Science & Sensibility

“Do women really eat their placentas?” I am asked this question in every Lamaze class I teach. This question is often accompanied by a raised eyebrow and a giggle. Many times, at least one mother will sheepishly avert her eyes and mention that she’s thinking about doing it because she’s heard of the amazing benefits that can be achieved by consuming her placenta. Our class discussion commences with differing opinions, theories, vague and distorted facts and many grunts of “ugh, gross!” It then becomes my job as the childbirth educator to sort this out and offer my students evidence based information with regards to placentophagy.

There’s been quite a bit in the news this last week or so about placenta eating.  Recently, Kim Kardashian, on her show, “Keeping up with the Kardashians,” queried her doctor about consuming her placenta after birth. She wanted to know if he thought that by consuming it, it would help keep her looking younger – a veritable fountain of youth. “Don’t you think it makes you look younger?” Kim asks her doctor during the episode. “Some people believe in that,” her doctor replies. “There are cookbooks on placentas.”

In 2012, Mad Men star, January Jones let it be known that she consumed her encapsulated placenta after her baby was born, per her doula’s suggestion.  ”Jones’s secret to staying high energy through the grueling shooting schedule? ‘I have a great doula who makes sure I’m eating well, with vitamins and teas, and with placenta capsulation.’ “

Hollywood seems to have picked up on the trend. Locally, in Pittsburgh, were I practice, there are at least three placenta encapsulation specialists and a few others who dabble in it. Talking to one recently, she mentioned that she was busy enough that she needed to bring in a partner to help her. It would appear that the trend is indeed on the rise.

Let’s take an in-depth look into the modern practice of placentophagy and the evidence behind it.

 How can placenta be consumed?

• Eaten raw
• Cooked in a stew or stir fry, or other recipes
• Made into a tincture
• Dehydrated and put into smoothies
• Dehydrated and encapsulated in pill form

Most modern mothers will choose to encapsulate their placenta. Taking it in a pill form seems to be most palatable for many women interested in consuming their placenta. The placenta is washed, steamed (sometime with other ingredients such as jalapeño, ginger and lemon), sliced, dehydrated, pulverized and encapsulated. Within 24-48 hours after birth, the mother has her placenta back in pill form and will ingest a certain number of pills each day.

Why would a woman want to take placenta capsules?

There are many claims made about the benefits of consuming placenta. The list below is from Placenta Benefits.info

The baby’s placenta, contained in capsule form, is believed to:

• contain the mother’s own natural hormones
• be perfectly made for that mother
• balance the mother’s system
• replenish depleted iron
• give the mother more energy
• lessen bleeding postnatally
• been shown to increase milk production
• help the mother to have a happier postpartum period
• hasten return of uterus to pre-pregnancy state
• be helpful during menopause

This is a rather amazing list. It would appear that consuming placenta postpartum is a bit of a magic bullet. This, in and of itself, makes me wary of the claims. There are a number of oft cited studies to back these claims up. However, my research turns up only studies in animals, anthropological studies and a recent survey of mothers who consume placenta.

Animal studies are good preliminary research and may provide indication for further study in humans. In and of themselves, they provide insufficient information to recommend placentophagy in human mothers.

Anthropological studies are a fascinating peek into human evolution, history and practice. They may provide clues as to why humans, as a rule, do not consume placenta. Or for those limited cultures that did/do consume it, the rationale behind doing so may be revealed. However, as with animal studies, anthropology alone does not give us cause to say that we should or should not be participating in placentophagy.

There is ongoing research out of Buffalo, NY by Mark Kristal, as well as from the University of Nevada, Las Vegas by Daniel Benyshek and Sharon Young on placentophagy. I look forward to their further contributions and hope their work provides impetus for additional hard science.

To date, there is not one double-blind placebo controlled study on human placentophagy.

Although advocates claim that these nutrients and hormones assumed to be present in both the prepared and unprepared forms of placenta are responsible for many benefits to postpartum mothers, exceedingly little research has been conducted to assess these claims and no systematic analysis has been performed to evaluate the experiences of women who engage in this behavior. (Selander et al. 2013)

 A note on Selander, et al: Jodi Selander is the owner of Placenta Benefits LTD. Her financial conflict of interest is noted in the survey.

