24h-payday

Archive

Archive for the ‘Postpartum Depression’ Category

Series: Welcoming All Families; Working with Women Pregnant after Infertility

September 9th, 2014 by avatar

Continuing the Science & Sensibility occasional  series: Welcoming All Families, Certified Nurse Midwife Emalee Danforth examines the research on perinatal and postpartum mental health on the family who arrives in your classroom or office with a history of infertility.  As the childbirth educator, you (and the rest of the class) most likely will not be aware of the families with this specific history, unless the family chooses to share privately or in the class group.  The educator needs to understand and recognize the increased risk of perinatal and postpartum mood disorders these families face.  Childbirth educators should evaluate their language and stories to be sure that they are providing sensitive and appropriate language and examples that welcome and apply to those whose path to parenthood might not be the same as other families in your class. – Sharon Muza, Community Manager, Science & Sensibility.

By Emalee Danforth, CNM

© Wikipedia

© Wikipedia

Infertility, defined as the inability to conceive after 12 months of timed intercourse or donor insemination (Practice Committee for the American Society of Reproductive Medicine, 2013), is a common experience. While estimates range, approximately 6-15% of the United States population will experience infertility (Chandra, Copen & Stephen, 2013) with higher rates possible when viewed from the global perspective (Mascarenhas, Flaxman, Boerma, Vanderpoel & Stevens, 2012).

The majority of research on the experience of pregnancy and parenting following infertility examines only those who have conceived using IVF (in vitro fertilization, also referred to as ART, assisted reproductive technology). This group of patients is easy to identify and therefore study, but represents only a portion of those who have experienced infertility. Additionally, study designs have often excluded those with multiple gestations, those with same sex partners, and those who have utilized donor gametes. In everyday life, all of these types of clients will cross the path of a care provider or childbirth educator and each has a unique experience. The available research can outline some of the known characteristics of persons who have conceived via IVF after infertility but caution should be applied to generalizations.

The Psychology of Pregnancy after Infertility

There is a particular psychology of infertility that can transfer to pregnancy, childbirth and postpartum. The emotional hallmark of infertility is anxiety (Bell, 2013). Once pregnant, this worry does tend to persist through the pregnancy and heighten as the due date approaches. The level of general anxiety appears similar to those who have conceived spontaneously, but pregnancy-focused anxieties are heightened in previously infertile women, especially those who experienced prolonged treatment failure and high infertility-related distress (Hammarberg, Fisher & Wynter, 2008). McMahon et al. (2011) points out that “the relatively low correlation between pregnancy-focused anxiety and state anxiety…confirms that pregnancy-focused anxiety needs to be considered as a separate construct from more generalized anxiety” (p. 1394) and that this phenomena may be due to a particular reproductive history rather than individual personality factors.

Infertility is also known to be associated with elevated rates of depression (Cousineau & Domar, 2007). However, evidence is consistent that once pregnant, ART women and men experience lower levels of depressive symptoms than those that have spontaneously conceived (Hammarberg et al., 2008). This may be related to higher rates of psychosocial factors that are protective for perinatal mood disturbance in ART expecting women and men including higher socioeconomic status, higher education, higher quality and longer lasting intimate relationships, being older than average and having a planned conception (Fisher, Hammarberg & Baker, 2008). This same study posits that “it is possible that this low rate of distress is reflecting an almost elated mood, in which the pregnant state and family formation achieved after a long period of anticipation and via intrusive and disruptive interventions are somewhat idealized”(p.1110). Indeed, Hjelmstedt, Widstrom, Wramsby & Collins (2003) found that ART women experienced pregnancy in a less negative way and were also less worried about possible “loss of freedom” in their future lives as parent compared to the spontaneous conception control group.

It is therefore surprising that after birth, ART women experience postpartum depression at similar rates to the rest of the childbearing population (Hammarberg et al., 2008). Fisher et al. (2008) found significantly higher rates of admission for ART women in Australia for postpartum mood disturbances despite their more elevated mental state antepartum. This may be because after a long struggle with infertility and undergoing invasive and costly procedures, ART women feel “a low sense of entitlement to complain or to express any doubts, uncertainty, or mixed feelings about the realities of motherhood (Fisher et al., 2008, p. 1111).” However, once the baby or babies are born, ART women must adjust to motherhood and cope with the demands of a newborn just as any other mother. The combination of idealization of motherhood and lack of preparation for the experience of ambivalence can cause mental distress postpartum. In addition, the higher frequency of birth complications among ART women including preterm birth, cesarean section, low birth weight and multiple gestation (Hammarberg et al., 2008) all can have an additive effect on the stresses of motherhood.

There is evidence that ART women experience the process of emotional attachment to the fetus differently from those with spontaneous conception. Fisher et al. (2008) found that ART women thought about their fetus as much in early pregnancy as the general population of mothers did in advanced pregnancy. In late pregnancy, ART women had significantly more intense and protective emotional attachments to the fetus than women who spontaneously conceived. McMahon et al. (2011) found that with age taken into account, there was a strong association between ART conception and more intense maternal-fetal attachment. This is likely the result of extended anticipation of parenthood, investment in the process of conception and intimate awareness of the biology and timing of conception.

© infertile.com

© infertile.com

There remains a dearth of information on the experiences of ART women during childbirth. There exists one recent prospective multicenter study out of Finland on this topic (Poikkeus et al., 2014) which finds that dissatisfaction with childbirth was similar between ART women and controls with singleton pregnancies. The factors that have been previously found to be related to risk for a negative childbirth experience still remained true for both groups: low educational level, inadequate social support, dissatisfaction with her partner or spouse, untreated fear of childbirth and antenatal depression. Also recalled intolerable pain in birth and giving birth by emergency cesarean section increased dissatisfaction with birth. The authors’ conclusion was that dissatisfaction with childbirth was not related to mode of conception but rather lay with the underlying individual psychosocial and obstetric factors of each patient.

Recommendations for Care

While the body of research on the experience of women pregnant after infertility remains emergent, we can use what we know to help guide the most optimal and sensitive care for this population. Firstly, it is important to remember that this group is often invisible, particularly in the childbirth education classroom. The question “how many months did it take you to conceive?” or the unwitting quote from Ina May Gaskin “What got the baby in is what will get the baby out” will land quite differently on the ears of a woman who has gone through ART. In the clinical setting most if not all patients will share their mode of conception, but in the setting of CBE it may be kept private and language usage should be sensitive to this.

