Photo by Volkan Olmez

There You See It, There You Don’t? Postpartum Depression

Editor’s note: This article first appeared in Midwifery Today, Issue 130, Summer 2019.
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What if I told you that nearly 100% of the women with whom I have worked over the past four decades who’d had either all, or many, of the trademark symptoms of postpartum depression (PPD) didn’t have it with their subsequent babies? What if we had to consider that how a woman gives birth influences whether or not she experiences postpartum depression?

I was very, very sad after my son was born years ago. I spent many a day—which spanned into weeks and then months—crying my eyes out. When my second child was born, I was mildly upset but able to cope. When my third child was born, I was so not sad that I went out swimming the next day and then to see friends—with my daughter in tow—the next night. I felt only happy, energetic, exhilarated, and delighted; nary a sad feeling crossed my mind, even though I was tired and over-busy with three young children.

I became very interested in “all things birth” and began to research and write on the subject and teach childbirth classes. I wrote several articles about what happens to women when they have a difficult, disappointing, or traumatic birth, and began to receive hundreds of letters and phone calls (in those early days, there was no Internet or cell phones). I co-founded a national childbirth organization and, within months, there were chapters all over the world. During this time, I heard from thousands of women who had recently become mothers and were extremely sad and quite depressed. Many of the women who contacted me had had miserable birth experiences and were seriously depressed following the delivery of their babies. I spent thousands of hours on the phone as well as face-to-face with hundreds of women doing what could certainly be called “postpartum counseling, my-style” and learned over time that many things can be done to help women heal from “the blues” without them having to take any kind of meds. In fact, there are things that can be done to help prevent postpartum depression in the first place.

I became a midwife. I have attended over 2300 births since the beginning of my training. What I have learned—and what all too few are willing to consider—is that what happens during labor, at the time of birth, and during the first hours following the baby’s arrival, has quite a bit to do with whether or not a woman is depressed after her baby is born. Few want to consider that what takes place during the pregnancy, the kind of prenatal care—or non-care, which is what most American women receive—also has an influence on mood and adjustment after birth.

Women who are seen by obstetricians or medical midwives who have never had a natural birth themselves—and who may or may not even be at the birth—are at a distinct disadvantage. Women who are given no solid nutritional counseling during pregnancy—the vast majority of American women—are also at a disadvantage. Women who wait in waiting rooms for upward of 30–45 minutes, only to be seen by any one of a dozen providers for anywhere from 6 to 11 minutes are at a disadvantage as well. Valuable time when discussions about getting and staying healthy, avoiding postpartum depression, and learning about the “ties that bond” are dismissed in favor of “the numbers”—weight gain, blood pressure, and fetal heart rate (which is ascertained by use of a Doppler, a concentrated exposure to ultrasound that babies dislike for very good reason and which many researchers are quite certain is not safe).

The women who come to me know that they will be seen for at least an hour, if not more. They know that we will have a discussion about nutrition, sex during pregnancy, and fear. They know that at the birth they will be supported by two or three women whom they have come to know and who have themselves had natural births. They learn that a medicated birth can interfere with certain hormones that help the woman feel good after birth and keep her energized and focused. They learn what they can do to help increase the chances that they have a healthy baby. Any parent who has a baby who is not healthy obviously has a reason to be anxious, concerned, and depressed that is apart from any of the characteristic benchmarks of postpartum depression.

My first birth was a preventable cesarean. Most of the cesareans in this culture are preventable, but they are big business. Just refusing an induction can decrease the chances for a cesarean (if the body was ready to have a baby, the body would be in labor; if it is not in labor, the body and the baby are not ready). My second was a medicated (at the doctor’s insistence) vaginal birth and the third was a natural homebirth. I have seen women who had very serious PPD not shed a single tear after the natural births of their subsequent babies. The interventions that we are foisting on laboring women may all play a significant role in the development of depression: epidurals, drugs, IVs, fetal monitor belts—these are just a few of the interventions that are not without physical, physiological, and emotional sequelae.

