Empowering Reproductive Health: A Conversation with the Seleni Institute
On Thursday, September 26, the Association of Foreign Press Correspondents (AFPC-USA) met with staff members and collaborators from the Seleni Institute, an organization renowned for its efforts in the advancement of maternal mental health. The Seleni Institute provides therapy services for individuals, couples, and families and essential training to healthcare professionals, addressing the needs of individuals and families within the realm of reproductive health.
International correspondents had the opportunity to hear from three speakers on behalf of the organization.
Ashanda Saint-Jean, MD, is a board-certified OB/GYN Physician with over 20 years of experience working in New York City, focused on the delivery of quality care to underrepresented minority women. Her life’s work has been devoted to the excellence in health care delivery via patient centered comprehensive care, which is inclusive of mental health wellness and combating social determinants of health. Dr. Saint-Jean is committed to women’s health issues, most importantly focusing on racial disparities, health equity and inclusion, maternal health safety, policy, and access. She is a subject matter expert on maternal mortality, racial and cultural concordant care and health care disparities. She is the Chair of Obstetrics and Gynecology at Health Alliance Hospitals of the Hudson Valley, part of the Westchester Medical Center Health Network and an Associate Professor in the Department of OB/GYN at New York Medical College. She is a consultant for the New York City Department of Health, a member of the Ulster County Board of Health, the Diversity, the Hudson Valley section Chair for ACOG District II, the ACOG District II Diversity, Equity and Inclusion delegate for ACOG national delegation, an appointed member of both the New York State and New York City Maternal Mortality Review Boards and a physician consultant and member of the New York State Coalition for Doula Access.
Cori Galdo, MA, LMHC is an experienced licensed psychotherapist, with over 10 years working with individuals and groups from diverse backgrounds, helping those struggling with a multitude of mental health challenges including anxiety, depression, anger management, and overall life changes. She uses an individualized integrative approach utilizing scientifically supported techniques from cognitive behavioral therapy, exposure response prevention, acceptance commitment therapy, and mindfulness.After receiving her BS with magna cum laude honors from Santa Clara University, she later earned an MA in counseling for mental health and wellness from NYU's Steinhardt School of Culture, Education, and Human Development. She is a member of the academic honors society Phi Beta Kappa. Galdo has received specialized training at the Beck Institute for Cognitive Behavior Therapy, the Albert Ellis Institute, and the Association for Contextual Behavioral Sciences. She also completed further education in PMADs, grief, loss, and fertility-related distress at Seleni to later train hundreds of therapists on behalf of the institute in perinatal mood and anxiety disorders in Colombia and Panama. Outside of her practice, Galdo has continued to be involved in philanthropic work by assisting the psychology department at CANIA, a center for malnourished kids and adolescent mothers in her hometown of Venezuela.
Lavinia Lumu, MD, is the elected President of the International Marcé Society for Perinatal Mental Health. Dr. Lumu completed her fellowship in psychiatry and obtained the prestigious FCPsych (SA) qualification from the Colleges of Medicine in South Africa and a Master of Medicine in Psychiatry from the University of the Witwatersrand. Currently in private practice with a special interest in perinatal psychiatry, she is an advocate for maternal mental health and supports the Grow Great – Flourish Foundation in maternal mental health training. She is an honorary lecturer at the University of the Witwatersrand, Department of Psychiatry, Faculty of Health Sciences.
This program was moderated by journalist Patrícia Vasconcellos, the White House Correspondent for the Brazilian television network SBT. AFPC-USA is solely responsible for the content of this educational program. Below, foreign correspondents will find a summary of some of the most important takeaways from the presentation.
ON WHY MATERNAL MENTAL HEALTH IS A PRIORITY
Saint-Jean emphasizes the urgent need to address maternal mental health in the U.S., noting that it has become the leading cause of maternal mortality. She highlights several key issues: first, the importance of early screening for mental health conditions, both before and during pregnancy. However, many women face stigma, fear, and shame around disclosing mental health issues, particularly those with preexisting conditions who may fear medication-related risks. Saint-Jean also points out that current screening tools like the Edinburgh Depression Scale and PHQ-9 primarily assess depression but often miss anxiety, which is equally prevalent and impactful during the prenatal and postpartum periods.
Despite the identification of mental health issues through screening, there are significant gaps in linking patients to care due to a lack of mental health providers. She notes the rise of reproductive psychiatry as a specialized field addressing the needs of pregnant and postpartum women, which could help bridge this gap. Additionally, she stresses the importance of cultural understanding in healthcare, especially for Black women who may use different language to describe their mental health struggles, leading to miscommunication with healthcare providers.