The within-group differences in an ART population can also be significant. A woman who needed help getting pregnant due to a very low sperm count in her male partner and conceived on her first round of IVF will likely have a different experience and outlook than a woman who has gone through multiple rounds of failed IVF for unexplained infertility and a miscarriage before having a term pregnancy with an egg donor. Each woman will be having her own unique experience.

The combination of early and intense attachment to the fetus as well as increased levels of pregnancy specific anxiety for ART women points to the need for frequent reassurance and quite possibly increased frequency of care, particularly in the first trimester and prior to quickening. Sensitive care during pregnancy can help transition a client, if appropriate, from a sense of herself as “high risk” and under specialty care to generalist obstetric or “low risk” midwifery care. Bell (2013) suggests that this reassurance will help women “slowly grow to trust in the process which is pregnancy, and … gain a sense of accomplishment and fulfillment as they continue to gestate” (p.51).

Promoting physiologic birth is the goal for all women including ART women. ART women are more likely to have protective social factors such as greater age, income, education and more stable relationships that can help increase satisfaction with childbirth but concurrently more likely to have characteristics such as older age, multiple gestation and preterm birth that lead to higher rates of obstetric intervention, which leads to a decreased satisfaction with childbirth. Working with each client’s individual strengths and limitations will help best prepare her for birth. For many women, feeling like they are active participants in their childbirth care and decision making is critical to their feeling of satisfaction. Involvement in this process may help a client regain a sense of control that may have been eroded during invasive and intensive infertility treatments.

While baby blues and postpartum depression and anxiety should be discussed with every client, understanding more about the psychology of ART women can help guide a practitioner to have a nuanced and sensitive discussion with these clients. A skilled provider or childbirth educator will be able to recognize and honor the joy and gratefulness that an expecting woman or couple feels after conceiving through ART, but also understand that this is likely layered with pregnancy-specific anxiety, a desire to regain some sense of control over one’s body or birth, and a vulnerability to postpartum mood disturbances. Anticipatory counseling including statements such as “some women who give birth after successful IVF treatments are surprised by the many ups and downs of caring for a newborn and may not have anticipated any negative feelings” or “no matter how glad you are to become a mother, it is normal to experience fatigue and feelings of ambivalence.” can help new parents allow their full range of feelings to surface. When mothers feel safe to share their feelings, more prompt identification and treatment of depression and anxiety is possible.

Understanding the prevalence of infertility and its psychological effects can help the childbirth educator, nurse, clinician or other birth professional provide sensitive and optimal care to the often invisible population of women or couples who are pregnant following infertility treatment.

Have you had families with a history of infertility in your childbirth classes?  As clients? What if anything did you do different to be sure to meet the needs of these families?  Can you share how you have handled this in your classroom environment?  Did your families choose to let you know?  Your thoughts and comments are valued in our discussion section below. – SM

References

Bell, K.M. (2013). Supporting childbearing families through infertility. International Journal of Childbirth Education, 28(3), 48-53.

Cousineau, T.M. & Domar, A.D. (2007). Psychological impact of infertility. Best Practice & Research Clinical Obstetrics and Gynaecology, 21(2), 293-308. doi: 10.1016/j.bpobgyn.2006.12.003

Chandra, A., Copen, E.E. & Stephen, E.H (2013). Infertility and impaired fecundity in the United States, 1982-2010: Data from the National Survey of Family Growth. National Health Statistics Report, 67, 1-18.

Fisher, J., Hammarberg, K. & Baker, G.(2008). Antenatal mood and fetal attachment after assisted conception. Fertility and Sterility, 89(5), 1103-1112. doi: 10.1016/j.fertnstert.2007.05.022

Hammarberg, K., Fisher, J. & Wynter, K. (2008). Psychological and social aspects of pregnancy, childbirth and early parenting after assisted conception: A systematic review. Human Reproduction Update, 14(5), 395-414. doi: 10.1093/humupd/dmn030

Hjelmstedt, A., Widstrom, A-M., Wramsby, H. & Collins, A. (2003). Patterns of emotional responses to pregnancy, experience of pregnancy and attitudes to parenthood among IVF couples: A longitudinal study. J Psychosom Obstet Gynecol, 24, 153-162.

Mascarenhas, M.N., Flaxman, S.R., Boerma, T., Vanderpoel, S. & Stevens, G.A. (2012). National, regional, and global trends in infertility prevalence since 1990: A systematic analysis of 277 health surveys. PLOS Medicine, 9(12), 1-12. doi: 10.1371/journal.pmed.1001356

McMahon, C.A., Boivin, J., Gibson, F.L., Hammarberg, K., Wynter, K., Saunders, D. & Fisher, J. (2011). Age at first birth, mode of conception and psychological wellbeing in pregnancy: Findings from the parental age and transition to parenthood Australia (PAPTA) study. Human Reproduction, 25(6), 1389-1398. doi: 10.1093/humrep/der076

Poikkeus, P., Saisto, T., Punamaki, R., Unkila-Kallio, L., Flykt, M., Vilska, S., Repokari, L. … (2014). Birth experience of women conceiving with assisted reproduction: A prospective multicenter study. Acta Obstet Gynecol Scand 2014; doi: 10.1111/aogs.12440
Practice Committee for the American Society of Reproductive Medicine (2013). Definitions of infertility and recurrent pregnancy loss: A committee opinion. Fertility and Sterility, 99(1), 63. doi: 10.1016/j.fertnstert.2012.09.023

Toscano, S.E. & Montgomery R.M. (2009). The lived experience of women pregnant (including preconception) post in vitro fertilization through the lens of virtual communities. Health Care for Women International, 30:11, 1014-1036. doi:10.1080/07399330903159700

About Emalee Danforth

Danforth Emalee head shotEmalee Danforth is a Certified Nurse-Midwife working in Seattle, WA. She practices at University Reproductive Care, the University of Washington’s infertility and reproductive endocrinology clinic. Previously she spent 5 busy years practicing full-scope midwifery in the hospital setting. She holds a BSN from the University of Michigan and an MSN from the University of Washington. She is also a co-facilitator of Maybe Baby, a resource and support group for LGBT persons on the path to parenthood.