Photo by Brian Odwar

I told the women who came to me that I was not a trained psychologist. I told them that I had gone to see a few after I’d had the cesarean and did not feel as if I had gotten much help. I told them that that trial and error had allowed me to learn what seemed to assist most women who felt as if they were falling apart and unable to cope after the birth of their babies. I told them that it had occurred to me that if something had helped me, it might help them as well. And so, we began working together.

Eileen was the first to let me know that I was on the right track. She had been seeing a psychiatrist since a few weeks after her baby had been born—by cesarean. She’d had three more c-sections and had continued to see this doctor and take medication. I asked her to tell me the story of each of the births. I stopped her at times and asked her to give me more details.  She came to see me three times and each time I spent three or four hours with her. I handed her tissues, pointed out some things that seemed obvious to me but possibly not to her, and, at one or two points, held her and rocked her while she sobbed. To make a long story short, she called after our third meeting and said that she had fired the psychiatrist and was not taking the antidepressants that had been prescribed. I wasn’t at all sure that was a good idea and told her so. However, Eileen kept in touch with me and never went back to that—or any other—psychiatrist. She had a homebirth with her fifth child and said that that was the frosting on her “cake of healing.” She understood that she had made the decisions about her births based on information at the time, fear, and concern for each of her babies. She realized that the lack of understanding about her disappointment regarding the births, having to recover from major surgery at the same time that she took care of a newborn and was up all night nursing, and everyone’s complete lack of empathy for her were key issues in her having had “PPD.” Of course, she said, if a man is upset that he can’t ejaculate, everyone understands his frustration and desire to “be a man.” “Why then,” Eileen asked, “didn’t anyone until now understand my desire to birth a baby like all normal women—to have the whole experience, not just the pregnancy?”

Being listened to when a woman tells her story over and over again as she peels its layers is very healing and powerful. She then doesn’t carry the weight of it with her wherever she goes. Letting her know that she is justified in feeling the way she does, after having either been treated poorly or ending up with a surgery she never expected or wanted, is validating and soothing to her bleeding soul.

Rose also felt as if our time together was healing. I sat next to her—not across from her at a distance. We talked about the baby having been taken away from her for hours. I handed her the stuffed animal she had been asked to bring in, something that represented the baby who had been ripped from her arms for no good reason. Her baby was 6 months old at the time and she said she hadn’t felt bonded to him. We talked for a long time about bonding, attachment, love, and related matters.

Two weeks after our time together, she called me. I didn’t know it was her at first; all I could hear were loud sobs. I was momentarily concerned that it was someone in big trouble. I asked the person to please take a nice, slow, deep breath because I couldn’t understand what was being said to me. I told her I would wait until she was able to speak clearly. After a few moments of breathing together on the phone: “This is Rose,” she said. “Oh, Nancy, I fell in love with my baby today,” she said and began sobbing again—deep, loud, heaving sobs of relief.

One of the most deeply healing things that we do together is to recreate the first moments with the baby, at which time the woman gets to count the baby’s fingers and toes and to tell the baby all the things that she would have said either silently or out loud to him/her during those first precious moments after birth. The vast majority of women whom I see did not get to see their babies right after birth or, if they did, it was for milliseconds. Having them pick up their sleeping baby or child or, if that baby is now too big, having them talk to a photo of that child when he/she was newborn, is quite powerful.

One of the women who came to my three-day “Grieving and Healing after a Disappointing, Upsetting, or Traumatic Birth” workshop had had what we called a vaginal cesarean. The baby had been pulled out with forceps and the mother received upward of 70 stitches in her vagina and perineum. Jill could not sit for weeks and had not resumed lovemaking—this was almost four years later. She was depressed and barely spoke to anyone for months. Her husband didn’t understand how upset she was; after all, they had a baby and the baby was well. She had been sorely traumatized. I invited her, with a pregnant couple’s permission, to come to a birth that I was attending. She saw how peaceful birth could be. We then pretended that she herself was the woman who had just given birth. We did several sessions together and I got a note from her that she had surprised her patient husband and that they had begun to make love again.

