May is Maternal Mental Health Month, and although we tend to hear a lot about postpartum depression, as our guest today has pointed out, perinatal distress is really a spectrum of reactions. Childbirth and new parenthood are major life transitions that involve many physical, psychological, and practical changes. These changes may interfere a little or a lot in a mother’s ability to function optimally and, in turn, affect her relationship with the child and the child’s development. Today’s global crises, including climate change, the pandemic, and war, can add an additional layer of stress so normalizing the experience is more important than ever.
Our guest is public health expert Jennifer Barkin, Ph.D., M.S., a Professor and Vice Chair of Community Medicine and Obstetrics and Gynecology at the Mercer University School of Medicine in Georgia. A biostatistician and psychiatric epidemiologist, Dr. Barkin was formerly an analyst at the University of Pittsburgh’s Epidemiology Data Center, where she designed the Barkin Index of Maternal Functioning (BIMF), the first patient-centered wellness assessment tool focusing on mothers’ daily lives during the first year after giving birth. She is a peer reviewer for journals including Archives of Women’s Mental Health and serves on the Board of Directors for Postpartum Support International, Georgia Chapter.
The following transcript has been edited for length and clarity. Listen to the audio of the interview here:
Miranda Spencer: You work in the field of public health, with your recent research focusing on the mental health of mothers and children, and your particular emphasis is on what we could broadly call environmental stressors.
So, let’s look first at what you’re most known for, which is the Barkin Index of Maternal Functioning. When, why, and how did you develop it?
Dr. Jennifer Barkin: I developed that actually during my doctoral studies… and the reason that I developed it was I linked up with a sort of famous reproductive psychiatrist named Dr. Kathy Wisner, and she would say, “We have a lot of depression screens and anxiety screens, but we don’t have as a good measure of maternal functioning in the postpartum period.”
And her rationale—because I didn’t know much about this particular part of psychiatry at that time, even though my background was in mental health research — [was], patients don’t present for treatment wanting to get a certain score on the Edinburgh Postnatal Depression Scale. They want to function better every day in their role as a mother, wife, employee, member of society, etc. The functioning was a core goal for the patient, but then we approach it more through a mood assessment model, so that is really how I got the idea ….
One feature I think that’s particularly attractive about it is that we developed the items after interviewing 30-plus postpartum women. We went right to the population that’s experiencing the condition of interest to populate the content for the survey. So instead of us academicians going off on our own and making up the questions, we ask the women to define: What does a good day look like? What does a bad day look like? And everything in between.
Spencer: What kind of questions are on it?
Barkin: It asks about everything from your own care of yourself to adjustment over time as a mother. Now this is self-rated, right, so the mothers are rating themselves. It asks about… are you getting enough adult interaction? Everything from how do you feel feeding and diapering and infant care tasks are going to how well do you think you’re juggling other parts of your life? And how well are you taking care of yourself? Are you getting what you need?
So, you can really use this as two scales: like a maternal competency scale, and then there’s a second subset that are more self-care items, which I think are one of the most important parts, because women generally understand how to change diapers and how to get their baby to feed, and that that all kind of works itself out. What I think the biggest struggle is, is the self-care part, because you’ll have mothers say, … “When you become a mom, it’s all about your kids. It’s not about you anymore,” and then the same mom maybe would say in the same focus group, “Yeah, but if I’m not happy, the family is going to suffer.” So my happiness is important, and I think that tension between that kind of ambiguity around the role of self-care and maybe even guilt, if you do take care of yourself as a woman, is a major learning curve and area of weakness for a lot of women.
Spencer: So if you scored low on the index, what would that mean? What would be done with it that’s different from something like a postpartum depression kind of scale?
Barkin: It doesn’t indicate anything for depression; you would use this as a complement or a supplement for a depression screen, so there’s nothing on there about suicidality or suicidal ideation….This is more [about] what parts of this role are you struggling with? And what parts are you doing well at, and that would indicate what type of support you needed around skills improvement. One of the things that was interesting to me is, I work with clinicians every day, but maybe in the past few years, I’ve had some growing interest from occupational therapists, and they’ll say to me, “When I saw this measure, I thought it was made for occupational therapy.” Because that’s what they do, they help people function better.
Spencer: Who are some of the other people that use it, and how?
Barkin: It’s being used in community-based settings and academia. It’s probably the biggest use in clinical settings, and to our surprise in industry, so commercial research type situations. Within the clinical world, psychiatrists use it, psychologists, like I said, occupational therapists, and sometimes I don’t even know about the use, like, I’ll hear somebody say, “Oh, I went to your conference, and I saw slides on your measure,” and they’re using it at whatever state hospital and I don’t know about it. A lot of the times, I do know about it, because people will want collaboration, or if they want to publish the results, they’ll want me on board to help them publish the results and interpret the findings….
