Who could have guessed that THIS reduces the risk of postpartum depression?

Health Visitor With New Mother Suffering With Depression

Why are natural childbirth and breastfeeding advocates relentlessly looking for a physical cause for a mental health problem?

As part of their ongoing effort to demonize both C-sections and formula feeding, they seem desperate to show that mode of birth or “failure” to breastfeed are risk factors for postpartum depression. But why would anyone think that a mental health problem had a physical cause? And wouldn’t the best place to look for risk factors for a serious mental health problem be psychological issues?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Women who were psychologically flexible and able to be compassionate to themselves were at lower risk of postpartum depression.[/pullquote]

According to a 2016 review in the New England Journal of Medicine:

…Symptoms of postpartum depression often include sleep disturbance (beyond that associated with the care of the baby), anxiety, irritability, and a feeling of being overwhelmed, as well as an obsessional preoccupation with the baby’s health and feeding. Suicidal ideation and worries about causing harm to the baby have also been reported. The strongest risk factor for postpartum depression is a history of mood and anxiety problems and, in particular, untreated depression and anxiety during pregnancy.

We already know factors that impact mental health play an important role:

…including low social support, marital difficulties, violence involving the intimate partner, previous abuse, and negative life events.

“Wait,” I hear natural mothering advocates cry, “what about hormones?”

The rapid decline in the level of reproductive hormones after childbirth probably contributes to the development of depression in susceptible women, although the specific pathogenesis of postpartum depression is unknown.

The impact is serious:

Postpartum depression results in maternal suffering and diminished functioning and is asso- ciated with increased risks of marital conflict and impaired infant–caregiver attachment, as well as increased risks of impaired emotional, social, and cognitive development in the child, and in rare cases, suicide or infanticide.

Given the high incidence, serious nature and profound effects of postpartum depression, we should be doing everything we can to prevent it. A new paper to be published in the March issue of the Journal of Affective Disorders asks the critical question, What protects at-risk postpartum women from developing depressive and anxiety symptoms?

The authors describe the problem:

The adjustment to motherhood is marked by a range of different internal experiences, including negative thoughts and emotions. However, societal ideologies highlight that a normative response to motherhood is the presence of immediate and continuous feelings of happiness and joy. These expectations of motherhood may lead to women having more difficulties accepting their internal experiences, such as negative thoughts and emotions, when they do not reflect such ideals…

They found:

Women not presenting depressive and anxiety symptoms reported significantly higher levels of psychological flexibility, nonjudgmental appraisal of thought content and self-compassion than women presenting depressive and anxiety symptoms. Hierarchical logistic regression showed that women with higher levels of psychological flexibility (OR = 1.06, CI: 1.01–1.12) and nonjudgmental appraisal of thought content (OR = 1.33, CI: 1.15–1.53) had a significantly higher likelihood of not presenting depressive and anxiety symptoms.

They explain:

Consistent with previous studies, our results showed that women presenting no depressive and anxiety symptoms reported significantly higher levels of psychological flexibility, nonjudgmental appraisal of thought content and self-compassion when compared with women presenting depressive and anxiety symptoms. We also found a significant negative association between these variables and depressive and anxiety symptoms… Thus, these findings corroborate our hypothesis that a more accepting and self-compassionate attitude towards private events in the postpartum period for women presenting a risk for PPD is associated with lower levels of depressive and anxiety symptoms.

Women who were psychologically flexible and able to be compassionate to themselves were at lower risk of postpartum depression. Unfortunately we live in the milieu of natural mothering ideology that is psychologically rigid and so far from compassionate as to be cruel:

…[T]he social idealization of motherhood can hinder the acceptance of negative private thoughts and emotions during this period and lead to maladaptive avoidance strategies, which have a significant impact on the psychological adjustment of postpartum women…

The authors conclude:

Our results suggest that a tendency to be more accepting and nonjudgmental of internal experiences might be beneficial and that promoting this tendency could be an important feature of perinatal psychological prevention interventions…

That’s why, for example, the insistence of lactation professionals that breastfeeding reduces the risk of postpartum depression is such an egregious lie.

It is a lie because we know that the risk of postpartum depression depends on intention to breastfeed not on the process of breastfeeding itself.

