Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary developmental science can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Wednesday, December 3, 2014

Is Postpartum Depression Really Postpartum Neglect?

Postpartum depression may be a misnomer. A more accurate term might be postpartum neglect- not by mothers, but of mothers.

The human infant is uniquely helpless in the early weeks and months of life. His arms fly up over his head at random moments in a primitive “startle reflex.” His sleep patterns have no rhyme or reason. He eats and poops round the clock. Serving an evolutionary purpose, in part to achieve an upright bipedal posture, the human brain does 70% of its growth outside of the womb.  

For a new human parent, the young infant’s absolute dependence may translate to no sleep, no showers, no ability to do anything but care for the baby. Harvey Karp has referred to this time period as the 4th trimester. His popular Happiest Baby on the Block series offer advice about what to do for a range of behavior challenges in this time period.

But as pediatrician turned psychoanalyst D.W.Winnicott identified, a mother knows what to do. He referred to this kind of care as “primary maternal preoccupation” a preoccupation that is not only healthy but also highly adaptive. The problem lies in the fact that in contemporary culture new mothers do not themselves have a "holding environment" that supports caring for the baby in the way his immature nervous system requires.
  
In an equally important evolutionary adaptation, the human newborn is available from the earliest hours of life for connection and complex communication.  In a calm, quiet setting, at just a few hours of age a baby will turn to a mother’s voice, follow her face, make imitating movements with his mouth.  He makes himself available for falling in love.

These two evolutionary adaptations come together in the concept as described by J Ronald Lally of the “social womb.” The human infant, with his highly developed capacity for social interaction even from the first hours of birth:
turns this seeming weakness into strength. During this dependent period the human brain is very active, developing more rapidly than at any subsequent period of life. It is picking up clues as to how it should grow, learning what it needs to survive, how to relate to others, and how to fit in and function in various settings and situations.
However, when the expectation exists that a new mother will function as she did before the baby was born, offering this “social womb” may be very difficult. Faced with this expectation, many mothers feel very much alone. 

As Winnicott wisely observes, "It should be noted that mothers who have it in themselves to provide good-enough care can be enabled to do better by being cared for themselves in a way that acknowledges the essential nature of their task."

 In my behavioral pediatrics practice, whether a child is 2, 5, 10 or 17, mothers frequently describe feelings of deep loneliness in those earliest weeks and months that stand in stark contrast to the cultural expectation of joy and love.

Social isolation, anxiety, sadness, and marital stress color the experience of caring for a newborn who cried all the time, never slept, couldn’t breast-feed. Fussy infants became challenging toddlers. Tantrums, separation anxiety and family conflict define the preschool years. When these children enter the structured school system, problems of emotional regulation may lead to psychiatric diagnosis as defined by the DSM (Diagnostic and Statistical Manual of Mental Disorders.)

As I describe in detail in my forthcoming book, The Silenced Child, primary prevention lies in caring for mother and infant as a unit. In the first 8-12 weeks, brain growth (the infant brain makes 700 connections per second) and with that healthy development, requires care by the mother, or mother figures, in the same way that the mother’s body held the baby in pregnancy- 24 hours a day, seven days a week.

There is an evolutionary purpose to what in this country was once termed "lying in." During a period of 3-4 weeks mothers were able to rest and connect with their baby while a group of women helped with household chores and offered emotional support.

Cultures around the world recognize the need for protecting the mother–baby pair in this way. Contemporary American society, with its unrealistic expectation of rapid return to pre-pregnancy functioning, is uniquely lacking in a culture of postpartum care.

We cannot go back in time to a period when extended family was available to provide a community of support. Nor will we be able or even want to return to a time when mothers stayed in bed for 3-4 weeks after childbirth. But some steps must be taken.

For just as we know that supporting mother-baby pairs leads to healthy development, we know that when early relationships suffer, the long-term consequences, for both mother and child, are significant and worrisome.

To optimize brain growth and development by providing a “social womb”, new families need to be held in the same way that the mother’s body holds the baby during pregnancy. Mother-baby groups, as offered by the Community Based Perinatal Support Model developed by MotherWoman, as well as increased paid parental leave and home visiting programs offer other forms of support, as does recognizing that physical recovery from childbirth does not happen overnight.

Perhaps the first and most important step in promoting healthy development lies in locating postpartum “illness” in its proper place- not in the mother, but in the way our society cares for mothers.


