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Series: Welcoming All Families; Working with Women of Color – Educator Information

February 27th, 2014 by avatar

By Tamara Hawkins, RN, MSN, FNP, IBCLC, CHHC, LCCE

Today, contributor Tamara Hawkins, RN, MSN, FNP, IBCLC, CHHC, LCCE finishes her two part post series “Welcoming All Families; Working With Families of Color” with a fantastic post on evaluating how well your classes are meeting the needs of Women of Color and tips and information to create a space that welcomes and celebrates WOC and their families.  While, February is Black History Month, educators have a responsibility to offer classes that are inviting and appropriate for WOC all year long. Find Tamara’s first post here. – Sharon Muza, Community Manager, Science & Sensibility. 

black mother and newborn

© David Blumenkrantz

Are your classes inviting and supportive for Women of Color? Or are WOC not your “target market”? I received a comment after sharing my post about Tuesday’s Welcoming All Families; Working with Women of Color blog post; “Sadly many of my (as you say) ‘women of color’ friends, associates and even just casual acquaintances have told me straight up ‘you don’t need to do all that!’,” referring to the belief that taking a childbirth class is not really a valuable or important part of preparing to have a baby for African American women. I believe that it will take more than a few focus groups to get to the bottom of why some WOC do not feel the need to take childbirth education. In today’s post, I would like to focus on childbirth educators! How can childbirth educators be sure their classes are appropriate and inviting to Women of Color?

Prior education experiences

The first thing childbirth educators have to be aware of is that people are more likely to connect with people of their own culture. An example of this; a vegan may be more likely to seek out health care from a provider who blogs about a vegan lifestyle. WOC and other ethnic communities will seek out education from a provider they can relate to culturally. At the least, the educator will have proven to be sensitive to their needs whether those needs are cultural, ethnic or economic. Vontress writes in the Journal of Multicultural Counseling and Development, “Members of minority groups bring an experience of consciously having to negotiate and even survive educational treatment of invisibility or negative ultra-visibility,[ultra-visibility; being singled out or made to be the “token” Black person], lower expectations, stereotyping, hostility and even abuse.” If an expectant mother or her partner has ever had this type of experience, why would they want to sit in yet another class and perhaps have those same feelings brought up all over again? What if they are presently feeling dismissed, their concerns ignored and rushed with their health care provider? Childbirth educators have the responsibility to understand this and make our classes welcoming by using language and images that subconsciously allude to our support and equal treatment and understanding of families of color.

I am guilty of saying “the baby’s mouth and lips should look pink to indicate great oxygenation.” A WOC in class raised her hand and said, “Even brown babies?” I responded “Well, yes, especially a newborn.” Be mindful that WOC have babies of all color hues. Some babies may be dark when born and others may be very light. Darker hued mothers who have not been around newborns may not know to expect their newborn to look light skinned.  A culturally sensitive childbirth educator should mention this fact, so that all families can be prepared. During early pregnancy class, talk about how WOC may experience expansion of the areola and that yes even though they may have dark areolas to start, the areolas can get darker. In discussions about nutrition, talk about soul food cooked in a healthy flair. Remember that the standard American diet is not a one size fit all solution. The Physician Committee for Responsible Medicine mentions 70 percent of African Americans are lactose intolerant (compared with only 25 percent of whites) and may suffer from cramping, diarrhea, and bloating after eating dairy products. Encouraging a WOC to have cheese and yogurt to get calcium and added protein may not be the best advice. Offer alternatives that are appropriate for everyone.

Marketing and teaching materials

Next, evaluate your marketing materials. Have you placed images of women of color on your website, brochures, and social media pages? Do you keep up with the health disparities and concerns for women of color? Do the images on your classroom walls or your teaching posters represent a wide variety of ethnicities?

Review your teaching materials. Do you show birth and breastfeeding images of WOC? Are there images of WOC exercising, eating well, and asking questions of their care providers? In order to effect behaviorial change, one has to be able to envision oneself doing something similar. A great example is a commercial from fatherhood.gov. This videos features an African American dad learning cheerleading moves with his daughter with the grandmother listening and approving of the interaction in the background. AA women love this commercial because we remember performing the same type of cheers when we were young. This type of imaging will promote interest in fatherhood and also plant a seed in the minds of some men that it’s okay to spend daddy-daughter time, maybe even doing something fun or a little silly. The commercial would not be as effective if it showed a Caucasian father doing the same thing. There would be no connection. And if there is no connection, there is no assimilation, and therefore no change in behavior. When expecting parents can see themselves in the “role models” then they can see themselves emulating this behavior with their own children, or their own birth or breastfeeding experience.

Be ready to make change

Once your evaluation is complete, make some changes. There are not many sources to purchase ready made childbirth class images of women and families of color. Don’t hesitate to create your own. Look for images of AA couples on sites such as Shutterstock, Corbis Images , iStockphoto, or Fotosearch. Then use some creativity to create posters and images you can use! Or better yet, have a contest in your classes, asking them to create a poster. Invest in videos that show women of color birthing and breastfeeding. I use Injoy’s products in my classes as I find their videos do a good job representing multicultural families.

In Injoy’s “Miracle of Birth 4″ video, Natasha’s birth shows a biracial couple experiencing a birth supported with analgesia. In “Understanding Labor 2″ and the “Miracle of Birth 3,” Chelsea’s birth follows a young African American couple as they have an epidural birth with augmentation. Daniela’s birth follows a bi-lingual Spanish speaking couple as they have a cesarean birth. Injoy offers an option to purchase these videos individually which is great for a limited budget. The Baby Center has a video of Samiyyah‘s birth center birth which can be imbedded in PowerPoint presentations or played on a monitor. Unlike the well edited and discreet videos Injoy offers, this Baby Center video feels raw and uncut. Be prepared with Kleenex. This birth is a great lead in into discussing orgasmic birth, normal birth emotions, vocalization for pain relief and the fetal ejection reflex during pushing.

Language used when addressing health concerns of African American women is important. As an instructor, you don’t want to talk about pre-eclampsia and preterm birth in a manner that assumes that AA women should already know they are at higher risk for these diseases, but rather frame it as health care workers and researchers are uncovering higher rates of pre-term birth, diabetes, cesareans and lower rates of breastfeeding in the AA community. Presenting these subjects in this fashion, as an awareness among health care providers, may remove any feelings of guilt or negative self-consciousness for those who may not know the information ahead of attending class. Sources to find information related to women of color include Office of Minority Health, March of Dimes, Womenshealth.gov and Women’s Health Guide to Breastfeeding.

