Science & Sensibility

With Mother’s Day coming this Sunday, many women will be enjoying their first Mother’s Day celebration.  Hopefully, all mothers will be pampered, celebrated, honored and cherished.  For many women, finding a balance of being the mother and taking care of yourself and meeting your individual needs is often a struggle.  Walker Karraa takes a look at a recent study examining the importance of self care for new mothers and asks how birth professionals can stress the importance of new mothers making time for themselves as they transition to their new role. – Sharon Muza, Science & Sensibility Community Manager

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I have a confession. One year I volunteered over 2,000 hours at my children’s school. Yes, I was one of those moms. From wearing an orange vest directing carpool in the morning, to planting the garden with the green team, Xeroxing homework packets for the teachers, and planning the Spring Auction, I chose to put everything into public displays of affection for motherhood. Selflessness was superior parenting.

Fast forward a few years and I am rounding the corner on my PhD.  I am now one of those moms. I barely know the name of the Principal, miss school functions regularly, never volunteer in the class, and avoid direct eye contact with anyone on the PTA at all cost. I am caring for myself in ways that don’t directly involve caring for my children. Many would perceive it as selfish, or at a minimum, I am recognized as not being “an involved parent”.  I feel the judgment from other parents.

I would imagine anyone reading this right now understands the mine field of guilt, disappointment, and distress we walk through regarding balance between self-care and caring for children. Childbirth professionals often find themselves torn between the demand for caring for clients and the need for self-care.

A paradox for women lies between the need for self-care and the social construct of selflessness as superior in parenting.  Moreover, socio economic stressors regarding childcare and ongoing employment bear critical weight on time and resources for women to engage in self-care in addition to caring for their infant, other children, and family. Women need and deserve physical, intellectual, mental, emotional and spiritual health and well-being—yet engaging in self-care is a social construct that views it as selfish, or a luxury. And dare I say we engage in keeping this paradigm alive by extoling the virtues of some women who display self-sacrifice and dishing about the deviance of others who are not at the PTA meeting. We compare ourselves to both, often rejecting the parts of ourselves that are in desperate need of time, privacy, exercise, prayer, creativity, recovery. For that matter we could all use a nap, a shower, and time to do with as we want, desire, or dream.

New Study Emerges

This push and pull of visions of perfect martyrdom with the need for self-care is at no other time more present than new motherhood.  A recent qualitative study, “The Role of Maternal Self-care in New Motherhood” by Barkin and Wisner (2013) explored women’s perceptions of the role of maternal self-care in postpartum period and the barriers to employing self-care. Critical to postpartum wellness are increasing understandings of the mechanisms of self-care and their importance in the lives of new mothers. In a qualitative study of three focus groups consisting of 31 new mothers (had given birth during the year prior to enrolling in the study), Barkin & Wisner (2013) examined the relationship of 1) women’s perceptions of self-care, 2) how women applied self-care in new motherhood, and 3) the barriers to practicing self-care.

Semi-structured interviews with three focus groups elicited responses regarding the responsibilities associated with new motherhood, changes experienced since the birth of their child, feelings in response to those changes, describing constructs of a ‘good mom’, and the circumstances surrounding their high functioning and low functioning periods.

Transcripts related to maternal functioning were extracted and grouped into one of three categories: (1) women’s valuations of the role of self-care in new motherhood, (2) applications of self-care and (3) barriers to practicing effective self-care.

Barkin & Wisner (2013) noted two conflicting themes where women were both aware of the importance of self-care while holding the belief that good parenting is tantamount to selflessness. Participants described knowing that even the most basic self-care such as good nutrition and rest were of paramount importance, however they experienced barriers to engaging in self-care for themselves. One participant described the dilemma in this way,

“Because I really didn’t pay attention to myself. Like my main focus was on him. Making sure he was eating every hour. And as far as me, when a counselor came in and she was like, ‘Well, are you eating breakfast?’ ‘Are you eating lunch?’ And you really have to stop and look back and think like okay, yes, I need to take care of myself as well as the baby’. But you don’t really think about that until someone brings it to your attention.” (Barkin & Wisner, 2013, p. 5)

Participants described breastfeeding as a source of conflict.  Barkin and Wisner (2013) reported,

There was also substantial discussion of maternal self-care in relation to breastfeeding. For a portion of the women, breastfeeding was physically and mentally uncomfortable. The women described guilty feelings associated with deciding to artificial milk-feed their child. Despite the guilt, some of the mothers made the ultimate determination to transition to formula feeding. This was recognized as an act of self-care. (p. 5)

Conversely, where selflessness was seen as synonymous with motherhood, some participants reported what the authors called “potentially unhealthy degrees of selflessness” (Barkin & Wisner, 2013, p. 5) such as neglecting their hygiene or refusing to let trusted family members care for the baby.

Barriers

While some engaged in self-care shared examples of taking time to exercise, delegating infant care to partner, taking showers, applying cosmetics, socializing with friends, and dining out—many women reported barriers to self-care. Lack of time, limited financial resources, and one’s own inability to set boundaries were reported as significant barriers to self-care.