What we have is anecdotal evidence from mothers who have consumed placenta (Selander 2013). Care providers who witness the effects of placentophagy in the mothers have been noted as well. There are a number of studies in animals, both with regards to behavioral and, chemical and nutritional benefits.  There are a number of anthropological studies, as well as a recent survey (Selander 2013).

What we truly lack is a double-blind, placebo controlled human study of the affects of placentophagy.

“While women in our sample reported various effects which were attributed to placentophagy, the basis of those subjective experiences and the mechanisms by which those reported effects occur are currently unknown. Future research focusing on the analysis of placental tissue is needed in order to identify and quantify any potentially harmful or beneficial substances contained in human placenta… ultimately, a more comprehensive understanding of maternal physiological responses to placentophagy and its effects on maternal mood must await studies employing a placebo-controlled double blind clinical trial research design.” (Selander 2013)

 This leaves us with a few unanswered questions. 

1. Is the benefit we see in the human mother after consuming placenta because she has consumed it, or is this placebo effect?
2. Are their benefits or risks to consuming amniotic fluid after birth?
3. If there is no biological imperative for human mothers to consume placenta, is there a reason for that? Is this a reason suggesting harm from eating placenta, a social norm, or something larger with regards to our need for bonding with our community of women during and after birth?

“This need for greater sociality during delivery then, in combination with the consequent pressure to conform to cultural norms, led to a strengthening of socials bonds and a reduction in the likelihood of placentophagia.” (Kristal 2012)

Coming full circle; how do we approach the topic of placentophagy in our Lamaze classes? Keep it simple. As of today, consuming placenta is not an evidence-based practice. Therefore, we cannot directly recommend it to our students.

However, to support our students’ autonomny, I believe a mother should be able to take her placenta home and do with it as she will. If your students wish to engage in this practice, I’d encourage them to speak to their care providers prenatally, to ensure safe handling of the placenta and to set appropriate expectations at birth.

References:

Kristal, M. B. (1980). Placentophagia: A biobehavioral enigma (or< i> De gustibus non disputandum est</i>). Neuroscience & Biobehavioral Reviews,4(2), 141-150.

Kristal, M. B., DiPirro, J. M., & Thompson, A. C. (2012). Placentophagia in humans and nonhuman mammals: Causes and consequences. Ecology of Food and Nutrition, 51(3), 177-197.

Selander, J. (2013), Placenta Benefits, placentabenefits.info. Retrieved June 09, 2013, from http://placentabenefits.info/index.asp.

Selander, J., Cantor, A., Young, S. M., & Benyshek, D. C. (2013). Human Maternal Placentophagy: A Survey of Self-Reported Motivations and Experiences Associated with Placenta Consumption. Ecology of food and nutrition, 52(2), 93-115.

Soykova-Pachnerova E, et. al. (1954)  “Placenta as Lactagagen” Gynaecologia 138(6):617-627

Young, S. M., Benyshek, D. C., & Lienard, P. (2012). The conspicuous absence of placenta consumption in human postpartum females: The fire hypothesis. Ecology of Food and Nutrition, 51(3), 198-217.

 

Deena Blumenfeld Childbirth Education, Depression, Evidence Based Medicine, Guest Posts, Maternal Mental Health, New Research, Perinatal Mood Disorders, Postpartum Depression, PTSD, Research, Uncategorized Childbirth Education, Deena Blumenfeld, guest post, maternity care research, placenta, placentophagy, postpartum depression, postpartum mood and anxiety disorders

 

I first became interested in childbirth-related psychological trauma in 1990.  Twenty-three years ago, it was not something researchers were interested in studying.  I found only one study, and it reported that there was no relation between women’s birth experiences and their emotional health. Those results never rang true for me. There were just too many stories floating around with women describing their harrowing births.  I was convinced that the researchers got it wrong,

To really understand this issue, I decided to immerse myself in the literature on posttraumatic stress disorder (PTSD). During the 1980s and 1990s, most trauma researchers were interested in the effects of combat, the Holocaust, or sexual assault. Not birth. But in Charles Figley’s classic book, Trauma and Its Wake, Vol. 2 (1986), I stumbled upon something that was quite helpful in understanding the possible impact of birth. In summarizing the state of trauma research in the mid-1980s, Charles stated that an event will be troubling to the extent that it is “sudden, dangerous, and overwhelming.” That was a perfect framework for me to begin to understand women’s experiences of birth. It focused on women’s subjective reactions, and I used it to describe birth trauma in my first book, Postpartum depression (1992, Sage).

