March 26, 1999
Volume 1, Issue 13
Midwifery Today E-News
“Postpartum Blues/Depression”
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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Homebirth Offsets Depression
5) Neurotransmitters, the Neuroendocrine System and PPD
6) Psychosocial Factors in PPD
7) From the Garden
8) Switchboard
9) Coming E-News Themes

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1) Quote of the Week:

"The essence of midwifery is staying in the moment, being humble, and paying attention... it is the antithesis of control."

- Elizabeth Davis, midwife, educator, author

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2) The Art of Midwifery

For postpartum baby blues, have the mother lie in a bath to which a few drops of jasmine oil have been added. Jasmine oil dropped on her pillowcase before she goes to sleep at night is also helpful. If jasmine oil is not at hand, ylang ylang or clary sage oil is nearly as effective.

- Maggie Tisserand, "Aromatherapy for Women," Healing Arts Press, 1996

Few families readily perceive the full extent of the woman's vulnerability once labor has ceased. Many times, the intense focus and concentration that friends and family members direct toward the mother are abruptly withdrawn and transferred to the infant or elsewhere. Some women who are strongly dependent on this psychological/emotional support sense the loss acutely. This may contribute to postpartum depression.

- Judy Edmunds in "The Grand Finale to Birth," Midwifery Today Issue No. 34

Some ways to monitor for a potential depression, allowing a timely and critical intervention, include: suggesting the mother join a support group; hiring a doula to assist in the home; enlisting friends to call every day to chat and see how the mother is doing.

- Midwifery Today Issue No. 34

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3) News Flashes

Breastfeeding Aids Adjustment to Motherhood

Recent studies show that breastfeeding mothers with normal hormone levels and good social support have better adjustment to a maternal role, greater confidence as parents, and less anxiety than bottle feeding mothers, leading to an apparently reduced risk of postnatal depression (PND). Authors of one of the studies point out that those women at risk of PND should be encouraged to breastfeed and should be given the social support needed to initiate and maintain the breastfeeding relationship. Those women with PND need to be encouraged and supported to continue breastfeeding because it helps increase maternal confidence.

- Nursing Mothers' Newsletter, Jan/Feb 1997

Window of Fertility

Researchers at the National Institute of Environmental Health Sciences report that the highest probability of pregnancy each month occurs during a six-day period ending on the day of ovulation, a time frame several days earlier and considerably shorter than has been traditionally thought. The Institute's researchers found that all 192 pregnancies in the study group of 221 healthy women aged 26 to 35 were initiated on the day of ovulation or during the five previous days; none was produced by intercourse after this interval. The probability of conception ranged from one in ten on the fifth day prior to ovulation to one in three on the day of ovulation.

- New England Journal of Medicine, Dec. 7, 1995

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4) Homebirth Offsets Depression

Women who give birth in a hospital are much more likely to experience postpartum depression or even post traumatic stress disorder. British childbirth expert Sheila Kitzinger states that the more interventions a woman experiences, the more likely she is to be depressed, with cesarean sections obviously carrying the greatest risk of depression.

Aidan McFarlane, a British physician, notes that while 68 percent of hospital mothers experience postpartum depression, only 16 percent of homebirth mothers do. On The Farm, a self contained, alternative lifestyle community in Tennessee, the rate of postpartum depression was 0.03 percent. Almost all mothers on The Farm had both a homebirth and a supportive, loving community of women to assist them postpartum. Avoiding depression, in itself, would be a major reason for mothers to consider giving birth in their own homes, if that is where they are most comfortable, especially if they had previously experienced postpartum depression and thus were at high risk for a repeat episode.

Aspects of hospital birth that may strongly contribute to the incidence of postpartum depression in our country are the way the moment of birth is handled and routine separation of baby and mother. In a study published in the New England Journal of Medicine in 1972, Marshall Klaus found that holding the baby close released "dormant intelligences" in the mother and caused "precise shifts of brain functioning and permanent behavior changes." Bonding therefore is not just an emotional thing that only mothers think happens; it is a biochemical process that forever changes the mother so that she knows more instinctively how to relate to her baby. Routine separation of mom and infant makes baby frightened and mom depressed. This may be why postpartum depression and difficult adjustments are so common in the United States and rare elsewhere.