Create an event

Consider bringing in guest speakers to your class. Is there a WOC birth advocate in your area that has a large following? Collaborate with her to spread the word. Can you host a Twitter chat or Facebook party discussing your intent to serve the needs of WOC and clarifying the wants and needs of your birth community. Have WHO code compliant corporations donate products for a baby shower or a baby fair. Ideas for a fair may include a pediatric dentist who discusses the important of infant oral care. Bring in a safety expert who will discuss and demonstrate car seat safety and installation. Have a prenatal fitness expert and/or nutritional counselor to discuss food and the connection to gestational diabetes. A community midwife or OB can discuss the impact of lifestyle choices on the risks of developing pre-eclampsia, diabetes related to induction and cesarean births and low birth weight babies. Conclude the event with a game show set up like Family Feud with topics covering medical options, comfort techniques and support strategies for breastfeeding families. Having a fun event always draw crowds.

Offer tiered pricing

Are your classes accessible on an economic level? Do you accept insurance or have a sliding scale for families. The National Health Service Corp has a great resource on how to set-up a discount fee schedule. Is your practice set up to accept social service coupons or Medicaid for childbirth class subsidies such as what Washington State offers? The Kaiser Family Foundation reports 27 states out of 44 that responded to their Medicaid Coverage of Prenatal Services Survey offer coverage for childbirth education. Independent instructors will have to research their own state Medicaid offices for specific information on provider eligibility and reimbursement rates. When receiving reduced fees or subsidies, it may be tempted to schedule classes during the day. Please remember even people on Medicaid or WIC have jobs. Let’s respect that and offer flexible schedules for classes in the evening and on weekends.

Can you set up scholarships? Human Resources and Services Administration has several large grants available to serve the maternal child health community. The March of Dimes has scholarships available for grants reducing disparities in birth outcomes. The What to Expect Foundation has a new program to teach practices that build a healthy pregnancy. The wonderful Kellogg Foundation is another resource to tap into for help building a program to be inclusive and inviting to women of color.

Community connections

Do you have local resources so you can connect AA women to WOC birth workers that share their ethnicity and culture? Sista Midwife Productions has a resource list by state of birth workers of color. If we have to refer out to help a mother feel more comfortable and get what she needs rather than what we have to offer, that’s a win-win situation.

Educators need to learn from the clients they serve. We have to ask the community what information is important to WOC. The Black Mothers Breastfeeding Association can serve as a template to build networks that educate and support pregnant WOC. Invite mothers and fathers of color to lead groups for expectant parents. Groups can cover topics such as how to have conversations about birth options, cultural expectations of birthing mothers and parenting styles and ethnic cooking with a healthy spin and specific topics related to controlling or preventing gestational diabetes and pre-eclampsia, reducing cesarean birth and increasing breastfeeding success.

In order to attract WOC to our classes, educators need to become culturally sensitive and appropriate. Evaluations of our marketing and teaching materials are in order to ensure inclusion of AA women. Educators have to be up to date on the statistics and health facts and challenges facing AA families. Our hospitals, birthing centers, birth support groups and networks should brainstorm ways to fund and provide scholarships and/or grants to make classes economically feasible. Lastly, if we are serious about supporting all mothers and helping them to have a safe and healthy birth, let’s build and support local birth support groups.

Change can be challenging. Start with small goals. The first step is self-evaluation. What had been working and what can be improved? Share your resources? Where do you find images and videos that are welcoming to women of color and all ethnicities? After you have evaluated your program, come back and let me know what worked and did not work. If you need some help, please contact me. I’m excited to try some of these resources myself. I’ll keep you posted on my Facebook page.

References

Vontress, C. “A Personal Retrospective on Cross Cultural Counseling.” Journal of Multicultural Counseling and Development, 1996, 24, 156-166

About Tamara Hawkins

tamara hawkins head shotTamara Hawkins, RN, MSN, FNP, IBCLC, CHHC, LCCE is the director of Stork and Cradle, Inc offering Prenatal Education and Breastfeeding Support. She graduated with a BSN from New York University and a MSN from SUNY Downstate Medical Center. She is a Family Nurse Practitioner and has worked with mothers and babies for the past 16 years at various NYC medical centers and the Elizabeth Seton Childbearing Center. Tamara has been certified to teach childbirth classes since 1999 and in 2004 became a Lamaze Certified Childbirth Educator and an International Board Certified Lactation Consultant.  Follow Tamara on Twitter: @TamaraFNP_IBCLC

Babies, Childbirth Education, Guest Posts, Infant Attachment, Newborns, Parenting an Infant, Series: Welcoming All Families , , , , ,

Research Review: Are There Any Benefits to Performing an Early Frenotomy on Newborns?

December 10th, 2013 by avatar

By Elias Kass, ND, LM, CPM

Breastfeeding is often considered the next big challenge after childbirth. New mothers and babies work together to establish a successful breastfeeding relationship. Sometimes, there are complications that can make things harder than they should be.  Tongue tie is one of the circumstances that can interfere with getting the breastfeeding relationship off to a good start. Please welcome Dr. Elias Kass, to Science & Sensibility as he reviews a recent study on early frenotomy (tongue tie clipping) in newborns and shares his thoughts on the study results. – Sharon Muza, Community Manager

With tongue tie seemingly on the rise, it’s always nice to see new literature approach the issue. “Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie” (Emond et al) compares releasing the tongue tie (frenotomy) immediately versus waiting and providing standard breastfeeding support.

What is tongue tie?

Tongue tie describes the presence of a frenulum that restricts the tongue’s ability to reach out and grasp the breast for successful breastfeeding.

Anterior tongue tie Image Source: Melissa Cole, IBCLC, RLC

Anterior tongue tie
Image Source: Melissa Cole, IBCLC, RLC

The most profound anterior tongue tie is one that connects the tip of the tongue to the edge of the gum. These babies have a V- or heart-shaped tongue when they cry, cannot extend their tongue at all, cannot follow a finger tracing along their bottom gum, and cannot generally latch well. Tongue ties can occur all along the spectrum of the tongue and the floor of the mouth, and some are hidden under the surface layer of skin, which we call “posterior tongue tie.”

The role of the tongue in breastfeeding

The tongue is incredibly important in breastfeeding. The baby must reach out with his tongue and grasp the breast. The tongue forms the primary seal, preventing milk loss and air intake. The movement is intrinsic to the tongue. Rather than sawing the tongue in and out, the muscular impulse starts at the tip of the tongue and moves inward, moving milk from the breast into the mouth. The middle of the tongue acts to form the milk into a ball, and the back of the tongue is responsible for coordinating swallowing, raising the larynx so that milk is directed down the esophagus and not down the trachea into the lungs.

What happens when a baby is tongue tied?

