By: Rae Sampson-McMillan, LCSW-R, SIFI
October 20, 2026
A new mother sits in an examination room with a clipboard in her lap. The questionnaire asks whether she has been feeling down, whether she has been anxious, whether she has had thoughts of harming herself. She has. She has had thoughts that frighten her badly enough that she has not said them aloud to anyone. She holds the pen and she does the arithmetic that women in that room have always done. What happens to me if I answer this honestly?
That question is not a symptom. It is an assessment — and often an accurate one. She is not a symptom either. She is a woman making a decision with incomplete information about an institution that has not told her what it will do.
We have built a great deal of machinery to find her. The American College of Obstetricians and Gynecologists recommends screening for perinatal depression and anxiety at the initial prenatal visit, again later in pregnancy, and at postpartum visits, using standardized, validated instruments; the American Academy of Pediatrics recommends screening mothers at the one-, two-, four-, and six-month well-child visits. Home visiting programs bring screening, education, and case management into the home at no cost. Provider access lines allow an obstetrician with a worried patient and no psychiatric training to consult a specialist the same day. Some U.S. states require providers to offer screening questionnaires; others mandate reimbursement through Medicaid, the U.S. public health insurance program for people with low incomes, for maternal depression screening. Perinatal mood and anxiety disorders are among the most common complications of childbirth, and mental health conditions are a leading contributor to maternal deaths in the year after birth. The case for finding these women early is settled, and the infrastructure for finding them is real.
What follows is written mainly for the practitioners doing the related child and family work — though the stakes belong to all of us.
The same ACOG guideline says something else that receives far less attention. It recommends that screening be implemented with systems in place to ensure timely access to assessment and diagnosis, effective treatment, and appropriate follow-up. Screening, in other words, was never meant to stand alone. The body that wrote the recommendation said so plainly.
What is not settled is what happens next.
Detection is the inexpensive part of the system, and it is the part that has been built. Treatment is the expensive part, and it is thinning. Medicaid financed forty-one percent of births in the United States in 2023, and nearly half — forty-seven percent — of births in rural areas. About two-thirds of Black mothers and six in ten Hispanic mothers rely on it for delivery. There is no doubt that Caribbean immigrant mothers are included in these numbers. That distribution means a general reduction in Medicaid is never a general reduction. It lands where it lands.
Postpartum coverage beyond the immediate weeks after delivery remains a state option rather than a guarantee, in the very window when most maternal deaths occur. Coverage for immigrant families is narrowing rather than widening. Lower provider payments close obstetric units and widen the areas where there is no maternity care at all. When coverage is unstable, postpartum eligibility is limited, and reimbursement is inadequate, screening identifies need without guaranteeing access to care. A woman can be correctly identified as ill and still wait months for someone qualified to treat her.
This is not half of a system. It is a different system — one that gathers information about mothers more reliably than it delivers care to them. And the woman with the pen understands this, even if she could not articulate it in those terms.
The research is unambiguous about what she fears. A 2023 meta-review in BMJ Open, synthesizing thirty-two systematic reviews, identified fear that a child would be removed by protective services among the individual-level barriers keeping women from perinatal mental health care. A study of Black and South Asian women in the United Kingdom, published in BJPsych Bulletin, found that this fear did not obstruct one point in the pathway but shadowed the entire length of it — from first contact through referral and treatment. Providers report the same thing from their side of the desk: patients do not fully disclose, and the screening instruments are undermined as a result. One mother, asked what stopped her from answering honestly, said plainly that she feared her child would be taken if she admitted how she felt.
It would be a mistake to file this under Sanism and leave it there. Sanism is real in this room, and she may well carry it — shame at being unwell, reluctance to be seen as failing at something she was expected to manage. But something else is operating at the same time, and in a different direction. She is also making a forecast about an institution, and the accuracy of that forecast varies by who is making it. A woman whose community has long experience of being investigated rather than assisted is not being irrational when she predicts investigation. She is reading the record. The two compound: a mother who already fears she is failing has all the more reason to expect that a system will agree with her. And the women whose forecasts are most accurate are frequently the women whose need is greatest — so the illness with the highest mortality in the year after childbirth goes unspoken precisely where it is most dangerous.
