Postpartum depression is a psychiatric illness, not a marketing opportunity for natural childbirth advocates

Alone

To a hammer, everything looks like a nail. To a natural childbirth advocate, everything looks like an opportunity to push her agenda.

It was ugly when natural childbirth advocates expropriated the tragedy of maternal mortality among women of color — a tragedy largely rooted in socio-economic conditions — to claim, falsely, that these deaths reflect the failure of modern obstetrics. Their solution? Providing the natural childbirth services that privileged women want.

Jennifer Block’s recent piece on postpartum depression is cruel, deadly, self-serving bullshit!

Now it’s ugly when Jennifer Block and Alisa Alpert (a natural childbirth celebrity and doula respectively) are trying to expropriate the tragedy of postpartum depression — a tragedy of serious psychiatric illness — to claim, falsely, that it is the result of the pressures of capitalist societies. Their solution? You guessed it! Providing the natural childbirth and lactivist services that privileged women want.

Referring to the first ever approved drug for the treatment of postpartum depression, Block and Alpert write:

Postpartum depression is a serious problem, affecting, by some estimates, one in nine American mothers. It can be incredibly painful and is believed to be a growing cause of maternal deaths in the year following a birth. Insurers are expected to cover the exorbitant cost of Zulresso, which suggests that there’s finally a will to address our country’s dismal record on maternal health. Hurray!

But if we really want to tackle postpartum depression, we need more than a drug…

The clinical definition of postpartum depression is a “medical complication of childbirth,” but this doesn’t take into account women’s emotional lives, and the fact that the way our culture treats some new mothers amounts to abuse.

That, not to put too fine a point on it, is bullshit!

What is postpartum depression?

Postpartum depression (PPD), the onset of depressive episodes after childbirth, is the most common postnatal neuropsychiatric complication. Postpartum depression affects 10% to 20% of women after delivery, regardless of maternal age, race, parity, socioeconomic status, or level of education.

It is NOT the mild, self limited alteration in mood experienced by many women in the postpartum period:

Postpartum blues occurs in 50% to 80% of new mothers. Signs and symptoms appear within 1 to 2 days postpartum and include depressed mood, anxiety, tearfulness, irritability, poor appetite, and sleep problems. These changes are mild and resolve spontaneously within 10 to 14 days …

In contrast, symptoms of postpartum depression include: persistent depression, persistent loss of interest and pleasure in previous enjoyable activities, changes in appetite, changes in sleep, persistent fatigue, difficulty concentrating, feelings of worthlessness, thoughts of suicide.

In other words, postpartum depression is major clinical depression in the peripartum period.

It is critically important to understand that while any major depression, including postpartum depression, can be exacerbated by socio-economic problems, socio-economic problems do NOT cause major depression including postpartum depression. It is a MEDICAL ILLNESS with an ORGANIC cause, even if we don’t yet know the exact cause. As anyone who has ever loved or cared for a person with major depression learns, no amount of love and support can prevent it, treat it or cure it. Only therapy and medication can do that.

A drug that can treat postpartum depression specifically is a major medical breakthrough! I have no idea how well it works or whether it will work at all, but it marks an important milestone: a recognition that postpartum depression is a disease.

Not according to Block and Alpert:

Pregnant women are often pickled in horror stories about birth, then subjected to unnecessarily intrusive care. Many suffer pelvic trauma; one in three wind up with major abdominal surgery. Then they are sent home with a newborn, typically without support. According to 2015 data, a quarter of women return to work in two weeks. Everyone says that “breast is best,” but new mothers get a decent place to pump at work only if they’re lucky. Most won’t see their doctor again for six weeks. No wonder depression is so common.

As one mother we know who plans to quit her job (because she can afford to) said about the lack of parental support in this country: “It’s just so mean.”

A new expensive drug is not enough; we need humane, evidence-based maternity care, respect for the “fourth trimester,” months if not years of paid parental leave, and affordable child care.