Spencer: What do you think is the reason for this growing interest?
Barkin: I think the website definitely helps with visibility. I think, the more it’s published, the more people see it in papers. The other thing, honestly, is that there’s only one other measure that claims to assess functioning in the postpartum [period], and it’s called the Inventory of Functional Status After Childbirth, and it was wonderful foundational work. But there are some flaws in the formulation of the calculation of the total score, in terms that it specifically it penalizes the woman for not resuming all of her pre-childbirth activities.
If you were on the PTA, and you jogged every day, etc. etc., and then you had baby and then afterwards you gave up five of your six activities, where you re-prioritize—which, by the way, is a healthy process, right? It’s not a bad thing to reprioritize, it’s your your psyche and your emotions and everything else telling you that you need to change some things around. But [the inventory] kind of penalizes a woman for having done that.
Spencer: It makes it sound more pathological when actually it’s just a life adjustment?
Barkin: It almost makes it look like if you changed things, you’re not adjusting well. When really, that could be an indicator that you’re adjusting really well. The other thing is, and I don’t want to criticize the work, [but] it’s pretty long. It’s a little bit burdensome…
I know any of us that have gone to the doctor and filled out like the fifth medical-history form that seems like it’s repetitive, you just get frustrated, which is what you do not want when someone’s filling out a survey. ….
Spencer: Based on the index, in which low scores show more distress and high scores show better mood and functioning, what seems to be stressing mothers out versus what helps them thrive?
Barkin: I would say, to be honest, that I’m a little bit biased on this. I think a big problem in women is that they do not recognize their own signs of burnout, right? So we would hear women in our more affluent focus groups say, “Well, my husband, he is great with the kids, but I just can’t leave them alone with him because he’ll feed them hot dogs, or he won’t do this right or that right.” And instead, the healthier response would be, “I’m really burned out, I’m snapping at everyone, I’m not seeing things clearly because I need a break. It’ll be fine if they’re with my husband for two hours and he feeds them hot dogs or doesn’t let them brush their teeth.” That would almost be a healthier response than what you hear is sort of a hypervigilance. That’s unhealthy, and I think that awareness is something we need to develop in women because they’re not always good at sensing when they’re getting burned out.
Now, that said, that all rolls into this idea of self-care. The activities related to self-care are not as broad if you have less resources, right? If you have financial resources, you have human capital, you’ve got social support, you have all of that, you can have a babysitter, pay for them, and go out with your [partner] for a night or join a gym, etc., etc.
If you don’t have trusted child support backup and you don’t have an excess of financial resources, where you’re really strapped, that self-care looks really different, right? You’re not going to go buy a massage, and you may have multiple children and you don’t have another trusted caregiver. In that scenario, you have to be a little more creative.
Now reading a book for 10 minutes can be an act of self-care, or taking a walk. What I’ve heard in lower-income women, and this is really fascinating, is that one way they take care of themselves is to include their children in the activity. One woman said to me, when I’m really stressed—she worked at a grocery store— I will go and buy up flower arrangements when they’re like at a deep discount and me and my daughter will make flower arrangements at our house, which is a way that she didn’t need a babysitter. It was soothing to her, it made her daughter happy, and it was low cost.
I think that that was a beautiful example of how to take care of yourself, and in a way, a simplistic way that wasn’t really resource intensive, but I think that self-care piece is huge. If you’re strapped for resources, that’s going to tax anybody, no matter how good you are at self-care. There comes a point where you just don’t have the time, the money, etc. etc., to take care of yourself….
Spencer: Then self-care is the thing that seems to help, but I gather some of the other research shows that skills-building and programs that provide assistance cause people’s scores to go up. Meaning that they’re thriving better and they’re less stressed out?
Barkin: Yeah, and if you look at social support in general, social support is protective for mental health—and not just in postpartum and pregnant women. Across the board, it’s generally a helpful thing, just like maintaining a healthy weight is generally a healthy thing and not being sedentary is a healthy thing. It’s pretty consistent. Some of these better home-visiting programs are the Jewish Family and Children’s Services’ Visiting Moms program: They’ll have a volunteer of go into the home and help the mom with whatever she needs. Hold the baby while mom answers e-mails or hold the baby while the mom does a little laundry. Anything that she needs, it’s kind of tailored support from volunteers. I think those programs are all really helpful. Now, here’s the thing: A lot of them are concentrated in cities. The cities have the mental health infrastructure, [but] rural areas do not.