- Jennifer L, Griebenow, excerpted from "Home Birth vs. Hospital Birth: How Safe?," Birthing magazine, Summer 1998

5) Neurotransmitters, the Neuroendocrine System and PPD

Female reproductive hormones have many significant effects on the brain chemicals (neurotransmitters) responsible for communication between brain cells, including how much of the neurotransmitter is present, the length of time it is present between cells, and how the receiving cell is affected by the incoming neurotransmitter. The neurotransmitters serotonin, norepinephrine, dopamine, and acetylcholine are known to be out of balance in serious emotional or psychiatric illnesses. In fact, many studies have documented low levels of the metabolites (the breakdown by-products) of these neurotransmitters in the blood, urine and cerebrospinal fluid in clinically depressed people. Most mental health researchers agree that dysregulation of these neurotransmitters is a causative factor in clinical depression. Each of these neurotransmitters is modulated by female reproductive hormones.

At least half of clinically depressed people have a detectable abnormality in the neuroendocrine system, called the hypothalamic-pituitary-adrenal axis, that shows up as an abnormality of cortisol regulation. Many show another sign of hormonal dysregulation in which their pituitary fails to react to the chemical signal to release a hormone to stimulate the thyroid. The hypothalamic-pituitary-adrenal axis is dramatically affected by childbearing, and it may be that although all women experience these hormonal changes, some are vulnerable to experiencing depression and anxiety as a result. The thyroid gland is very significantly affected by childbearing, and we know that even subclinical cases of low thyroid can cause depression.

It is not yet known which one or what combination of these neurochemical agents initiates postpartum depression (PPD). It is unlikely that there is a single cause for all sufferers. On one end of the spectrum are women who have what seems to be a "pure" biologic disease. They have very strong biologic symptoms such as insomnia, weight loss, extreme fatigue, profound difficulty getting out of bed in the morning, inability to function even minimally, and/or hallucinations. For other women, massive stress seems to be the major cause. Still others will feel that events in their past, such as being abused or neglected, have left them vulnerable to depression during any major life crisis. Some have elements of each.

- Karen R. Kleiman MSW & Valerie D. Baskin MD, "This Isn't What I Expected," Bantam Books 1994

6) Psychosocial Factors in PPD

Postpartum depression refers to a group of poorly defined, severe, depressive-type symptoms which usually begin at four to eight weeks postpartum but can occur later in the first year, and can sometimes persist for more than a year. The incidence ranges from 10 to 16 percent of new mothers.

Symptoms are prolonged and include exhaustion, irritability, frequent crying, feelings of helplessness and hopelessness, lack of energy and motivation so that the woman's ability to function is disturbed, there is a lack of interest in sex, she experiences disturbances of appetite and sleep and feelings of being unable to cope with the new demands placed on her. Anxiety is often related to the infant's welfare and may persist in spite of doctors' reassurances. Some mothers with postpartum depression may lack affection for the baby, and in turn, experience self-blame and guilt. It is not uncommon for a woman with postpartum depression to have psychosomatic symptoms such as headache, backache, vaginal discharge and abdominal pain for which no organic cause can be found.

Most studies show that a person's previous history or a family history of psychiatric problems increases the chances of postpartum depression. In most cases, however, psychosocial factors are important. The woman may be experiencing bereavement, the effects of unemployment or inadequate income, unsatisfactory housing, or unsupportive relationships. The experience of childbirth may have aroused memories of a past stillbirth or miscarriage, abortion or death of her mother. When a woman has had a poor relationship to her own mother or was separated from one or both parents before the age of eleven, she is more likely to be depressed and anxious. Another factor may be the woman's inability to confide in her partner or a friend. Women are often embarrassed to tell another how badly she feels. Loneliness, isolation and lack of support are serious contributors to postpartum depression. Some mothers may find it difficult to reconcile the realities of mothering with their prenatal fantasies.

- Marshall H. Klaus, MD, John H. Kennell, MD, and Phyllis H. Klaus, M.Ed., "Mothering the Mother," Addison Wesley, 1997

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Learn more about the postpartum period from Midwifery Today Issue No.22, on Postpartum. Get this back issue for only $6.00 plus shipping. (Regular price: $7.00) Call 800-743-0974 to order today! Mention code 940 and save $1. Expires April 9, 1999.

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7) From the Garden

Postpartum Herbal Bath

Start up a big pot of hot water for steeping herbs for a postpartum bath soon after birth. Strain the tea before adding to bath water. Steeping in glass gallon jars is very effective, then strain directly into bath through cheesecloth placed in a plastic colander.