34 comments:

  1. Woohoo!!! This is a wonderful article!! I've been preaching this for 30yrs. Thank you Claudia. I appreciate seeing it out there......

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  2. My aim in writing this piece is to point out that the very real emotional suffering of mothers can only be understood in social context. In turn, treatment of that suffering involves creating a holding community for mother and baby. All too often the issue is oversimplified.

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    1. Totally fantastic and right on Claudia M. Gold! Please check out the postpartum training I have created and am offering-- to train birth workers and health care professionals in EXACTLY what you speak to in your article! http://www.innatetraditions.com/physiologic_postpartum_care.html

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  3. This is curious to me. I had two pregnancies, two labor/deliveries, and two postpartum periods with my newborns. The first, I felt this way, for sure. I'm grateful I was aware enough of my emotions and body to recognize that there was a neglect of who I was and a certain loss of who I was and a true change in becoming a mother who devoted everything to her newborn. But the second (he's now just over a year), it was a different feeling and one I could not recognize and looking back on those days now I am realizing was a true depression and one I probably should have sought help for. Just a caution, yes, our culture needs to change and allow women to be mothers with appropriate care, benefits, leave, support, etc., but it has to be acknowledged that sometimes, the hormone flux truly is a depression for which true help, counseling, doctoring, etc. is best.

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    1. Hi Casey
      I absolutely agree that treatment is essential, where a mothers feelings can be heard and understood. This is true for any person who is suffering emotionally. The piece in no way meant to diminish the problem, but rather to identify the need for recognizing the social context. Support groups for mothers and babies, individual therapy for mothers, dyadic therapy for mother and baby together, as well as therapy that addresses strains in relationship between parents all may have a role to play. All too often the problem, and treatment, is oversimplified.

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  4. Thank you for this article...as a new mother I truly appreciate it.

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  5. Thanks so much for such a nicely written article. As a mom and Ob/Gyn, I can definitely appreciate the difficulty and importance of the postpartum weeks for the mom-baby dyad and for the family as a whole. The impact of the cultural context and our expectations for this vulnerable time is huge and I appreciate you bringing it to light. Cheers, Kristi Angevine (www.kristiangevineMD.com)

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  6. Great article! I'm the Co-Founder and Executive Director of MomsBloom (momsbloom.org) in Grand Rapids, MI and this type of support is exactly what we provide with our Flourishing Families program. We have had great community support, but it's still an uphill battle to get many to understand how important the mother/baby dyad is during the "4th trimester" and beyond. Articles like this are very beneficial for our cause, thank you!

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  7. I concur. Our midwife community strongly recommended three-four weeks in, on, and around the bed. I did it for 3.5 weeks. Plus my husband got five weeks paternity leave and cared for us by doing all the cooking and laundry while I tended to our newborn. He's taking his final five weeks now when she's four+ months old. I paused every so often in those early weeks and thought to myself how we may never have this precious amount of time together ever again in our lifetimes, so I was deeply committed and pur postpartum experience was very sweet - albeit exhausting - because we took the time and set the intention to bond as a family in this way.

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  8. Most of what I wish I'd had during that postpartum period was a safe space in which to struggle out loud with the way that motherhood smashed my previous self to pieces, my previous self that was competent, self-possessed, and didn't have huge bleeding boulders with cracked nipples instead of breasts. I am a better, stronger, kinder person for having gone through that transition, but I felt very alone with my difficult feelings. Also contributing to that was that we'd just had an awful case of a poor depressed mother jumping in front of a train with her baby, and paradoxically, that made it even harder to admit that I was sad and wanted to cry every day. My daughter and I are very close now, and she's a wonderful person that I am so very proud of, but those were dark times.

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  9. This could help explain my post-adoption depression.

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  10. Only posts in agreement will be published ? Defeats the object really !!

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    1. This is a fabulous article exploring the context of Perinatal Mood disorders that is not often addressed. Thank you! Wonderful article.

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  11. What happens to this explicit bonding period when you are separated from your newborn? My daughter was born at 34 weeks due to several complications, one being IUGR. She ended up in the NICU for a month. 20 days after she was discharged I had to return back to work full-time at the very hospital she was in the NICU. Recovering from a c-section with a 3 year old at home while trying to balance NICU visits when I had a babysitter (my significant other is self employed and travels for work), after being away from home admitted 6 weeks prior to delivery. I had twenty days to bond...twenty days with a baby that would latch and I had to exclusively pump. Twenty days until my FMLA ran out and my job would have been on the line. This was an incredibly difficult time and I am having a hard time mentally, dealing with this all 10 months postpartum. It has all come to a head and now I must deal with the repercussions of not having the time to bond, mend, and thrive as a mother.