Childbirth Education, Guest Posts, Perinatal Mood Disorders, Postpartum Depression, Series: Welcoming All Families , , , , , , ,

Kathy Morelli Shares Highlights from the 2014 Postpartum Support International Conference

July 15th, 2014 by avatar

Regular contributor Kathy Morelli attended the Postpartum Support International conference in Chapel Hill, North Carolina this past month.  In today’s post, Kathy shares her thoughts, some big take-aways and checks in with the keynote speakers, who share important messages on postpartum mood disorders with our S&S readers.  We all have a responsibility to increase awareness and treatment options for pregnant and postpartum women.- Sharon Muza, Science & Sensibility Community Manager.

PSI QuiltI want to shout from the rooftops that there are so many well-educated, caring and ethical professionals who are focusing on Maternal Mental Health! I was so fortunate to be able to attend this year’s Postpartum Support International 27th Annual Conference at the University of North Carolina (UNC) campus at Chapel Hill on June 18 – June 21, 2014.

PSI’s theme this year was “Creating Connections between Communities: Practitioners and Science: Innovative Care for Perinatal Mental Health.” It was a wonderful meeting where scholar-practitioners in the Perinatal Mental Health field met and exchanged information and best practices in order to hone their collective craft. Researchers, clinicians and identified survivors met and shared their professional and personal stories. PSI’s outgoing president, Leslie Lowell Stoutenburg, RNC, MS, reports that PSI had its largest attendance ever this year.

The keynote speakers were a group of experienced professionals, researchers and clinicians presenting on clinical, scholarly and advocacy topics: Dr. David Rubinow, of UNC Chapel Hill, Dr. Samantha Meltzer-Brody of UNC Chapel Hill, Dr. Marguerite Morgan, of Arbor Circle Early Childhood Services in Grand Rapids, Michigan, Ms. Joy Bruckhard of California’s 20/20 Mom Project, and Dr. Susan Benjamin Feingold, clinical psychologist, all presented about their work in the different aspects in the field of Maternal Mental Health. Advocate Katherine Stone of Postpartum Progress served as emcee at the Saturday night banquet.

Dr. David Rubinow presented on his team research regarding female hormonal fluctuations and the relationship to postpartum mood disorders in sensitive women. Dr. Rubinow is an internationally known expert in the evaluation and treatment of women with mood disorders that occur during periods of hormonal change. Regarding the team’s research, he states “Our data demonstrate that normal changes in reproductive hormones can produce affective disturbance in a susceptible group of women.” The study (Bloch et al, 2000) examined the role of endocrine factors in the etiology of postpartum depression (PPD) by comparing women with a history of PPD and without PPD. Progesterone and estriadiol was measured at baseline, addback, withdrawal, and folIow-up. 67% of the women who had PPD had a recurrence of significant affective symptoms, including a constellation of depressive and hypomanic affect, while none of the control group experienced significant affective symptoms. This indicates that women who suffer from PPD may have a trait vulnerability that isn’t present in women who do not suffer from PPD.

Dr. Susan Benjamin Feingold, the keynote speaker on Saturday evening, presented on her clinical work around the transformational nature of surviving postpartum depression, documented in her newly released book, Happy Endings, New Beginning: Navigating Postpartum Mood Disorders. Dr. Feingold presented inspirational journal entries from women in her clinical practice. She says: “ In my book, I focus on a new view of the postpartum experience and how this difficult time can be a catalyst for change, personal growth and positive transformation. Postpartum depression can be the opportunity for not only healing, but ultimately, it can be a life-changing event.”

Ms. Joy Bruckhard, MBA, of Cigna, presented on her advocacy work in as one of the founders of the Maternal Mental Health Care Collaborative in California called the 20/20 Mom Project. The 20/20 Mom Project is a national campaign and movement for moms and by moms to create specific pathways to treatment for maternal mental health disorders, to address barriers to mental health care. The 20/20 Mom Project has teamed up with Postpartum Support International, a sister non-profit to launch first-of-a-kind web-based training for clinical professionals with the aim of addressing the shortage of mental health and medical professionals who specialize in maternal mental health. Joy says: “I’m so honored to be a part of this important work. Three years ago, my worlds collided: my training through Junior League, my experience in health care working at Cigna and having had two babies myself (and perhaps mild postpartum depression), and some family experience with mental illness, I felt compelled to step up and do more.”

Dr. Samantha Meltzer-Brody, a psychiatrist at UNC Chapel Hill, presented about the ongoing stigma about using psycho-pharmaceuticals during pregnancy and breastfeeding. She expressed frustration that other medications are readily accepted for use during pregnancy, but that there is an ongoing stigma against using medications that treat the mother’s mental health.

Dr. Marguerite Morgan, LCSW, presented on her successful program with African American women at the Arbor Circle Early Childhood Services in Grand Rapids, Michigan. She emphasized that she drops her “PhD-Dr” demeanor and constantly strives to connect at a human level with the people she serves. She is well versed in Christianity and quotes biblical passages about helping oneself during dark times, thus normalizing the experience of depression to her population in an accessible manner.

The psychodynamic approach to perinatal mood disorders was presented by Ms. Lorraine Caputo, LMFT, which addresses the mental health of women across the lifespan. Research and clinical practice indicates that a woman’s previous life experiences can have an impact on her transition to parenthood. On the lifelong care of a woman’s mental health, Ms. Caputo says: “I believe it’s crucial to help women with a history of trauma to make connections between the past and present in a way that psychodynamic treatment is uniquely poised to provide. The perinatal period is a natural time of enormous change, and in the best of circumstances will cause dysregulation, psychological transformation and re-identifications and dis-identifications with one’s own parents. And, given how entirely a pregnant woman and a postpartum mother surrenders her body to her child, childhood sexual traumas in the mother’s past can be triggered by this intense period of physical and emotional bonding with her baby. A psychoanalytic intervention that involves the development of a coherent narrative about how she was parented, and making connections between unrelenting anxiety, ruminations, self blame, and her past history can free a new mother from self doubt, guilt, and fear that she will not be a good mother. This work is done in a carefully paced way, using self reflection and the relationship with the therapist to help the mother feel safe and her powerful feelings contained and held by the therapist.”