Saint-Jean addresses the fear many women have that disclosing mental health struggles could lead to negative consequences, such as losing custody of their children. This reinforces the need to normalize maternal mental health screening and improve access to care. Saint-Jean calls for systemic changes to uplift maternal mental health, reduce stigma, and provide specialized treatment to reduce maternal mortality related to mental health conditions.
Galdo provides a clinical mental health perspective, emphasizing that maternal mental health is shaped by biopsychosocial factors. As a psychotherapist, Galdo highlights the importance of addressing mental health throughout the entire perinatal period—before, during, and up to a year after pregnancy. She explains that maternal mental health exists on a continuum, from severe psychiatric emergencies to more common experiences like "baby blues" and perinatal mood and anxiety disorders (PMADs), which affect 1 in 5 women in developed countries and 1 in 4 in developing nations.
Galdo emphasizes the role of psychoeducation in her practice, providing patients with accurate information to validate their experiences and help them recognize that there is treatment available. She also discusses her work in Venezuela, where culturally sensitive psychoeducation has proven to be effective. Galdo stressed the importance of training a wider network of professionals, not just in mental health but across various specializations, to raise awareness, create prevention strategies, and provide treatment for perinatal mental health issues.
Lumu emphasizes the vulnerability of pregnancy, which is a biologically stressful period that can exacerbate untreated mental illnesses due to hormonal changes. For too long, mental health has been sidelined, with stigma leading many to dismiss its seriousness. This stigma has historically resulted in pregnant women being advised to stop psychiatric medication, which has been proven through research to be safe for both pregnancy and breastfeeding.
Lumu explains that untreated mental health issues during pregnancy can lead to severe outcomes such as depression, suicidality, psychosis, and complications during delivery. These issues can also interfere with bonding between mother and baby. In lower and middle-income countries like South Africa, peripartum depression and anxiety rates are as high as one in three, contributing to increased maternal suicides and infanticide. Lumu advocates for a movement that gives mental health the same attention as other medical conditions during pregnancy to ensure better outcomes for both mother and child.
ON THE MOST SIGNIFICANT MATERNAL MENTAL HEALTH ISSUES ENCOUNTERED
Lumu highlights the major challenges faced by low and middle-income countries regarding maternal mental health. The primary issue is a severe shortage of mental health professionals, particularly those specialized in pregnancy-related mental health, as mentioned by Saint-Jean. Another significant obstacle is the widespread stigma surrounding mental illness, with fears of losing children or beliefs in spiritual causes for mental health conditions.
Lumu explains that cultural factors, poverty, lack of education, teenage pregnancy, and substance use during pregnancy further complicate the situation. These psychosocial factors significantly increase the risk of mental illness during the vulnerable perinatal period, making the situation even more complex.
Saint-Jean reflects on her experiences working in both urban and rural settings in New York, highlighting the stark differences in access to care. In New York City, she had access to a range of mental health professionals and community partnerships that allowed for easier connections to care once trust was established with patients. However, after moving to a rural area during the pandemic, she saw a lack of collaborative care models, with limited access to mental health specialists and barriers to treatment for substance use disorders during pregnancy. She recounts how a pregnant patient, fearful of relapsing, revealed her use of a friend's medication. Saint-Jean was able to connect her with proper care through collaborative efforts.
Saint-Jean also discusses broader issues such as "medical deserts" in rural areas, barriers posed by insurance policies, and social determinants of health like language, healthcare literacy, and housing instability. She stresses that many patients face stigma around mental health, particularly in relation to motherhood, which adds pressure to meet societal and family expectations of being a "perfect mother." The fear of disclosing struggles can prevent patients from seeking help. She emphasizes the importance of providers being trusted messengers and praises patients for their bravery in opening up, ensuring them that their struggles are not their fault but due to hormonal changes. Saint-Jean advocates for extending Medicaid coverage to a full year post-pregnancy, as most maternal mortality occurs after the initial six-week period.
Galdo reflects on her clinical experience at the Seleni Institute and her observations of women in her hometown of Caracas, noting a common struggle across different cultural and socioeconomic groups: the discrepancy between the idealized narrative of motherhood and the reality, particularly during the postpartum period. Many women experience a sense of disillusionment when their reality does not match the romanticized expectations of motherhood. They often express frustration, asking why no one warned them about the challenges.
Galdo identifies intrusive thoughts as a key manifestation of this struggle. These are distressing, repetitive thoughts that new mothers may feel ashamed or afraid to share, fearing that they make them bad mothers. She emphasizes the importance of psychoeducation, explaining to these women that such thoughts are a hallmark of perinatal mood and anxiety disorders and do not define their character. The fact that these thoughts are distressing suggests a protective instinct. She also highlights the cultural aspect of motherhood, particularly within the Latinx community. In this culture, the ideal mother is often seen as self-sacrificing, placing the needs of her children and family above her own. This expectation, tied to the concept of Marianismo (linked to the Virgin Mary in Catholicism), can make it difficult for women to ask for help or prioritize their own well-being, which exacerbates their struggles.