This is what the Oppressiveisms™ Framework was built to make visible. Racism, Sexism, Classism, Ableism and Sanism do not take turns. They stack. The woman with the clipboard is not weighing one thing. Her calculation is shaped at the same moment by race, by immigration status, by income, by language, by whether she has a car, and — critically — by which of these the person across from her is reading. Nobody’s pain shows up alone. A screening tool that treats her as a set of symptoms will miss the assessment she is actually conducting, which is not about her mood but about the institution in front of her.
The Oppressiveisms™ Social Impact Model sets out seven systemic sectors in which these harms accumulate: health and healthcare, education, economic and employment, criminal justice, housing and environment, family and community, and mental health and well-being. At a minimum, three of them describe this woman at once. Under health and healthcare sit unequal access to quality care, to mental health services, and to reproductive healthcare — along with medical bias and the undertreatment of marginalized communities. Under family and community sits the disproportionate removal of children of color from their families by child welfare systems. Under mental health and well-being sit the barriers to services created by cost, cultural bias, and Sanism. She is not experiencing one sector and then another. She is sitting where these sectors stack, and the stacking is what produces her silence.
The DARE Test™ — Discover, Acknowledge, Reflect, Empower — is a personal self-assessment tool rather than a clinical instrument, and that distinction matters here. It is not something to administer to the woman in the room. It is something the practitioner does beforehand, using the Social Impact Model to ask which sectors have touched their own life, which they have witnessed in the lives of people close to them, and — the question that does the most work in this setting — which they have never had to think about at all. A clinician who has never had cause to fear a child protection referral may not recognize that the woman across the desk is calculating one. That blind spot is not a character flaw. It is simply a sector of the model the clinician has never had to occupy, and it will shape what the clinician hears in the silence.
What follows from that reflection is practical. It is an honest account, offered before the questions are asked, of what a disclosure will and will not set in motion — who sees the answer, what it triggers, what it does not. That is the step most often skipped, and it is the one she is waiting for. A mother who knows what happens next can make a decision. A mother guessing will usually guess in the direction of silence.
None of this is a demand that practitioners abandon their judgment or overlook genuine risk. Some findings are correct, and children are sometimes in real danger. The ask is smaller and, in its way, more generous: that a practitioner be able to show, to themselves as much as to anyone reviewing the file, what a finding actually rests on. A conclusion built on evidence and a conclusion built on assumption can look identical once they are written down. The habit worth building is checking, gently and consistently, which one you are holding.
We are unlikely to screen our way out of this. The instruments are adequate; the honesty is what is missing, and honesty is a function of consequence. As long as telling the truth reliably produces documentation and a waiting list, while silence produces nothing at all, silence will remain the reasonable choice. The task is not to persuade mothers to be braver. It is to build something on the other side of the question that makes bravery unnecessary.
What Practitioners — and the Systems Around Them — Must Change
• Screening should open with plain language about confidentiality, documentation, and what triggers a mandated report — before the questions are asked, not after.
• A positive screen should be a referral to timely assessment, treatment, and follow-up, not an endpoint in itself.
• Practitioners should be trained to separate an evidence-based safety concern from a read shaped by who the family is.
• Systems should track what happens after the screen — treatment access, follow-up completion, and whether mothers report feeling safer disclosing — not screening rates alone.
• Practitioners should stay current about coverage and eligibility changes, so they can make accurate, informed decisions when working with their clients.
The woman with the pen is not the problem to be solved. She is not the symptom. She is telling us, by what she withholds, exactly what she expects from us. We should be able to hear it. For those of us doing this work — in a maternal health clinic, a behavioral health setting, a school, a home visit, a child welfare case review — hearing her starts with understanding what many of us have never had to fear. Her silence reflects both a fear shaped by mistrust of these systems, and an accurate reading of what they still do — quick to document risk, slow to answer it with care, if any — a forecast that speaking would reduce her to a symptom, and her children to a case file, removed or taken from her.