Implications for Childbirth Educators and Doulas

In addition to a call for more research, the authors concluded:

The development of a behavioral intervention aimed at improved self-care practice among new mothers is the long-term goal of this research. Interventions should be tailored to the mother’s individual circumstances and preferences. Self-care strategies that are both attractive and feasible for the individual woman will be more effective. Additionally, the availability of such an intervention will enable health-care providers to make better recommendations to women who are struggling to care for themselves and their infant concurrently. (Barkin & Wisner, 2013, p. 6)

This is where we share!

How do you cover the topic of self-care in your childbirth education classes, or prenatal sessions?

What do you consider some good examples of feasible and attractive self-care strategies that you suggest to your clients?

What have you learned about self-care strategies from your clients?

What are your thoughts regarding the causes of this paradox between self-care and selflessness?

As we educate our next generations of families to navigate the waters of parenting, how might we offer support, education and support for women to not only practice self-care, but prioritize it?

References

Barkin, J. L., & Wisner, K., L. (2013). The role of maternal self-care in new motherhood. Midwifery, http://dx.doi.org/10.1016/j.midw.2102.10.001

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“Childbirth educators are crucial front-line professionals in providing information to women about their risks for medical complications related to pregnancy and birth, and postpartum depression is a common problem.” – Dr. Katherine L Wisner

Katherine L. Wisner, M.D., M.S., has been involved in clinical work and research since the mid-1980′s. Prior to her medical training, she achieved a Master’s Degree in Nutrition. Dr. Wisner did a pediatrics internship, is board-certified in both adult and child psychiatry, and completed a 3-year postdoctoral training program (NIAAA-funded) in epidemiology. Her major interest area is women’s health across the life cycle with a particular focus on childbearing. In January 2011, Dr. Wisner was chosen as the recipient of AMWA’s Women in Science Award for the year 2011. Dr. Wisner is a Norman and Helen Asher Professor of Psychiatry and Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine.

Most recently, Dr. Wisner and colleagues (2013) published the largest American study to date (N = 10,000) investigating the value of screening for depression in postpartum period (4 to 6 weeks) using the Edinburgh Postnatal Depression Scale (EPDS)¹. 

I know I speak for all in welcoming Dr. Wisner to Science and Sensibility.

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Walker Karraa: Congratulations to you and your colleagues on this most recent JAMA Psychiatry study. The findings have significant implications regarding the value of screening for postpartum mood and anxiety disorders. What role do you think childbirth education has in the area of perinatal mental health?

Dr. Wisner: Childbirth educators are crucial front-line professionals in providing information to women about their risks for medical complications related to pregnancy and birth, and postpartum depression is a common problem.  

WK: Should childbirth educators and doulas be trained to screen for PMADs? 

Dr. Wisner: My answer would be yes, but the controversy in the field is about routine screening – that women with depression can be identified, but getting them to mental health treatment if it exists outside the obstetrical care setting is difficult.  So the counterpoint is– why screen if we don’t have on-site, accessible, acceptable services for mental health?  My opinion is that we ought to work toward this model of integrated care rather than decide not to screen!   I certainly think childbirth educators and doulas can increase education and awareness and are often the first professionals that women call for help, so that group of women who want to and can access care can get the help they need.

WK: How could childbirth education organizations use this study to inform their practices and curriculum?

Dr. Wisner:The study provides evidence that the prevalence of depression is high both during and after pregnancy and evidence that screening is effective in identifying women with major mood disorders.  Women with psychiatric episodes certainly can be assured that they are not alone, which is a common belief of pregnant women and new mothers.  

WK: Due to the prevalence of self-harm ideation in postpartum period found in your study and other studies supporting this alarming rate, and the fact that suicide is the second leading cause of maternal death, how might childbirth education organizations and professionals address this critical problem?

Dr. Wisner:Screening with the EPDS, which has the item 10 self-harm assessment questions, and sensitive exploration of self-harm and suicidal ideation is the primary approach to suicide prevention.  It has to be identified before intervention can occur.  

WK: A remarkable finding in your study was the rate of bipolar disorder among women who had screened positive (10 or higher) on the EPDS. Additionally, among those with unipolar depression, there was high comorbidity for anxiety disorders. What are your thoughts as to how childbirth education might begin to help childbearing women unpack and understand the symptoms of anxiety in prenatal education?

Dr. Wisner: In our study we found that women with depression usually had an anxiety disorder that pre-dated the depressive episodes—this observation is true for women who are not childbearing as well.  Having anxiety or depression as a child or adolescent increases the risk for peripartum episodes.  There are excellent pamphlets and websites about perinatal depression (www.womensmentalhealth.org; www.postpartum.net) which can be used to frame a brief discussion and give to the patient for reference.  This also gives the message that talking about mental health before and during childbearing is an important topic, just like surgical births, anesthesia etc.    

WK: The data you have contributed to science are unsurpassed, yet early in your career many questioned whether postpartum depression was real, and doubted if you would be able to pursue a research career in postpartum mood disorders.

Dr. Wisner: Indeed!

WK: How did you persevere–and particularly in a male-dominated field?

Dr. Wisner: I got angry that so few data were available to drive care for pregnant and postpartum women and never let go of the importance of obtaining that information.  That motivation was coupled with a real joy in taking care of perinatal women and their beautiful babies!  

WK: Do you think there is still an underlying doubt as to whether postpartum depression (or perinatal mood/anxiety disorders) is real?

