The first shock of the pregnancy came when Lexie Grant learned she was expecting triplets.

She and her husband, Collin Grant, were eager to have another baby. But they hadn’t been doing IVF. So they had zero expectations of having multiples, much less very rare naturally-conceived triplets.

Lexie was suddenly considered a “high risk” patient, so she started seeing doctors at the UCHealth Women’s Care Clinic on the Anschutz Medical Campus in Aurora.

At an early appointment, Lexie’s doctors offered her access to an extra service. Would she be interested in receiving behavioral health support during her pregnancy from a therapist?

The PROMISE Clinic at UCHealth University of Colorado Hospital is unique among obstetrical programs nationally, even those at prestigious academic medical centers.

“There are very few truly integrated OB (obstetrics) programs around the country,” said Dr. Bethany Ashby, director of the PROMISE Clinic.

Often patients who are struggling during pregnancy or after the birth of a baby will be referred to therapists or psychiatrists elsewhere in a hospital or community. But at University of Colorado Hospital, obstetrics experts work side-by-side with psychologists, psychiatrists and other behavioral health providers so they can give patients essential access to therapy and medications.

“There are very few obstetrics clinics where you have clinicians on site every day who can see you right then and there,” said Ashby, who has a doctorate in psychology and is also an associate professor of psychiatry and OB-GYN at the University of Colorado School of Medicine.

Along with Ashby, Dr. Stephen Scott, associate professor of OB-GYN and pediatrics, and Dr. Debbie Carter, associate professor of psychiatry, serve as co-directors of the PROMISE Clinic, ensuring that medical experts can address all aspects of perinatal mental health.

At least one of every five pregnant patients will experience mental health challenges during pregnancy or the postpartum period. Rates of perinatal depression and anxiety are highest among people who don’t speak English and those who identify as LGBTQ+. For non-English speaking patients, PROMISE has bilingual clinicians and works closely with interpreters to provide mental health support. PROMISE Clinic providers also have developed tailored treatment options for LQBTQ+ patients.

“Depression and anxiety are the most common complications of pregnancy,” Ashby said.

Thus, access to behavioral health care is essential, but as many patients know, it can be extremely difficult to find help.

That’s where the PROMISE Clinic is remarkable and life-changing.

Psychiatrists, psychologists and licensed clinical social workers work side-by-side with doctors, midwives, nurses and other medical experts to care for those who are pregnant or have recently given birth.

The program has grown dramatically in recent years and now serves more than 1,200 individual patients each year, Ashby said.

The clinic receives funding through Medicaid and the University of Colorado School of Medicine. UCHealth contributes support staff, space at the hospital and access to electronic health records. At least 35% of patients whom the clinic serves are low-income Medicaid recipients.

First, news of triplets, then a roller coaster of hopes and losses

At first, Lexie thought she’d be fine and wouldn’t need any counseling during her pregnancy.

Then, reality hit.

“I was so stressed,” she said.

Lexie and her husband learned they were expecting three boys — each growing in his own amniotic sac with his own placenta — or what’s known as a highly unusual “tri/tri pregnancy.”

When she learned that she was carrying triplets, Lexie went into practical mode. The couple already had an older son, Campbell, then age 3. Lexie tried to envision how their family of three would instantly double.

“I wanted a second child, but I was a little pessimistic about having four children overnight. I thought, ‘How are we going to do this? Our daycare costs alone are going to be $6,000 a month. We’re going to have to buy a new car and move to a new house.’”

Just when Lexie and her husband were getting used to the idea of welcoming triplets, another shock hit.

The water of “Baby C’s” sac had broken. The couple had named him Noah. Without fluid to sustain this baby, Lexie and Collin presumed they had lost one of their triplets. At a subsequent prenatal appointment, however, they learned that the fluid in Noah’s sac had somehow filled again.

“We ended up trying to continue carrying all three of them. It was this roller coaster of emotions, week after week,” Lexie said.

Thankfully, Cindy Covell, a licensed clinical social worker with the PROMISE Clinic, had become a key part of Lexie’s team. Whenever Lexie needed mental health support, she could see Cindy either in person or via online appointments, which had greatly expanded during the COVID-19 pandemic.

“Cindy became an invaluable part of our team. I can’t imagine what it would have been like without her. We leaned on her every single week,” Lexie said.

As Lexie’s challenging pregnancy became more and more complex, she opted to start taking antidepressants and anti-anxiety medications. With guidance and expertise from Dr. Carter, a psychiatrist and the PROMISE Clinic’s co-director, Lexie tried various options, from sertraline (also known as Zoloft) to escitalopram, lorazepam and trazodone.

“I had never been on medications like this,” Lexie said. “But I definitely needed them. We’ve had some very scary moments. I call them my crisis medications.”

Carter is an expert at prescribing and managing medications for anxiety, depression and other mental health issues that can arise during the perinatal period. She also helped Lexie with education materials and parenting strategies to support the Grants’ son, Campbell, as his mom coped with a complex, difficult pregnancy.