Dr. Kelly Brogan, of Womens Holistic Psychiatry, discussed holistic clinical pathways to reproductive mental health.

Of note was the unique reproductive psychiatric sharing session, where reproductive psychiatrists came together to discuss clinical situations which they have encountered. This session was an extension of the collaborative professional LISTSERV that PSI hosts for clinical member reproductive psychiatrists.

Sessions on Healthy Postpartum Relationships were presented by both Ms. Elly Taylor and Ms. Karen Kleiman, LMFT, of the Postpartum Stress Center. Karen Kleiman has recently published her book, Tokens of Affection: Reclaiming Your Marriage after Postpartum Depression, informed from her extensive clinical experience with postpartum couples. Ms. Kleiman presented her overarching framework for treating distressed postpartum couples, identifying 8 tokens to be cultivated in the therapeutic encounter. One of the tokens she refers to as a “Token of Affection.” Ms. Kleiman notes: “Recovery from postpartum depression does not happen overnight, thus, creating a lag between the crisis and a sense of well-being for the couple. During this transitional period both partners are anxious to return to normal while they are simultaneously challenged by buried negative emotions and unmet expectations. Tokens of Affection are gift-giving gestures on behalf of the relationship. As a reparative resource, the Tokens lead the way toward renewed harmony and reconnection.”

Elly Taylor remarks: “It’s common for couples – even happily married ones – to find that the bond between them becomes stretched following the birth of their baby. This comes as a shock for most and increases the risk for perinatal mood disorders for some. But prepare for this, and its possible not only to protect the bond, but build on it as the foundation for family.” She has recently published her book about the postpartum couple’s experience called, Becoming Us, in the United States.

Included here are some closing thoughts from the incoming PSI president, Ann Smith, RN, MSN, CNM:

“PSI is the original and leading organization dealing with perinatal mood disorder which we now know affects approximately 1 in 7 moms. It’s the leading complication of childbearing. All women can be affected regardless of age, race, socioeconomic status and whether the pregnancy was wanted. When treated promptly and by someone who has familiarity with these disorders, moms get better quite quickly. PSI has training programs nationwide which train providers in evidence based treatments. Many women need a combination of medication and talk therapy to get better as quickly as possible. There are a number of medications which have been proven safe for pregnancy and breastfeeding. Support groups are also helpful.

PSI wants everyone to remember three things:

You are not alone, you are not to blame, with help you will be well.

For assistance, call the PSI Warmline at 800-944-4PPD or visit online

References

Bloch, M., Schmidt, P. J., Danaceau, M., Murphy, J., Nieman, L., & Rubinow, D. R. (2000). Effects of gonadal steroids in women with a history of postpartum depression. American Journal of Psychiatry157(6), 924-930.

.

Babies, Birth Trauma, Childbirth Education, Guest Posts, Infant Attachment, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, PTSD, Trauma work , , , , , ,

One of a Kind: An Interview with Dr. Meltzer-Brody about UNC’s Inpatient Mother Baby Psych Unit

June 19th, 2014 by avatar

As Postpartum Support International’s 2014 Annual Conference kicks off this weekend in Chapel Hill, NC, regular contributor Kathy Morelli shares her interview with Dr. Samantha Melzter-Brody as Kathy learns more about the only inpatient psychiatric Mother-Baby Unit in the USA.  Perinatal mood and anxiety disorders affect up to 1 in 7 mothers, and at times, inpatient help is what is needed to properly serve the mother and her family.  This unique five bed unit is offering this inpatient care to help mothers get treatment for their perinatal mental health illnesses.  Learn more about this groundbreaking clinic in Kathy’s interview with Dr, Meltzer-Brody. – Sharon Muza, Community Manager, Science & Sensibility.

© Dr. Meltzer-Brody

© Dr. Meltzer-Brody

Dr. Samantha Meltzer-Brody has developed a substantial career as a psychiatrist in the areas of Reproductive/Maternal Mental Health. She is an Associate Professor and Director of the Perinatal Psychiatry Program at the University of North Carolina, Chapel Hill. It’s a comprehensive clinical and research program that includes a five bed inpatient psychiatric Mother-Baby Unit, the first and only of its kind in the United States. UNC’s unit is based on the standard of care psychiatric Mother-Baby Units in Europe and Australia.

In addition, Dr. Meltzer-Brody is scheduled to be the Keynote Speaker on Saturday, June 21st at the Postpartum Support International (PSI) 2014 Conference hosted at the University of North Carolina at Chapel Hill Center for Women’s Mood Disorders. At PSI, she’s speaking about the psychopharmacological treatment of perinatal mental illness.

As a mental health clinician, I admit it took me a while to feel comfortable with the idea that women who are pregnant or lactating who are in need of psycho-pharmaceuticals can do well on them. Now I know there’s a risk-benefit analysis that women should be empowered to employ. Many women in my practice are extremely opposed to taking any medications suggested for their mental health (even when not pregnant or not lactating), so this is a topic with many facets. Each woman is an individual and each woman should talk to her doctor about what’s best for her situation. I’m attending the PSI conference and looking forward to learning more.

Kathy Morelli: How did you become interested in your particular niche, Reproductive/Maternal Mental Health?

Dr. Samantha Meltzer-Brody: First of all, I want to say that I love being a part of the Reproductive Mental Health field.
There are many different roles in the area of Reproductive and Maternal Mental Health, not just one. There are many different types of people needed to work in this area and fill these many different roles. I love that we all can work together, helping each other.

When I began working at the University of North Carolina (UNC) at Chapel Hill, there was no formal women’s mental health program in place. Our women’s mental health outpatient clinic was created at a grassroots level, beginning in the clinics on Wednesday mornings. I was fortunate as UNC Chapel Hill functions with a wonderful collaborative and interdisciplinary atmosphere, so the psychiatry program and the obstetrics program were able to dovetail nicely. In addition, in 2006, our new chair of the psychiatric department arrived, Dr. David Rubinow, who is an international expert in women’s reproductive mood disorders, thus, the time was ripe to create our interdisciplinary Perinatal Outpatient Clinic.