Bullshit! Bullshit!! Bullshit!!!

Postpartum depression exists in every time, place and culture: those with high C-section rates and those without access to C-sections; those in which mothers return to economic employment and those where they are not allowed to work; those with high breastfeeding rates and those with low breastfeeding rates; those with easy access to doctors’ visits and those with no doctors; those with evidence based maternity care and those without; those that provide copious postpartum support and those with none; those that provide parental leave and those that don’t; those that provide affordable childcare and those that provide no childcare of any kind.

That’s because it is a MEDICAL ILLNESS with an ORGANIC cause, not a barometer of socio-economic conditions.

Block and Alpert write:

We’d be foolish to believe that any drug is the magic fix that will once and for all end the metaphysical conundrum of experiencing fear, sadness, anger and despair during the most vulnerable time of our lives.

Bullshit! Postpartum depression is NOT a metaphysical conundrum any more than schizophrenia is.

If insurers are willing to throw down tens of thousands of dollars for a mother’s mental health, we can think of some alternatives that might have a better cost-benefit ratio: Six months paid leave. A live-in doula and a private sleep-training coach. Weekly massages and pelvic-floor rehab sessions. Relocation to a commune in the Bahamas.

Would they dare recommend six months paid leave, a live-in doula, weekly massage and a tropical vacation as a cure treatment for schizophrenia? I doubt it because they understand that schizophrenia is a serious psychiatric illness, not a manifestation of stress. Postpartum depression is a serious psychiatric illness, too, and pretending that a tropical vacation could prevent, treat or cure it is both flip and disrespectful.

In the meantime, we fear that Zulresso is just a stopgap, and yet another instance of pathologizing a very sane reaction to our very insane culture.

Bullshit! Cruel, deadly, self-serving bullshit!

  • JDM

    If insurers are willing to throw down tens of thousands of dollars for a
    mother’s mental health, we can think of some alternatives that might
    have a better cost-benefit ratio: Six months paid leave. A live-in doula
    and a private sleep-training coach. Weekly massages and pelvic-floor
    rehab sessions. Relocation to a commune in the Bahamas.

    Sure, why not; of course that would be several times more expensive than therapy. It would disrupt people’s lives enormously. And it ultimately wouldn’t work as well (although I’d think six months paid leave in the Bahamas and massages would help a lot of people). But of course it’s not a serious suggestion; they’re quite comfortable making jokes at depressed new mothers instead.

    • GeorgiaPeach23

      Are they bitter that insurance pays for medication but not always for their services? Or are they angry that women might get real health care? Seems the doula doth protest too much: if she was in the business of providing bona fide health care, insurance would reimburse her, too.

  • rational thinker

    I wonder what Florence Leungs husband would have to say about that article.

  • Anna

    Same shit going on here. Doulas posting about how no woman would need PND drugs if they all just had nacheral birfs and breastfed. Ugh.

  • rational thinker

    So all Andrea Yates needed was a tropical vacation? These two women are just a couple of privileged assholes or they have their heads up their asses, or both.

    • swbarnes2

      Can I just say, it sucks that Andrea Yates has become the household name, and not her husband Rusty Yates, who forced her to keep breeding, knowing how it was devestating her health and well being. If she pulled the trigger while not of sound mind, Yates definitely put the gun in her hands knowing she was a wreck.

      • rational thinker

        You are absolutely right. I have always been angry about that and he is at least 50% at fault for what happened.

        • rational thinker

          Whenever I think about those kids I get angry at him not her. I think a lot of people just think she was sick of the kids and killed them. They dont take the time to learn what actually caused this tragedy. I have nothing but sympathy for that woman.

          • StephanieJR

            Me too. It’s very clear that she was spiralling into psychosis, and yet he impregnated her against the advice of her doctors, then left her and the children alone despite being explicitly told not to, and unfortunately that poor woman’s mental health deteriorated enough that she sadly killed her children.