ON BARRIERS TO ACCESSING CARE
Galdo addresses barriers to accessing care during the postpartum phase from both individual and systemic perspectives. She highlights that the postpartum period is often chaotic, with many new mothers lacking the time, energy, or capacity to seek help, especially when their partners return to work due to the lack of paid leave. Many women do not realize they are struggling until later, making it difficult for them to reach out. Additionally, stigma plays a significant role in preventing women from seeking care. Women often fear that admitting they are struggling will lead to negative consequences, such as their baby being taken away or themselves being institutionalized, which leads to guilt and shame.
Galdo also touches on the importance of screening during pregnancy and postpartum. Although women frequently interact with healthcare providers during this period, there is a gap in care after six months postpartum when crises such as depression and suicidality often peak. While screening efforts have improved, Galdo says that it’s “not just about knowing what to ask but also how to ask it.” Trust and rapport are essential in encouraging women to open up and provide honest responses, which may not happen during rushed or impersonal screenings.
Lumu discusses the barriers to accessing mental health care in low and middle-income countries, particularly in South Africa. She highlights the overwhelming workload for midwives, who often screen up to 50 women a day, leading them to avoid mental health-related questions. Despite the existence of validated tools like the Edinburgh Postnatal Depression Scale, cultural and linguistic diversity complicates their use, prompting the creation of a simpler, three-question screening tool. However, even these questions are frequently overlooked due to the lack of mental health services, which are often only available in larger centers. Stigma surrounding psychiatric care and healthcare professionals discouraging medication use further hinder treatment.
Lumu stresses the need for collaborative care, where healthcare professionals across disciplines work together to provide holistic maternal health care. Empowering healthcare workers to ask simple check-in questions can help women feel heard, facilitating early interventions and referrals. She emphasizes the importance of preventing the severe consequences of untreated mental health conditions, such as increased maternal mortality, child abandonment, and even infanticide. For her, mental health care during pregnancy and postpartum is an essential yet often overlooked issue, one she equates to a "forgotten pandemic" that demands urgent attention.
Saint-Jean emphasizes the need for a patient-centered approach in addressing mental health care during the perinatal period. Upon becoming chair of her department, she implemented depression screenings before patients are discharged from the hospital, acknowledging the limitations of traditional screenings due to early discharge after delivery. She developed an escalation algorithm to connect patients with mental health specialists if they test positive for depression. Recognizing the often overlooked fourth trimester, Saint-Jean introduced a postpartum wellness visit within a week of delivery, focusing on four key areas: repeated depression screening, lactation support, blood pressure monitoring (especially for Black women, who have higher rates of cardiovascular issues), and wound care for C-section patients. She advocates for normalizing discussions about mental health, encouraging more open conversations rather than simple check-ins.
Saint-Jean calls for broader access to mental health resources, including at-home visits, mobile mental health units, and community health workers. She says there is an urgent need to address maternal mental health and the serious consequences of neglecting it, such as increased maternal mortality and risks to infant safety. Her aspirations include advocating for funding and support systems to improve access to mental health care, emphasizing the importance of collaboration among healthcare professionals globally to address these challenges effectively.
ON THE IMPACT OF UNTREATED MENTAL HEALTH CONDITIONS
Lumu discusses the serious consequences of untreated mental illness during and after pregnancy, highlighting its impact on both maternal and fetal health. She explains that untreated mental illness can complicate pregnancy, leading to lower antenatal care attendance, poor nutrition, and increased substance use. During delivery, mental health issues can elevate stress hormones, adversely affecting fetal growth and increasing the risk of neonatal ICU admissions. In the postpartum period, untreated mental illness, particularly psychiatric disorders, can manifest as postpartum psychosis, depression, or mania. The abrupt drop in pregnancy hormones can trigger these conditions, sometimes requiring hospitalization for the mother, which can lead to separation from the baby and potential harm to both.
Lumu says that untreated mental illness can result in child neglect and disrupt the attachment process, increasing the risk of developing mental health issues in the child later on. She underscores the importance of addressing mental health care during the perinatal period to prevent poor outcomes for both mothers and their babies, advocating for increased awareness and treatment to reduce morbidity and mortality rates associated with untreated mental illness.
Saint-Jean raises a critical question regarding the lack of prioritization for mental health treatment, particularly for pregnant patients and new mothers. She compares untreated mental health conditions to other serious health issues, like diabetes or hypertension, emphasizing that if we treat those illnesses, we should also prioritize mental health, especially given its significant impact on maternal mortality in the U.S. She highlights the reality that mental health issues can overshadow the joy of motherhood, as new mothers may struggle with conditions like anemia and fatigue while dealing with breastfeeding challenges. Saint-Jean calls for a shift in perception to recognize maternal mental health as a public health crisis that deserves urgent attention and resources. Her message underscores the need for systemic change to ensure that mothers receive the support they need to experience the joy of motherhood.