Since writing Postpartum Depression, there has been an explosion of excellent research on the subject of birth trauma. The bad news is that what these researchers are finding is quite distressing: high numbers of American women, as well as women in other countries, have posttraumatic stress symptoms (PTS) after birth. Some even meet full criteria for posttraumatic stress disorder. For example, Childbirth Connection’s Listening to Mothers’ Survey II included a nationally representative sample of 1,573 mothers. They found that 9% met full-criteria for posttraumatic stress disorder following their births, and an additional 18% had posttraumatic symptoms (Beck, Gable, Sakala, & Declercq, 2011). These findings also varied by ethnic group: a whopping 26% of non-Hispanic black mothers had PTS. The authors noted that “the high percentage of mothers with elevated posttraumatic stress symptoms is a sobering statistic” (Beck, et al., 2011).

If the number of women meeting full-criteria does not seem very high to you, I invite you to compare it to another number. In the weeks following September 11^th, 7.5% of residents of lower Manhattan met full criteria for PTSD (Galea et al., 2003).

Take a minute to absorb these statistics. In at least one large study, the rates of full-criteria PTSD in the U.S. following childbirth are now higher than those following a major terrorist attack.

In a meta-ethnography of 10 studies, women with PTSD were more likely to describe their births negatively if they felt “invisible and out of control” (Elmir, Schmied, Wilkes, & Jackson, 2010).  The women used phrases, such as “barbaric,” “inhumane,” “intrusive,” “horrific,” and “degrading” to describe the mistreatment they received from healthcare professionals. 

“Isn’t that just birth?,” you might ask. “Birth is hard.” Yes, it certainly can be.

But see what happens to these rates in countries where birth is treated as a normal event, where there are fewer interventions, and where women have continuous labor support. For example, in a prospective study from Sweden (N=1,224), 1.3% of mothers had PTSD and 9% described their births as traumatic (Soderquist, Wijma, Thorbert, & Wijma, 2009).  Similarly, a study of 907 women in the Netherlands found that 1.2% had PTSD and 9% identified their births as traumatic (Stramrood et al., 2011).  Both of the countries reported considerably lower rates of PTS and PTSD than those found in the U.S.

How Does this Influence Breastfeeding?

Breastfeeding can be adversely impacted by traumatic birth experiences,  as these mothers in Beck and Watson’s study (Beck & Watson, 2008) describe:

• I hated breastfeeding because it hurt to try and sit to do it. I couldn’t seem to manage lying down. I was cheated out of breastfeeding. I feel that I have been cheated out of something exceptional.
• The first five months of my baby’s life (before I got help) are a virtual blank. I dutifully nursed him every two to three hours on demand, but I rarely made eye contact with him and dumped him in his crib as soon as I was done. I thought that if it were not for breastfeeding, I could go the whole day without interacting with him at all.
• Breastfeeding can also be enormously healing, and with gentle assistance can work even after the most difficult births.
• Breastfeeding became my focus for overcoming the birth and proving to everyone else, and mostly to me, that there was something that I could do right. It was part of my crusade, so to speak, to prove myself as a mother.
• My body’s ability to produce milk, and so the sustenance to keep my baby alive, also helped to restore my faith in my body, which at some core level, I felt had really let me down, due to a terrible pregnancy, labor, and birth. It helped build my confidence in my body and as a mother. It helped me heal and feel connected to my baby.

What You Can Do to Help

There are many things that nurses, doulas, childbirth educators, and lactation consultants can do to help mothers heal and have positive breastfeeding experiences in the wake of traumatic births. You really can make a difference for these mothers.

• Recognize symptoms.