          • rational thinker

            Someone should have been with her if he had to go to work. Both she and the kids needed a babysitter. He was told she should not be alone with the kids. The saddest part is that because of shitheads like the 2 women who wrote that article and the natural ideology being pushed on vulnerable women something like this WILL happen again.

          • mabelcruet

            And he claimed that the psychiatrists had never warned him she had psychosis or that she was at risk of harming herself or her children. And tried to blame the deaths on the doctor for changing her meds. I hope she’s getting mental health support now, but prison medicine being what it is, I doubt it.

      • Sarah

        What an abusive arsewipe.

      • PeggySue

        She’s in prison for the rest of her life and he got to remarry and have at least one more child.

  • BeatriceC

    I have a lot to say on this topic, so let me see if I can condense it down to reasonable comment length.

    Dealing with perinatal mood disorders is complicated at best. These people aren’t entirely wrong. There are social factors that contribute to incidence and severity of all of the mood disorders. And while lack of appropriate “support” in the form of adequate maternity leave in the US is part of the problem, it’s certainly not the only problem, and I’d venture to say not more than marginally significant.

    Most of you know I run a large peer support group for people with perinatal mood disorders. So while I am not a licensed mental health professional, I do work with people every single day who are dealing with these issues. I hear the stories every single day. My own observations are, of course, not a scientific study, but they absolutely indicate that we need to do more research, and actually listen to the people who are living with mood disorders. Based of what my observations, here are my sticking points for social factors that contribute to the development or increase the severity of perinatal mood disorders:

    1. Inadequate expectations of the reality of childbirth. NCB has done a great job of convincing people that childbirth is inherently safe, so when complications arise, gestational parents are ill equipped to deal with them. They feel like failures, or that they did something to cause the complication. Sometimes this becomes a downward spiral as the pregnant person clings to the myth of a easy “natural” labor and delivery, refusing earlier interventions that may have been less invasive or traumatic until there’s a full scale crisis. These people often develop PTSD in addition to depression and/or anxiety.

    2. Breastfeeding pressure. We’ve discussed this multiple times so I don’t think it needs to be rehashed.

    3. Inadequate expectations to the reality of having a newborn. First time parents are often expecting this magical experience that is so often described in mommy blogs. It’s a fairy tale, and when reality doesn’t live up to expectations, there’s frequently a crash.

    4. Inadequate access to mental health care. I am unaware of any country that operates their mental health care system effectively to prevent crisis, but instead focuses on putting out proverbial fires. To put it bluntly, nobody cares until you’re ready to kill yourself. And even then, there’s inadequate beds in inpatient facilities to care for everybody who needs them. On top of those issues, there is the fear, based on a handful of well publicized cases, of having CPS called in when they do admit to struggles, so people don’t answer screening questions honestly, delaying availability of treatment until the situation is far more critical.

    5. Societal shaming of mental illness and medication shaming. This is self explanatory.

    After all that, we still have the fact that mental illness is absolutely physical in nature. The Chinese MRI studies published in 2016 and 2017 show actual structural differences in the brains of people with MDD and GAD vs people without those conditions. There is still a question of what causes those differences. Are they caused by biochemical reactions to stress or do the biochemical pathways operate differently in the face of stressors because the brain structures are different. We don’t know that yet.

    And lastly, this is not just a US issue. Focusing on poor maternity leave in the US may make people feel good, but it’s not realistic. The photo attached is the geographic breakdown of the members in my PPD group. The caveats here are that this is a FB group, which is primarily US based, and the people in the group are self selecting for science based support. And of course you have to put the numbers in proportion to the populations of the various countries represented (what on earth is going on in the Philippines!). https://uploads.disquscdn.com/images/ad3c0c74134478d6614110f19802be9cfe49f147cd2b292243108afa586d360a.png

    • demodocus

      I don’t see my Dragonastan on that list 😉

      Of course, being in English is limiting, too. It’s just an inborn element of your group, since it was set up by English speakers. Still, that’s a pretty broad swath, considering.