For the bath I combine: one quarter cup sea salt, one ounce uva ursi (bearberry), one to two ounces comfrey, two ounces shepherd's purse, and one crushed fresh garlic bulb.

Place a bath towel in the bottom of the tub for comfort and to prevent slipping. Let mom enjoy the bath until she asks for baby, at which time the baby can be introduced to the bath slowly, feet and legs first, then bottom. The salty garlic is astringent and mildly antiseptic so immersing the baby's cord is OK.

Since the bath is quite warm (102 to 104 degrees F), I have mom drink three cups of a strong infusion of shepherd's purse at room temperature soon after birth and before entering the bath.

The following are my criteria for using the herbal bath soon after birth:

- mom's uterus has good tone
- any source of significant bleeding has been identified and repaired
- the baby has been assessed and is fine
- mom is able to walk to the tub with minimal assistance
- mom and babe are not left alone in the bath

- Linda Lieberman, excerpted from "Postpartum Herbal Care," Midwifery Today Issue No. 25.

Call or email to order this issue for just $7 plus shipping.

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8) Switchboard

Readers, at what rate do you see postpartum blues or postpartum depression in homebirth or birth center situations? Do you think it differs from the rate it is seen following hospital births? Why or why not?

My midwives were herbalists with lots of experience under their belts. One of them made me a wonderful herbal cocktail that is delicious and effective for not only postpartum blues but for fortifying breastmilk. I make a tea from red clover, great for purifying the blood and helping improve breastmilk; lemon balm, which works wonderfully for lifting the spirits; red raspberry leaf, which helps the uterine walls contract so the uterus can shrink back down to size; and nettles, which contains vitamin K, important for clotting. Nettles also is a good source of iron which is important for breastfeeding babies. I steep a teaspoon of each per cup of tea for about five minutes. It is best fresh!
It is hard being a new parent, especially if you have never done it before. Be patient and make sure to get as much fresh air as you can.
Grace

Postpartum depression is a serious thing. I have had it following both my pregnancies. The first time it lasted from a couple days after my daughter's birth until about a year later. It got a little better as time went on, but it was still hard. My second daughter has had different effects on me. I have my good days and my bad days. On good days, I just don't want to do anything. On bad days, I just sit and hold my seven month old daughter. I can't do anything. I cry and I sit. The only time I don't cry is when I'm breastfeeding my daughter. I thought this time I was not going to get postpartum depression because I didn't get it until four months postpartum. My husband thinks I use PPD as an excuse not to do housework. He doesn't understand that it is serious, and can hurt my family in a severe way. I am glad I have my mother on line to talk to. Family can be a great help. If you think you have PPD talk to your healthcare provider. It is a very serious thing; I know first hand.
Amber W.

I am doing a research project for school and am looking for information on mortality rates for newborns and for labouring women when using a midwife and using an obstetric MD. Any help would be appreciated. Email me at tonyandsharon@msinets.com or write to my home address at 3917 Brickland Road South Hill, VA 23970. Thank you.
Sharon K Varner

I am a childbirth educator in England and will be moving to Japan for two years where I hope to have my fourth baby. My other three were born at home using water with the best independent, radical midwife ever! I wonder if anyone knows anything about the system in Japan. Any information or contacts would be greatly appreciated. Mail to claygrubb@clayncc.demon.co.uk. Thank you!

I am an aspiring midwife finishing my last year of an undergraduate degree in English. I have been researching the various paths to becoming a midwife and have applied to a BSN-MSN program in nurse-midwifery, but am not sure that it is the best route for me to take. I am trying to understand the pros and cons of a nurse-midwifery program versus a good direct-entry program and am curious to hear the opinions of experienced midwives on the subject. You can email me at jessial@earthlink.net.

Thanks for the great newsletter; I find it really inspirational and exciting, and thanks for any of your thoughts on my dilemma.

- Jessi Schwarz

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9) Coming E-News Themes

Coming issues of Midwifery Today E-News will carry the following themes. You are enthusiastically invited to write articles, make comments, tell stories, send techniques, ask questions, write letters or news items related to these themes:

- posterior labor (April 2)
- infections (April 9)
- education (April 16)
- tear prevention (April 23)
- episiotomy
- epidurals
- breastfeeding
- waterbirth
- breech birth
- postpartum depression
- homebirth

We look forward to hearing from you very soon! Send your submissions to mtensubmit@midwiferytoday.com. Some themes will be duplicated over time, so your submission may be filed for later use.


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