Although it is not within many of our scope of practice to diagnose PTSD, you can listen to a mother’s story. That, by itself, can be healing. If you believe she has PTS or PTSD, or other sequelae of trauma, such as depression or anxiety, you can refer her to specialists or provide information about resources that are available (see below). Trauma survivors often believe that they are going “crazy.” Knowing that posttraumatic symptoms are both predictable and quite treatable can reassure them. 

• Refer her to resources for diagnosis and treatment.

There are a number of short-term treatments for trauma that are effective and widely available. EMDR, is a highly effective type of psychotherapy and is considered a frontline treatment for PTSD. Journaling about a traumatic experience is also helpful. The National Center for PTSD has many resources including a PTSD 101 course for providers,  and even a free app for patients called the PTSD Coach.

The site HelpGuide.org also has many great resources including a summary of available treatments, lists of symptoms, and possible risk factors.

• Anticipate possible breastfeeding problems mothers might encounter.

Severe stress during labor can delay lactogenesis II by as much as several days (Grajeda & Perez-Escamilla, 2002). Recognize that this can happen, and work with the mother to develop a plan to counter it. Some strategies for this include increasing skin-to-skin contact if she can tolerate it, and/or possibly beginning a pumping regimen until lactogenesis II has begun. She may also need to briefly supplement, but that will not be necessary in all cases.

•  Recognize that breastfeeding can be quite healing for trauma survivors, but also respect the mothers’ boundaries.

Some mothers may be too overwhelmed to initiate or continue breastfeeding. Sometimes, with gentle encouragement, a mother may be able handle it. But if she can’t, we must respect that. Even if a mother decides not to breastfeed, we must gently encourage her to connect with her baby in other ways, such as skin to skin, babywearing or infant massage.

•  Partner with other groups and organizations who want to reform birth in the U.S.

Our rates of PTS and PTSD following birth are scandalously high. Organizations, such as Childbirth Connection, are working to reform birth in the U.S.  

2013 may be a banner year for recognizing and responding to childbirth-related trauma. The new PTSD diagnostic criteria were released in May in the DSM-5, and more mothers may be identified as having PTS and PTSD.

There has also been a large upswing in U.S. in the number of hospitals starting the process to become Baby Friendly, which will encourage better birthing practices.

I would also like to see our hospitals implementing practices recommended by the Mother-friendly Childbirth Initiative.

There is also a major push to among organizations, such as March of Dimes, to discourage high-intervention procedures, such as elective inductions.

And hospitals with high cesarean rates are under scrutiny. This could be the year when mothers are care providers stand together, and say that the high rate of traumatic birth is not acceptable, and it’s time that we do something about it. Amy Romano describes it this way.

 As we begin 2013, it is clear from my vantage point at the Transforming Maternity Care Partnership that the transformation is underway. In Childbirth Connection’s nearly century-long history, we’ve never seen so much political will from leaders, so much passion from grassroots advocates, and so much collaboration among clinicians and other stakeholders. This new landscape presents many new opportunities for educators and advocates. 

There is much you can do to help mothers who have experienced birth-related trauma. Whether you join the effort to advocate for all mothers, or simply help one traumatized mother at a time, you are making a difference. Thank you for all you do for babies and new mothers.

This article originally appeared as an editorial in the journal Clinical Lactation: Kendall-Tackett, K.A. (2013). Childbirth-related psychological trauma: An issue whose time has come. Clinical Lactation, 4(1), 9-11

References

Beck, C. T., Gable, R. K., Sakala, C., & Declercq, E. R. (2011). Posttraumatic stress disorder in new mothers: Results from a two-stage U.S. national survey. Birth, 38(3), 216-227.

Beck, C. T., & Watson, S. (2008). Impact of birth trauma on breast-feeding. Nursing Research, 57(4), 228-236.

Elmir, R., Schmied, V., Wilkes, L., & Jackson, D. (2010). Women’s perceptions and experiences of a traumatic birth: A meta-ethnography. Journal of Advanced Nursing, 66(10), 2142-2153.

Galea, S., Vlahov, D., Resnick, H., Ahern, J., Susser, E., Gold, J., . . . Kilpatrick, D. (2003). Trends of probable post-traumatic stress disorder in New York City after the September 11 terrorist attacks. American Journal of  Epidemiology, 158, 514-524.

