Science & Sensibility

By Walker Karraa

Regular contributor Walker Karraa has written an excellent three part series on Perinatal Mood and Anxiety Disorders (PMAD) and what the childbirth educator or birth professional can do to help women get the help they may need when dealing with mental illness during the prenatal and postpartum period.  Walker interviews experts in the field who all offer concrete steps, activities and resources so that educators and others can do to be more prepared to discuss this important subject with students and clients.  Recent press coverage of a British mother suffering from severe PMAD has made headlines and the topic is one that belongs in whatever childbirth class a woman chooses to take. – Sharon Muza, Community Manager.

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Safety regarding the use of a specific type of antidepressant medication, selective serotonin reuptake inhibitor (SSRI’s), is an important topic as maternal health care providers address the prevalence and negative effects of depression and other mood disorders in pregnancy and postpartum. Recently, the study The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond (Domar, Moragianni, Ryley & Urato, 2012) has garnered tremendous attention from media, researchers and childbirth professionals. I had the opportunity to ask the study’s authors and other experts about the dangers of discontinuation in a piece for Giving Birth With Confidence. From that article, we hear the overwhelming agreement; including two of the study’s authors, that sudden discontinuation of SSRI antidepressant medications in pregnancy is not advisable.

A week later, I learned about the tragic case of Felicia Boots, a 35 year old woman in the United Kingdom who, fearing she was harming her baby by taking SSRI’s and breastfeeding, suddenly stopped. Shortly after, she took the lives of her 14-month old and 10 week old children. A special editorial published by The Lancet (November 10, 2012), noted: “She had stopped her prescribed antidepressants because she was convinced that the drugs would harm her baby through her breastmilk and feared that her children would be taken away from her”(p. 1621). The authors went on to state: “A society in which women know that they will receive empathy, understanding, and help might be one in which women seek advice more readily, and accept appropriate treatments” (Lancet, 2012, p. 1621).

This is a vision shared by the guiding principles of maternity care–as childbirth professionals have always worked for a society where women know they will be cared for, understood, and have access to appropriate interventions. Unfortunately, we have failed to include mental health. How might the childbirth education community better address these issues? Asking experts is a place to start. What is uniquely helpful here is that the same questions were given to all participants—shedding light on one commonality: education.

Today’s article features Julia Frank, MD. Dr. Frank is a Professor of Psychiatry and Behavioral Sciences at the George Washington University School of Medicine and Health Sciences, where she has been the Director of Medical Student Education in Psychiatry since 2000. A graduate of the Yale University School of Medicine and of the residency program in psychiatry at Yale, Dr. Frank is also the founder of `Five Trimesters Clinic, a service for women with mental health needs relating to pregnancy and childbirth. In this installment, Dr. Frank addresses how childbirth educators might address these complex issues.

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

Dr. Frank: It is important to stress that the condition is rare but serious and treatment is generally quickly successful. Women with a family history of bipolar disorder or of postpartum psychosis in relatives should be told that they are at somewhat increased risk. Giving information in writing to them and their partners about what to look out for (especially profound sleeplessness and confusion) in the first couple of weeks postpartum might also be helpful.

WK: The recent Lancet editorial regarding the Felicia Boots tragedy stated: “Postnatal depression and, more broadly, perinatal mental health disorders, are among the least discussed, and most stigmatizing, mental health illnesses today” (p. 1621).   

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

Dr. Frank: I think the widespread publicity given to the sensational cases with terrible outcomes makes it hard for women to admit to any difficulty postpartum. The general public tends to conflate postpartum depression with psychosis. I have had women say to me “I don’t think I’m depressed, because I don’t want to hurt my baby”. We also overemphasize depression and neglect anxiety. I am not sure that is a factor of stigma, but it certainly contributes to under diagnosis.

Obstetricians and pediatricians may not recognize or discuss a postpartum psychiatric disorder for fear of offending the affected mother. Other aspects of stigma that apply to professionals are the belief that psychiatric disorders are overwhelmingly time consuming to address, that women who have them lack insight, that treatment is generally no better than passage of time.

WK: What do you see as the most significant barriers to treatment for women with perinatal mood and anxiety disorders (PMAD)? 

Dr. Frank: In the US, the disconnection between mental health care and medical care, written into our insurance systems, is a major barrier. Also, the way pediatricians are trained to deal only with the child, and not to assume any responsibility for the health of the mother, keeps them from screening appropriately. Obstetricians also maintain an overly narrow focus on the woman’s organs, and they tend to have very little contact with mothers after delivery, nor do most of them see mental health as within their sphere of interest or expertise. Fears of liability from the effects on the fetus of treating the mother are another barrier, especially in the US, where medical injury to an infant can bring astronomically high damage awards. This is a particular barrier to some psychiatrists being willing to initiate or maintain treatment related to pregnancy.

WK: How would you respond to media-based concerns regarding the safety of SSRI medication in pregnancy? 

Dr. Frank: There is no pregnancy without risk, and the risks of not treating a serious psychiatric disorder are as important to consider as the risks associated with treatment.  When we bypass maternal suffering out of concern for the safety of a fetus, we are making a misguided moral judgment that privileges “innocent” life over life as lived. The risks of these drugs are important and should be weighed carefully, but it has taken literally decades and the review of the experience of tens of thousands of women to identify the risks. Absolute and percentage risks remain acceptable, when weighed against the known benefits of taking medication when necessary. Over fifty percent of pregnant women take something during pregnancy, and treating a mood disorder is as important as treating a UTI, or diabetes, or heartburn or any of the conditions that are typically addressed.