ON CURRENT SOLUTIONS AND INITIATIVES
Galdo builds on Saint-Jean's imagery of a mother experiencing sleepless nights while breastfeeding, emphasizing the isolation and overwhelming feelings new mothers may face during those moments. She highlights the importance of resources like the national maternal mental health hotline, which offers support in both English and Spanish. This hotline allows mothers to connect with trained professionals, providing immediate assistance during times of crisis, even in the early hours of the morning.
Galdo also addresses the challenges of maternal mental health in her home country of Venezuela, where data on the subject is scarce and many initiatives are funded privately or by NGOs. She notes that while basic needs like food and shelter are prioritized, there are opportunities to integrate mental health support into existing programs, such as those focused on lactation and nutrition. By incorporating psychoeducation into initiatives led by community leaders, such as faith-based organizations, Galdo believes that it is possible to take meaningful steps towards improving maternal mental health, even in dire circumstances.
Lumu discusses initiatives in South Africa aimed at integrating mental health services into antenatal care. She emphasizes the importance of collaboration among healthcare providers, including obstetricians, midwives, and mental health practitioners, to address perinatal mental health effectively. This teamwork is crucial for breaking down stigma and making mental health support more accessible to all mothers.
She references the Friendship Bench initiative in Zimbabwe, where new mothers share their experiences and struggles while waiting at antenatal clinics, serving as a form of psychotherapy. Lumu notes that in South Africa, community health workers are being trained to support mothers through groups organized by nonprofits like the Flourish Foundation, which also teaches them how to screen for mental health conditions and make referrals. She concludes by highlighting a universal goal: that happy mothers lead to happy babies, which in turn contributes to the overall well-being of nations and improved global GDPs.
Saint-Jean describes a multidisciplinary approach to maternal care known as the maternal medical home, which brings together various specialists—including obstetricians, midwives, doulas, community health workers, mental health specialists, social workers, and even receptionists—to customize care plans for each pregnant patient. This collaborative model allows for better communication about patient experiences and needs, particularly from those who interact with patients before their appointments. She also highlights the "centering in pregnancy" program, which facilitates group prenatal care organized by gestational age, enabling expectant mothers to connect and share their experiences, creating a supportive environment. This model can effectively serve as both prenatal care and support group therapy, allowing participants to discuss common challenges.
Additionally, Saint-Jean emphasizes the importance of incorporating doulas and reproductive mental health specialists into care teams to address the needs of patients throughout their pregnancy journeys, including those facing infertility and postpartum issues. She acknowledges that many obstetricians may hesitate to prescribe psychiatric medications due to a lack of understanding, advocating for a collaborative care model where specialists recommend treatments, and primary care providers handle prescriptions. This patient-centered approach focuses on the well-being of the individual and reinforces the importance of collaboration among healthcare providers. She expresses enthusiasm for the initiatives in Zimbabwe and South Africa, particularly the idea of creating community support spaces like the Friendship Bench.
ON INNOVATIONS AND FUTURE DIRECTIONS
Galdo emphasizes the importance of interdisciplinary collaboration and expanding professional networks to enhance maternal mental health initiatives. She advocates for ongoing training and engagement among professionals in the field, believing that a collective presence can lead to greater impact. She also highlights the role of technology in improving patient care, particularly for new mothers who may seek information online during challenging moments, like late-night feedings. Galdo points out the risks of misinformation that can arise from online searches, suggesting that artificial intelligence could be utilized to curate and fact-check health information. This would provide mothers with reliable resources during vulnerable times, ultimately benefiting both patients and healthcare providers.
Lumu mentions the critical need for educational reform in medical and health training curricula to better address mental health issues in South Africa. She says there is a limited budget allocated for mental health services, which contributes to the scarcity of available resources. Additionally, Lumu points out the significant amount of research being conducted in low- and middle-income countries that often goes unpublished and is not featured on global platforms. She argues for the necessity of reforming this publication process to ensure that research findings inform policy changes and help establish effective care pathways. Lumu stresses that while there are similarities between the issues faced in high-income and low- and middle-income countries, the differences are substantial and should be recognized in policy development.
Saint-Jean advocates for the creation of more pipeline programs to increase the number of mental health specialists. She emphasizes the need for funding and recruitment efforts to address the current deficit of professionals in the field. Saint-Jean highlights that many students are uncertain about how to pursue a career in mental health, so developing accessible programming and clear pathways to enter the profession is essential. She connects this initiative to improving patient access to care, stressing that recognizing the significant impact of mental health on the pregnancy journey will help drive the development of these programs and ultimately enhance patient support.