KM: The Mother-Baby Unit at UNC Chapel Hill is the only Maternal-Baby Psychiatric Unit in the United States. I’d love to know more about how the idea came about to develop the Mother-Baby Unit at Chapel Hill. 

SM-B: At UNC, we found there was a high demand for reproductive psychiatry in our outpatient mental health clinics. We have clinic locations in a variety of settings and we found that there was a certain percentage of patients to whom we couldn’t deliver much needed proper care in the outpatient setting nor on a general inpatient psychiatry unit. The Mother-Baby Unit was developed to serve the needs of women experiencing severe perinatal mental illness in a safe and specialized setting to meet the needs of women at this vulnerable time.

As the collaborative team discovered and documented the needs of our patients, we were able to work together at UNC to engage hospital administration at higher levels. We were very fortunate to have a number of champions for this idea within the healthcare system. Initially, we piloted our inpatient program by designating two beds for perinatal patients on a geropsychiatry unit. We developed specialized programming for the perinatal patients and began to get an enormous number of referrals. Eventually, we were able to document that we needed an expanded and completely separate perinatal psychiatry inpatient unit and were able to obtain the support of hospital administration at UNC to launch a new program. And that’s how we became the only Mother-Baby inpatient unit in the United States.

At UNC, we feel it’s critical to have a unit to meet needs of mothers and babies. We feel you can’t mix all the different types of psychiatric populations together. We were able to remodel existing inpatient unit space to create the new unit on a relatively small budget. It’s extremely difficult for the family when a new mom becomes mentally ill and requires hospitalization. Our Mother-Baby Unit helps families through this difficult time by providing family care. It’s extremely rewarding to provide whole care that positively impacts the entire family. We are a state hospital committed to serving the population of the state. Indeed, there’s a state mandate to care for the people of the state, and we take that very seriously.

Keep in mind that our Mother-Baby Unit is a psychiatric care unit, not a respite or spa facility. To be admitted, the patient must meet the criteria for psychiatric inpatient hospitalization, such as suicidal ideation, a heightened bipolar episode or postpartum psychosis or inability to care for self. Most of our patients have suicidal ideation at the time of admission. The average length of stay (LOS) is seven days. Compare this average LOS in the US to the average LOS in a Mother-Baby Unit in Australia of 21 days. We also have a growing number of referrals for women presenting with postpartum psychosis.

When a mother and her baby comes to stay with us, it’s required that a family member, such as the grandmother or father or other identified care provider accompanies the baby on the unit. This is because the babies don’t stay overnight as the health insurance companies in the United States won’t pay for babies to stay overnight. But we work as best we can with the family, in order to preserve the mother’s sleep time for her mental health and also preserve the healthy attachment with her infant. Sleep is especially important when a person is suffering from a mental illness.

In the units, we have bassinets and breast pumps available for the patients and their babies. The nurses’ interaction with the babies vary based on the needs of the particular mother.

Our treatment plans focus on several psychosocial areas of concern. We focus on maternal mood, impaired mother-baby attachment issues, the relationship with the partner and on improving what the partner and family understands about what has happened. To serve these needs, we run several targeted groups: a maternal mental health group, a mother-infant attachment group and a partner group for fathers. But the treatment is individualized; it’s tailored to meet the needs of the family. Due to the typical short length of stay allowed by insurance companies in psychiatric units in the United States, the emphasis is on teaching self-help skills and tools to the patient and family. Such skills and tools are mindfulness, biofeedback, breathing, trigger identification, and post-discharge planning.

KM: There is so much stigma around the diagnosis of mental illness and perhaps more so around perinatal mental illness. Research shows that individuals suffer from both externalized and internalized stigma around a diagnosis of mental illness, much more so than a physical medical condition. So, there’s already stigma about depression and anxiety….it’s already difficult to come forward and then even more so for women to come forward about how they feel, as new mothers and with a baby. There’s shame associated with not coping and also fear about having the baby taken away.

Do you believe there is unconscious stigma around mental illness? Have you seen this phenomena in your work?

SM-B: Stigma is a huge and well documented issue in perinatal mood disorders. It’s very hard and terrifying for people to admit to having a mental illness, especially during the transition to motherhood. There are so many fears around hurting the baby. It’s documented that actual harm to the baby is quite rare, but when it happens, of course it’s a tragedy and the media sadly sensationalizes the event. Plus there is enormous personal shame. Research and clinical experience indicate this shame around feeling emotionally ill and then being diagnosed with a mental illness is exaggerated during the perinatal period. New mothers can feel so insecure and inadequate in their new roles. The stigma, shame and guilt issues are important and need to be part of the therapeutic sessions.

KM: There is so much contradictory information about how hormones, breastfeeding, formula feeding can affect a woman’s self-esteem and mood. Some studies suggest that breastfeeding is protective of depression, yet clinically, some women feel better when they choose to discontinue breastfeeding.

In layman terms, what are your thoughts about the relationship between breastfeeding and postpartum mood disorders? What are some of your guidelines for clinicians to follow regarding the choice of infant feeding method for a woman and her family?

SM-B: At the UNC Perinatal Psychiatry Program, we love to educate organizations that support new moms that women have psychiatric needs. We enjoy the opportunity to educate and influence breastfeeding groups with information about the unique needs of the perinatal population of women with mood disorders. Our feeling is that setting up breastfeeding as an all-or-nothing construct is a set up for feelings of failure for some new moms and can lead to exacerbation of psychiatric symptoms.
It would be great to see the prescription for sleep as a recognized treatment for new moms. And, for mothers with a perinatal mood disorder, to define successful breastfeeding to include one bottle nightly so that mom can sleep for an adequate block of time. This is important for the mom’s brain health.

We also want to emphasize that mothering is not a competitive sport. Our goal is a healthy mother and a healthy baby. Whether or not a woman breastfeeds shouldn’t be colored by judgment of right versus wrong or success versus failure. We need to keep in mind that the goal is that the baby must be fed, even when the mother is suffering from a severe perinatal mental illness.