Jill became pregnant the following year and I had the privilege of being her midwife. She had a homebirth and no stitches at all: “You already gave at the office,” I told her (she had already “donated” her skin for the countless punctures/assaults it had endured with her first baby’s birth). It was peaceful. We—my assistant and I—both believe that women were designed to give birth safely and unharmed, that babies were designed to be born, and that trust and respect go a long way toward giving each woman confidence and helping to ward off anything but pride and strength. Jill did not have any PPD this time and eventually became a homebirth midwife herself.

Medications can be useful at times, but in the decades I have been doing this work, I have found that women need to feel the pain that they are feeling in a safe space with warm tea, a comfortable couch, two shoulders to lean on, and an ample supply of tissues. They need to know that what they are feeling is normal. After receiving over a million (yes, a million!) letters, phone calls, and e-mails from women and after doing many weekend seminars on grief after birth, it becomes apparent that what looks like PPD for many women is a different animal with related qualities.

What if ultrasounds cause depression? They can in some respects. Finding out the sex of the baby can lead to great excitement—if the baby is the sex the couple want. However, when one of the parents-to-be is upset about the sex, that can cause changes in how that parent relates to the other parent, the pregnancy, and the unborn baby. More than one woman has told me that once she found out that she was carrying the “wrong” sex baby, she felt sad. “I am glad that I know, though,” said one woman. “Now I can get my disappointment over with and welcome the baby when it is born, with a smile on my face.”

However, the welcome was not the surprise, wonder, delight, and pure joy that it would have been had she not known the sex—because after the labor, any baby is welcome in a different way! “I was still disappointed and now I know that the rest of the pregnancy the baby must have felt my sadness while he was growing on the inside.”

Another woman said that her husband almost seemed to “blame her” for having “picked the wrong sperm.” She felt as if she had let him down by not giving him his son. Old-fashioned bull, perhaps, but that is how she felt.

The women who birthed naturally after having had a cesarean did not have to deal with anesthesia in their bodies or drugs from IVs. Oxytocin is, as you know, the “love hormone” and while hospital staff members tell us all that Pitocin is the same thing, it is not. We push that into women’s and babies’ systems and then wonder why mothers and babies are so hormonally different—hormonally deficient—when they meet than they would have been had they been given the information, space, love, and complete faith to birth normally and naturally.

One of the women who’d had a miserable, long labor that had resulted in a c-section had been very depressed and had considered not having any more children. Carol became pregnant when her son was 4 years old. We talked about how to help insure that this labor was not a long one (she had been told not to cross her legs, not to sit tailor-style, not to lean back/recline during the pregnancy, and not to drink milk—all of which would help her baby to line up properly and be easier to birth). When the head of this next baby was born, she looked at her husband, who had been very concerned about another few years’ with a wife with PPD, and said, “Oh, honey, this is so cool. Can we do this again?” To which her husband replied, “Could we have this baby first and then discuss having another?”

Carol did not have one day of the blues—she felt accomplished, supported, confident, respected, and delighted with herself and her birth. The umbilical cord was not cut for over an hour after the baby was born and no one took the baby away from her.

If a mother orangutan or other primate has her baby taken from her, she gets violent and then disoriented and depressed. We are mammals; almost all of our babies are taken away from their mothers within minutes after birth. The baby will weigh approximately the same in a few hours as it does at birth, give or take, so why does it seem so imperative that the baby be taken away to be weighed so quickly? Why are we shooting babies up with all kinds of agents that have formaldehyde and other toxic substances at birth—which change the “composition” of that baby as well, making the baby nervous and uptight (after all, if someone picked you up to nurse you once, but then picked you up to jab you with a needle, it would be difficult for you to feel trusting and relaxed when someone picked you up).

Many of the things I have done with women to help them through feelings of sadness and sorrow after their babies were born are in my three books. However, I want to reiterate that the more I work with women postpartum, the more I realize that we are all missing the mark when we say that PPD is rising, without looking at the rising rate of unnatural births, epiduralized births, and cesareans in this culture. They go hand in hand. The testing that is done during pregnancy, most of which is unreliable, unnecessary, and even dangerous, also contributes in many ways to women feeling frightened, sick, and vulnerable rather than strong and ready—to birth and to become mothers—which can lead to and later exacerbate PPD.