Tongue tie interferes with this intricate coordination in many ways. Some babies cannot extend their tongue. Those babies will have difficulty finding and attaching to the breast, but they may be able to nurse if the nipple is placed in their mouth just right. These babies come off the breast easily and become frustrated because they cannot adjust the position of the nipple in the mouth. The babies who are so tied they cannot extend their tongue over their bottom gum will reflexively clamp their gums. To the nursing parent, this pressure can feel like biting, and can damage nipples incredibly quickly, causing cracking, bleeding, pain, and because the skin is now broken, infection. 

Some babies can extend their tongue against the “rubber band” of the tongue tie, but their tongues “snap back” frequently. This can feel like a sawing against the underside of the nipple, and that friction can also damage nipples. These babies tire easily, because their feeding is made more difficult by the resistance of the rubber band. Snap back can sound like clicking. Clicking can also be caused by loss of suction from the underside of the breast. The tongue should stay mostly in the middle of the mouth when breastfeeding, with the jaw opening to create suction in the middle and back of the mouth. If, when baby opens her jaw, the tongue is tied to the bottom of the mouth, her tongue will snap away from the breast, losing suction.

Some babies can extend but not cup their tongues. These babies generally mash the nipple against the roof of the mouth, causing flattened, ridged nipples. Others thrust their tongue against the nipple instead of reaching under it, which leaves the nipple looking like a lipstick applicator.

What is a frenotomy?

Frenotomy refers to the procedure where this tongue tie is released (or in some places, “revised”). Though not all providers perform this procedure, providers from many different specialties have been known to offer it: pediatricians, family practice doctors, ear nose and throat specialists, dentists, and some midwives. For most, it is a simple, in-office procedure.

What did this study look at?

The researchers determined which babies were tongue tied based on the Hazelbaker Assessment Tool for Lingual Frenulum Function and the LATCH score (Latch, Audible swallowing, nipple Type, Comfort, Hold ). Those who had mild-moderate tongue tie according to the Hazelbaker score, as well as a LATCH score less than 8 out of 10 were eligible for the study. Those babies with severe tongue tie according to the Hazelbaker score were not randomized, and were instead offered immediate frenotomy; their outcomes were not considered as part of the study. Some parents of babies who otherwise qualified for the study refused to be randomized because they felt strongly about receiving frenotomy upon diagnosis.

When considering whether to intervene for tongue tie, it’s important to consider appearance as well as functionality. Some tongue ties are not readily visible but interfere greatly with functionality. Some tongue ties appear dramatic, but breastfeeding is not affected. (There are other long-term considerations, like speech and oral health, in deciding whether or not to release a tongue tie that is not affecting breastfeeding.) The Hazelbaker score is a good way to evaluate functionality because it takes into account whether baby can extend her tongue, cup it into the appropriate shape, moved it appropriately, and maintain suction, as well as the severity in appearance. The Hazelbaker score has good inter-scorer correlation, meaning that different professionals using the tool will arrive at the same conclusion (whether or not the baby should have a frenotomy) nearly 90% of the time. Using a consistent tool can help the individual provider get a better sense of who needs the procedure, but it can also help us as readers to know whether the study population was appropriate, and whether the study’s conclusions can inform our own practice.

V-shaped tongue Image Source: Osama Moshet, MD, FAAP

V-shaped tongue
Image Source: Osama Moshet, MD, FAAP

The LATCH score is a very broad evaluation of how breastfeeding is going, and despite its name, only barely addresses latch itself. Using such a general assessment in conjunction with the Hazelbaker score may have helped the researchers isolate the babies who were both tongue tied and having difficulties breastfeeding, as opposed to those who were tongue tied but doing okay.

In measuring outcomes, they used these two measures again, and added several more measures concerning breastfeeding behavior of newborns, breastfeeding self-efficacy (how confident mom felt in her ability to feed her baby, as well as an observer’s evaluation of breastfeeding effectiveness), and pain.

Conclusion

The primary outcome was LATCH score at 5 days. Secondary outcomes were LATCH score at 8 weeks, and the other measures listed above at 5 days and 8 weeks. The Hazelbaker score was another “outcome of interest” at 5 days, as was infant weight at 8 weeks. At 5 days, parents could choose to have frenotomy regardless of whether they had been randomized to the control arm or the intervention arm.

The researchers concluded “Early frenotomy did not result in an objective improvement in breastfeeding but was associated with improved self-efficacy. The majority in the comparison arm opted for the intervention after 5 days.”

Discussion

Though the study is structured fairly soundly, it doesn’t really answer its own question of whether frenotomy helps improve breastfeeding, largely because of the outcomes they chose to study. The LATCH score is not an indication of tongue functionality, success of frenotomy, or long-term breastfeeding success. Five days is also probably too soon to pass final judgement on whether the frenotomy helped; babies and nipples are still healing. The study also excluded those with severe tongue tie, and it’s safe to assume these babies would have significant improvement when their tongue ties were corrected.

Mothers did feel significantly more effective in their feeding when their babies had received frenotomy (which is correlated with duration of breastfeeding), and more of those who didn’t receive frenotomy were feeding by bottle. It’s unclear whether this bottle feeding was because of the pain associated with breastfeeding or because of inadequate milk transfer or nutrition, but it’s possible that some of those parents have been helped by immediate frenotomy. Indeed, some of the mothers who had been randomized to the control group requested early frenotomy because their feeding was so painful. There were statistically significant improvements in the Hazelbaker score, representing improvement in both appearance and functionality.

Very thick  submucosal/posterior tongue tie. {link url="http://www.bayareabreastfeeding.net"}Bay Area Breastfeeding & Education, LLC{/link} Image Source: Bay Area Breastfeeding & Education, LLC

Very thick submucosal/posterior tongue tie.
Image Source: Bay Area Breastfeeding & Education, LLC www.bayareabreastfeeding.net

Many features of this study mirror how I treat tongue tie in my practice. Almost all babies are referred by lactation consultants or their own pediatricians because they are having difficulty breastfeeding, or because their tongue ties are so profound that we can anticipate speech and oral health problems if it’s not corrected. I use both the Hazelbaker score and the scoring tool in the appendix of RL Martinelli’s “Lingual frenulum protocol with scores for infants” to capture the infant’s feeding history, anatomy, and functionality on both the gloved finger and at the breast. These scores help support a systematic approach to these infants, and helps communicate back to their referring provider what I’m looking for when I decide whether or not to recommend frenotomy. Though most babies referred do need frenotomy, some need other kinds of support instead, and some just need reassurance around normal feeding patterns.