    • alongpursuit

      I had one year of maternity leave, was paid 100% of my salary, live a 5-minute walk away from a store/cafe that is all about breastfeeding, had access to a weekly doula-run support group for postpartum depression, and saw ~10 lactation consultants (either free or affordable) over 5 months. Where I live breastfeeding is pushed really hard and it almost killed me.

      The pressure and my inability to breastfeed exclusively significantly exacerbated my existing depression/anxiety. The pressure and shaming I felt directly from nurses, doctors and LCs, as well as the societal pressure, was worse than any bullying I’d experienced in school. I tried to triple-feed (following the advice of the LCs) for 5 months and it destroyed me. The LCs seemed to have no qualms about pushing a triple-feeding schedule, making it seem like it was the minimum I should do if I want to be a good mom. It’s less effort training for a marathon than triple feeding! And when it didn’t help, I was blamed for not doing it properly.

      It was not about the maternity leave! It was the BFHI hospital where I gave birth and its nurse/doctor breastfeeding ideologues that pushed me over the edge. I had all the support in the world, but that support could not make my breasts produce more milk or help my baby be satisfied sucking on an empty breast.

      • PeggySue

        I am so sorry you had to go through that. It sounds awful. I hope you’re feeling better now.

      • BeatriceC

        I am so sorry that you went through that. Triple feeding is barbaric and should be outlawed, not pushed on exhausted mothers. I am only an observer, yet I am constantly angry on behalf of the people in my group because yours is not an uncommon story. It needs to stop.

        I don’t know if it helps, but you are enough for your child. Whatever the state of your ability to lactate, YOU are enough. Your child is clearly cherished and loved, and that is the most important thing.

      • Emilie Bishop

        Triple feeding is of the devil. I did it for 6 weeks and it was horrible for probably ten distinct reasons. I am so sorry you went through it for so long.

  • Manly Seadragon

    I had 6 months paid parental leave (thank you Australai) I still got PPD. You know what made it worse? Being touched-out and exhausted from breastfeeding, where ‘on-demand’ is the recommendation and I was told that any sort of mixed feeding would be the end of my supply.

  • J. Raven Star

    My concerns after reading about it, like some others, is access. We’d all like to hope these mothers will have supportive people in their lives to look after other children they may have while receiving inpatient treatment, since that is apparently what is needed, but we also all know the reality is many mothers don’t have that. Will that be a bar to treatment for some women?

    • PeggySue

      Of course. Plus, Medicaid and other insurance may elect not to cover, and, in any case, most insurance does not cover mental health treatments well… It’s a start, and I hope work continues in this area.

    • demodocus

      Yes it is. There are several people in Bea’s PPD group who simply have no one else to watch their kid/s.

    • KeeperOfTheBooks

      Heck yes.
      I have three kids. The oldest just turned 5. I also get nasty PPD/A for a year postpartum.
      I tried counseling this time, and it was a joke. $80 for 50 minutes in which absolutely nothing useful was said, plus another $20 to the babysitter, and after 4 visits, she decided to no longer have afternoon time slots available (the only time I had childcare), and could I “just” drive across town at 7 PM or so to see her then instead of 5 minutes up the road during the afternoons? Also, in her very own words after I summed up briefly my issues (emotional turmoil over having had to have medically-necessary C-sections, obsessive thoughts over what a lousy mom I was because I couldn’t breastfeed or give birth naturally despite knowing intellectually that I did the right thing, etc) at our first visit: “Well, natural IS best, of course.”
      Yes, this was a licensed therapist. *snort*
      Between lack of access and the number of quacks out there…

      • MaineJen

        Oh my gawd. She ACTUALLY said “Natural is best” to you??

        Counseling is minimally useful when your problem is chemical; at least, that’s what I’ve found.

