, but Smith couldn’t bring herself to ask for help.

“You’re afraid to say it because you think the next step is (for the authorities) to take your children away from you,” she said. “You’re young and you’re African American, so it’s like (people are thinking), ‘She’s going to be a bad mom.’ “

Smith’s concern was echoed by several black women interviewed for this story. Maternal health experts said some black women choose to struggle on their own rather than seek care and risk having their families torn apart by child welfare services.

Nationally, postpartum depression affects 1 in 7 mothers. Medical guidelines recommend counseling for all women experiencing postpartum depression, and many women also find relief by taking general antidepressants, such as fluoxetine (Prozac) and sertraline (Zoloft).

In March, the Food and Drug Administration approved the first drug specifically for the treatment of postpartum depression, which can include extreme sadness, anxiety and exhaustion that may interfere with a woman’s ability to care for herself or her family. The mood disorder can begin in pregnancy and last for months after childbirth.

But those advances help only if women’s needs are identified in the first place—a particular challenge for women of color and low-income mothers, as they are several times more likely to suffer from postpartum mental illness but less likely to receive treatment than other mothers.

The consequences of untreated postpartum depression can be serious. A report from nine maternal mortality review committees in the United States found that mental health problems, ranging from depression to substance use or trauma, went unidentified in many cases and were a contributing factor in pregnancy-related deaths. Although rare, deaths of new mothers by suicide have also been reported across the country.

Babies can suffer too, struggling to form a secure attachment with their mothers and increasing their risk of developing behavioral issues and cognitive impairments.

‘I Was Lying To You’

For many women of color, the fear of child welfare services comes from seeing real incidents in their community, said Ayesha Uqdah, a community health worker who conducts home visits for pregnant and postpartum women in Philadelphia through the nonprofit Maternity Care Coalition.

News reports in several states and studies at the national level have found that child welfare workers deem black mothers unfit at a higher rate than they do white mothers, even when controlling for factors like education and poverty.

During home visits, Uqdah asks clients the 10 questions on the Edinburgh Postnatal Depression Scale survey, one of the most commonly used tools to identify women at risk. The survey asks women to rate things like how often they’ve laughed or whether they had trouble sleeping in the past week. The answers are tallied for a score out of 30, and anyone who scores above 10 is referred for a formal clinical assessment.

Uqdah remembered conducting the survey with one pregnant client, who scored a 22. The woman decided not to go for the mental health services Uqdah recommended.

A week after having her baby, the same woman’s answers netted her a score of zero: perfect mental health.

“I knew there was something going on,” Uqdah said. “But our job isn’t to push our clients to do something they’re not comfortable doing.”

About a month later, the woman broke down and told Uqdah, “I was lying to you. I really did need services, but I didn’t want to admit it to you or myself.”

The woman’s first child had been taken into child welfare custody and ended up with her grandfather, Uqdah said. The young mother didn’t want that to happen again.

Screening Tools Don’t Serve Everyone Well

Another hurdle for women of color comes from the tools clinicians use to screen for postpartum depression.

The tools were developed based on mostly white research participants, said Alfiee Breland-Noble, an associate professor of psychiatry at Georgetown University Medical Center. Often those screening tools are less relevant for women of color.

Research shows that different cultures talk about mental illness in different ways. African Americans are less likely to use the term depression, but they may say they don’t feel like themselves, Breland-Noble said.

It’s also more common for people in minority communities to experience mental illness as physical symptoms. Depression can show up as headaches, for example, or anxiety as gastrointestinal issues.

Studies evaluating screening tools used with low-income, African American mothers found they don’t catch as many women as they should. Researchers recommend lower cutoff scores for certain African American women in order to better identify women who needs help but may not be scoring high enough to trigger a follow-up under current guidelines.

Bringing Treatment Home

It took Smith six months after daughter Nelly’s birth to work up the courage to see a doctor about her postpartum depression.

Even then, she encountered the typical barriers faced by new mothers: Therapy is expensive, wait times are long, and coordinating transportation and child care can be difficult, especially for someone struggling with depression.

But Smith was determined. She visited two different clinics until she found a good fit. After several months of therapy and medication, she began feeling better. Today, Smith and her three daughters go to weekly $5 movies and do their makeup together before big outings.

Other mothers never receive care. A recent study from the Children’s Hospital of Philadelphia found that only 1 in 10 women who screened positive for postpartum depression at the hospital’s urban medical practice sites sought any treatment within the following six months. A study examining three years’ worth of New Jersey Medicaid claims found white women were nearly twice as likely to receive treatment as were women of color.

Noticing that gap, the Maternity Care Coalition in Philadelphia tried something new.

In 2018, the nonprofit started a pilot program that pairs mothers with Drexel University graduate students training to be marriage and family counselors. The student counselors visit the women an hour a week and provide free in-home counseling for as many weeks as the women need. Last year, the program served 30 clients. This year, the organization plans to expand the program to multiple counties in the region and hire professional therapists.

It was a game changer for Stephanie Lee, a 39-year-old who had postpartum depression after the birth of her second child in 2017.

“It was so rough, like I was a mess, I was crying,” Lee said. “I just felt like nobody understood me.”

She felt shame asking for help and thought it made her look weak. Lee’s mother had already helped her raise her older son when Lee was a teenager, and many members of her family had raised multiple kids close in age.

“The black community don’t know postpartum,” Lee said. “There’s this expectation on us as women of color that we have to be … superhero strong, that we’re not allowed to be vulnerable.”

But with in-home therapy, no one had to know Lee was seeking treatment.

The counselors helped Lee get back to work and learn how to make time for herself—even just a few minutes in the morning to say a prayer or do some positive affirmations.

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