One thing we do know is that sleep deprivation exacerbates depression anxiety and mood disorders. So we try to help women who wish to breastfeed increase the odds of successful lactation without significant sleep deprivation. We encourage women and families who wish to breastfeed to continue but also set up some guidelines to help the mothers heal mentally and emotionally. We don’t see breastfeeding as an all or nothing activity. At UNC, we say that there can be a combination of breastfeeding and formula feeding in order to support the needs of both mom and baby. We feel that breastfeeding has many benefits and that it’s not an all or nothing equation. We want to enable women with perinatal mood disorders to continue to breastfeed but also help them succeed at mothering, in a way that’s realistic and healthy for them.

KM: Dr. Meltzer-Brody, thank you so very much for your time! You’ve shared enlightened information and guidelines for perinatal clinicians and expanded the definition of mothering to be more inclusive. I look forward to seeing you at the conference at UNC!

What are the health care providers and clinics doing in your area to support the needs of women suffering from perinatal mental illness?  Do you think that your community would benefit from such an inpatient clinic?  How could this become a reality around the country, so all women are served as they should be, with the professional help and treatment they deserve?- SM

Babies, Depression, Guest Posts, Infant Attachment, Maternal Mental Health, Newborns, Perinatal Mood Disorders, Postpartum Depression , , , , , ,

Childhood Sexual Abuse as a Risk Factor for Postpartum Depression- Part 2: The Educator’s Role

June 5th, 2014 by avatar
© CC Smoochi: http://flickr.com/photos/smadars/4758708634

© CC Smoochi: http://flickr.com/photos/smadars/4758708634

Kathy Morelli, perinatal mental health expert and S&S contributor is sharing information about the impact of childhood sexual abuse on women during the childbearing year.  Tuesday, in Part 1,  Kathy discussed the brain changes that can occur as a result of such abuse and today, Kathy shares the impact during the childbearing year and the role of the childbirth educator.  - Sharon Muza, Community Manager, Science & Sensibility

How do these underlying biological changes affect a woman during the childbearing year?

Childhood sexual abuse (CSA) and a woman’s subsequent reproductive life, including menstruation, pregnancy, birth and ongoing sexuality, occur at different times, maybe even in different decades, in a woman’s life. Yet, in clinical practice and in the research, these issues are intertwined.

In general, the research indicates that women who experienced childhood sexual abuse have more emotional distress in pregnancy, which directly impacts their physical health, which then impacts their pregnancy and leads to more medical interventions (Lev-Weisel, Daphna- Tekoah, and Hallak, 2009).

The somatic, body-based feelings in pregnancy can be re-triggering to a woman who has deep, non-verbal somatic memories of childhood sexual abuse. It’s important that women receive sensitive reproductive care, both physically and emotionally. An unaccepting attitude from her healthcare providers can trigger deeply held feelings of helplessness, fear, low self-worth and shame and actual flashbacks, symptoms of post-traumatic stress disorder (Lev-Weisel, Daphna- Tekoah, and Hallak, 2009).

The obvious sexual themes resonate on multiple levels: body-based, emotional and psychological. Yet, there hasn’t been lot of research about how a history of childhood sexual abuse impacts a woman’s mental health during pregnancy and postpartum. However, what research exists, finds that women who suffered from childhood sexual abuse have an elevated risk of postpartum depression (Lev-Weisel, Daphna- Tekoah, and Hallak, 2009).

There are a lot of body-based feelings in pregnancy that could be re-triggering to a woman who has deep, non-verbal somatic memories of childhood sexual abuse, even if she is being treated with respect and kindness in the present day.

Pregnancy

Prenatally, simple things such as the position of a woman’s body as she lays on her to be checked vaginally can bring back non-verbal emotional memories of past abuse. The baby moving inside her body might cause intense joy, but might also create an underlying, non-verbal uneasiness.

Birth

Childbirth is an intense experience; a time of hormonal, physical and emotional exertion. Due to the pre-existing priming of early trauma memory networks – an intense distressful emotion, a particular scent, or a body position – can trigger flashbacks to earlier traumatic experiences. Feeling powerless, not heard, or disregarded by healthcare providers during childbirth, can activate the symptoms of post-traumatic stress disorder. Her present day feelings of powerlessness and fear are amplified by pre-existing traumatic memories (Beck, Driscoll & Watson, 2013).

Remember the disregard by the medical professionals may just be due to the rush of the medical team as they attend professionally to a medical emergency. The medical protocol doesn’t have a person assigned to talking and listening to the mother during the event, so she feels disregarded (Beck, Driscoll & Watson, 2013).

However, even if she is being treated in a kind way, your client’s body positioning or a scent can recollect something from her past trauma. In an uncanny and timeless way, her body and mind remember the past and take her back to feelings of fear and helplessness. She may wordlessly freeze or panic, for what seems to be no present day reason.

Postpartum

Postpartum, there are physical, emotional and psychological factors feeding emotional health. As has been noted over and over again, a pre-existing personal depressive or anxiety disorder (PTSD is in the spectrum of anxiety disorders) will set up the body up for another episode postpartum. Drs. Deborah Sichel and Jeanne Driscoll (2000) say the brain chemistry “remembers” its previous old depressive pathway and finds its way back there. Plus, there’s a major swing in hormonal activity in your body as you adjust from high levels of pregnancy and birth hormones to pre-pregnancy levels. This adjustment is different for all women, depending on whether or not they are breastfeeding and on their individual differences in metabolism and individual sensitivity level to their own hormonal shifts (Sichel and Driscoll, 2000).

For new parents who grew up in an abusive home, there’s the added challenge of the emotional and psychological work required to examine and modify negative repetitive childhood patterns. It’s not an easy task for your client as she evaluates her past behavioral, emotional and psychological patterns and replaces them with new and more positive patterns about family life and parenting. This adds another level of complexity to parenting a newborn, itself a major lifestyle adjustment.

Adjusting to a new lifestyle with an infant and baby care is physically and emotionally challenging. Feelings of frustration emerge as your client adjusts her schedule yet again to accommodate her baby plus the endless touching and carrying may leave her feeling like her body isn’t her own anymore. Breastfeeding may feel triggering to some women if it invokes past experiences.

A Childbirth Educator Can Help

Childbirth educators can play a key role in helping a woman who has survived childhood sexual abuse to proactively manager her experience of pregnancy, birth and postpartum.The good news is that, even with all these challenges, it’s important to realize that your client’s childhood sexual abusive does NOT define her. There are many aspects of the self that compose her constellation of self-definition.