Welcoming a 1-pound baby and grieving for two brothers

As more stress and more shocking news hit, access to both medications and regular counseling proved critical.

When Lexie was about halfway through a traditional 40-week pregnancy, the couple suddenly learned they had lost both Noah and another of the triplets, James. Even more frightening, the lone surviving triplet, Sutton, was not growing well due to what’s known as IUGR or intrauterine growth restriction.

Still, there was little doctors could do. Sutton was too small and undeveloped at that point to deliver. Lexie had to do her best to nourish tiny Sutton, while mourning the two other babies in her belly who had died. She did her best to make it long enough so doctors could safely bring Sutton into the world.

“It’s been a lot,” Lexie said of the unrelenting challenges. “We made it to 28 weeks.”

Sutton was born on Jan. 3, 2023 and weighed just 1 pound, 3 ounces and measured about 10 ½ inches long.

“He was the tiniest baby, a micro-micro preemie,” Lexie said.

As she and Collin welcomed Sutton, doctors also delivered Noah and James, who, as expected, had not survived. While celebrating the arrival of one baby, Lexie and Collin had to grieve for two lost sons.

They also entered a new world of stress, navigating daily hopes and fears as Sutton fought for his life in neonatal intensive care units (NICUs) at University of Colorado Hospital and later, at Children’s Hospital Colorado. In all, Sutton spent about seven months in NICUs in both Aurora and Broomfield, where the Grants live.

Sutton is now 14 months old. He still needs oxygen but is a smiley happy toddler and has been growing beautifully.

“When we last weighed him, he was 17 pounds. He’s gotten huge. We’re so proud,” said Lexie. “He’s the sweetest little boy. He’s really starting to develop his personality. He’s calm, observant, easy-going and very, very happy.”

Lexie and Collin have plenty of nicknames for their son, calling him “Suttie,” and “Bubba,” while now 4-year-old proud big brother, Campbell, calls his younger bro, “Sutton Button.”

Program started as a one-day-a-week clinic

The PROMISE Clinic began nearly 15 years ago as a one-day-a-week clinic, with Dr. Scott leading the integrated behavioral health efforts.

Services grew dramatically during the COVID-19 pandemic, as PROMISE started offering regular video visits in addition to in-person appointments.

While some patients like to see a behavioral health provider in person, those who have just had a baby can find it very challenging to get out of the house for doctors’ appointments.

Ashby said the online visits have proven to be extremely popular.

Patients can seek help throughout the perinatal period, which includes both prenatal care before a baby arrives and the postpartum period after the birth of a baby.

“Patients can be seen at any point during their pregnancy and up to six months postpartum, and there’s not a limit to the number of visits. We match the frequency of visits to the patient’s needs,” Ashby said.

Why are the prenatal and postpartum periods so difficult for some women?

Ashby said many people don’t understand how precarious both the prenatal and postpartum periods can be. The reasons that anxiety, depression and other challenges surface or grow more severe during pregnancy are complex.

“One significant component is the rapid hormone changes that occur in pregnancy,” Ashby said.

“In addition, some patients are more biologically susceptible to these hormone changes than others. Some patients already have a history of depression, anxiety or bipolar disorder. So, they’re more likely to have an exacerbation of symptoms,” she said.

For some low-income patients, finances can be lacking, along with paid maternity leave.

“People who lack financial resources are likely to have a lot more stressors,” Ashby said.

In addition to dealing with economic challenges, some new parents may not have strong support symptoms.

“In pregnancy and during the postpartum period, we need to rely on partners, family members and friends to help us. If we don’t have a strong network of support, we can really struggle,” Ashby said.

Physical challenges also can make mental health challenges much worse.

“The lack of sleep that happens right after you’ve had a baby can exacerbate mental health symptoms,” Ashby said.

Furthermore, having a baby can bring back memories of childhood trauma or struggles earlier in life.

“If your childhood experiences were difficult, trauma, anxiety and depressive symptoms can surface again,” Ashby said.

Are antidepressants and anti-anxiety medications safe during pregnancy?

For many pregnant women and new mom, antidepressants and anti-anxiety medications can be very helpful.

Obstetricians, psychiatrists, psychologists and other behavioral health experts have learned in recent years that many medications are safe and beneficial for pregnant women and postpartum patients.

And, in fact, not treating mental health issues during pregnancy can be bad for both mothers and babies.

“There are poor pregnancy outcomes associated with untreated depression,” Ashby said. “Patients with untreated depression are more likely to have pre-term deliveries and low birth weight babies.”

Can family members receive help with behavioral health, too?

Yes, Ashby said spouses or partners can accompany the pregnant person as they receive counseling. All of the clinicians also have training in infant mental health, meaning they can assess whether newborns and older babies are thriving or need extra support.

“We are always thinking about the baby and the parents’ relationship with their baby,” Ashby said.