Grajeda, R., & Perez-Escamilla, R. (2002). Stress during labor and delivery is associated with delayed onset of lactation among urban Guatemalan women. Journal of Nutrition, 132, 3055-3060.

Soderquist, I., Wijma, B., Thorbert, G., & Wijma, K. (2009). Risk factors in pregnancy for post-traumatic stress and depression after childbirth. British Journal of Obstetrics & Gynecology, 116, 672-680.

Stramrood, C. A., Paarlberg, K. M., Huis in ‘T Veld, E. M., Berger, L. W. A. R., Vingerhoets, A. J. J. M., Schultz, W. C. M. W., & Van Pampus, M. G. (2011). Posttraumatic stress following childbirth in homelike- and hospital settings. Journal of Psychosomatic Obstetrics & Gynecology, 32(2), 88-97.

Reports from Childbirth Connection on Important Issues Regarding Birth in the U.S.

Helpful Links to Share with Mothers

• Prevention and Treatment of Traumatic Childbirth
• Midwifery Today
• Trauma and Birth Stress
• Posttraumatic Stress After Childbirth
• Birth Trauma Association

About Kathleen Kendall-Tackett, Ph.D., IBCLC, RLC, FAPA

Kathleen Kendall-Tackett is a health psychologist and an International Board Certified Lactation Consultant. She is the Owner and Editor-in-Chief of Praeclarus Press, a small press specializing in women’s health. Dr. Kendall-Tackett is a Fellow of the American Psychological Association in both the Divisions of Health and Trauma Psychology, Editor-in-Chief of U.S. Lactation Consultant Association’s journal, Clinical Lactation, and is President-Elect of the American Psychological Association’s Division of Trauma Psychology. Dr. Kendall-Tackett is author of more than 320 journal articles, book chapters and other publications, and author or editor of 22 books in the fields of trauma, women’s health, depression, and breastfeeding, including Treating the Lifetime Health Effects of Childhood Victimization, 2^nd Edition (2013, Civic Research Institute), Depression in New Mothers, 2^nd Edition (2010, Routledge), and Breastfeeding Made Simple, 2^nd Edition (co-authored with Nancy Mohrbacher, 2010).

 

Kathleen Kendall-Tackett Babies, Breastfeeding, Childbirth Education, Depression, EMDR, Guest Posts, Infant Attachment, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, PTSD, Trauma work breastfeeding, breastfeeding and depression, Childbirth Education, childbirth PTSD, Kathleen Kendall-Tackett, Listening to Mothers surveys, Post Traumatic Stress Effects, post-traumatic stress disorder related to childbirth, trauma in childbirth, traumatic birth

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

Walker Karraa Babies, Guest Posts, Infant Attachment, Maternal Mental Health, New Research, Newborns, Parenting an Infant, Research Childbirth Education, guest posts, infants, Mother's Day, postpartum, research, self-care, Walker Karraa

“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.

_____________

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!  

___________

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

In this series about EMDR (Eye Movement Desensitization and Reprocessing), Part One looked at qualitative research evaluating EMDR as treatment for post-traumatic stress disorder (childbirth onset). In Part Two, EMDR clinicians weighed in on their feelings about the safety of EMDR during pregnancy. When those EMDR posts were published, I received a lot of behind the scenes feedback from women who either loved or hated their experiences with EMDR; there didn’t seem to be a middle ground!

I felt these women’s voices need to be heard (many thanks to Sharon Muza, S&S Community Manager, for her gracious agreement!) The results are here: four interviews conducted with four real women who suffered from trauma in the perinatal period and tried EMDR.

It’s unfortunate these lovely women suffered extreme emotional turmoil at such an important time in their life; when they were working and hoping to build their emergent family and when they were primarily responsible for the safety and care of their infants.

Through sharing their stories, all women indicated to me that they hope that their voices will contribute to the collective movement to incorporate mental health care into the overall care of women and their families in the childbearing year.

Characteristics of Their Trauma

All of the women interviewed experienced trauma in the early postpartum period. Three suffered specifically from birth trauma; all experienced a severe perinatal mood disorder. Three of the women additionally were coping with complex, long-term, multi-layered emotional trauma, stemming back to abuse in childhood.