        • KeeperOfTheBooks

          Yep. I was sitting there wondering seriously if she was hard of hearing. I had literally just explained that a) my issue was this obsessive thinking over how I’m a terribly mom for not having my baby naturally/not breastfeeding, b) why those things were not actually possible for me, and c) not being able to get the rational part of my brain to make my emotional brain (sorry for the weird terminology, best I can do at explaining) go along with understanding that it really is okay. And the first. words. out. of. her. mouth. were “Well, natural is best, of course.”
          *facepalm*
          I mean this quite seriously: spending a fraction of the cash I paid her on my hobbies, including MMOs, was more psychologically healthy for me than seeing her, because the occasional hour spent doing something I found interesting was a much more positive experience than meandering, unfocused discussion with the occasional interjection like that.

  • AirPlant

    In my experience as a person with anxiety:

    Stressful situations can make my condition worse but good circumstances don’t eliminate it. We need to freaking fix post partum care in america because it is inhumane and as a side note it probably doesn’t do anything positive for post partum depression, but also even in the best of times I still have anxiety and even with all the support in the world you will still have women with post partum depression and they need treatment outside of patronizing agenda driven nonsense.

    • Emilie Bishop

      This!

  • KeeperOfTheBooks

    “Pregnant women are often pickled in horror stories about birth, then subjected to unnecessarily intrusive care. Many suffer pelvic trauma; one in three wind up with major abdominal surgery. Then they are sent home with a newborn, typically without support. According to 2015 data, a quarter of women return to work in two weeks. Everyone says that “breast is best,” but new mothers get a decent place to pump at work only if they’re lucky. Most won’t see their doctor again for six weeks. No wonder depression is so common.
    As one mother we know who plans to quit her job (because she can afford to) said about the lack of parental support in this country: “It’s just so mean.”
    A new expensive drug is not enough; we need humane, evidence-based maternity care, respect for the “fourth trimester,” months if not years of paid parental leave, and affordable child care.”
    Here’s the thing: aside from the word “unnecessarily” in paragraph one, I actually agree with this. Support for new moms in this country SUCKS. But it isn’t an either/or thing, where either we can support moms appropriately (good parental leave policies, good pumping setups at work for those who want to, better follow-up, respectful healthcare professionals) or have an effective, albeit expensive, pharmacological treatment for postpartum depression.
    Here’s a totally crazy idea: maybe we should be better aware of maternal mental health stuff, treat it appropriately, AND change the culture to one that supports new parents?
    The crack about live-in doulas (oh good, someone to reinforce the message my brain already has on repeat postpartum about what a lousy mother I am–just what I need!) and Bahama vacations is beyond the pale.

    • PeggySue

      Years of paid parental leave ain’t gonna fly either.

      And may I risk opprobrium by saying support for most categories of people SUCKS. Take the person I know who is a cancer survivor — couple different primaries. Radiation caused damage to patient’s hip joints which caused lack of mobility and great pain. Surgeons don’t want to replace hip without weight loss and a range of medical tests. Primaries don’t want to prescribe pain relief because opioids (this has been going on for awhile). Patient now living in a recliner. All services she needs are incredibly difficult to access or require travel of over 20 miles (she cannot walk or drive) and insurance fights everything. There is no one in the system who is looking at the whole patient. So, I’m saying, it isn’t just new mothers. It’s hard to get a system bent on saving $$ to think out of that box.

      • KeeperOfTheBooks

        Fair point on both counts. I wonder if a better emphasis on general practice might help? Someone to help coordinate that kind of whole-patient care? Of course, someone would no doubt see that as a waste of money, never mind if it actually saves money in the long term…

  • demodocus

    They need to study more philosophy and psychology if they think depression is a metaphysical problem.