Again, that’s an act of self-care to some degree—participating in a program like that— because you’re allowing someone to help you, but if you’re in an area where you don’t even know that exists, and there aren’t a lot of assets in the community, all of those circumstances cause a tension that it is hard to alleviate from just good management. It’s just [that] the resources aren’t there.
Now, that said, there’s a group called Postpartum Support International – they’re global, and we have a really strong chapter in Georgia— and they offer all kinds of free programs for women. …peer-support groups, you can call a 1-800 line and get assistance, tons of free resources, all you need is a phone or a computer.
That may not substitute for in-person counseling or something like that if you got into mental health trouble in the postpartum or during pregnancy. But it’s a lifeline for these rural areas that don’t have the home-visiting programs and the licensed counselors that specialize in perinatal.
Spencer: Would someone’s doctor know about Postpartum International and be able to refer the person?
Barkin: Yeah, it’s a really well-known organization in perinatal mental health circles….However, I think that if you traveled around the state of Georgia, and I’m sure this is true of many other states, [if] you went to the rural areas, there will be a lot of PCPs that have never heard of them … as an organization, [PPI] knows that building out in rural areas and building awareness is something that’s a goal of theirs.
Spencer: That’s great. So moving on, you and your colleagues are developing another index to measure distress and resilience called the Climate Distress Index. We covered it briefly at Mad in America a while back. Can you remind us what the Climate Distress Index is, and update us where it stands today?
Barkin: So the Climate Distress Index is a brief self-report measure, you would fill it out yourself…[it]takes about 5-10 minutes. We have a version that’s in testing right now that we developed in the same way that we developed the Barkin Index. We first…interviewed people that were vulnerable to the effects of climate: agricultural workers in Georgia and Florida, and mothers, working mothers and coastal Floridians. So we would have liked to talk to people that have gone through the wildfires in California, but those were three groups that we thought we could get at pretty fast, and get them on for an interview and talk through what makes you the most anxious about climate change. So we took all that material, synthesized it, and we are in testing. ….it hasn’t been published yet, but it is pretty far along in the process.
Spencer: So how will it be used?
Jennifer Barkin: Academia, for sure, because academics do research, and they need ways to measure stuff. So academia, maybe community-based organizations or climate organizations, especially if you’re taking on research activities [such as post-disaster screening]. I personally do not see immediate clinical use on this. I have trouble seeing that just because we’ve only recently kind of broadly adopted the belief that, yes, climate change is real, it is caused by man. So yeah, we’re still trying to educate both [health care] providers and the public… Not all understand the amount of damage this can cause across a number of organ systems. So I guess that this is, in a way, early stage in the game in terms of connecting the health effects of climate on a broader scale to both providers and the public.
Spencer: So, you told me that mothers often get short shrift compared to kids when it comes to research on extreme weather events and climate-related issues. …What are pregnant and postpartum moms telling you when it comes to their own climate-related concerns?
Barkin: We looked at extreme weather events and children to see what the psychological symptoms are, and a broader range of psychological symptoms have been studied in children. The work around mothers in the research area in terms of climate and mental health has largely been borne out of two studies, Project Ice Storm [in Canada], and the Queensland Flood [study in Australia]. So it isn’t as rich or as varied as the child research. This is not surprising at all because anyone in perinatal mental health will tell you that. They think that the way that we treat it in this country is it’s like a piece of candy, where the baby is the candy and the mom is the wrapper, and you take the wrapper off the candy and throw away the wrapper.
So we’re trying to change that, and things have gotten a lot better in terms of recognizing the importance of women’s mental health and perinatal mental health, in particular how that impacts the entire family unit. You can’t talk about child health if … you’ve got a really unhealthy caregiver. So that’s always an issue, not just in climate research, just in general.…Even in the mainstream media around climate and mental health, [it] is much more focused on effects on the child. I’m not saying that’s a bad thing. I have two kids myself. I think about the effects on them all the time. …
Generally, the research shows that regardless of employment status, the mothers are generally the primary caregivers and kind of the lioness of family health, right? So I’m the one that remembers when my kids need shots or checkups or to brush their teeth and eat vegetables, etc., etc. And that’s not uncommon, even though I work full time. So, you know, with the role of women, climate change is really important because [it’s] the moms noticing …a child that now needs an inhaler because the child is having asthma, and notices it’s getting worse because air pollution and increased heat are linked. They exacerbate each other.
So I think women are more acutely aware [of climate impacts], and when we interviewed mothers, they would say things like, “Are there going to be any animals around when my kids get older?” Or my son, for example, would say “Mom, what if all the bees die? What’s going to happen, what it’s going to happen?” So I think kids are more aware, which makes moms more aware, and mothers in general are more aware of family health issues. …When my kids sign up for tennis camp in the summer, I think, okay, we’re in Georgia, you know, it can be 100 degrees. Do the camp counselors know how to handle that if it gets too hot? Do they – are they aware of hydration issues…? So I think a lot of people are going to get caught flat-flooded on the heat illness issue, but as a mother, I’m [already] acutely aware.