All of the women interviewed were seeing licensed therapists who incorporated EMDR into their overall treatment plan for trauma. Some asked to have their identities masked, so identifying details and names are obscured, but the overall personal statements and feelings are preserved.

They are empowering to all of us in that ALL of them valued their mental health and were brave enough to seek professional help!

Personal Healing Processes

The women interviewed are all emotionally mature adults. They’re aware of their life situations and the impact of trauma on their well-being. They’ve worked hard to explore and develop life-long skills and methods of managing their emotions. Thus, these are all women who are proactive, sophisticated and intelligent about their emotional healing processes. Before they used EMDR, all of the women had already incorporated many forms of healing into their personal self-care plans.

Their self-care plans included: long-term psychotherapy, journaling, expressive therapies such as art, music and movement, yoga, exercising, gardening, cognitive behavioral therapy, goal setting and medication. One woman indicated she was in so much pain from long-term, severe, past abuse she had seriously discussed electroconsulsive therapy with her psychiatrist. So, when their trusted therapists suggested trying EMDR, specifically designed to treat trauma, all the women agreed.

Personal Perinatal Traumatic Events:

In their own words, the women share their individualized, personal perinatal trauma experiences below.

Birth Trauma:

Kim (not her real name) shares her traumatic birth story:

“My son was born after an easy pregnancy but a complicated birth. I’d very nearly had a vaginal birth; the nurses could see the top of his head, but it was turning to the side each time I pushed. After nearly 2 hours of this, I underwent a c-section because I had spiked a fever and things were not progressing. During my c-section, I was overcome by anxiety and completely paralyzed by fear.

I literally thought I was dying as my son was being born, yet due to the panic, I was unable to verbalize this fear to anyone.

I spent that time shaking and having what I thought were my last panicked thoughts and breaths. It was the the most afraid I’ve ever been in my entire life, and also the most alone I’d felt, despite being surrounded by others.

After the surgery, I wasn’t able to hold my son for 3 hours. I spent the time in recovery, scared that something were wrong and nobody was telling me. I am still not sure of the reason for the delay.

My maternity leave felt long, due to postpartum anxiety and depression and a baby who barely slept and I cried nonstop some days. I felt like a terrible mother who was unable to console her child or enjoy him. I felt tremendous guilt. In addition to the emotional aspects, my c-section scar was not healing properly, so I felt as if I were constantly making a 30-mile trek (newborn in tow) to my ob-gyn’s office for checkups. “

Birth Trauma Layered on Childhood Trauma:

Karen (not her real name) said:

“My very traumatic birth triggered already active memories of severe childhood abuse, parental suicidal attempts in front of me, active alcoholism & substance abuse in the family and severe childhood neglect.”

Helen (not her real name) said:

“I was working on birth trauma at the start of the EMDR, but later on, abuse, illnesses, and marital distress. I was mainly focused on the birth trauma I had experienced when I used EMDR.”

Postpartum Traumatic Event Layered on Childhood Trauma:

Jessica Banas explained her perinatal trauma as such:

“I was traumatized by my childhood with my father. He was very emotionally abusive. Seeing him overdose (on a drug called GHB) the first night my parents were to supposed to have been watching my infant son for me, so I could rest, felt like the ultimate betrayal. Once again, not only were they NOT there for ME, but I had to SAVE them (again) instead!!!”

Women’s Experiences Show Us Moms with PTSD Suffer Co-morbid Perinatal Depression & Anxiety

It is fascinating and sad that all three women with pre-existing trauma stated their prior trauma was re-triggered by a perinatal traumatic event (traumatic birth or other traumatic event postpartum). And all four suffered from severe postpartum depression and anxiety after their traumatic perinatal event. A woman’s mental health is an important aspect of the childbearing year.

As discussed in a previous blog post, one in four women suffers depression at some point in her life, and women are more likely to suffer depression during and shortly after pregnancy than at any other time (Nonacs, 2006). Ruta Nonacs, MD (2011), editor-in-chief of Massachusetts General Hospital’s Center of Women’s Mental Health’s website estimates annually in the US, there are about 4 million births, and about 950,000 to 1,000,000 mothers suffer from depression either during or after childbirth every year. 

