His life as a younger brother to a sister with Down syndrome helped shape Robert Keefe’s career.
His sister, Sandra, struggled with mental and physical disabilities while the siblings grew up in southwest New Hampshire. Their parents, Dorothy and Richard, were forced to maneuver the limited services in the “Live Free or Die” state at a time when no laws mandated an education for children with special needs.
“Among my earliest memories is my mother, during the 1960s, with white gloves on, in church, cornering this lady,” said Keefe, a University at Buffalo social work professor. “It turns out she was head of the school board. My mother would take my sister and me every single day to school and we would just sit there waiting for them to take my sister to a class.”
This helps explain why Keefe has spent the last two decades researching the needs of mothers and children of color, including a groundbreaking research study released recently that showed low-income African-Americans and Latinos with postpartum depression are less likely to respond to typical treatment: counseling and antidepressant medications.
Read a previous WNY Refresh story here about myths surrounding postpartum depression, as well as symptoms and support services.
Keefe, 54, holds a bachelor’s degree in sociology from Ithaca College, a master’s in social administration from Case Western Reserve University and a doctorate in social welfare from the State University at Albany. He taught at Syracuse University before coming to UB in 2005. He has lived – and conducted much of his research – in Rochester while at both schools.
Q. How can diversity challenge a community support system?
I grew up in Newport, N.H. Its only claim to fame is that Grace Metalious lived nearby when she wrote “Peyton Place.” When I grew up there, it was so homogenous. Everyone was white and had a similar ethnic background. That made things easier when you were planning services. How you go about planning things and responding to people in need when you’re in a place like Buffalo, which is so very diverse, you have to find diverse ways of approaching the problem.
Q. Did you know much about Buffalo before you took the job?
No, and I confess I’m still not all that familiar with it because I live in Rochester and commute. Before I came here, I started looking at some of the issues that Buffalo was facing. I had been living in Cleveland for five years – I got my master’s there and stayed there after I finished – and one of the things that struck me is that it and Buffalo looked similar in a lot of ways. The public health issues we’re addressing here were things I had seen when I was living there. Syracuse was smaller but they, too, had a lot of similar kinds of things we have here, among them trying to plan services for refugees and new immigrants. In central and western New York we really have to look at that.
The group I work with now is primarily mothers of color, and what has impressed me so much is that these women are dealing with amazing life problems. ... I have been very impressed with how they soldier on.
Q. Why do you think the rate of postpartum depression is higher in women of color?
In the population in general, we say that 12 to 15 percent of new mothers have postpartum depression. In mothers of color, we see about 38 percent. Part of the reason we’re seeing this dramatic difference is that mothers of color are less apt to go for services themselves. A lot of these mothers have a lot of trauma and they live in communities where there’s a lot of crime, where they’re used to hearing gunshots, where they don’t have access to healthy foods, where they don’t feel comfortable going to parks. Because they tend to live in areas of high crime, they repeatedly face trauma and the trauma seems to mask that depression ...
These mothers do get themselves up, they do get going. These mothers might be experiencing depression – they score very high on those scales – but they refuse to acknowledge it. They’re too busy. They have to feed these kids. They may live in housing where lead paint is an issue. There may be problems with infestations. There’s lead in the water in some cases. That’s what they’re dealing with. So when I talk to them about depression, they go, “Pick a number.” In some respects, it’s a healthy way to be. They may not be able to acknowledge it but there’s so many other things to cope with.
Q. What were some of the key conclusions?
One of the things is that traditional therapy does not seem to be cutting the mustard here. If we look at just the mother in isolation, if we don’t look at the community in which she lives, if we don’t look at her access to healthy things – recreation, food, housing, transportation – those are the things we need to be addressing. Antidepressants aren’t going to take those things away. And the therapy is not going to take the problems away unless the therapy is helping you address these bigger issues, bigger pictures. A lot of people who are doing the screenings are pediatricians and their job is to treat the child, not the mother. They can get into a bit of a quandry if they came up with a diagnosis for the mother and they don’t do anything about it, so a lot of providers would rather not address it at all. Only about 50 percent of African-American mothers show up for services, and by the time they show up with depression, their depression is at a more severe level than tends to be the case for white mothers. This may be with their third child and, if you don’t address depression, it generally worsens.