Dr. Wisner: Not in academic medicine, and I have not heard anyone say this in about a decade (thankfully!). 

WK: What is your favorite part of the research? Data collection, analysis, or interpretation?

Dr. Wisner: Publishing findings that make a difference in women’s lives, and holding the babies. 

WK: What new trends do you see in research as hopeful signs of progress?  

Dr. Wisner:  The incredible number of young clinicians and investigators who are interested in perinatal mental health.  Also,  our field has been so accepting of interdisciplinary enrichment of research questions.  

WK: What advice would you share with women in research today? 

Dr. Wisner: Network with  your colleagues inside and outside your organization frequently, attend perinatal mental health meetings and don’t ever give up!  

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What are your thoughts regarding Dr. Wisner’s expert opinion?   How do you currently address postpartum depression and anxiety in your childbirth classes?  After reading this interview and taking at look at Dr. Wisner’s just published research, might you reconsider how you teach about this important topic or change your approach?  Let us know in the comments section below- Sharon Muza, Community Manager

More about Dr. Wisner

Dr. Wisner’s research has been NIMH funded since she completed her post-doctoral training in 1988. She served on NIMH grant review sections continuously from 1994 to the present. Dr. Wisner completed was a founding member of the NIMH Data Safety and Monitoring Board, and is only the second American to be elected President of the Marce International Society for the study of Childbearing Related Disorders.

Her major interest area is women’s health across the life cycle with a particular focus on childbearing. She is a pioneer in the development of strategies to distinguish the effects (during pregnancy) of mental illness from medications used to treat it (Wisner et al,JAMA 282:1264-1269, 1999; MHR01-60335, Antidepressant Use During Pregnancy).

In recognition of her work, she was a participant in activities related to the FDA Committee to Revise Drug Labeling in Pregnancy and Lactation, a committee member for the National Children’s Study (Stress in Pregnancy), a consultant to the CDC Safe Motherhood Initiative and the Agency for Healthcare Research and Quality Report Perinatal Depression: Prevalence, Screening Accuracy and Screening Outcomes.

Dr. Wisner was elected to membership in the American College of Neuropsychopharmacology in 2005. She received the Dr. Robert L. Thompson Award for Community Service from Healthy Start, Inc., of Pittsburgh in 2006 and the Pennsylvania Perinatal Partnership Service Award in 2007 from the State of Pennsylvania. 

Dr. Wisner was the first American psychiatrist to collect serum from mothers and their breastfed infants for antidepressant quantitation as a technique to monitor possible infant toxicity. She published the only two placebo-controlled randomized drug trials for the prevention of recurrent postpartum depression and showed that a serotonin selective reuptake inhibitor was efficacious.

References 

1.Wisner, K.L., Sit, D., McShea, M. C., Rizzo, D.M., Zoretich, R.A., Hughes, C.L., Eng, H.F., Luther, J.F., Wisneiweski, S. R., Costantino, M.L., Confer, A.L., Moses-Kolko, E.L., Famy, C. S., & Hanusa, B.H. (2013). Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry, Published online March 13, 2013. Doi: 10.1001/jamapsychiatry.2013.87

 

Walker Karraa Childbirth Education, Depression, Evidence Based Medicine, Guest Posts, Maternal Mental Health, New Research, Perinatal Mood Disorders, Postpartum Depression, PTSD, Research Childbirth Education, depression, guest posts, Katherine L Wisner, maternal mental health, MD, PPMAD, PPMD, PTSD, Walker Karraa

By: Walker Karraa

Regular contributor Walker Karraa wraps up her interview with Jennifer Carney, who became active with The Preeclampsia Foundation and the Unexpected Project after suffering from eclampsia while pregnant with her second child.  Have you had to answer any questions in your classes or with your clients and patients after the recent episode of Downton Abbey, where one of the characters developed eclampsia?  What have you shared with your pregnant families? Part one of Walker’s interview with Jennifer Carney can be found here. – Sharon Muza, Community Manager.  

Walker: What do you see are the common myths regarding pre-eclampsia?

JC: Common myths? Oh, there are so many. A lot of people seem to think they know what causes preeclampsia and how to cure it. There’s a whole faction of advocates who buy into the work of Dr. Tom Brewer, who in the 1960′s, devised a very high protein diet for mothers based on the idea that preeclampsia is caused by malnutrition. This isn’t supported by the current research, but it gets repeated all the time. Other people argue that preeclampsia is a so-called “lifestyle” disease – caused by obesity and poor prenatal care. Obesity is a risk factor, but it is only one of many and poor prenatal care can cause the disease to go undetected, but it will not cause it to happen in the first place. There are also a lot of people who think that the delivery of the baby will end the risk to the mother – and while it’s true that the removal of the placenta is essential, preeclampsia or eclampsia can still happen up to 6 weeks after delivery. There are other myths, but it strikes me that so many of these myths are rooted in a desire to control pregnancy. If we can blame preeclampsia on one central cause or on the women who develop it themselves, then we can reassure ourselves that we won’t develop it, too. There are risk factors that can increase a woman’s chances of developing the disease, but women without any known risk factors have developed it, too.