The human mind and body are plastic, so the past isn’t destiny. Remember to factor in the resiliency of human nature. With patience and perseverance, human beings can move beyond survivorship, learn to bloom and move into the “thriving” phase.

However, learning to thrive is not an easy task. There are no “five steps” here! Managing the effects of an abusive childhood is an ongoing, deeply personal experience. It’s honorable life work, and highly individualized. As your client moves along her healing path, she’ll choose what feels right for her.

She can work positively on herself and experience post-traumatic growth. Post-traumatic growth is inner growth through personal development. It’s possible for her to experience this growth arising from her painful experience, with her own inner work.

Below are some positive ideas you may want to keep in mind as you teach your childbirth education curriculum to a diverse set of families. Your raised consciousness will help create an inclusive space for women survivors CSA to enhance her experience of pregnancy, birth and postpartum.

Be sensitive to the emotional aspects of working with someone recovering from CSA.

Help her honor the importance of pregnancy, childbirth and motherhood

  • Encourage women to honor their experience of childbirth as the important developmental life passage it is. CSA survivors may tend to dissociate and dismiss their experiences
  • Encourage women to interview some providers. Have a list of referrals of gynecologists/obstetricians/midwives that you know are open to and sensitive to working with women recovering from CSA
  • Encourage women to give themselves the respect of investigating the hospital or birth center where her provider practices
  • Allow women to have the freedom to have a personally honorable birth experience, in any manner that birth happens
  • Allow women to feel that they are not less of a woman or a mother, however the birth experience happens. Each woman gets to choose her path in childbirth. Not other people or the unseen, but felt, social pressures.
  • People heal individually at their own pace.
  • Don’t pressure women to use her childbirth experience as a healing ritual. Childbirth is a life-changing experience, and each woman gets to choose how to experience this. If she wants to explore the idea of birth as healing, encourage her to be open to many options. But birth is unpredictable, don’t put this out there as the only way to define healing. There are many paths to healing.
  • Help her by doing what you’re best at: demystify childbirth while accepting her choices. Don’t impose your personal agenda about what is right and wrong for her birth experience
  • If she has alot of anxiety about childbirth, honor her by encouraging her to put in the emotional work with a mental health professional. Childbirth education, while important, may not be enough to manage anxiety, depression and post-traumatic stress symptoms. Prenatal fear of childbirth increases the likelihood of postpartum depression.
  • Encourage her to develop a daily, holistic relaxation practice to counteract the effects of stress imbalance

Discuss postpartum planning in your curriculum

  • Have a babymoon/postpartum plan in place
  • Encourage women to practice self-love by allowing time to rest
  • Encourage women to gentle with themselves – pregnancy and childbirth puts body and mind through a lot of hormonal changes!
  • Educate her about hormonal changes. Hormonal balance takes at least three months to come back to pre-pregnancy levels. The hormonal adjustments are individualized; it also depends on if the mother is breastfeeding or not.
  • Educate women to protect her fourth trimester, and help her body shift to-wards balance:
    • Rest; develop the mindset of being, not doing
    • Practice good nutrition with whole foods and good supplements
    • Get help: If she can afford it, time with a postpartum doula or a baby nurse will help her achieve balance and rest
    • Don’t underestimate the power of sleep; discuss sleep planning
    • Practice mindfulness and relaxation to counteract the inevitable chal-lenges of caring for a new born and the emotional change of identity in motherhood
  • Complementary care is nurturing, safe touch helps rebalance the body and mind
  • Social support is important. Have resources available. Women who “Tend and Befriend” in real life and online help mothers feel supported, Women and birth circles are important resources.
  • Expect emotional ups and downs
  • De-stigmatize professional help; there’s a lot of professional help available. If she feels very sad or anxious, it’s ok to seek help.

As a childbirth professional, you can positively affect your clients and their families. Know that childhood sexual abuse,  though prevalent, doesn’t define people, they can work through it to experience positive personal growth, through resilience and post-traumatic growth.

References

Beck, C. Driscoll, J., and S. Watson (2013). Traumatic childbirth. New York: Routledge Press.

Lev-Weisel, R., Daphna- Tekoah, S., Hallak, M. (2009). Childhood sexual abuse as a predictor of birth-related posttraumatic stress and postpartum posttraumatic stress. Child Abuse and Neglect, 33, 877-887.
Perez-Fuentes, G., Olfson, M., Villegas, L., Morcillo, C., Wang, S. & Blanco, C., (2013). Prevalence and correlates of child sexual abuse: a national study. Comprehensive Psychiatry, 5(1), 16-27. http://www.ncbi.nlm.nih.gov/pubmed/22854279

Plaza, A., Garcia-Estave, L., Ascaso, C., Navarro, P, et al. (2010). Childhood sex-ual abuse and hypothalamus-pituitary-thyroid axis in postpartum major depression. Journal of Affective Disorders, 122, 159-163.

Sichel, D. & Driscoll, J. (2000).Women’s Moods. New York: Harper Paperbacka.

Yampolsky, L., Lev-Wiesel, R., & Ben-Zion, I. Z. (2010). Child sexual abuse: is it a risk factor for pregnancy?. Journal of Advanced Nursing, 66(9), 2025-2037. doi:10.1111/j.1365-2648.2010.05387.x

Childbirth Education, Depression, Guest Posts, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression , , , , , , , ,

Childhood Sexual Abuse as a Risk Factor for Postpartum Depression – Part 1

June 3rd, 2014 by avatar

Childhood sexual abuse can play a key role as a risk factor for postpartum depression.  Kathy Morelli takes a look at the impact of this horrible childhood event on a woman during her childbearing year.  Today, in Part 1 – we learn how the brain actually undergoes changes as a result of the trauma experienced.  On Thursday, Kathy Morelli will discuss how the woman who has experienced childhood sexual abuse (CSA) and what affect that has on her during the childbearing year,(pregnancy, birth and postpartum)  along with information and tips  for what childbirth educators can do.  Join us on Thursday for Childhood Sexual Abuse as a Risk Factor for Postpartum Depression – Part 2. – Sharon Muza, Community Manager, Science & Sensibility.