The article didn’t go into much detail about the aftercare. Aftercare is a crucial variable in improving breastfeeding and maximizing success of the procedure. Seattle area practices who perform significant numbers of frenotomy have collaborated to create a list of exercises we ask parents to do with their babies 5 times daily for a week to keep the area open, reduce reattachment, and help baby learn to maximize their new freedom of movement. We also generally recommend craniosacral therapy to help release tight muscles and retrain movement patterns. Many families have incorporated other feeding tools or accessories into their regimens, whether that’s nipple shields, bottles, supplemental nursing systems, or formula. With frenotomy, most will be able to start to move away from those tools, and need continued support from a lactation consultant to relearn how to nurse at the breast. Though most mothers feel that baby nurses differently immediately, some babies take longer to change their approach, and some do not benefit at all.

Releasing tongue ties is a very satisfying part of my practice. I love when breastfeeding parents nurse immediately after the procedure and their faces light up because for the first time it doesn’t hurt to feed. These parents have been working very, very hard to breastfeed, and I feel strongly that this procedure removes a significant obstacle. The more I work with breastfeeding families, the more in awe I am of the complexity of breastfeeding, and importance of excellent breastfeeding support.

Childbirth  and breastfeeding educators should be sharing that painful breastfeeding sessions are not normal and should be evaluated by a lactation consultant.  Educators should provide resources for qualified LCs in their communities to families in need.  For those that work with breastfeeding dyads, what are you seeing in terms of tongue tie and treatment success? Please share your experiences.- SM

References

Ballard, J. L., Auer, C. E., & Khoury, J. C. (2002). Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad.Pediatrics, 110(5), e63-e63.

Emond, A., Ingram, J., Johnson, D., Blair, P., Whitelaw, A., Copeland, M., & Sutcliffe, A. (2013). Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie. Archives of Disease in Childhood-Fetal and Neonatal Edition, fetalneonatal-2013.

Martinelli RL de C, Marchesan IQ, Berretin-Felix G. Lingual frenulum protocol with scores for infants. Int J Orofacial Myology. 2012;38:104–112.

About Dr. Elias Kass

elias kass head shot

Elias Kass, ND, LM, CPM

Elias Kass, ND, LM, CPM, is a naturopathic physician and licensed midwife practicing as part of One Sky Family Medicine in Seattle, Washington. He provides integrative family primary care for children and their parents, including prenatal, birth and pediatric care. He loves working with babies! Practice information and Dr Kass’s contact info is available at One Sky Family Medicine.

Babies, Breastfeeding, Guest Posts, New Research, Newborns, Parenting an Infant, Research , , , , , ,

What is Pregnancy Negation? What is the Childbirth Professional’s Role?

November 14th, 2013 by avatar

Today on the blog, regular contributor Kathy Morelli shares information on an uncommon but very serious mental health disorder called pregnancy negation (pregnancy denial and pregnancy concealment) that can occur in women.  This unusual phenomena may never have crossed your radar or you may have met women who have experienced this situation.    Learn more here about this illness and what you can do as a childbirth professional, should you meet a woman or family dealing with this situation. –  Sharon Muza, Community Manager for Science & Sensibility.

Original Painting © Johann Heinrich Füssli

The research studies about negation of pregnancy generally consist of small sample sizes, so there isn’t a lot of data available about negation of pregnancy. More study is needed in order to understand this topic more thoroughly. I do see this phenomena in my psychotherapy practice, so I believe it’s a topic that birth professionals might see it in their community as well.

Negation of pregnancy, a term that encompasses both pregnancy denial and pregnancy concealment, are rare, but not uncommon, disorders of pregnancy. One in 475 pregnancies result in negation of pregnancy. A very minute portion of this statistic results in neonaticide- the act of killing a baby in the first 24 hours of life (Beier et al, 2006).

As with other psychological conditions, the underlying etiology of negation of pregnancy exists on a spectrum. The person can suffer from a lifelong, persistent “splitting” of the self due to trauma, she can suffer from a persistent biological mental illness, such as schizophrenia, or she can be experiencing a type of severe adjustment disorder.

Current research indicates that not all women who experience negation of pregnancy have previous diagnoses of serious and persistent mental illness. Some women who experience negation of pregnancy have pre-existing diagnoses of biploar with psychotic features and schizophrenia, and psychosis is part of their life experiences. But others do not have a previous diagnosis and after integrating the episode of negation of pregnancy, they adjust to their life situation and cope realistically.

Definition 

Pregnancy denial is defined as a woman’s unawareness, in varying degrees, of her pregnancy. Pregnancy concealment is defined as actively deciding and hiding the pregnancy from others. Pregnancy denial and pregnancy concealment often co-occur and occur intermittently. There is usually a great deal of shame, fear, guilt and dissociation, a strong psychological and emotional defense, accompanying this disorder. Due to the level of emotional conflict around the pregnancy, there are gradations of denial and complexity and subtlety of emotional response from both the pregnant woman and those around her.

The term negation of pregnancy is also used to encompass and describe these co-occuring disorders, whereas the internal process is called denial and the external process is called concealment. Therefore, it is considered the same process, but the woman’s defense mechanisms vary in intensity.

Neonaticide, the killing of an infant on the day of birth, is a form of infanticide that is often preceded by pregnancy denial. Neonaticide can be one of the complications of pregnancy denial.

Pregnancy denial is a real phenomena that has a long history of documentation, by doctors, mothers, their families and artists.

One famous literary exploration of pregnancy denial and neonaticide is illustrated in George Eliot’s novel, Adam Beade, published in 1859. It is the novel of a woman’s experience, examining the intersection between women’s unique emotions around reproduction and their disempowered social standing. Taking place in 1799, the story is about a love triangle involving Hetty, a 17 year old girl. She becomes pregnant out of wedlock. Hetty knows she is pregnant, but never openly acknowledges this. She knows she will face extreme shame and ostracization by the town, should anyone find out. She successfully hides her pregnancy and gives birth to her baby in a field. She commits neonaticide, abandoning her baby boy where she birthed him.

Characteristics of Women Who Negate Pregnancy

Early research indicated that pregnancy denial and neonaticide is more likely to occur  in women who are young and unmarried, where the relationship with the father is dissolving or non-existent and the woman lives at home with relatives.

However, more recent research shows that pregnancy denial and neonaticide occurs in women of all age groups, cultures and marital status in response to a conflicted pregnancy. Many women already have several other children, so it is not always the first time mother who negates her pregnancy.

Research by Shelton and colleagues (2011) indicates that pregnancy at an early age, multiple young children, a history of childhood abuse and trauma, current fear of abandonment (even if in a stable relationship), and a deprived social situation are all risk factors and common characteristics for women who negate their pregnancy.

