Postpartum Depression

Denise Boyle
Buffalo Grove, Illinois, USA
From: LEAVEN, Vol. 29 No. 4, July-August 1993, pp. 53-4, 58

We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time

Sue is a Leader in the United States Western Division who became a mother for the first time seven years ago. Her son was born by cesarean section after a twenty-eight hour labor. Sue remembers having a slight case of "baby blues" a day or two postpartum. "I can vividly recall staring at the tray of food that was brought to me in the hospital the day after my son was born. I remember staring at the tray and crying . . . just crying and crying. It seemed positively overwhelming to have to eat what was on the tray. Later that day I was told that I needed to walk in order to recover. That too seemed overwhelming, and tears just poured down my face as I pushed the baby up and down the hall. I couldn't cope with even the smallest degree of frustration. By the next day, it was over. I felt fine."

Julie, a Leader in the Eastern US Division, remembers a time three months after the birth of her second child: "I had been raised not to complain, so I didn't, but I was very depressed. My pregnancy had been very difficult and I was on bed rest for much of it. My baby was healthy and I couldn't understand what was wrong with me. I remember telling my best friend, 'I could drive away today and leave my husband and the boys, and not care, and not look back.'

"Susie, a mother in Illinois, had a wonderfully healthy pregnancy, and a successful home delivery. Although her daughter was born with a deformity, she was very healthy, and Susie was able to breastfeed the baby. But in the months after the baby's birth, she struggled with depression that would not go away. When the baby was six months old, Susie was hospitalized at her own insistence because she was afraid she would not be able to control her suicidal feelings.

Sue, Julie, and Susie have all had experiences with postpartum depression (PPD), to various degrees. The term PPD (or PND, Postnatal Depression, in some countries) itself is controversial, as are many other aspects of the condition. There is no official psychiatric diagnosis, and there is widespread disagreement about causes and risk factors. Research is often contradictory and inconclusive. The question of whether postpartum depression is unique to the childbearing experience, or is an expression of an already existing depression or a tendency toward depression, is debated in professional circles.

What is clear are the fear, misery, and isolation of women who experience it. LLL Leaders are in close and regular contact with women in the early postpartum period. We are in a position to offer empathy and support to a mother who is having difficulty adjusting to motherhood, whether for her first or fifth time. But just as we need to know when a physical problem requires the attention of a professional, it is important for us to be aware of the possibility that the adjustment period may need the attention of a professional, too. (Although support may be enough for some women, others may need professional help.) Believing in the mother's perception of her situation and emotional state is critical. Women are often hesitant to express their concerns for fear that they will be labeled as crazy, maladjusted, or bad, uncaring mothers. Acceptance of feelings without minimizing them or judging may be the single most important thing we can offer a mother suffering from PPD.

What Is Postpartum Depression?

Carol Dix, a medical writer and mother with a personal interest in PPD explains in her book, The New Mother Syndrome, that PPD falls into three categories. The first is a mild form that usually dissipates within two or three weeks after the delivery. Commonly referred to as the "baby blues," it is characterized by onset within a few days of birth, uncontrollable weeping, feelings of being overwhelmed by the demands of a new infant, and isolation. Although this usually disappears in a short time, women who have experienced it report that it can have an effect on how they feel about their babies and themselves as mothers. It leaves some women anxious, confused, and worried about their maternal instincts. It is estimated that at least two-thirds of new mothers experience the "baby blues."

The second type of PPD is a more severe, longer lasting depression. It may begin as early onset "baby blues" that never go away or may not appear until three weeks to six months after the birth of a baby. This depression lasts longer and is more severe. Women report feelings of lack of concern for the baby, loss of appetite, inability to sleep, and overwhelming feelings of futility and sadness. Obsessive thinking and irrational fears are also symptoms. Estimates for the number of women who experience this type of depression range from 10% to as high as 30%.

The third and most severe type of postpartum psychological disturbance is known as postpartum psychosis. It is characterized by dramatic changes in behavior, including memory loss, auditory and visual hallucinations, depression, and severe mood swings. Hospitalization and antidepressant medication may be recommended. Postpartum psychosis appears during the first few weeks after birth, and affects one in one thousand postpartum women.

What Causes It?

Much of the medical controversy surrounding PPD centers on the question of its cause. Although many authorities suspect a hormonal basis, social and adjustment issues cannot be ruled out. At least one study found a lessened incidence of depression in traditional societies that provided a ritual transition period for new parents.

The authors of this study note that a review of scholarly anthropological literature on childbirth shows remarkably little evidence of PPD. For example, according to one observer of Chinese households, more attention is lavished on the mother, relative to the newborn infant, than in the United States. Extra attention from their families and social networks seem to preclude Chinese women from experiencing PPD as understood by Western cultures. However, the same biological factors are obviously present. It is interesting to note that fathers, adoptive mothers, and stepmothers also report depression that coincides with the arrival of a child, however much that child is loved and wanted. According to a study recently published in Pediatrics, the journal of the American Academy of Pediatrics, women with pregnancy complications are three times more likely to suffer PPD. The expectations of parenthood often clash, sometimes harshly, with the realities. The fantasy of being a perfect parent and the expectations of others may contribute to feelings of inadequacy. Isolation and loss of identity were cited as issues that contributed to depression among new parents who could not be considered postpartum. There is also speculation that nutritional deficiencies may be to blame, at least in part. Hypothyroidism has been linked to depression in some individuals. A drop in thyroid levels occurs naturally during the postpartum period.

Sometimes a mother who is depressed may believe that breastfeeding is causing her problem. Although some studies indicate that depression is more prevalent among nursing mothers, these studies don't screen for other factors, such as social isolation or lack of support from family members. Breastfeeding is not a contributing factor to postpartum depression. In fact, the hormonal changes after birth occur more gradually when a mother breastfeeds.