New Evidence on Breastfeeding and Postpartum Depression: The Importance of Understanding Women’s Intentions found:

…[T]he effect of breastfeeding on maternal depression symptoms was found to be highly heterogeneous and, crucially, mediated by breastfeeding intentions during pregnancy. Our most important finding relates to the majority of mothers who were not depressed during pregnancy, and who planned to breastfeed their babies. For these mothers, breastfeeding as planned decreased the risks of PPD, while not being able to breastfeed as planned increased the risks.

Furthermore:

For the majority of mothers who did not show symptoms of depression before birth, breastfeeding … increased the risk of PPD among mothers who had not intended to breastfeed.

When women could not meet their own goal of breastfeeding, the risk of postpartum depression doubled. And the exact same thing happened when women who did not want to breastfeed were pressured to do so even when they were able to successfully breastfeed. If breastfeeding itself were protective, that would not have happened.

The claim that of lactation professionals that breastfeeding prevents postpartum depression is a particularly heartless lie for two reasons. First, they are the ones who have exaggerated the benefits of breastfeeding out of all proportion to reality. Because of their claims of (mostly debunked) benefits, women pressure themselves to breastfeed. Second, when these women have trouble, either because of insufficient breastmilk, pain or other cause, lactation professionals refuse to demonstrate psychological flexibility or compassion.

The bottom line is that while postpartum depression may have physical components, nearly all risk factors are psychological. If lactation professionals cared about women (as opposed to breastfeeding rates) they would stop lecturing, hectoring and shaming them. I’m not holding my breath that will happen anytime soon!

  • GeorgiaPeach23

    Thank you, Dr Amy. I took this to heart and restarted therapy 3 weeks post partum when BF wasn’t working.

  • Lisa

    Never being AWAY from the baby might contribute to depression too. I don’t mean weeks away–minutes to one’s self can make a huge difference.

  • mabelcruet

    OT. For some reason, this post is trending on Buzzfeed and a friend sent me the link:

    https://www.buzzfeed.com/hilarywardle/stop-calling-the-midwife

    It’s basically a list of complaints (we work such long hours, such long shifts, we don’t get breaks, we don’t get a drink, we don’t get enough holidays, we don’t get paid enough, we cry a lot because of our job, our job is emotionally draining and we just can’t give anymore), alternating with a list of inaccurate information (we are responsible for removing babies-no, they aren’t, that’s social workers. We are responsible for ‘the life, health and wellbeing of more than one person’-not really, if things go tits up its the obstetricians and the neonatologists). Even the positive comments are accompanied by a whine-we love cuddling babies, even though we don’t have enough time for it really. And then comments loading on the guilt-all parents love their baby immediately, partners are badly behaved and we tell them off for it.

    Is it me? Does this not read really badly and give a very poor impression of midwives as a whole? Personally, if you aren’t able to maintain sufficient detachment during work to allow you to work professionally, and instead cry a lot and are emotionally drained, should you actually be working?

    Maybe its just me, but it has irritated me rather.

    • No I completely agree with you. empathy, not sympathy, we used to be told when we were nursing students. Detachment is essential for a good professional if you are going to give the best care.

    • Mattie

      It seems very UK focussed, so no midwives aren’t entirely responsible for the life and health of mothers and babies (and we have sadly seen what happens when they try to be) but they are generally the ones responsible for managing the basic care, noticing when things aren’t going right, and actually managing some low-level complications.

      Also with removing babies, technically it’s the court that removes children (they give the order). Midwives and social workers can work together to physically get the baby from the room, a social worker might not be present for the birth so the midwife could deliver the baby and then physically take it away.

      I do agree that this post did seem a little whiney, but also I think you’re being a little harsh. It is emotional sometimes, and I’d rather have a care provider that cared deeply for me and was therefore emotionally impacted, than a provider who didn’t care or didn’t seem to care. But that might be personal preference.

    • rational thinker

      I agree it was rather whiney.

  • demodocus

    so, people at an increased risk of depression are more likely to get depressed when they have a baby? shocking.

  • crazy mama, PhD

    The widespread biological essentialism around postpartum depression is so frustrating, because we know that dads / non-gestational parents experience it too! At lower rates, yes, but men are also less likely to be the primary caregivers and less likely to be judged on their parenting choices.