It’s not comforting to think that no one is safe, but with knowledge of the signs and symptoms – a woman can react to it promptly and receive the care that she needs. But this will only happen if women get the information and understand that it CAN happen to them. I am blown away by the ways in which preeclampsia and other serious complications are downplayed and dismissed in pregnancy books, online and even by some medical practitioners. Preeclampsia CAN happen to you – but you can deal with it IF you know the signs and the symptoms.

Walker: Can you share with our readers what you are doing with Anne Garrett Addison at The Unexpected Project?

JC: The Unexpected Project is a documentary, website, and book project that will examine the rate of maternal deaths and near-misses in the United States. Anne Garrett Addison, who founded the Preeclampsia Foundation, and I are both classified as near-misses due to preeclampsia. With Unexpected, we want to take a look at all maternal deaths regardless of the cause – preeclampsia, amniotic fluid embolism, hemorrhage, placenta previa, placental abruption, infection, suicide, and any other causes. We also want to look at the women who survived these complications because the line between surviving and dying is in these cases, often quite thin. Every case is different and there is no one factor to blame for the maternal death rate in the US. We will look at interventions and cesarean sections, but we will also look at the lack of information available to women and the tendency of some birth activists to minimize the dangers of serious birth complications.

Current Preeclampsia/Eclampsia StatisticsMaternal mortality and morbidity are, unfortunately, a part of the pregnancy and childbirth experience for women and their families in the US and the world.  While most (99%) of maternal mortalities occur in the developing world, the 1% that occur in developed countries like the US are still of concern to maternity care providers and advocates.  Indeed, U.S. still ranks 50th in the world for its maternal mortality rate (1). More common than a maternal death, are severe short- or long-term morbidities due to obstetric complications (2).  Some estimate that unexpected complications occur in up to 15% of women who are otherwise healthy at term (2).   In particular, hypertensive disorders of pregnancy, including elevated blood pressure, preeclampsia, eclampsia and HELLP syndrome are estimated to affect 12-22% of pregnant women and their babies worldwide each year. (3)  Adverse neonatal outcomes are higher for infants born to women with pregnancies complicated by hypertension.   In the U.S., upwards of 8 percent or 300,000 pregnant or postpartum women develop preeclampsia or the related condition, HELLP syndrome each year. This number is growing as more women enter pregnancy already hypertensive (cite).  Preeclampsia is still a leading cause of pregnancy-related death in the US and one of the most preventable.  Annually, approximately 300 women die and another 75,000 women experience “near misses” – severe complications and injury such as organ failure, massive blood loss, permanent disability, and premature birth or death of their babies.  Usually, the disease resolves with the birth of the baby and placenta. But, it can occur postpartum–indeed, most maternal deaths occur after delivery. Recent statistics from Christine Morton, PhD.

The trend toward “normal” or “natural” birth does not seem to allow a lot of space for our stories to be heard or to be told. This has the effect of making survivors feel marginalized – as though their experience is somehow too far outside “normal” to be a part of the overall conversation. The one constant of all of our stories is that none of us expected to become statistics. Our birth plans did not include emergency cesarean sections, seizures, ICUs, blood transfusions, strokes, hysterectomies, CPR, prematurity, PTSD, depression, or death. No one was more surprised than us. This isn’t about assigning blame – this is about finding answers, improving birth for ALL moms to come, and learning to live with the unexpected.

Walker: How did you get involved with researching for the Preeclampsia Foundation?

JC: I started out volunteering with the March of Dimes in the spring following my son’s birth. I started a walk team and raised money, hoping that I would be able to meet other moms who had been through something similar. I felt very alone in the months following his birth. I was dealing with postpartum depression (PPD) and post-traumatic stress disorder (PTSD) symptoms and struggling to feel normal again. I had a premature infant – which meant sleeping through the night was a problem for a long time. When I returned to work, I was greeted by a coworker who declared that she now no longer wanted to have children because of what I had gone through. This weighed heavily on me – and I felt like I was the cautionary tale, the one bad pregnancy story that everyone knows. I know I had never heard a story as bad as mine – so I felt deflated, flattened by the whole thing.

With the March of Dimes, I found moms to help me deal with the preemie part of it. As he matured and grew out of the preemie issues, I found that I still had a lot of issues to deal with regarding my own health – both physically and mentally. I decided to volunteer with the Preeclampsia Foundation after they merged with the HELLP Syndrome Society.  The Preeclampsia Foundation is much smaller than the March of Dimes, which allowed me to be much more active as a volunteer. I was able to use my writing and editing skills to work on the newsletter – and when I suggested that someone do a review of the available pregnancy literature based on how well they cover preeclampsia, I was given the opportunity to conduct that research and write the report myself. This was something I had been doing informally in bookstores for a while anyway, so it felt good to be able to look at the literature and confirm that the information really is severely lacking if not downright misleading in a large number of so-called comprehensive books. It really isn’t my fault that I missed the symptoms.

This year, I am coordinating the Orange County, California Promise Walk in Irvine as part of the foundation’s main fundraising campaign on May 18. I am hoping to bring a mental health expert from the California Maternal Mental Health Collaborative out to the walk to talk to the moms about dealing with the emotional impact of their birth experiences.  Many of these moms lost babies, delivered preemies, or suffered severe health issues of their own. Our community as a whole is at a very high risk for mental health issues, myself included.