© CC Michelle Brea: http://flickr.com/photos/itsallaboutmich/451493421

© CC Michelle Brea: http://flickr.com/photos/itsallaboutmich/451493421

Woman to Woman Support

As I’ve said in my previous articles about Perinatal Mental Health, Lamaze childbirth professionals are very often the first point of contact for pregnant and new mothers. You’re an important resource in your community about pregnancy and childbirth, so becoming educated about the signs of perinatal mood/anxiety disorders and having an awareness about the prevalence of childhood sexual abuse (12% -20% of women) is an important aspect of your knowledge base. This article is meant to:

  • Increase awareness about the emotional aspects of surviving childhood sexual abuse (CSA)
  • Present a broad overview about the research regarding CSA
  • Present how CSA impacts a woman holistically, over her lifespan
  • Present how CSA impacts a woman specifically during childbearing
  • Discuss the complex recovery process from CSA
  • Generate ideas about whom to add to your community resource and referral list
  • Encourage being effective and supportive while preserving your own personal, certification and/or licensure boundaries

Remember, you may be the first person with whom she feels safe enough to discuss her personal history, even before her healthcare provider and sometimes even before her family. You can help out by being positively aware, being appropriately supportive and providing a list of contacts in the community and online.

Holistic View of a Woman’s Emotional History

Whenever a woman comes into my office for help for feelings of emotional and somatic distress during her pregnancy, childbirth experience and postpartum, I look at her life holistically, across her lifespan. I don’t assume, but I wonder, if she might be in that estimated 12% – 20% of women who have been sexually abused in their lifetime.

Is there a likelihood that past abuse affects how a woman feels about herself during pregnancy and childbirth and can be an underlying causative factor for antenatal depression or anxiety?

The research literature about the link between a woman’s past childhood sexual abuse and distress during pregnancy is scarce, but emergent research does show a connection.

How does a history of childhood sexual abuse (CSA) intersect with postpartum depression? This is a complicated question, but I’ll try to list some influential factors.

The HPA Axis is Modified: Fear and panic of CSA alters internal stress response

In general, research shows us that people who suffered from childhood sexual abuse (CSA) have a higher incidence of emotional, psychological and social distress, in addition to post-traumatic and physical, or somatic, symptoms. Specifically, research shows us that adult survivors of CSA suffer from higher rates of diabetes and cardiovascular symptoms (Plaza et al, 2010).

Women who have suffered past childhood sexual abuse suffer more unexplained gynecological symptoms, such as recurrent pelvic pain and more painful periods and sexual dysfunction than women who don’t have a traumatic sexual history (Lev-Weisel, Daphna- Tekoah, and Hallak, 2009). The stress and fear from childhood abuse manifests later on in adult life on all levels: body, mind and spirit.

What are some of the physical processes underlying this distress on the body and mind levels?

Researchers believe that long-term negative emotions, such as fear, panic and pain, cause an over-activation of the neural pathways in the brain associated with these strong emotions. The internal production of neurotransmitters, which affect mood, is affected. So chronic emotional stress impacts brain health.

The brain communicates with the pituitary and adrenal glands via the feedback loop called the Hypothalamus-Pituitary-Adrenal Cortex Axis (HPA Axis). The pituitary and adrenal glands are responsible for hormone production, which, in turn, affects the brain and our emotional state (Plaza et al, 2010).

During long-term childhood sexual abuse, the HPA Axis is continually activated and, with overactivation, the stress response becomes chronic, persisting throughout a lifetime. Thus, the chronic over-activation of the fear and pain response underlies anxiety disorders and chronic pain syndromes across the lifespan (Plaza et al, 2010).

During pregnancy and postpartum, hormonal changes are very dramatic, so there’s an additional adjustment for the mind and body to cope with. Thus, the hormonal changes during pregnancy also impact brain health via the pituitary and adrenal glands feedback loop.

Brain Development is Modified: Fear and panic of CSA can inhibit encoding of memories

Research shows that chronic fear and stress in childhood can actually inhibit the growth of some brain structures. In fact, some parts of the brain, such as the hippocampus, which is in charge of memory, are smaller in CSA survivors than people who were not abused in childhood. So, recollection of childhood memories is impaired.

In addition, brain imaging shows brain development is hindered in that there are less robust connections between the emotional part of the brain and the upper part of the brain (Plaza et al, 2010).

How do these underlying biological changes affect a person’s emotional health?

Survivors of childhood sexual abuse survivors are known to suffer from post-traumatic stress disorder, which has a constellation of symptoms on many levels: depression, anxiety, panic attacks, somatic pain, flashbacks and dissociative episodes.

Events that occured long ago in a woman’s life can still play a large role in her mental and physical health when she is pregnant, birthing and in the postpartum period. Join us on Thursday for Childhood Sexual Abuse as a Risk Factor for Postpartum Depression- Part 2: The Childbirth Educator’s Role.- SM

References

Beck, C. Driscoll, J., and S. Watson (2013). Traumatic childbirth. New York: Routledge Press.

Lev-Weisel, R., Daphna- Tekoah, S., Hallak, M. (2009). Childhood sexual abuse as a predictor of birth-related posttraumatic stress and postpartum posttraumatic stress. Child Abuse and Neglect, 33, 877-887.
Perez-Fuentes, G., Olfson, M., Villegas, L., Morcillo, C., Wang, S. & Blanco, C., (2013). Prevalence and correlates of child sexual abuse: a national study. Comprehensive Psychiatry, 5(1), 16-27. http://www.ncbi.nlm.nih.gov/pubmed/22854279

Plaza, A., Garcia-Estave, L., Ascaso, C., Navarro, P, et al. (2010). Childhood sex-ual abuse and hypothalamus-pituitary-thyroid axis in postpartum major depression. Journal of Affective Disorders, 122, 159-163.

Sichel, D. & Driscoll, J. (2000).Women’s Moods. New York: Harper Paperbacka.

Yampolsky, L., Lev-Wiesel, R., & Ben-Zion, I. Z. (2010). Child sexual abuse: is it a risk factor for pregnancy?. Journal of Advanced Nursing, 66(9), 2025-2037. doi:10.1111/j.1365-2648.2010.05387.x

Childbirth Education, Depression, Guest Posts, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, Uncategorized , , , , , , ,