    Postpartum hormones ARE powerful, but for me, the effect of hormones was the “baby blues” phase, that first week-ish of weird emotions and sudden, inexplicable sadness. The depression came later.

  • AnnaD2013

    Thank you for the clarification of the relationship between PPD and breastfeeding. I was very attached to the idea of breastfeeding (new mommy brainwash), and that all of my friends who were moms breastfed w/o issues. When I “failed to breastfeed,” I was devastated, and I truly suffered mental anguish over giving my daughter formula. At 5 months post partum, I was finally diagnosed with PPD/PPD/PTSD due to birth trauma; and it took months of treatment and counseling and reading the right research before I could unwire myself from that anguish over only breastfeeding for about 4 months when my plan was a year or more. Speaking from personal experience, the breastfeeding component was A HUGE cause of my PPD/PPA. There were other factors, but BF’ing was intwined with all of them.

    • MovingOn

      I had a similar experience, but didn’t seek help for 15 months because of the epically shitty social support I had. I assumed any counselor I saw would either call CPS or be just like the assholes in my life who didn’t understand my traumatic birth or difficulty with breastfeeding. I wasn’t allowed to heal mentally or physically before having to triple-feed my son, and at that point I just wanted to do something “right” for him.

      I did eventually successfully EBF him, until he was 14 months old in fact! but the first two months of pumping, formula feeding, and attempting to nurse were horrific.

      And the whole time, nobody asked me what had happened or how I was really doing. Just told me it was “hormones” and “baby blues” and to get my thyroid checked. I went through the new mommy brainwashing and it all blew up in my face leaving me with serious trauma, and the problem was my fucking THYROID? Not my history of depression and anxiety, not me living out in the middle of nowhere with no friends or family nearby, not my traumatic c-section that I was not at all prepared for and struggling to both process mentally and recover from physically? you sure the problem is my fucking THYROID?

      My son is 2 and a half now and I’m still pissed, as you can tell.

  • Glia

    I just had this crazy vision of replacing the part of childbirth classes where they have women focus on visualizing and planning how they will give birth with self-acceptance meditation. You don’t write a birth plan, you write a POST birth “survival plan”. You don’t focus on how to avoid an epidural, you focus on how to avoid feeling like you failed if you decide you want one. Partner still practices giving back rubs though, that part can stay.

    • fiftyfifty1

      This is SUCH an excellent idea!

      • Glia

        Well, it would have helped me a heck of a lot more than all the detailed discussion about Why C Sections Will Make Your Baby Stupid (And Also Hate You), that’s for sure.

    • Zuul

      This is brilliant.
      Post-birth survival plan – I love it!

      Seriously, I hope people start teaching this.

  • rational thinker

    Andre Yates was not a monster. In fact she loved her children very much. She always had mental issues but was in and out of treatment and on and off meds. She was told by doctors after a few kids not to have any more. Her husband had no intention to stop having kids, his religion made it clear to have a large family and he was the head of the family(according to their church) and she knew she could not say no. What makes this more of a tragedy is the fact that they were told something like this could happen. I guess they thought the church knew better than her doctors. This was someone already at risk then you add PPD and its a perfect storm. We should learn from it not ignore it.

    • Spamamander ctrl-alt-right-del

      I have always felt for her. Trapped with no way she could see out, declining mentally, then finally going into a psychosis that resulted in tragedy. She has to live knowing what she did forever.