By the way, after careful research and several years of reading about placenta encapsulation, I am not a fan. The placenta was not meant to be dried and placed into gel tablets for future consumption. If the woman is inclined to ingest it in part or in full after the birth, in its natural state, we can talk turkey, but to tell women that it will stave off PPD has not yet been proven. Not enough studies have been done to determine whether or not there is a placebo effect, despite what we hear extolling the virtues of placentophagy. Many of us are convinced this is a passing fad and that, in time, we will all understand that eating this organ, which belonged to the baby, is not in anyone’s best interest but perhaps the encapsulator’s bank account. Certainly, it is not a good idea to encapsulate the placenta and have the woman take it in if she had had any kind of drugs or anesthetics during the birth that may reintroduce those substances into her already precarious physiological-hormonal balance.

For women who have had PPD, we must talk about the kind of care they got during pregnancy and the kinds of things they did and did not discuss. One of the classes I teach during pregnancy has to do with the changes/losses that women and their partners go through after the baby is born. The women lose their bodies as they knew them, and some lose the ability to bring in a paycheck for a period of time after the baby is born (of course, in many countries in Europe and elsewhere, they get a year paid maternity leave). Their relationship with their partner changes as does their connection to friends who don’t have kids. The spontaneity of their lives changes—they are no longer free to just pick up and go whenever they want—and their sexual connection to their partners may change for at least a period of time after the birth (many of the women I serve, who generally birth without trauma to their bodies, often resume sexual intercourse within days of the birth). All these losses and changes can set the stage for PPD when they are not expected or have not been discussed. Loss of sleep causes even the best of us to feel disoriented and upset. Anything that is new can create concern—and certainly a newborn who wiggles and needs to be fed and changed and has no concept of night or day can be a source of worry. I found that when I added this class to those that were being taught about labor and birth, couples were far more prepared to face the first days and weeks with a realistic mindset, which helped them to cope and to keep any kind of serious PPD at bay. Oh, and new dads can be subject to anxiety and upset as well, although we don’t talk about that too often now, do we?

In other parts of the world, grandmothers, aunts, cousins, and neighbors help take care of the new mother, while here in our culture we generally live in isolated family units so that the woman is responsible for taking care of her newborn, herself, her other children, her home, and life in general—not to mention having to return to work within just a few weeks of the baby’s arrival. Anyone would feel overwhelmed and depressed having to deal with all that after having brought life to the planet.

I see happy women around me: women who had previously had miserable, interfered-with births that resulted in PPD—including feelings of failure, distance from their partners and babies, lack of energy, and feelings of anger, confusion, overwhelm, and sadness. These women were—or initially believe they were—candidates for PPD after their next birth and were delighted, surprised, and relieved when they birthed naturally and were free from any of the debilitating and disturbing symptoms that plagued them previously.

Women are eager to feel well. They need to feel well; they are taking care of beings who are dependent on them and who deserve happy, emotionally healthy beings at the helm. Women are generally resilient, creative, communicative, and resourceful and when they get the kind of support, caring, and listening they need, good things—including healing—happen. The increase in PPD that has been noted in this culture may very well be preventable, but in order to quell the tide we must look at the whole picture and change much of how we view and “take care of” pregnant women before, during, and after their pregnancies, as they give birth, and during the postpartum period and beyond.

Note: As this article was going to press, we learned about the first drug to be approved by the FDA for postpartum depression. One can only wonder how quickly the studies were done and how many drug companies stand to benefit. Many of us remember all too well the previous “wonder drugs,” such as thalidomide and diethylstilbestrol, that damaged countless mothers and babies before they were taken off the market. We all know that any “side” effect is not a side effect—it is an effect, and that anything transmitted through the breast milk (and just about everything is, of course) will most certainly also have some effect at some point down the road. It is better for us to truly begin to understand how to help the hormones in the first place and to do everything we can to naturally help mothers feel good during their pregnancies, labors, and deliveries—and for many months after the baby arrives, as well.

Photo by Phano Kong

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