It wasn’t until this year – 6 years after the birth of my son – that I finally sought professional help dealing with the PTSD from the very difficult birth experience. I feel that the volunteer work helped fill that spot for the past 6 years and brought me to the point where I can now process the trauma in a healthy way. I am not happy that I had eclampsia, but I am beyond grateful for all of the great people that it has indirectly brought into my life.

Closing Thoughts

To have to wait 6 years to receive the vital treatment for PTSD is a travesty. We are so thankful that Jennifer survived both the initial trauma, but endured its legacy of traumatic stress that lingers today. Unfortunately, PTSD subsequent to traumatic childbirth is growing in prevalence, and under-recognized by the majority of women’s health and maternity care providers.  I have learned a great deal from Jennifer and look forward to the work she and her colleagues will continue to do for the benefit of all women.

References

1.  WHO. Trends in maternal mortality: 1990 to 2008 estimates developed by WHO, UNICEF, UNFPA and The World Bank, World Health Organization 2010, Annex 1. 2010. http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdf. Last accessed:January 3, 2011.

2. Guise, J-M.  Anticipating and responding to obstetric emergencies.  Best Practice and Research Clinical Obstetrics and Gynaecology. 2007; 21 (4): 625-638

3. American College of Obstetricians and Gynecologists. Diagnosis and management of preeclampsia and eclampsia; ACOG Practice Bulletin No. 33. Obstetrics & Gynecology. 2002;99:159-167. 

 

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By Walker Karraa

Regular contributor Walker Karraa interviews Jennifer Carney, a mother of two, who suffered from eclampsia at the beginning of her third trimester.  Jennifer shares her real life story, on the heels of a favorite character’s similar experience on the popular TV show “Downton Abbey.”  Today, we learn about Jennifer’s experience and on Thursday we learn more about resources and organizations working hard to make this potentially deadly disease less harmful to pregnant and postpartum women.  - Sharon Muza, Community Manager

Introduction: 

The recent episode of “Downton Abbey” brought much needed attention to the maternal health issue of pre-eclampsia. Why is it we rely on fiction for permission to get real? Where is the line between evidence-based research and fictional representations of the lack of it? How do we encourage each other and the next generation of maternal health advocates to harness the undeniable power of media but not become part of a social construction of maternal mortality as not real? As a qualitative researcher, I believe that some of our best evidence stems from researching real experiences from real women. It is my pleasure to introduce a real woman who experienced the full range of eclampsia and its psychological aftermath: Jennifer Carney.

Note: Consultation with Science and Sensibility contributor, Christine Morton, PhD was conducted to insure accurate and current statistical data regarding pre-eclampsia and eclampsia. 

Walker: Jennifer, can you tell us your story?

JC: My second pregnancy was easier than my first. Up until it wasn’t. I conceived as soon as we started trying. We had no soft markers on the ultrasounds, no need for an amnio, and no borderline gestational diabetes. I was only 34 and with a successful full-term first pregnancy; I was considered “safe” from preeclampsia. The only risk factor I had was my weight, but even with that, statistically my risks were much lower than for a healthy first time mom. There was something about it that seemed too easy. I felt like the other shoe was going to drop – but I never imagined that it would fall with such force.

In my 32nd week, I began to feel ill – like I had the flu. I took a day off from work to rest and recover. I thought I was getting better, but that night I began feeling worse. I called in sick to work again – it was a Friday – and my husband and son went off to work and daycare. I was alone. I laid down and slept for about 4 hours. When I awoke, I felt much, much worse. The headache radiated out from behind my eyes. I was seeing spots. I was incapable of thinking clearly. The phone rang several times, but the receiver was not on the base. I couldn’t locate it before the answering machine picked up. By this point I was aware that something was very wrong, but I wasn’t able to do anything about it. I stayed on the couch, barely moving for as long as I could.

Signs and Symptoms of Pre-eclampsia  High blood pressure. 140/90 or higher. A rise in the systolic (higher number) of 30 or more, or the diastolic (lower number) of 15 or more over your baseline might be cause for concern. Protein in your urine. 300 milligrams in a 24 hour collection or 1+ on the dipstick. Swelling in the hands, feet or face, especially around the eyes, if an indentation is left when applying thumb pressure, or if it has occurred rather suddenly. Headaches that just won’t go away, even after taking medications for them. Changes in vision, double vision, blurriness, flashing lights or auras. Nausea late in pregnancy is not normal and could be cause for concern. Upper abdominal pain (epigastric) or chest pain, some- times mistaken for indigestion, gall bladder pain or the flu. Sudden weight gain of 2 pounds or more in one week. Breathlessness. Breathing with difficulty, gasping or panting. If you have one or more of these signs and symptoms, you should see your doctor or go to an emergency room immediately.  Source: Preeclampsia Foundation

Sometime after 5:00, I realized that I was going to have to call someone else to pick up my son at daycare by the 6:00 closing time. I managed to get to my feet and stagger toward the kitchen. I reached out to steady myself on the counter and missed. I fell to my left, onto the hard tile floor in front of the stove. I knew this was bad, but all I could think was that I had to hold on and that someone would be coming. I told myself that I couldn’t let this happen. Shortly thereafter, I tried to scream and felt the beginning of what I later learned was a tonic-clonic or grand mal seizure.  