Until there is a definitive cause found for all cases of PPD, it seems reasonable to assume that it has many causes, and that reasons may vary from individual to individual.

How Leaders Can Help

Most people are aware of the existence of the early "baby blues." Mothers expect it to hit while they are in the hospital. Some even plan for it, warning husbands and older children. Still others may not be aware of it, or may not believe it will happen to them. A brief mention of the existence of postpartum depression at a series meeting, (which should not detract from the main focus of the meeting) may be appropriate, and may prepare a mother for the possibility. Mothers often contact us during the first week after birth, when they are most likely to be experiencing the blues. We can be sensitive to the possibility that mothers' feelings about breastfeeding and mothering in general may be affected by the blues. Patience, willingness to repeat information several times, and gentle supportive reinforcement of her nurturing skills are all helpful. Since the blues usually disappear on their own, nothing more than reassurance and the passage of time are needed.

Postpartum psychosis is a frightening and devastating mental illness. Women afflicted with it are often a danger to themselves and to their families, especially their newborn infants. This situation is obviously outside of our expertise, but a Leader may find herself in contact with a mother with postpartum psychosis as the result of contact initiated during pregnancy. If a Leader suspects that a mother may be hallucinating or intends to harm her infant, it is vital that a family member be notified so that professional help can be enlisted immediately.

A mother with depression that lasts longer than a few weeks or depression that appears suddenly more than three weeks after the baby's birth may have a case of PPD. A mother suffering from PPD:

* May be uncharacteristically withdrawn

* May be uninterested in personal hygiene/appearance

* May exhibit extreme concern about her baby's health

* May also express a feeling of not being connected or bonded to her baby.

Julie, the Leader who expressed a desire to drive away and not look back, says the single most important thing Leaders can do for a depressed woman is to believe in her perception of her feelings. Minimization of the mother's problem is common, since most people are uncomfortable with depression in any case, and especially so in the case of a new mother, who "has everything to be grateful for.'' Julie felt unable to express her own deep feelings of sadness to anyone in her immediate family circle. A Leader's willingness to listen and take the mother's feelings seriously can make a great difference. A woman whose thinking is obsessive, centering on fears that appear to have no rational or factual basis, or whose concerns appear morbid should be encouraged to tell her doctor so that he or she will be able to distinguish between baby blues and serious depression. A woman who has a perfectly healthy baby, but constantly worries that the infant will contract a rare or debilitating illness, or who seems out of touch with the reality of her infant's condition, may fall into this category. She could also be steered in the direction of a support group for women with PPD. Martha Leathe, a Leader from Maine, noted in Mothering Magazine, "One of the most effective and surely the safest means of combating PPD is through contact with other women who have experienced it, or are at least sympathetic to it. Getting in touch with other mothers is wonderfully therapeutic because it solves so many of the problems associated with PPD."

Involvement in an LLL Group can also help a mother overcome feelings of isolation. One mother said, "I looked forward to any reason to get out of our house. Having other mothers to talk to on a regular basis really made a difference in my outlook. "Leaders frequently receive calls from mothers with PPD who need information about the effect drug therapy will have on the nursing relationship. The safety of prescription medication is of great concern to mothers. Weaning is often advised by physicians who may feel the woman's emotional state is aggravated by the hormones produced by lactation. Some doctors believe that a quick return to the pre-pregnancy hormonal state facilitates recovery from PPD. However, little attention is paid to the effect on the infant, and consequently, on the mother's relationship with her baby.

Although we are not qualified to answer medical questions, we can help the mother formulate questions which will enable her, her partner, and her health-care provider to make a decision that is fully informed. As breastfeeding advocates, our role is to inform mothers of the very real benefits of continuing to breastfeed, and to help her understand the ramifications of her decision to wean in order to receive drug therapy. Every woman's situation is unique. A mother struggling to deal with suicidal urges is in a different position from one who may need a stronger support system or education about what constitutes normal newborn behavior. As in many situations, a Leader's role is to help a mother evaluate her options. The question is whether or not artificial feeding has more inherent risks than continuing to breastfeed while on medication. Questions about specific drugs should be handled on an individual basis. New information is constantly available. Our Professional Liaison Department is there to provide us with the information we need in order to help mothers. Some mothers have continued to nurse while on medication. One option, which is recommended by the American Academy of Pediatrics when there is a question about a drug, is to have the doctor regularly monitor the mother and the baby. (For more information see "Exploring Options When the Doctor Recommends Weaning" from THE BREASTFEEDING ANSWER BOOK, page 385.)

Leaders can be an especially important source of support for mothers with PPD. Few other resource or support people offer the degree of empathy and personal interaction Leaders do. Our own experiences as mothers enable us to respond to women in this situation with compassion and understanding. Our personal breastfeeding expertise, combined with the resources of LLLI, the world's foremost authority on breastfeeding, give us the ability to offer a unique combination of support for the nursing couple along with current information regarding treatment options and their impact on the nursing couple.

References

Burger J, et al. 1993. Psychological sequel of medical complications during pregnancy, Pediatrics 91, (3): 566-71.

Dix C. The New Mother Syndrome, Coping With Postpartum Stress and Depression. Pocket Books, New York, NY, 1985. Leathe, M. Post-partum depression. Mothering Magazine, No. 45, 72-78.

Mohrbacher, N. and J. Stock. THE BREASTFEEDING ANSWER BOOK. La Leche League International, Franklin Park, Illinois, 1991.

Stem G. and L. Kruckman. 1983. Multi-disciplinary perspectives on post-partum depression: an anthropological critique. Social Science Medicine, 17, (15): 1027-41.