Having a personal history of a mental illness in her lifetime, such as depression, anxiety, PTS/PTSD, OCD or bipolar disorder (remember, this is whether it was diagnosed & treated or undiagnosed & untreated) increases a woman’s risk of postpartum depression. A previous history of previous postpartum depression increases a woman’s risk of a recurrence to 50 – 80 % risk of recurrent PPD, as compared to a 10- 20% risk factor without having had a prior episode.

It’s important to note that the women’s constellation of PTSD symptoms intensified and they developed severe postpartum depression and anxiety.

Jessica eloquently states how important women’s mental health is to the postpartum period:

” One important symptom of my PTSD that complicated and worsened my PPD was when my infant son would cry and interrupt my ruminations of my father Od-ing. I’d get angry….that would trigger thoughts of wanting to harm my son and cause me great anxiety and incredible guilt…..there were many times I was too afraid if I went to tend to him, I’d treat him harshly, or hurt him This created such a sense of worthlessness and shame, I thought of suicide one night. Instead, I told my husband and we reached out and got help.

It is a very important aspect of PTSD in that I am personally aware how detrimental it is on PPD. My PPD rapidly escalated after getting PTSD. And one seemed to feed on the other. Getting treated for BOTH issues was very important.”

Women’s Experiences Show Us the EMDR Outcomes

Two very positive experiences

Kim’s Experience with Traumatic Birth & Postpartum Anxiety & EMDR

Kim, who suffered from birth trauma and postpartum anxiety, had a positive experience with EMDR. Here is her story of healing.

Kim said that her therapist incorporated EMDR into her current psychotherapy sessions. She said she hadn’t realized that she’d been suffering with PTSD until almost a year after the incident. She says she discovered her anxiety was stemming from a traumatic birth experience at a therapy session:

Kim says:

“…of course I’d had PTSD from thinking I was dying while my son was being born! My anxiety, which had a lot to do with waiting for something terrible to happen to me or my son, started to make sense in light of this new revelation.”

Kim experienced the EMDR itself as calming. She held tappers in her hands while her therapist led her through visualizations. Her therapist warned her that EMDR could be emotionally triggering and if she needed to call her, she was welcome to do so. And it was triggering for Kim. After her first session, she suffered from an anxiety attack and had to call her therapist, and received the help she needed.

Ultimately, Kim’s overall experience with EMDR was emotionally freeing and healing.

She goes on to say:

“Up until the EMDR, I was unable to speak about my c-section at all. I couldn’t see anything related to the birth experience (with or without c-sections involved) on television, either. If I caught a glimpse of a birth on TV, I cried. I had a lot of anxiety on the few occasions I tried to watch A Baby Story on TLC, as a test to see how I felt watching another woman’s experience.

After EMDR a few times, I became more comfortable thinking about and processing my experience, and even eventually talking about it with others. I no longer viewed my scar as something horrible and ugly. Having EMDR gave me back my confidence because it helped me stop seeing myself as a failure (because I needed a c-section instead of birthing vaginally). “

Kim would recommend EMDR to another person trying to recover from trauma, but with some warnings about the emotional response.

Jessica’s Experience of Postpartum Traumatic Event, PPD, Suicidal Ideation & EMDR

Jessica, who experienced the trauma of her father’s overdose while her parents were supposed to be watching her baby, had a positive experience with EMDR. Here is her story of healing:

Jessica said that her therapist incorporated EMDR into her current psychotherapy sessions. Her therapist suggested she try something “new” that would remove the sting of the trauma from her mind. Jessica was skeptical but thought she’d give it a try.

Jessica says:

“The EMDR was pretty much wrapped around by talk therapy in that we’d start out by talking and end up by talking… EMDR took the emotional ties from the traumatic memories away. I no longer find myself reliving any of those memories that were treated with EMDR. I no longer feel any emotional pain from the OD event. I have no loss of sleep, anger, depression, or any anxiety over that event.”

Jessica says she did not find the EMDR emotionally triggering at all, but many childhood memories came flooding back. .