The pathway to pregnancy denial and concealment often begins with an unplanned pregnancy. The woman has accompanying feelings of extreme fear and shame. She begins with pregnancy concealment. She hides her pregnancy with baggy clothes and isolates herself in her room. To help facilitate concealment, she sees less and less of people. Thus, she becomes more and more emotionally isolated.

Eventually, she finds she has no one to confide in. This results in a vicious cycle, and her emotional defenses develop a sense of pregnancy denial. The pregnancy denial is described by researchers as intermittent, her lack of self-awareness comes and goes and she is able to compartmentalize her pregnancy. She successfully dissociates from her body sensations.

The denial and dissociation is so potent that women often describe beginning birth pains as flu symptoms, gas pain and menstrual cramps. Women often go to the bathroom and deliver the baby silently, with others nearby. Women often describe the feeling of giving birth like having to defecate and are shocked when a baby appears.

Women in this type of delivery report dissociative symptoms at the birth and afterward when coping with the newborn. Women also often report a fantasy that the infant was preterm or stillborn. Often, sadly, the outcome for infants born to women who are experiencing negation of pregnancy are death a short time after birth, either from drowning in a toilet bowl, or hitting their head on the floor in a precipitous, unassisted birth.

Another fascinating aspect of pregnancy concealment and denial is that the family and even doctors are drawn into “community denial” by the emotional intensity of the denial. Interestingly, in one study, only 5 out of 28 women studied who negated their pregnancy had any family members inquire about their pregnancy at all (Amon et al, 2012)! Another study indicates that even long term family doctors who know the woman well will sometimes fail to diagnose the pregnancy (Amon et al, 2012).

Treatment

Treatment for negation of pregnancy is as nuanced and varied as each individual case. Whenever there is dissociation of parts of reality and parts of the self, the treatment path can include techniques used to treat post-traumatic stress. Such techniques would include EMDR, guided imagery, object relations techniques embedded in an overall therapeutic structure that balances leaving a woman’s psychological defenses intact, while at the same time helping her through her issues of denial (Anonymous, 2003).

Depending on the cause and severity of the negation of pregnancy, the processing of dissociated emotional material, the buried shame, the confusing physical symptoms, and the integration of the parts of her self could take place over an extended period of time in a safe, therapeutic atmosphere.

In general, directly asking or accusing a woman who is negating her pregnancy about her situation isn’t an effective treatment method. In order to survive, the person has most likely developed a method of dissociative “splitting” or “compartmentalizing” differing parts of the self. It is a normal psychological response to dissociate from trauma in order to survive. Dissociative coping exists along a continuum, from intermittent denial to having developed separate parts of the self to contain the trauma (Amon, 2012; Anonymous, 2003).

For example, in order to survive complex emotional trauma, such as childhood abuse, incest, rape, pregnancy from rape/incest, a woman would survive by dissociating. She may have unconsciously developed a way to “split” or “compartmentalize” parts of her self. Her unconscious coping mechanism assigns one part of the self to be covertly sexually active while another part of the self overtly maintains the social and familial facade that she is not sexually active. The psychological defenses can be so strong that she has intermittent dissociative awareness about her pregnancy and even amnesia around childbirth.

On the other hand, a woman may be experiencing a less mild form of dissociation and negation of pregnancy. She may need time to integrate her pregnancy into her life and shift towards healthy adjustment, coping and planning.

What birth professionals can do

If you suspect you have encountered a woman with this condition, be aware of your own reactions to her situation. Convey an accepting attitude about her situation. It’s best not to ask her overt questions about her circumstances. Ask open-ended questions, wait for her responses. 

Importantly, convey an accepting attitude about sexuality, pregnancy and motherhood, without being overt.

Have a good set of referrals to health professionals, including mental health professionals,  in your area. You may not be able to help her in the moment, but there may be another time you’ll see her and she might be open to accepting help. Your accepting attitude could be part of her healing and reaching out.

Conclusion

To sum up, negation of pregnancy has been documented in the popular literature and in medical literature for many years. It was once thought that negation of pregnancy only occurs in young and unmarried women, but current research shows that older women with multiple children experience this as well. It is a condition of many emotional and psychological nuances. In a very rare number of cases, can lead to neonaticide.

As a birth professional in your community, you can help by developing an awareness and understanding of negation of pregnancy as a real condition, with many emotional and psychological nuances. By being accepting and by having a solid set of referrals for her and her family if she reaches out to you. More study is needed in order to understand this topic more thoroughly. 

References

Amon, S., Putkonon, H., Weizmann-Henelius, G., Almiron, M.P., Gormann, A.K., Voracke, M., Eronen, M., Yourstone, J., Friedrich, M. & Klier, C.M. (2012). Potential predictors in neonaticide: the impact of the circumstances of pregnancy. Archive of Women’s Mental Health, 15, 167-174.

Anonymous (2003). How Could Anyone Do That? A therapists struggle with countertransference. In M.G. Spinelli (Ed.), Infanticide: Psychosocial and Legal Perspectives on Mothers Who Kill (pp. 201 – 208). American Psychiatric Publishing, Washington, D.C.

Shelton, J.L, Corey, T., Donaldson, W.H. & Dennison, E.H. (2011). Neonaticide: A comprehensive review of investigative and pathologic aspects of 55 cases. Journal of Family Violence, 26, 263-276.

Miller, L. J. (2003). Denial of Pregnancy. In M.G. Spinelli (Ed.), Infanticide: Psychosocial and Legal Perspectives on Mothers Who Kill (pp. 81- 103). American Psychiatric Publishing, Washington, D.C.

Spinelli, M. G., (2003). Neonaticide: A systematic investigation of 17 cases. In M.G. Spinelli (Ed.), Infanticide: Psychosocial and Legal Perspectives on Mothers Who Kill (pp. 105 – 118). American Psychiatric Publishing, Washington, D.C.

About Kathy Morelli

Kathy Morelli is a Licensed Professional Counselor in Wayne, NJ and the Director of BirthTouch®, LLC. She provides Marriage and Family counseling in Wayne, New Jersey with a special interest in perinatal mood disorders, sexual abuse and its impact on parenting. EMDR is one of the mindbody therapies she uses to address trauma.   She blogs about the emotions of pregnancy, birth, postpartum and couples. Kathy is the author of BirthTouch® for Parents-To-Be and BirthTouch® Healing for Parents in the NICU. Kathy has lectured on BirthTouch® at the University of Medicine and Dentistry of New Jersey’s Semmelweis Conference for Midwifery and at birth conferences. She presents trainings to allied health/birth organizations about maternal mental health, family systems and good-enough parenting and is found on web media, such as PBS’ This Emotional Life, writing and speaking about this subject. She volunteers on Postpartum Support International’s warmline. Kathy co-moderates #MHON , a psycho-educational and supportive Twitter chat led by credentialed Mental Health professionals around mental health issues, working to reduce the stigma around mental illness.