References
American College of Obstetricians and Gynecologists. Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 4. Obstetrics & Gynecology. 2023 Jun 1;141(6):1232–1261. doi:10.1097/AOG.0000000000005200
American Academy of Pediatrics. Incorporating Recognition and Management of Perinatal and Postpartum Depression Into Pediatric Practice. Policy statement. (AAP recommends screening mothers at the 1-, 2-, 4-, and 6-month well-child visits.)
Centers for Disease Control and Prevention, National Center for Health Statistics. Source of Payment for the Delivery: Births in a 33-State and District of Columbia Reporting Area, 2021. NCHS Data Brief No. 468. May 2023.
KFF. 5 Key Facts About Medicaid and Hospitals. September 2025. (Medicaid financed 41% of U.S. births and 47% of rural births in 2023.)
KFF. Medicaid Initiatives to Improve Maternal and Infant Health and Address Racial Disparities. (Medicaid covers about two-thirds of births among Black women and six in ten births among Hispanic women, compared with one in three births among White women.)
Georgetown University Center for Children and Families. Medicaid Plays a Key Role for Maternal and Infant Health in Rural Communities. May 2025.
KFF. Medicaid Postpartum Coverage Extension Tracker. Accessed 2026. (Federal law requires pregnancy-related coverage through 60 days postpartum; the 12-month extension is a state option made permanent by the Consolidated Appropriations Act, 2023.)
Georgetown University Center for Children and Families. New Immigrant Eligibility Restrictions Coming to Federally-Funded Health Coverage. October 2025. (Documents a pattern of narrowing, rather than expanding, health coverage eligibility for immigrant families.)
KFF. State Health Coverage for Immigrants and Implications for Health Coverage and Care. 2026. (Further Medicaid and CHIP eligibility restrictions effective October 1, 2026.)
Webb R, Uddin N, Constantinou G, Ford E, Easter A, Shakespeare J, Hann A, Roberts N, Alderdice F, Sinesi A, Coates R, Hogg S, Ayers S. Meta-review of the barriers and facilitators to women accessing perinatal mental healthcare. BMJ Open. 2023;13(7):e066703. doi:10.1136/bmjopen-2022-066703
Jovanović N, Packer KC, Conneely M, Bicknell S, Copello A, McCabe R, Dirik A, Janković J. Barriers to accessing perinatal mental health services and suggestions for improvement: qualitative study of women of Black and south Asian backgrounds. BJPsych Bulletin. 2025 Oct;49(5):299–306. doi:10.1192/bjb.2024.82
Gregory K, Jones A, Thompson L, Adams K, Hill M, Dzimbiri MN. Barriers and facilitators in identifying and addressing perinatal mood disorders: a healthcare provider perspective. Frontiers in Global Women’s Health. 2026 Jul 15;7:1880598. doi:10.3389/fgwh.2026.1880598
Sampson-McMillan R. The DARE Test™: A Personal Self-Assessment Tool. Oppressiveisms™. oppressiveisms.com/dare-test.html (The DARE Test™ is a qualitative self-reflection and educational tool; it is not a diagnostic or clinically validated instrument.)
Sampson-McMillan R. Oppressiveisms™ Social Impact Model. Oppressiveisms™. oppressiveisms.com/social-impact-model.html
Postpartum Support International. The Potential Cost of Honesty in PMAD Screening: Why So Many Parents Feel They Can’t Be Truthful. January 2026.
About the Author
Rae Sampson-McMillan, LCSW-R, SIFI, is a social work leader, psychotherapist, and organizational strategist with three plus decades in human services. Her career has spanned clinical, management, and executive leadership roles, including having served as Chief of Staff to the Executive Deputy Commissioner in the Division of Child Protection within the NYC Administration for Children’s Services (ACS) — one of the largest child welfare agencies in the United States. She holds a Master’s Degree in Social Work (MSW) from Columbia University and a Bachelor of Science (BS) from Fordham University, and is the recipient of the NASW-NYC Award for Exemplary Mid-Career Social Work Leadership in New York City. She is the originator of Oppressiveisms™, a word she coined in 2002, and the developer and author of its framework — A Transformative Framework: Magnified, Collective, Clarified and Inclusive for Social Justice and Public Well-Being — further explored at oppressiveisms.com. She has authored and published related Oppressiveisms™ articles. She is currently an independent consultant on the Oppressiveisms™ Framework.
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