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    1. HI Stephanie Thank-you for your comment. Yours sounds like a very difficult and painful experience, being torn in many different directions at once. I woud say that there is always opportunity for healing, and that disruptions as you experienced in the early months of your daughter's life can be repaired. The key is to recognize the trauma of this experience for you and to take care of yourself now, seeking whatever help you need in this process, as best you can.

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  12. Great article.... and able to be written in the 21st century as more understanding of women has evolved due to feminist movements ---- so why the gendered language : are we only only talking about male babies here?
    The article would be more effective if such language was avoided.... and I say this as a happily married heterosexual mum of two who suffered post natal depression back in the mid 90s :-)

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    1. Hi Dawn

      Thanks for your comment. You are correct in identifying a kind of automatic tendency to refer to the child as "he" in a short piece. However, in both my first book, "Keeping your Child in Mind" and my forthcoming book "The Silenced Child" http://www.amazon.com/The-Silenced-Child-Children-Lawrence/dp/0738218391 the chapters alternate gender.

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  13. Excellent article, and spot on in terms of a shift in perception. Just as prenatal care can make the difference between a healthy mom and baby so too does postnatal care. Social health between mother and child is crucial to the health of society. The cycles of dysfunction stemming from not addressing the 4th quarter of pregnancy are life changing. Though it's possible to step in later, why not address proactively? Thank you for this article, wish i'd known this in '85...

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  14. Excellent thoughts. I live near my extended family and each week for 4 weeks following the birth of each of my two daughters a relative would come to my home and keep house when my husband was gone to work. They were there 24 hours a day, kept the house and (for my second) kept the older child busy. It was a lifesaver.

    That said, in hind sight I think I needed even more help. After 4 weeks I was planning meals, grocery shopping, doing light housework, caring for a toddler and an infant, and nursing around the clock. I had a very difficult recovery phase, and I think I tried to jump back into things too quickly. Next time I'm going to plan a slower transition back to "full speed." It's probably going to mean hiring help. 3-4 weeks of care is a great start, but it might not be enough--particularly if there are older kids involved.

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  15. I like this article and I wish society will act on it. Nobody in my immediate family nor my partner seem to understand any of this. Therefore unfortunately we had a difficult first year and we are still struggling now that I have gone back to work. Does anybody know if Postpartum Depression only occurs in the first few weeks after birth or can it also happen later?

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    1. Thank you for your comment. Symptoms of PPD can last well beyond the first year. If you are still struggling, I would encourage you to seek help.

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  16. This is an interesting article. I agree that our society expects moms to be back to "normal" (whatever that is) way too soon. I felt a huge pressure and I was a stay at home mom! However I dont think that you can say that if we fix this societal problem we will no longer have women dealing with postpartum depression.

    I agree that new moms need more support in every aspect of their lives. However you also cannot say that if women had more support there wouldn't be postpartum depression. Postpartum mood disorders are due to chemical imbalances and honestly, community and family support cannot fix that.

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    1. HI Nicole
      I agree that hormones have a role to play and that more support will not solve the problem completely. My point is that we need to address the issue in its full complexity, which includes the social context.Protecting space and time to listen to the experience of mothers and fathers is critical. I discuss this problem in a more complete way in my forthcoming book, The Silenced Child, that will be released in May.

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    2. I dont agree that family and support cannot fix that. A massive amount of hormonal in-balance come from sleep deprivation. In a culture where your only job is to sleep and feed the baby and yourself the effects of sleep deprivation would be significantly less. We also don't live in a culture where women feel permission to slow down causing adrenal fatigue and the stress hormone cortisol. Creating a truly safe place for a women to heal in solitude with complete ongoing care is significant. I don't dismiss genetic or other factors that contribute however I am also speaking from experience. I had full fledged postpartum depression 3 times - 1 extreme. When I look what could have been done to create a safe place for me to nurture myself I am 100 percent convinced that it would have lessened considerably.