“Not at all…frankly, I thought it was lame at first (wiggling a finger in my face? REALLY?) and had no hope it would have ANY effect at all. Once we (quickly) healed the OD trauma, memories from my childhood did come flooding back! I found that to be very interesting! Fortunately, my childhood was not as terrible as many, so I could handle this phenomenon.”

Jessica recommends EMDR:

“…as long as the person is seeing a well trained, compassionate therapist! EMDR helped me and I have gone on to suggest it to other people who were in pain as I was….those people have been healed by EMDR as well….I find it a useful treatment and extremely non-invasive compared to other treatments!!”

Two very negative experiences

Karen’s Experience with Birth Trauma, Past Trauma, PPD, PPA & EMDR

“My experience was physical and emotional and in both cases negative. I felt physically ill, vertigo, nausea. Disorientation, short-term memory loss, headache. Emotionally, it was detrimental as it brought up my most difficult trauma and I felt completely triggered. I tried to hang in there with the process, but only did a few sessions. The EMDR sessions were not processed with in-between traditional talk therapy sessions. The EMDR made my symptoms worse, my anxiety worse, and the neurological side-effects were horrible. While my therapist did a wonderful job at regrouping,  after we decided to stop doing it, I actually went up on my medications and saw her 2x a week for a while. It was just too much. What I think had happened to me was more resurfacing of old memories that I had compartmentalized in years of talk therapy and medication. I actually think I needed a medication adjustment when I was so desperate for relief. “

Karen would not personally recommend EMDR to another.

Helen’s Experience with Birth Trauma, Past Trauma, Postpartum Mental Health Complications & EMDR

“My therapist suggested the EMDR may be helpful for both traumas (birth and childhood). I had 6 sessions that were each an hour long. Some of this process was also traditional talk therapy in between the EMDR. I found EMDR not helpful in treating my traumas.”

“It was extremely triggering and the therapist pushed me into a lot of it. She would try to help me regroup by taking deep breaths and little breaks in between. But I always felt drained after each session and even more triggered with PTSD.”

Helen would not recommend EMDR for another person:

“I do not think I would personally recommend EMDR to another person for a trauma. I believe the therapist shoved me into it too soon and left me for days swirling in the emotions of that. I have heard it can be wonderful and healing for others. For me, it triggered too much to soon and my experienced left me more traumatized. I can’t think of those (EMDR) coping skills and techniques without feeling overwhelmed with memories.” 

Conclusions

As we can see from real women’s experiences, EMDR was extremely triggering to two of the women, but resolved emotional distress well for the two other women. Again we are reminded that one size does not fit all when it comes to treating mental health.

The women’s experiences indicated that when working with EMDR for trauma, even experienced and trusted therapists encountered strong triggering responses in their clients. In these instances, these therapists needed to know how to appropriately re-group and therapeutically support their clients either in the session and/or be appropriately available outside of scheduled sessions.

It was not appropriate for a therapist to urge a client to try or keep using EMDR if the client did not really want to, or if the client was having an overall non-therapeutic effect.

As we can see from these real women’s experiences, the treatment of post-traumatic stress has the potential to be devastating to the client as far as awakening or re-triggering compartmentalized past emotional distress.

In this small article and small example, it is interesting to me that the four women who volunteered to share their stories in this small had extreme reactions to EMDR, none neutral. These results reinforce my usual conservative approach to managing emotional distress, that is, if one is suffering from debilitating mental and emotional distress, it is best to consult with a licensed professional.

What I find empowering about these interviews is that ALL of these women VALUED their mental health and were brave enough to seek help. Fight the stigma! Don’t be afraid to get help!

Author’s Note: None of these women were or are my clients. I sought out non-clients for the purpose of these interviews.

References

Nonacs, R. (2006). A deeper shade of blue. New York: Simon and Schuster.

Kathy Morelli Birth Trauma, Cesarean Birth, Childbirth Education, Depression, Do No Harm, EMDR, Evidence Based Medicine, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, Pregnancy Complications, PTSD, Research, Trauma work EMDR, guest posts, Kathy Morelli, maternal mental health, Post Traumatic Stress Disorder after childbirth, postpartum depression, PTSD, trauma, traumatic birth