If parents aren’t responding appropriately to their baby or won’t put the baby down, they might not be bonding with their child or might be dealing with excessive anxiety.

“Some parents are so afraid that something is going to happen to the baby that they won’t put them down or let others help care for the baby,” Ashby said.

Conversely, other new parents who are struggling with mental health issues might not respond enough to their baby’s cries.

“Really depressed patients often feel completely overwhelmed with the tasks of caring for a newborn. More depressed parents often respond more slowly to their baby’s cues or when their baby cries” Ashby said.

‘Nothing can prepare you for the NICU journey’

When Lexie was suffering through extreme stress, her PROMISE Clinic team wrapped her in a cocoon of support.

“We gave her a lot of reassurance,” said Lexie’s primary therapist, Cindy Covell, a licensed clinical social worker who has worked with PROMISE for five years.

“First she was dealing with the stress over having triplets. Then, there was the acute grief over the death of two of their three triplets and the uncertainty about Sutton’s health. It’s was a pretty tough situation,” Covell said.

She helped Lexie process her grief in the moment.

“I let her know that what you’re feeling is normal. You’ve had major life changes. You were just getting used to the idea of having triplets, then you lost two of them,” Covell said.

“It was beautiful that she named her boys. We concentrated on assisting her with Sutton so she could have a positive outcome with one of the triplets,” she said.

Along with their PROMISE team, Lexie and Collin Grant had a wonderful support system outside of the hospital including loving family, friends and great employers. Even so, Sutton’s survival at birth marked the beginning of a new period of ups and downs.

“Nothing can prepare you for the NICU journey. You hear it’s going to be a roller coaster, and you nod your head and think you’re going to understand,” Lexie said.

But the period after Sutton’s birth marked a new time of challenges and heartaches.

“Sutton was just so small and so underdeveloped. He was intubated and extubated. He had BRADY events (when an infant stops breathing and their heart rate slows), and that’s terrifying. One time, we thought he had a collapsed lung,” Lexie said.

“There’d be times when you’d leave at 3 p.m., then get a call a short time later and hear that he wasn’t acting right and had developed an infection. You’d kick yourself. And of course, we have a 4-year-old who goes to daycare, so we were extra terrified about seeing Sutton.”

Thanks to the seamlessness of the PROMISE Clinic program, Covell was able to continue supporting Lexie during the months after Sutton’s birth.

“There were a lot of ups and downs and emergencies. It was a rough time because progress (with preemies) can be very slow at first. You’re afraid all the time that your new babies is going to die. It’s pretty awful,” Covell said.

“I was able to talk with her throughout all of it. I would hear the alarms in the background,” Covell said. “I encouraged her to take breaks from the NICU even just to go for a short walk outside the hospital.”

Covell loves the integrated behavioral health model at the PROMISE Clinic.

“We’ve developed close relationships with all of the medical providers. They trust us and call on us to see any patients who might have mental health challenges,” Covell said.

As anxiety and depression rose among all populations throughout the pandemic, it became especially clear that pregnant and postpartum patients were especially vulnerable.

There’s a myth that expectant mothers and those with new babies are full of joy. The reality can be quite the opposite, Covell said.

“There are so many women who have had trauma,” she said. “It’s great to have mental health services and medications available to them.”

Covell loves working with babies and their moms. Many years ago, she worked with pregnant teens.

“I really enjoy working with women. It’s wonderful to help them with empowerment,” she said.

Hearts open to an expanded family

While the Grants have endured a very challenging journey over the last three years, Sutton keeps proving how resilient he is. After 107 days at the University of Colorado NICU, he finally got to go home. There were some setbacks soon afterward, and he had to spend additional time at Children’s Hospital Colorado, both in Aurora and in Broomfield.

But the Grants recently got to celebrate their babies’ first birthday, during which they honored all three of their triplets.

“James and Noah are part of our family, too,” Lexie said.

Remarkably, even after all they’ve been through, Lexie and Collin are open to having another child.

“We always talked about having two or three kids. Then we thought we were having three overnight,” Lexie said.

They had already bought a stroller that would accommodate triplets. They had told Campbell that he would soon have three new little brothers. He sometimes asks when Noah and James are coming home from the hospital. To help Campbell — and eventually Sutton — understand all that has gone on, Lexie is working on a children’s book about loss of siblings for a triplet.

The entire saga has been torturous, and at the same time, the Grants’ have found their lives, homes and hearts full of love.

“It’s heartbreaking and beautiful,” Lexie said.

So, why not add one more child to their lives?

Said Lexie: “The first baby breaks you in. Our second, third and fourth almost broke us. Our next one could build us up again.”

If she and Collin decide to add to their family, Lexie said they won’t be doing it without their University of Colorado obstetrics and PROMISE Clinic teams.

“There will only be another kid if we can walk that journey with them again,” she said. “Hopefully, we’ll leave the NICU out next time.”