Q. What were the most meaningful parts of your early years on the front lines of the discipline?
I was working at a hospital in Cleveland called Euclid General Hospital, which is now part of the Cleveland Clinic. I was working at a medical rehab facility with people who had had strokes and heart attacks, amputations. I was working with any number of mothers who had strokes during childbirth – which happens in a handful of cases – with many new mothers who had unchecked diabetes. In some cases it was so out of whack, they had to have below-knee amputations. Research has shown for years that mothers do a really good job making sure their kids are taken care of before they take care of their own needs.
During my work at this hospital, I was working with one mother at a time and feeling, “I’m having absolutely no effect here.” I made sure she had a good discharge plan from the hospital, that services were in place when she went home, but I felt like I was putting Band-Aids on the problem. I decided I was going to go get my doctorate and focus on the mother and the child – that’s always been my focus – in hopes I could start addressing the problem at a community level.
Most postpartum research has focused on the individual level: “Do you have a history of depression?” “Did you breastfeed your baby?” “Did you have gestational diabetes?” No one had looked at the greater communities where these mothers lived, and how to address the problems, and maybe start intervening at a community level. If we put a mother on an antidepressant, maybe that’s not the (biggest) problem. Maybe if we cleaned up a park, mothers would start going there? This is happening in Rochester. What if we got money for lead abatement? Rochester’s gotten a lot of money from HUD to do that so that babies living in old apartments aren’t eating lead paint chips. The research that I’ve done follows this idea.
Q. You recently announced the result of research involving women of color with postpartum depression. Can you talk about how you and your colleagues conducted the study? How many women were studied locally?
So little research is being done on African-American mothers. We received approval from our institutional review board here at UB to carry out the study at a very large agency that serves the lowest income zip codes in Rochester. Because all the research to date had focused largely on white mothers and we wanted to focus on mothers of color, we decided to make it a smaller-scale study. It’s a qualitative study. We interviewed, at length, 30 mothers. All of the mothers had had at least one child already. These interviews would go two hours. We started not using the word “depression,” because it kind of turned the mothers off. We were asking, “What has helped you get through the day?” Research with white mothers showed it was “having a relationship with my doctor, having a supportive spouse, having good friends around me.” The mothers of color said none of that. They said, “What helps is being involved in my church. What helps is that, even if I don’t have an ongoing doctor, just coming in and meeting with someone when I need to. What helps is when someone can provide transportation to a WIC clinic.” What seems to helps them through the depression is meeting real concrete kinds of needs. Therapy is not always as helpful and might make things worse. Depression can be very immobilizing. Some mothers said, “They put me on an antidepressant but it didn’t do anything about my problems. It made me feel numb to them.”
Q. So it sounds that women living in poverty with limited access to services drives what they’re feeling.
Right. The providers say, “That really helps us because so many of the mothers we have to terminate their services. Often, they don’t get here for appointments.” They don’t get there for appointments because they don’t have transportation or adequate child care, or they’re sick. A lot of things that stop them from seeking services are the things they need services to help them with.
Q. This seems pretty intuitive.
It is, once we look at the big picture. When you’re doing individual therapy, you’re not necessarily asking, “How’s your car running?” They ask, “Have you thought about hurting your baby? About hurting yourself?”
Q. But not so much, “Do you have enough food for your child?”
And, “Is the food healthy food?” We have things in place that make sure a child is well taken care of – WIC and well baby checks, for instance – whereas the mother has one visit with an OB/GYN after she gives birth and often that’s it. After that, if you don’t have a doctor or someone you see for services, no one is going to mandate that you get the service – whereas we will take your children away from you if they’re not getting (proper care).
Q. Is there a snowball effect for a mom with a second child who may be unmarried and not regularly employed, somebody already in the social services system but who hasn’t been treated for postpartum depression?