The other thing is if you’re worried about climate, or you’re aware and you’re trying to conceive or you’re thinking about conceiving, you might think twice or you might have some anxiety based on the reports you’re seeing in the media right now….
Spencer: Have you seen in your interviews [for the Climate Distress Index] that mothers and their kids have some overlap in what they worry about?
Barkin: I guess I think of what my own kids are worried about. They’re getting more education in school about climate change. So, you know, my son will say to me, “Mom, I don’t want to die. I don’t want to die.”… They know that this is time limited. We’ve got to act really fast before there’s permanent damage.…
We didn’t interview children specifically and the side we worked on [in the past] was, Okay, the child’s been exposed to disaster. Now, what are the psychological symptoms? With mothers, we interviewed them, and we’ve done some research in the literature about perinatal mental health as it relates to EWEs, Extreme Weather Events. And what we heard was women saying that they were nervous that their health care would be interrupted. So if you’re pregnant, you need checkups fairly frequently, and when you have a kid you need well-child visits fairly frequently. So if you are displaced because you endure a hurricane, your health care might be interrupted. Women worry about the evacuation process itself. Families, their whole family having access to health care, the schools reopening, some of these things are basic health care,.… utilities, where are we going to live? How does this affect my health care during pregnancy and postpartum? All of those things, that’s a lot to worry about if you’re pregnant or you just had a child.
Spencer: Almost sounds like the similar kinds of worries you might have in wartime.
Barkin: Right, it’s a disaster. And when you look at risk factors for perinatal mental health, around that time, it’s just high vulnerability, right? One in five women will have either postpartum depression or postpartum anxiety, some type of mood symptom…. So that’s the most common complication of childbirth…. So it’s already a vulnerable time frame.
And trauma is one of the risk factors that can amplify pre-existing issues …. So trauma, if you look up some of the measures that assess trauma, right on there is natural disaster, having a hurricane, etc., etc. And the higher the level of exposure—were you wading through floodwaters or [was] someone you know injured, were you injured? Did you lose your home? –the higher the level of loss, higher the level of exposure, the worse the mental health outcome, so that makes total sense. If you were unscathed, you know, you’re going to be able to rebound pretty quickly. If you got hit hard and incurred multiple losses, both financial and maybe healthwise or to your loved ones, it’s going to take a little longer to repair….
Spencer: Do you have any thoughts on what might help mothers and parents in general better cope with these climate concerns, emotionally?
Barkin: So one that comes up across the board is agency. It makes me feel better to feel like I’m doing something to help protect the environment, like personally doing something. Those types of things, people reported made them feel better. Now, let’s say that with a caveat because that’s a slippery slope. If it’s all on you, if you feel this intense personal responsibility to stop the climate crisis, you’re going to burn out because none of us alone can tackle this….. It’s like the mother of all public health crises….
I think when that level of personal responsibility gets amplified to a certain point, it can be counterproductive. So I can go and swap out my car for a hybrid and now our power is wind and solar, and I can do all of those things. But then I can’t flog myself for using a plastic spoon one day; you have to be realistic about it. It’s almost like goals for fitness. If you have an unrealistic goal, and you can’t meet it, it’s going to discourage you. So you kind of carve out smaller steps that you can succeed at, to feel a sense of achievement and to be able to sustain and not give up and say this is impossible….
Spencer: It’s also important to remember that on the policy level, what oil companies are doing or whatnot on the much more institutional level, that’s where the major change needs to take place. Perhaps we’re better off lobbying our congress people or educating ourselves about the bigger forces than feeling guilty about a plastic fork?
Barkin: No, exactly. It’s like a dysregulation, right? It’s almost like a woman can’t stop and say, I’m burned out, I need to hand the reins off to my husband or my partner for a couple hours…That sense of guilt and personal responsibility. It tips into an unhealthy zone, I think. But the other thing that I heard people say that help them was even though children having awareness is a scary thing, because it makes them more anxious in a lot of ways, it also makes people feel hopeful. Because if the next generation cares about this more than we did, maybe everything will be okay. So there’s kind of a sense of comfort in that, too, for future generations, maybe they’ll be better stewards of the earth than we have been.
Editor’s Note: Listeners who wish to participate in a short, onetime, online research survey about distress due to climate change and extreme weather events can sign up using this form.
Barkin Index of Maternal Functioning website (see the questionnaire here)