This was eclampsia – full blown seizures caused by extremely high blood pressure. Somehow, I held on. Somehow, I held on in this state for something like 3 full hours. I have no way of knowing how many seizures I had in that time. When my friend arrived after 8:00, she found me on the floor. I came to long enough to answer her question – “yes, I know where I am. I’m fine.” I tried to get up – and immediately started seizing again. She called 911 and within minutes the paramedics arrived. 

My son was born, not breathing, about an hour later. The doctors were able to revive him, thankfully. He went off to the NICU and I was sent to the ICU. Two days later, I regained consciousness. I was on a respirator and completely disoriented. I was later diagnosed with HELLP syndrome, eclampsia, pneumonia, acute respiratory distress syndrome (ARDS), and sepsis – any of which can be fatal on their own. My son was moved to another hospital with a larger NICU, and I spent 8 days in the hospital where he was born. I saw him briefly before they transferred him – but was unable to hold him until after I was discharged – more than a week after he was born. For the next 20 days, I was only able to see him and hold him during daily visits to the NICU. It would be 4 full weeks from his birth before we could take him home to meet his 4 ½  year old brother for the first time. This was definitely not what we had envisioned.

This experience changed my entire perspective on life. It was the first significant health crisis that I had ever faced and it shook my sense of security and safety. It took a long time to recover physically from the trauma and emotionally I was just a wreck. I was aware that Post-traumatic Stress Disorder (PTSD) was a possibility, but I think the picture I had in my mind of what PTSD was turned out to be very different from the ways in which I experienced it. I had envisioned a quick, big breakdown – but the reality was much subtler. At first, I experienced an aversion to seeing pregnant women. I wanted to warn them, but I also could barely look at them. It manifested in other ways, too – dreams about seizures, muscle spasms, intrusive thoughts. But it felt manageable and the antidepressants helped control the runaway anxiety that had hampered my first postpartum experience 4 years earlier.

The mental health issues were helped by the antidepressants, but I wish that I had tried therapy much sooner. It’s doing wonders for me now – but I waited over 6 years to try it. Today, my preemie is in kindergarten and doing well. Aside from my son, getting involved with the March of Dimes and Preeclampsia Foundation has been by far the best part of the whole experience. I wouldn’t change that part, at all.

Walker: How is mental health neglected in the overall understanding of the topic, treatment, and recovery?

JC: This is a huge problem. I got great care while I was in the hospital. I saw social workers, chaplains, and a wide variety of people who inquired after my pain levels and my coping skills. The problem with this is that I was on massive pain killers the whole time. Percocet and morphine can mask emotional pain as well as physical pain. I’m sure I came off as reasonably well adjusted to the whole experience, despite the mental confusion left over from the seizures and the serious health issues that remained. And I was relatively okay. Even during the month-long NICU stay, I was doing all right. I was sleeping well, eating, taking care of myself – but I was also still on Percocet. It smoothed over the rough edges.

It wasn’t until the help dried up, the prescriptions ran out, and the reality of being at home by alone with an infant to care for that the walls started to come down again. Here I was at the scene of the initial trauma, cooking at the same stove that I had seized in front of for hours, responsible for a premature infant who needed drugs to remind him to breathe. This is when I needed the help. This is when I needed information on PTSD and postpartum depression (PPD). This is when I needed support. And as I began the long process of understanding what had happened and why, I found I needed even more support to help me wrap my head around it all.

As I noted while talking about myths, there is a pervasive culture of blame in the overall birth discussion regarding preeclampsia. It can be hard to find information that doesn’t make you feel that you somehow brought this condition on yourself. I looked at the risk factors and the arguments about lifestyle, obesity, and diet – and found a lot of things that sounded like they made sense. But they only made sense if I internalized them and blamed myself for the shortcomings. Maybe it was my fault. This, as you can imagine, does not help the feelings of depression and trauma. It took a LONG time for me to come to the conclusion that there was no way for me to have known that this would happen or to have prevented it. Statistically speaking, I had a very low chance of developing eclampsia even with the risks factored in. Statistically speaking, my son and I should not have survived, either. But we did – and now I want to make sure that I use that in a meaningful way. 

Walker: Did your childbirth education prepare you for your experience?

JC: Heck no. I only took classes with my husband before our first child. We weren’t planning to take the classes again with the second, but since he was born at 7 months, we probably would have missed most of them even if we had planned to. I distinctly remember the childbirth educator talking about her own response to sleeplessness, which was a sort of slap happy, giddy reaction. She mentioned PPD, but not in any real way that conveyed the depths or potential seriousness of the condition. We also received almost no information on pregnancy complications. To me, preeclampsia meant high blood pressure – and I had never had problems with that before. It was totally off my radar. Plus, Preeclampsia very rarely happens in a second pregnancy if it didn’t happen in the first. So, no one prepared me for it. Not my doctor, not my classes, not my books.

Walker: What recommendations do you have for childbirth educators and doulas regarding this issue?

JC: Really, I think it comes down to trusting that the moms you are helping can handle the information that they NEED to know. I was alone. If I had known that these symptoms could mean eclampsia or preeclampsia, I might have been able to save myself from the seizures – which would have also likely saved me from the ARDS and pneumonia. My ICU stay might have not happened. My son was going to be born early – but if I had gone to my doctor or called an ambulance myself, it might not have been so close a call. It’s not my fault that I didn’t know – but it could have been tragic.  