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  17. A wonderful article. As a mother of 7, plus four losses, I have had many post partum times. My husband took as much time off as he could, and friends brought meals, after #3. For the first two, my husband had to return to work when I came home, and I struggled with ppd. I take a babymoon, now, staying in or around bed, as much as possible. Baby #7 had some issues, and we had to go to the dr a few times in the first two weeks. As soon as we got home, back in bed I went. My older kids helped a lot. My advice, if you have noone at home to help, is to find a homeschooled teenage girl. Many come from large families, so are very comfortable helping with baby, siblings, and the house. Rates vary in different areas, but can be affordable. Prepare at your baby shower. Gift cards for take out, vouchers for homemade meals, put cash aside to pay a helper. It will all pay off with a healthier, more emotionally stable mother. Even after an emergency c-section with #6, my recovery went well. Rest is under rated!!! Just BE with baby, drink them in. Really snuggle and nuzzle.

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  18. This is excellent. The pressure I felt, after my baby was born, to be happy, was horrible.

    I just have to give an anecdote. I was incapacitated mentally as a new mom. I couldn't function. And I felt like such a complete failure, and round-and-round it went, I was ashamed and miserable. I wasn't working out of the home but could barely manage to get dressed each day - trying to cook a simple meal was completely overwhelming. I made a list of 5 things to accomplish each day (because I had five fingers, and it had to be that simple) including getting dressed. I couldn't ask for help because I compared myself to all other moms and was consumed with shame..

    I finally mentioned this to my doctor. She said "Oh, I know what you mean, I was doing my residency when my son was born and I was EXHAUSTED".

    End of conversation.

    I sure coulda used one of them-there community support things.....

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  19. Thank you for this wonderful article. I will pass it along.

    Whenever I speak with a pregnant woman, especially a first-timer, I recommend La Leche League. My 2 children were born in the 1980s, a different age, but with no family around I needed and received so much loving support from going to LLL meetings. They give so much more than breastfeeding advice. I met a roomful of mothers and infants some of whom I still run into today. From the well-trained, experienced, compassionate and wise leaders I got so much information and advice about ALL aspects of caring for young infants and toddlers as well. And the child-rearing advice and philosophy is THE BEST. They knew then and know now the importance of the mother-child bond, the importance of fulfilling the needs of the infant and mother. I am often heartbroken by our culture that requires mothers to return to work within weeks or months of birthing. That baby needs you and you need her/him. Time put into bonding and caring fully for a baby and young child pays off 1000 fold because that baby will grow into a respectful happy and loving human. Priceless.

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  20. Thank you! In the 70s we called these helpers "doulas." I haven't heard that term in a long time. Are there still doulas out there? MAybe that's something our ACA could institute.

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    1. Doulas are available today, in most major cities in the US, but most charge

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  21. I agree with you, Sophia, and I only had one week of my mother coming and helping after both of my pregnancies. I wanted help, but I think since in recent generations, the woman seemed to be expected to happily do it all, it was like, well, you should be able to do this all by yourself kinda expectation because I was and still am a stay at home mom. I was completely sleep deprived, and wished that there was another non-working family member that could stay with us in my home and help me 24/7 with housework and cooking. I breast fed, so the first month was especially tough with both of my children, because I was feeding them every hour and a half around the clock. I heard that in other cultures, there were groups of women that would stay with new moms and post pregnancy moms for upwards of half a year. That idea sounded fantastic to me! I wish that was the case for every mom.

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  22. I hear what is being said but I think there is a danger of ignoring the fact that many women DO suffer from post partum depression despite having amazing love and support from their husband/partner and family. I had a much wanted baby at 39 with the most loving, caring and hands-on husband who cherished both myself and our baby. Despite this I suffered from post natal depression and would sit with my baby in my arms and just cry because he was so beautiful. I ended up five years later with severe panic attacks and a major depression due to the job I was doing. Fifteen years later and three stays in a mental health clinic and I take my meds religiously every day and am able to function effectively in all areas of my life. The hormonal causes of depression are very real and need proper treatment - both with medication and therapy. I support your call for more support of new moms - it's essential - but if you are one of those mom's get medical help if you need it too.

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    1. Thank you for your comment. I agree that family support is not the only factor, and certainly hormonal changes of pregnancy have a role to play in development of postpartum emotional complications. Here is how I address the issue in my forthcoming book.

      "Effective treatment of postpartum depression must include opportunity to address the issue in its full social and interpersonal context. This calls for acknowledging the massive biological and psychological shifts of motherhood, the reorganization of the relationship between parents, the role of the baby, as well as the normal ambivalence that accompanies this developmental phase. All this may be distorted in the setting of social isolation, severe sleep deprivation, and unrealistic expectations of rapid return to pre-pregnancy function."

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