 

 

 

 

 

Babies, Birth Trauma, Childbirth Education, Depression, Guest Posts, Infant Attachment, Maternity Care, News about Pregnancy, Parenting an Infant, Prenatal Illness, Trauma work , , , , , , ,

A Family Shares Their Experience Having a Now I Lay Me Down To Sleep Photographer Help Them Honor Their Daughter’s Short Life

October 17th, 2013 by avatar

October is Pregnancy and Infant Loss Remembrance Month, with a special call out on October 15th.  On that day, I interviewed Now I Lay Me Down To Sleep photographer Vicki Zoller, who volunteers her time with the Seattle chapter of NILMDTS, taking pictures of families who are experiencing a loss.  Read that interview here. Today on the blog, we meet Alison Mandi, the mother of Evelyn, whose brief life was recorded by Vicki through the NILMDTS program.

© Vicki Zoller

Sharon Muza: Who suggested that you consider using the services of NILMDTS to help you to record the life and passing of your child?

Alison Mandi: I stumbled upon Now I Lay Me Down to Sleep when I was searching online for information about chromosome conditions like the one my daughter had. I was amazed to learn that there were several photographers in the Seattle area that volunteer their services in this way. I contacted Vicki Zoller, who was compassionate toward our situation and eager to help us tell our daughter’s story with pictures.  I am so glad I found Now I Lay Me Down to Sleep! The photos I have of my daughter, Evelyn, are one of my most precious possessions.

SM: What was it like to have the experience of having a very intimate time recorded? (especially by someone you didn’t know)  

AM: It takes a very special person to voluntarily put themselves in the middle of such a difficult journey, generously offering their time, energy, and talent for free. NILMDTS photographer, Vicki, not only became an integral part of helping us tell Evelyn’s story but also became a dear friend. 

When we learned during the pregnancy that our unborn baby had a severe and life-threatening chromosome disorder, we started a blog to share our experience with friends and family.  Recording and sharing our experience really helped others know how to support and pray for us and also helped avoid uncomfortable questions and in-person encounters over and over again.

When we initially contacted Vicki, she acknowledged that even though our little girl was not yet born, she was still a very real and important part of our lives. She offered to do a maternity photo shoot in addition to coming to the hospital for her arrival.  ”Having those images while she is still snug and safe inside you will add to the story of her life”, wrote Vicki in her email.

© Vicki Zoller

At 3 AM, 36 weeks into the pregnancy, we were preparing for a cesarean section delivery.  In those early morning hours, we called Vicki, who, recognizing that our time with Evelyn could be short, came as quickly as she could to the University of Washington Medical Center.  By a miracle of God, our little girl was born at 4:39 AM, breathing on her own.  Vicki was there to capture her very first moments in the world and the first time she was placed in my arms. But more than just take pictures, Vicki shared our tears and our smiles, joining us in our oohs and ahhs at her tiny fingers and toes, her funny facial expressions, and her sweet baby scent.  Evelyn made it to the next day, but we learned that morning that she had a very rare condition called Triploidy (we did not have an amniocentesis during the pregnancy, so up until this point we had only a general sense that something was wrong based on the ultrasounds and quad screen).  With the new knowledge that there was little we could do to help Evelyn survive, we agreed to pursue “comfort care,” taking Evelyn out of the NICU and bringing her into my hospital room. Vicki returned to take more photos, this time without all of the wires, tubes, and limitations of the NICU.  That photo shoot is one of my favorite memories I have of her life.

SM: Were there any family members that objected or felt it was inappropriate to capture these moments and memories of your daughter on film?

AM: No, we are very grateful that our family was very supportive of our decisions throughout the process.

SM: Has having these memories and pictures helped you to deal with your grief?

© Vicki Zoller

AM: Absolutely.  Though painful, the memories of my time with Evelyn are ones I never want to forget.  In the weeks and months after her death, I spent time looking at her pictures, praying, journalling, blogging, and reading Bible passages to help me process my experience and loss.  I spent time putting together an album of the photos and story of her life.  Despite what some may think, the last thing I want is to forget what had happened.  The photos helped me feel closer to my daughter and to grieve the way that I needed to.

SM: What would you want childbirth educators and other birth professionals (doulas, midwives, doctors, L&D nurses) to tell parents about the NILMDTS program?

AM: I would strongly recommend the services of NILMDTS to any parent going through loss. Some mothers I’ve spoken with who have experienced infant loss were in such a state of trauma that they didn’t consider taking photos, unsure if they would want to remember such a difficult time.  But all of them now say that they wish they had a decent photo of their child to remember and honor them with.  I am so extremely thankful to have beautiful photos to help me cherish my sweet baby Evelyn.  In addition to a network of amazing, compassionate photographers, NILMDTS also has parent volunteers willing to connect with those parents who have recently experienced a similar loss. The amazing women that I met through NILMDTS were instrumental in helping me through my grief.

SM: Can you share a bit of your daughter’s story?  

AM: In early 2010, I experienced a miscarriage, which was devastating.  So, when my husband, Mark, and I learned we were expecting again later that year, we were nervous, but hopeful.  Making it to the 12-week milestone and hearing our baby’s heartbeat brought excitement and relief.  We started to plan for life as parents and shared our news with friends and family.  Just a few days before we were scheduled to find out the gender of our little bundle, around 18 weeks into pregnancy, a nurse called to inform me that the quad screen came back abnormal and we would need to come in for an ultrasound right away. The ultrasound confirmed that something was not right, and doctors believed our daughter had Trisomy 18, a rare and life-threatening chromosome disorder.  Our lives were completely changed from that point on.  Though our baby was still alive, the joyful anticipation of bringing new life into the world was lost.  Every day was a challenge filled with many fears and tears.  But, by God’s grace, he gave us the strength to make the most of each day and allowed us to create memories with her even while she was still in the womb. Mark and I are Christians and our faith in Jesus Christ and eternal life through him was the one thing that gave us hope and strength to endure the hardship.  Through prayer and encouragement from others, God made it clear to us that this baby was in his hands, loved and treasured, no matter what the outcome.  We named our baby girl Evelyn Grace.   We prayed every day for a miracle.