Know the signs and symptoms. Know that a woman with severe PE might be having cognitive issues – confusion, and vision problems. Don’t ask her to drive. Don’t downplay distress. And take complaints of headaches, upper quadrant pain, nausea, diarrhea, shoulder pain, visual disturbances, and a general feeling that something is “off” seriously. And if you have a client or patient that experiences something like this, please follow up and ask about mental health issues. Be careful not to ask questions that can be answered with the words: “I’m fine”. Dig deeper.

Closing Thoughts

How might we increase our understanding of this issue through Jennifer’s story? Is it possible to begin a dialogue here–one in which we agree to change paradigms of learning and knowing women’s experiences beyond an episode of a fictional television show?  Jennifer presents an exemplar synthesis of the fullest range of insight possible when empirical and phenomenological considerations are employed.. Her lived experience combined with and through her knowledge of the evidence creates an exemplar of how knowing and knowledge cannot be divided if the pursuit of knowledge is truly desired.

In the next installment, scheduled for February 7th,  Jennifer reflects on common myths about PE, and her work with the Unexpected Project and the Preeclampsia Foundation.   

Walker Karraa Birth Trauma, Childbirth Education, Depression, Guest Posts, Maternal Mental Health, NICU, Postpartum Depression, Pre-eclampsia, Pre-term Birth, Pregnancy Complications, PTSD Childbirth Education, depression, eclampsia, guest post, Jennifer Carney, March of Dimes, NICU, post-traumatic stress disorder related to childbirth, postpartum depression, preeclampsia, Preeclampsia Foundation, PTSD, treatment for pre-eclampsia, Walker Karraa

By: Walker Karraa

Regular contributor Walker Karraa has written an excellent three part series on Perinatal Mood and Anxiety Disorders (PMAD) and what the childbirth educator or birth professional can do to help women get the help they may need when dealing with mental illness during the prenatal and postpartum period.  Walker interviews experts in the field who all offer concrete steps, activities and resources so that educators and others can do to be more prepared to discuss this important subject with students and clients.  Today, Walker interviews Jennifer Moyer, an expert in the field of postpartum psychosis who is an active mental health advocate, and has had personal experience with postpartum psychosis after her son’s birth. Here you can find Part I and Part II of the series.– Sharon Muza, Community Manager.

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As many of you know, I am a big proponent of qualitative research methods. The lived experience of a phenomenon offers a depth of data that objectivist methods simply cannot collect. Researchers in women’s reproductive health have been on the forefront of the understanding and implementation of research that listens to mothers. In the same way, I wanted to offer Science and Sensibility readers the voice of a mother, postpartum doula, and advocate who has lived it—experienced postpartum psychosis (PP) and not only “survived”, but transformed the adversity into a path to helping others.

Jennifer Moyer has unique insight into mental health as a recovered mom herself. She overcame postpartum psychosis, a life threatening mental illness, which she was struck with when her son was eight weeks old. She has focused her efforts on being a mental health advocate in the area of perinatal mental health in order to help others experiencing mental illness related to childbearing.

Jennifer also has experience as a postpartum support and education consultant, a certified postpartum doula and a speaker on mental health issues.

WK: The recent Felicia Boots tragedy in the UK has brought media attention to the dangers of untreated perinatal mood disorders, specifically postpartum psychosis (PP). What are your thoughts as to the multiple factors that contribute to a tragedy such as this? 

Jennifer Moyer: I believe there are several factors that contribute to tragedies associated with perinatal mood disorders.  One of the factors is the ignorance about the difference between postpartum depression and postpartum psychosis, which is usually the disorder associated with infanticide.  In my experience with postpartum psychosis, I was completely unaware that postpartum psychosis even existed despite having an educated and proactive pregnancy.  I think many mothers are in the same situation.

Another contributing factor is that providers often do not provide education on the warning signs or risk factors of perinatal mood disorders making it difficult for a mother or her loved ones to recognize what is happening.  Of course the lack of preventative screening also causes a mother at risk from receiving early intervention.

There are other factors as well but I believe these are the primary obstacles contributing to unnecessary tragedies.

WK: Can you describe the sequelae of postpartum psychosis (PP)? 

Jennifer Moyer: An aftereffect or secondary result of postpartum psychosis is different for each mother but, in general, I have found that it changes the mother forever.  In my case, postpartum psychosis came on sudden and unexpectedly.  Once I was stabilized, the trauma I had experienced prior to my diagnosis left me with serious post-traumatic stress.  It also shattered the positive and strong bond I had with my son prior to the onset of postpartum psychosis.  It caused me to question my ability has a mother for a very long time.  The lack of understanding about my condition as well as lack of support from someone, who had experienced postpartum psychosis, lengthened my recovery and made it much more difficult.

Postpartum PsychosisPostpartum Psychosis is a rare illness, compared to the rates of postpartum depression or anxiety. It occurs in approximately 1 to 2 out of every 1,000 deliveries, or approximately .1% of births. The onset is usually sudden, most often within the first 4 weeks postpartum.Symptoms of postpartum psychosis can include: Delusions or strange beliefs Hallucinations (seeing or hearing things that aren’t there) Feeling very irritated Hyperactivity Decreased need for or inability to sleep Paranoia and suspiciousness Rapid mood swings Difficulty communicating at times The most significant risk factors for postpartum psychosis are a personal or family history of bipolar disorder, or a previous psychotic episode. source: Postpartum Support International

WK: How might childbirth professionals integrate an understanding of PP and other perinatal mood disorders in classes? 