  • mabelcruet

    I think in their own way, they are groping vaguely towards a position to say we need more resources and more money and more acceptance of mental illness. Which is entirely true-in the UK we don’t have nearly enough psychiatric beds for the general population, never mind enough beds in mother and baby units for post natal depression. Paid leave, domestic support etc will help deal with day to day issues-I’d imagine that if a mum was so unwell with PND having someone to help feed and care for the baby while she gets treated would be supportive, and also help her partner. But there’s absolutely no way all the social, domestic and emotional support packages could replace proper specialised psychiatric treatment even if all the money in the world was thrown at it. The drugs, ECT etc are needed and absolutely necessary at times, not just a bit of touchy feely head tilting sympathy.

    • Amy Tuteur, MD

      I suspect that they are heavily influenced by psychiatrist Tomas Szasz.

      According to Wikipedia” “Szasz argued throughout his career that mental illness is a metaphor for human problems in living, and that mental illnesses are not “illnesses” in the sense that physical illnesses are …

      Szasz was convinced there was a metaphorical character to mental disorders, and its uses in psychiatry were frequently injurious. He set himself a task to delegitimize legitimating agencies and authorities …

      In Szasz’s view, people who are said by themselves or others to have a mental illness can only have, at best, “problems in living”.”

      Szasz’s views on the idea that mental illness is not a disease have been widely discredited.

      • demodocus

        Dude can go jump in the lake. Most of Erie’s ice is melted

        • mabelcruet

          Seconded. I’ve seen the difference ECT can make-a close family member was basically catatonic with profound depressive illness. 3 months of in-patient treatment, lots of ECT and truckloads of medication later (and still taking 20 years after their acute admission) they are a functional member of society. But the fear of going back to that state frightens them-her GP wants to wean her off a lot of them, including the lithium, the idea of which she is very resistant to. The state of NHS psychiatry is absolutely appalling-she last saw a consultant about 10 years ago and has since been followed up by an assortment of mental health team workers, some of whom aren’t even nursing qualified, let alone medically qualified, but they are advising the GP on changing her meds. It’s pretty scary-and this is someone with a long history. I think a new mum with her first presentation of mental illness will find it an uphill struggle to get taken seriously, especially if midwives, doulas and the rest have the perception that PND isn’t genuine mental illness.

          • PeggySue

            The hospice I worked for cared for a patient whose doctor insisted on taking her off lithium because of the danger of complications; the newer drugs didn’t manage her symptoms so she spent the last years of her life in a nursing home rather than working and being independent, which she loved. Her kidneys failed anyway. And she might have died sooner on lithium, who knows, but I wish she could have had the choice to live her life the way she wanted.

          • mabelcruet

            Yes, same here. They tried her on various medication more recently (mirtazipine was the most recent) but it’s the lithium that works-there was a lot of discussion over the years about whether she has bipolar disorder, emotionally unstable PD, even schizophrenia. At her worst she was having persecutory hallunications, paranoia, hearing voices, the TV faces telling her to kill herself-it was just awful. The ECT worked-ok, so her short term memory is buggered, but she’s alive, she’s settled, she’s coping with life. Old fashioned ECT and lithium are doing that, and we all think the benefits outweigh the risks.

  • Russell Jones

    Natural childbirth pros will no doubt read this and think, “Hey, why can’t postpartum depression be both an illness and a marketing opportunity? Where’s the mutual exclusivity?”

    It’s reminiscent of a very old Saturday Night Live bit (“It’s a floor wax AND a dessert topping”), except that this bullshit isn’t even remotely funny. As always, mammon is everything to these clowns. Follow the money, straight to “[a] live-in doula and a private sleep-training coach. Weekly massages and pelvic-floor rehab sessions.”

    • Anna

      These things would probably help, but so would admitting its okay and your baby won’t shrivel up if you give them a bottle, or its okay to have a c-section and no women should be pushing 4 hours!

  • PeggySue

    Bravo. Apparently these idiots have never either experienced or witnessed a major depressive episode. I have news for them: when one is in a major depressive episode, none of that crap they mention would do any good at all. Or even feel good.

    Parity of benefits for psychiatric care would be helpful, though.