© Vicki Zoller

I had terrific care under our doctors at the University of Washington Medical Center. They were realistic about the situation, but championed Evelyn all the way and allowed us to spend extra moments in ultrasounds just to watch our little girl wiggle around.  At 36 weeks, I was concerned that I hadn’t felt Evelyn move much, so Mark took me to the hospital to make sure she was still okay.  After hours of monitoring, the doctors determined that a cesarean section delivery would be necessary if we hoped to meet our daughter. Evelyn Grace Mandi was born on Monday, February 28th, 2011 at 4:39am.  We had 69 wonderful hours with her before she passed away peacefully in my arms on Thursday, March 3rd around 1:40am.  We learned that she actually did not have Trisomy 18 (three sets of the the 18th chromosome), but Triploidy (three sets of EVERY chromosome).  Triploidy is actually not uncommon, but 99% of triploidy babies don’t make it past the first term, resulting in miscarriage. We felt so blessed by the time we had with her, even though we will miss her forever. She weighed only 2.0 lbs and measured just 15 inches, but the impact she had on my life and others was enormous. Truly, my prayers for a miracle were answered.

SM: Is there anything else that you would like to share or would like Science & Sensibility readers to know?

AM: Many other mothers who have faced child loss that I’ve spoken to feel the same way as I did about wanting to remember their child – that looking at pictures and having an opportunity to share what they went through was an important part of the healing process. However, most people, not without good intention, will try to avoid bringing up the loss in an effort to protect the grieving person from having to recall painful memories.  I actually believe this was one of the hardest things to deal with – the silence of loved ones, coworkers, and even doctors in the aftermath of my loss.  It felt like someone so precious to me had been completely forgotten, or worse, that she never existed.  If you know someone who is experiencing a difficult pregnancy and/or child loss, I would encourage you not to be afraid to talk about it with that person. Ask if they’d like to share photos or stories about their child. You may not know exactly what they are going through or what to say, but a listening ear and compassionate heart can go a really long way.

SM: Thank you, Alison and Mark for being willing to share the story of your beautiful baby girl, Evelyn and for helping us all to recognize the importance of the memories provided by Now I Lay Down To Sleep.

Resources for families who have suffered a loss during pregnancy, or experienced the death of their infant may find help and information from the following organizations:

October 15th

March of Dimes

Stillbirth Alliance

Share Pregnancy and Infant Loss Support Inc.

Compassionate Friends

MISS Foundation

Don’t forget local resources that your families can connect with for face to face support.  What are the resources that you share with families who have or are experiencing a pregnancy or infant loss?

Babies, Cesarean Birth, Childbirth Education, Newborns, Parenting an Infant, Trauma work , , , , , , ,

Postpartum Psychosis: Review and Resources Plus Additional PPMAD Resources

October 8th, 2013 by avatar

We are just a few days past the sad events that occurred in Washington DC, right near the capital, when Miriam Carey, a mother of a year old child slammed her car into security barricades and led law enforcement officials on a high speed car chase, injured federal officials and was shot and killed, all while having her baby in the car.

It is not clear at this time, what exactly led Miriam Carey to behave the way she did, but it has been suggested that she was suffering from postpartum depression.  Postpartum mood and anxiety disorders (PPMAD) affect approximately 20 percent of all new mothers.  While not every circumstance of PPMAD escalates into a situation like what we saw last week, we do know that many women and their families are not aware of the signs and symptoms of PPMAD, most women do not seek help and are not provided information and resources for proper treatment.  Left untreated PPMADs can become a situation where the mother may harm herself or others.

As childbirth educators and professionals who work with birthing women, it is imperative that we speak and share, both prenatally and in the postpartum period. about PPMAD illnesses, and provide resources for help.  Here is some previously provided information on Postpartum Psychosis along with great resources provided by regular contributor, Walker Karraa, PhD.  Click to see previous Science & Sensibility posts on postpartum mood and anxiety disorder topics, for even more resources for professionals to share with parents. – Sharon Muza, Science & Sensibility Community Manager.

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http://flic.kr/p/7U4sW

Despite mounting credible medical evidence of the realty of postpartum issues and their effect on the mindset of the new mother, we as a country still remain the only civilized society that refuses to legally acknowledge the existence of this illness.—George Parnham, Attorney for Andrea Pia Yates

I wrote an OP/ED recently titled, “Who is at Stake? Andrea Yates, CNN and the Call for Revolution” at Katherine Stone’s Postpartum Progress. Given the airing of the CNN Crimes of the Century featuring Andrea Yates, I compiled a brief review of the facts and resources that might be helpful in approaching the topic in childbirth education. Thanks to Sharon Muza for supporting this piece.

Postpartum psychosis (PPP) is a psychiatric emergency that requires immediate medical attention.

It has been acknowledged in medical literature since Hippocrates 4th Century (Brockington, Cernick, Schofield, Downing, Francis, Keelan, 1981; Healy, 2013). In a comparative study of epidemiological data regarding perinatal melancholia from 1875-1924 and then 1995-2005, Healy (2013) concluded:

History shows that complaints can be readily tailored to fashionable remedies, whereas disease has a relative invariance. The disease may wax and wane in virulence, treatments and associated conditions may modify its course, but the disease has a continuity that underpins a commonality of clinical presentations across time. (p. 190)

Women experience PPP. Women have experienced PPP. And women in the future could avoid this tragedy by recognizing this mental illness. PPP is frequently confused with postpartum depression in public and professional nomenclature. It is extremely important to emphasize the difference in discussion of perinatal mental health with clients and students, as the word “postpartum” means different things to different students and providers.

Postpartum psychosis is not postpartum depression, lack of sleep, or postpartum anxiety, or post-traumatic stress disorder. PPP is a psychiatric emergency, tantamount to a medical emergency that requires immediate medical attention.

Prevalence

Postpartum psychosis affects 1-2 women per 1,000 births globally, and while rare, it is an extremely severe postpartum mood disorder (Kendell, Chalmers, & Platz, 1987; Munk-Olsen, Laursen, Pedersen, Mors, & Mortensen, 2006). Postpartum psychosis (PPP) occurs in all cultures, affecting mothers across socioeconomic, ethnic, and religious communities (Kumar, 1994).

Symptoms

Symptoms of postpartum psychosis are sudden in onset, usually occurring within 48 hours to 2 weeks following birth. Postpartum psychosis represents “psychiatric emergency and warrants hospitalization” (Beck & Driscoll, 2009, p. 47).

  • Waxing and waning delirium and amnesia (Spinelli, 2009)
  • “Cognitive Disorganization/Psychosis”
    • Wisner, Peindl, and Hanusa (1994) discovered that disturbances of sensory perceptions were a feature of the cognitive disruption experienced in postpartum psychosis. These include auditory, tactile, visual, and olfactory hallucinations.
    • Memory and cognitive impairment such as confusion and amnesia (Wisner et al., 1994).
    • Agitation, irritability
    • Paranoid delusions
    • Confusion
    • Bizarre and changing delusions
    • Suicidal or infanticidal intrusive thoughts with ego syntonic feature (Spinelli, 2009; Wisner et al., 1994)

In other perinatal mood or anxiety disorders, intrusive thoughts of self-harm or harming the baby are known as ego-dystonic and are common (41%-57%; Brandes, Soares, Cohen, 2004). Ego dystonic cognitions are thoughts experienced by the woman as abhorrent, and she recognizes that they inconsistent with her personality and fundamental beliefs (see: Kleiman & Wenzel, 2010 Dropping the Baby and Other Scary Thoughts).