    • KeeperOfTheBooks

      Yep.
      I belonged to a really out-there traditionalist Catholic church when I was a kid. When I say “out there,” I mean it: the Pope was a raging liberal commie (yes, seriously, JPII…one of the guys responsible for the fall of communism in Eastern Europe) heretic, the bishops were likewise evil nasty vile commie heretics, we all had to homeschool and the women wear long skirts and sleeves because the world is evil, and, you guessed it, even the mainstream church’s views vis-à-vis birth control, conservative though they certainly are by general standards, were part-n-parcel of the vague New World Order Commie Plot to Take Over The Church from within by allowing couples to use NFP. *facepalm*
      I had a friend who was about my age, 15-16 or so, and the oldest of what became 10 kids by the time we were that age. Apparently, mom had a total mental breakdown with Kid #10, to the point of leaving, moving in with her parents, and not getting out of bed for weeks. That left the girl to run the farm, take care of the newborn and the other eight (homeschooled!) kids, and so on while Dad worked.
      That church did squat, aside from gossip about how ungodly mom must be to suffer from PPD or PPP or whatever it was. The family basically got shunned for not fitting the narrative, and even more so when mom got some much-needed mental health help (psychology is the work of the devil! You just need to pray more! If you play around with letters and numbers enough, DSM spells 666!). Then dad came to his senses after a couple of weeks, put his foot down, and enrolled everyone in (Gasp! Shock! Horror!) public school. They left that church shortly thereafter. Naturally, there was generalized Shaking Of Heads over How People Fall.
      Indeed.
      Personally, I’ve always been very, very glad mom DID get help and that she didn’t reach the point that Andrea Yates did, but then I kinda fled screaming a thousand miles away as soon as I turned 18, so I could be a tad biased. 😉

      • demodocus

        I’m glad the dad finally saw the light, the mom got help, and your friend wasn’t stuck with all the things

        • KeeperOfTheBooks

          So am I. So am I.

      • rational thinker

        I know what you mean. My bipolar husband joined a church cult and they told him there was no such thing as mental illness and then they would complain about his behavior. I had to pretend to join just to get him out. I had to do it slowly so it took me about two years to get him out. I saw a lot of shit during that time. It was sad how they treated people. The pastor was obsessed with exercise and did not like fat people so he would make people go on lemonade only fasts for a month at a time (even children and diabetics), and his wife (who seemed terrified of him) was always pregnant. Last we heard the kid total was 13. She could very well be the next andrea yates. She told me privately that she didn’t want anymore after the twins which were children 8 and 9.

        • KeeperOfTheBooks

          Egads. I’m so glad you and he got free of that church! They aren’t all like that, of course–my current parish, for example, has the loveliest, most supportive clergy I’ve ever met–but oh man, when a church is toxic, it’s TOXIC.

  • Amy Tuteur, MD

    My new piece on Slate: Will the Tide Ever Turn on Breastfeeding?

    https://slate.com/technology/2019/01/breastfeeding-mothers-recommendations-not-universal.html

    • Nicely done. I think the tide is turning–my hospital, and a few other commenters’ hospitals, have rejected the BFHI, and my sense on “mommy groups” is that it is no longer as fashionable to denigrate formula feeding. It will probably be a long time before the subject of infant feeding is considered in a reasonable manner, however, because of the biases you describe in your article.

    • fiftyfifty1

      Congrats! Your work is turning the tide.

    • Zornorph

      I’ve been having fun commenting on there. I’m also a mod on Slate, so been able to delete a few posts that crossed the line attacking you.

      • AKKW

        So you are blatantly filtering the conversation to show your biased? Used to be a Slate reader. No more. I’ll have fun exposing this to them.

        • Azuran

          My god, removing personal attacks is not being biased. If slate has rules against throwing personal insult, then it’s only normal that such comments are removed.
          If one wants to be part of a debate or a discussion, then they should be able to debate without spitting at other people’s face, if they can’t, it’s only normal they be removed.

        • Zornorph

          On Slate, personal attacks against the author of a piece are not allowed. Mods always remove those. Sorry if that gets your dandruff up.

        • KeeperOfTheBooks

          I assume, and Zonorph correct me please if I’m wrong, that he means he’s removing personal threats and attacks, ie “Dr. Tuteur is wrong because X, Y, Z,” would be allowed, while “Amy is a *c-word* *b-word* who HATES WOMEN!!!Eleventy!” gets pulled.

          • rational thinker

            He probably means the death threats.

          • KeeperOfTheBooks

            *winces* You’re probably right, and again, can’t really see how it’s unreasonable to remove such stuff.

        • rational thinker

          I think by personal attacks he means death threats and other physical harm. Yes those should be removed.

      • Amy Tuteur, MD

        You don’t have to do that on my account although it certainly elevates the level of discussion!

    • Amazed

      I can’t reach the piece from this link. In fact, I can’t reach it from your facebook page either. I’ll try directly from Slate.