One of the things I want to look at with the next study, anticipatory depression. We’ve done that with trauma but not with depression. A number of the mothers have said, “I thought this was just something everyone goes through. My mother said she was like this. Friends tell me they were like this. I just expected that you feel this way.” When we say, “No, it’s not.” They don’t know what to do with that. So when mothers have second or third children just assume they’re going to feel the way they feel. It’s only if they get to a point where the children might be taken away that they begin to think, “All right, I’d better do something about this.” There’s something very normative about the experience of the depression.
Q. Are the symptoms different for women of color?
No, but they may manifest differently. White mothers dealing with depression might deny it themselves – people fear being a bad mother, and read these baby books about what a glorious, wonderful experience it is to have a baby, and then their feelings don’t match up with that experience – so often white mothers might be much more able to acknowledge that they’re having the depression.
A lot of African-American or low-income mothers fear that if they acknowledge a problem their children may be taken away from them. They may look sort of flat emotionally but they won’t be as tearful. They won’t also talk about some of the classic symptoms. With the classic ones, you have the emotional ones – you feel depressed – but there’s also the mental, cognitive part, where you simply can’t get off the dime. You have trouble concentrating. Then we have the physiologic: the changes in weight. People with severe depression tend to lose weight. Women of color tend to deny the emotional part of it, so unless the diagnostitian is good at picking up on the mental, cognitive and physiologic, they may not start thinking about the emotional part. For so many of these mothers, the emotional part is normative.
Q. How do you work with these mothers?
When working with these mothers clinically, we need to stop them, to tell them this is a problem and we can work with it.
Often, mothers of colors tend to go to clinic-based services. In a clinic, if you’re seeing lots of mothers, you don’t want to necessarily intervene at an individual level. You want to start doing more group work. In the group work, you can focus on the counseling, but also on building friendship networks. And you need to start reaching out to where the mothers go: churches. One of the things I’ve started to do in Rochester is to make relationships in some of the African-American churches. What I’m finding so far is that in these churches, there are any number of older women who would be very happy to get involved with being birth coaches, with how they can be mothering to a pregnant woman, helping to make sure she’s taking care of herself. What does that look like? It means getting prenatal vitamins, eating three meals a day. ... In many inner-city communities, churches are like oases in the desert. You walk in and do feel a sense of peace.
The church is always there. Often, with African-American churches, they’re the biggest service provider. You go there and you’ll meet people who are largely non-judgmental, who can relate to the life experiences that you have.
Q. Are Buffalo and Western New York set up to administer to these needs successfully?
We’re getting there. Because we’re having such an influx of refugees and new immigrants, we’re realizing we need to take a look at our whole service delivery system anyway. Internationally, Pakastani women have about a 60 percent likelihood of developing postpartum depression. If you look at what’s going on in Pakistan, you can understand why that would be the case. When we have refugees coming from countries where we’ve seen a lot of trauma, we would expect that we would have problems with maternal and child health outcomes. Many young women when they’re coming here are pregnant. The problem is more reimbursement for the services. If these women are getting more from churches or volunteer transportation that aren’t being reimbursed, that becomes more of an issue.
Q. Might there also be a disparity between women in rural communities or with less education when it comes to postpartum depression incidence and treatment?
I have a doctorale student whose whole focus is looking at differences between urban and rural. We know rural communities have their issues, but when it comes to mental health issues, we tend to see a higher incidence in urban areas. We see a lot of people with severe and persistent mental illnesses migrating to larger cities. They often do that because services are available, for one thing. We’ve only had two studies I can think of that have focused on rural mothers. The findings are pretty similar, in that the percentage are 12 to 13 percent. We haven’t yet studied incidence in rural, mostly African-American areas in the South, for instance. We have a couple of large data sets that people are beginning to analyze, including my doctorale student, Rebecca Polmanteer.
Q. Where does this research go from here?
We’re hoping to get funding to start mobilizing communities, faith communities. Also, looking at mothers who have repeat pregnancies where we’re seeing the depression, and getting into agencies that serve these mothers ... in Rochester. We do know if a mother is depressed prior to delivery, she’s likely to be depressed afterward. In those assessments, we want to look at what needs mothers have and perhaps work with the church to help get those needs met.
Twitter: @BNrefresh, @ScottBScanlon