Jennifer Moyer: I believe education on perinatal mood disorders should be included in every childbirth class.  In fact, when I worked as a Postpartum Support and Education Consultant, I did a presentation on perinatal mood disorders in every childbirth class conducted at a hospital in my area.  By educating the mother and her partner about the risk factors, symptoms and proper treatment, early intervention occurred when a case did occur.  My involvement helped educate the childbirth professionals, which led to them ultimately address perinatal mood disorders on their own in their classes.  To me, the goal is to educate as much as possible so that the information can be passed on to women and their families.  Childbirth professionals have a unique opportunity to reach a tremendous number of women and families as most pregnant women participate in some type of childbirth class.

WK: How would you describe the stigma of perinatal mental health disorders and its impact?

Jennifer Moyer: The stigma of perinatal mental health disorders prevents women from getting help when they need it.  Often because of the stigma and lack of understanding, women are often afraid they will lose their child (children) if they do seek help.  The stigma of perinatal mental health disorders is devastating to families and communities. When families and the community are not educated about perinatal mental health disorders, it makes it difficult for the disorders to be properly addressed, treated and prevented.  I have heard of way too many cases of the mother losing her children because of the lack of understanding and education of perinatal mental health disorders in the community.

WK: What do you see as the most significant barriers to treatment for women with PMADs?

Jennifer Moyer: I believe the most significant barrier is the lack of proper education and training of health care professionals.  Another barrier is the failure of the providers, who are not properly trained, to refer the women to perinatal mental health resources or if no resources available in the area, to consult with an expert in perinatal mental health.  So many women are improperly treated.  I know of many cases where the woman contacted her doctor for assistance and were only prescribed an antidepressant, often over the phone, and received no further direction or support.  So it goes back to education or, in the case of the primary barrier, the lack of education.

WK: Recently, the study The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond (Domar, Moragianni, Ryley & Urato, 2012) attracted attention regarding the safety of using SSRI medication in pregnancy. Would you like to respond to the study directly?

Jennifer Moyer: I am not a medical professional so I cannot respond in depth but from a lay person’s perspective, this information can cause many pregnant women from seeking help, if they are experiencing any perinatal mental health issues.  My understanding is there is always a risk/benefit analysis when it comes to medication so education about options is so important.  In my opinion, it seems that medication is often the only intervention presented rather than a more complete and balanced plan of treatment, which may include medication when necessary. Educating women about their options should always be a priority but if the health care professionals are not properly educated in perinatal mental health, how can they educate anyone else?

WK: What suggestions do you have regarding how childbirth organizations can encompass perinatal mental health into training curriculum and practice? 

Jennifer Moyer: Offering and requiring specific training on perinatal mental health for all members would increase awareness, education, treatment and most importantly prevention.  Offering continuing education and ways of implementing mental health into their practice would help eliminate stigma and, when necessary, increase referral and treatment to perinatal mental health professionals.

WK: What can we do to increase the understanding that a woman’s mental health is part of maternal health?  

Jennifer Moyer: Although the old saying “if mom is not happy, no one is happy”, puts pressure on moms, it does stress the importance of maternal health.  The health of mothers is critical to society and communities everywhere.  The more mental health is talked about, the better understanding will occur.  As you probably have realized from my previous responses, I am a huge proponent of education.  I believe it is the key to decreasing stigma and bringing about positive changes in the health of women both mentally and in general.

Next Steps

In what ways can childbirth educators participate in bringing about positive changes within this paradigm? How can health care professionals learn more about how the role mother’s mental health plays in so many of the dynamics of the new mother and child(ren). Would you be interested in a webinar on this topic?  Where do you as a birth professional go for more resources, information and teaching tools on the topic of postpartum mental health?

About Jennifer Moyer

Jennifer Moyer has various media experience including her personal story being published in the February 2002 issue of Glamour Magazine resulting in a guest appearance on CNN’s The Point. She was also interviewed for an article appearing in the December 2002 issue of Psychology Today. Jennifer is a member of the National Perinatal Association, the National Alliance on Mental Illness, Mental Health America, The Marcé Society, the National Association of Mothers’ Centers and Postpartum Support International. Jennifer is also now a member of the International Association for Women’s Mental Health.

Please contact Jennifer through her website or by emailing her at jennifer@jennifermoyer.com. Jennifer blogs at: www.jennifermoyer.com/blog

Walker would like to thank Jennifer Moyer, Nancy Byatt, D.O., MBA, and Julia Frank, MD, and the Listserv of the Marce Society for their assistance with this article.

Walker Karraa Childbirth Education, Depression, Guest Posts, Infant Attachment, Maternal Mental Health, Newborns, Perinatal Mood Disorders, Postpartum Depression guest posts, Jennifer Moyer, maternal mental health, mental health, postpartum depression, postpartum mood and anxiety disorders, postpartum psychosis, treatment for postpartum psychosis, Walker Karraa