In contrast, for a woman experiencing postpartum psychosis, the intrusive thoughts or ideations, of harming self or other are ego-syntonic—intrusive thoughts experienced as reasonable, appropriate and are “associated with psychotic beliefs and loss of reality testing, with a compulsion to act on them and without the ability to assess the consequences of their actions” (Spinelli, 2009, p. 405).

If left untreated, some dire potential outcomes include: 

  • 5% of women who experience PPP commit suicide (Appleby, Mortensen, & Faragher, 1998; Knopps, 1993).
  • 2%-4% are at risk of harming their infants (Knopps, 1993; Spinelli, 2004).
  • As high as a 90% recurrence rate (Kendell et al., 1987)

Risk Factors

  • Women with history of bipolar disorder or previous postpartum psychosis

“A personal history of bipolar disorder is the most significant risk factor for developing PP.” (Dorfman, Meisner, & Frank, 2012, p. 257)

  • Having a first-degree relative who has bipolar disorder, or experienced an episode of postpartum psychosis
  • Current research demonstrates that contrary to popular beliefs, PPP is often the result of either bipolar disorder or major depressive disorder with psychotic features, and there is little frequency of PPP caused by reactive psychosis or schizophrenia (McGorry & Connell, 1990).

Suggestions for Educators:

Reflect/Remind/Review/Refer

Given the stigma, misinformation and confusion regarding postpartum mental illness and particularly postpartum psychosis– it is important to clearly, and objectively identify and differentiate the full spectrum of perinatal mood and anxiety disorders. From the most prevalent and benign ‘baby blues’ to the most rare and severe postpartum psychosis, women and partners need accurate, accessible information to dispel myths, and give resources. See your education organization for their handouts, citations and referrals regarding PMADs in your curriculum.

Reflect back that you hear their concern. Repeat the question out loud so that others hear it. Chances are everyone in the room has a question around the topic of mental health, and as we know, 1 in 7 of the general population of childbearing women will develop a postpartum mood or anxiety disorder. Acknowledging the topic non-judgmentally by restating the question brings the topic into the room, reflects that you have heard the concerns expressed and not expressed, and that you are capable of holding the space for a quick, accurate review. 

Remind: PPP is Rare but Real

Remind class/clients that the incidence of PPP is extremely rare. Only 1-2 per 1,000 women develop postpartum psychosis. Secondly, with medical attention and treatment, PPP is preventable, and treatable. It is different than postpartum blues, depression, PTSD, or anxiety. Symptoms of PPP require immediate medical attention. 

Review the Facts

  • Rates: Only occurs in 1-2 per 1,000
  • Risk: Women with history of bipolar disorder or previous postpartum psychosis, and women with family history of bipolar disorder or first degree relative with history of postpartum psychosis are at higher risk.
  • PPP is preventable
  • PPP is treatable
  • PPP prevention and treatment require medical evaluation, intervention and care

Refer to Resources

What makes a good resource? Referring to accurate and accessible resources is an essential response to questions and concerns regarding postpartum psychosis (PPP).  Avoid any anecdotal advice regarding complimentary alternative medicine. The onset of PPP is tantamount to a medical emergency and requires immediate medical attention.

Have resources available in several formats and languages just as you would for other resources regarding childbirth education. Make sure your links, telephone numbers, and local resources are working and up to date.

Resources for Women and Partners Postpartum Progress

 Postpartum Psychosis Symptoms (in Plain Mama English)

Postpartum Support International 1-800-944-4PPD

 National Suicide Prevention Lifeline 1-800-273-TALK

Mother to Baby (formerly OTIS)

Medications & More During Pregnancy & Breastfeeding.

(866) 626-6847

Text-4-Baby Health Info Links

References

Appleby, L., Mortensen, P., & Faragher, E. (1998). Suicide and other causes of mortality after post-partum psychiatric admission. British Journal of Psychiatry, 173, 209-211.

Beck, C. & Driscoll, J. (2006). Postpartum mood and anxiety disorders: A clinician’s guide. Sudbury, MA: Jones and Bartlett.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77-101. doi:10.191/1478088706qp063oa

Brockington, I. F., Cernik, K. F., Schofield, E.M., Downing, A.R., Francis, A.F., & Keelan, C. (1981). Puerperal psychosis: phenomena and diagnosis. Archives of General Psychiatry, 38, 829-833.

Dorfman, J., Meisner, R., & Frank, J.B. (2012). Prevention and diagnosis of postpartum psychosis. Psychiatric Annals, 42(7), 257-261. doi:10.3928/00485713-20120705-05.

Doucet, S., Letourneau, N., & Blackmore, E. R. (2012). Support needs of mothers who experience postpartum psychosis and their partners. Journal of Obstetric, Gynecological & Neonatal Nursing, 41(2), 236-245.

Healey, D. (2013). Melancholia: Past and present. Canadian Journal of Psychiatry, 58(4), 190-194.

Kendell, R., Chalmers, J., & Platz, C. (1987). Epidemiology of puerperal psychosis. British Journal of Psychiatry, 150, 662-673.

Knopps, G. (1993). Postpartum mood disorders: A startling contrast to the joy of birth. Postgraduate Medicine, 93, 103-116.

Kumar, R. (1994). Postnatal mental illness: A transcultural perspective. Social Psychiatry and Psychiatric Epidemiology, 29, 250-264. doi:10.1007/BF00802048

McGorry, P., & Connell, S. (1990). The nosology and prognosis of puerperal psychosis: A review. Comprehensive Psychiatry, 31, 519-534.

Munk-Olsen, T., Laursen, T., Pederson, C., Mors, O., & Mortensen, P. (2006). New parents and mental disorders: A population-based register study. Journal of the American Medical Association, 296(21), 2582-2589. doi:10.1001/jama.296.21.2582

Spinelli, M. (2004). Maternal infanticide associated with mental illness: Prevention and promise of saved lives. American Journal of Psychiatry, 161(9), 1548-1557.

 

Guest Posts, Infant Attachment, Maternal Mental Health, Newborns, Parenting an Infant, Perinatal Mood Disorders, Postpartum Depression, PTSD , , , , , , ,