WK: What are your thoughts regarding discontinuation of medication in pregnancy? 

Dr. Frank: Depends on the medication, the woman’s history, and the illness being treated. Certainly, discontinuing a medication should not be an automatic response to a woman becoming pregnant.

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

Dr. Frank: Widespread education in the use of efficient screening methods, particularly the PHQ 9 or the Edinburgh Postnatal Depression Scale would be a first step.  Educators  also need to develop routines for referring women to mental health services—the postpartum depression self-help  community , embodied in organizations like Postpartum Support International, is pretty well organized and can help bridge the gap between screening and referral . Ideally, these organizations could reach out to women postpartum, rather than waiting for them to come in. Routine phone calls two and four weeks after delivery, providing encouragement for everyone while also identifying and facilitating referrals for women in difficulty, might be quite effective in both preventing and intervening in postpartum mood problems. This is an area that merits systematic study. Finally, organizations that include mothers themselves might consider urging women who have been identified and treated to write thank you notes to the health care providers who contributed to them getting help. I think this would counter the fears that providers have about giving and offense and doing harm.

Conclusion

Dr. Frank contributes to the broadening conversation regarding how childbirth educators might better address perinatal mental health. How do her suggestions resonate with your practice? In what ways could you use her information?  Will you consider adding this information to your classes and new mother contact? And how could your certifying or professional organization become a source of support and education?

The second post in this series, scheduled for Thursday, features Nancy Byatt, D.O., MBA–Assistant Professor of Psychiatry and Obstetrics & Gynecology;  Psychiatrist, Psychosomatic Medicine and Women’s Mental Health UMass Medical School/UMass Memorial Medical Center.

References

Domar, A. D., Moragianni, V. A., Ryley, D.A., & Urato, A.C. (2012). The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond. Human Reproduction, Vol.0(0) pp. 1–12 doi:10.1093/humrep/des383

Bringing postnatal depression out of the shadows The Lancet – 10 November 2012 (Vol. 380, Issue 9854, Page 1621 ) doi: 10.1016/S0140-6736(12)61929-1

Other Resources: 

Department of Health and Human Services: Depression During and After Pregnancy: A Resource for Women, Their Families, & Friends

The Organization of Teratology Information Services (OTIS), (866) 626-6847

 

 

Walker Karraa Babies, Breastfeeding, Childbirth Education, Depression, Giving Birth with Confidence, Guest Posts, Infant Attachment, Maternal Mental Health, Maternity Care, News about Pregnancy, Perinatal Mood Disorders, Postpartum Depression, Prenatal Illness, Research antenatal mood disorder screening, Childbirth Education, guest posts, Julie Frank, MD, mental illness, PMAD, postpartum, postpartum depression, PPMD, prenatal depression, prenatal depression screening, screening for postpartum depression, Walker Karraa

This is part one of a two part series on the support needs of women who experience postpartum psychosis, and their partners and is written by regular contributor Walker Karraa.  Part two will run next week. – SM

Support Needs of Mothers Who Experience Postpartum Psychosis and Their Partners (Doucet, Letourneau, & Blackmore, 2012), is a study published in the Journal of Obstetric, Gynecological & Neonatal Nursing (JOGNN) has offering new qualitative data regarding the support needs of mothers who experience postpartum psychosis (PP).

It is important to note that this is the first published study looking directly at the support needs, preferences, and access to support for women who have experienced PP and their partners, and the importance of qualitative research in deepening our understanding of maternal health.

As you know, qualitative research attempts to make explicit the lived experience of a phenomenon. Rather than quantifying an objective symptom in empirical methods and deducing what an experience is through external measurements, qualitative research methods put the lived experience of the individual center stage, and develop inductive strategies for learning about the human experience. In this study, for example, the authors use semi-structured interviews from mothers and partners to find themes in the content that may suggest more effective prevention and treatment strategies. Listening to mothers and using their subjective experience of PP and the needs they had in recovery offered a quality of information (data) that traditional quantitative data does not, and could not—by the very nature of its design and purpose. We cannot measure motherhood. But we can learn to listen to motherhood through multiple perspectives in order to learn its meanings and mitigate our advocacy.

Postpartum Psychosis: Some Background               

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). This most debilitating illness 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. PP represents “psychiatric emergency and warrants hospitalization” (Beck & Driscoll, 2009, p. 47). If left untreated, some dire potential outcomes include:

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

According to the American Psychiatric Association (APA, 2000, p. 332), symptoms of PP include:delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior occurring within 4 weeks following childbirth, and that is not accounted for by other medical conditions, substance use, or mood disorders with psychotic features. Current research demonstrates that contrary to popular beliefs, PP is often the result of either bipolar disorder or major depressive disorder with psychotic features, and there is little frequency of PP caused by reactive psychosis or schizophrenia (McGorry & Connell, 1990).

Study Review

The goal of the recent JOGNN study Support Needs of Mothers Who Experience Postpartum Psychosis and Their Partners (Doucet, Letourneau, & Blackmore, 2012) was: “To explore the perceived support needs and preferences of women with postpartum psychosis and their partners” (p.236).  A multisite, exploratory, qualitative descriptive design was implemented using a purposive sample of nine mothers (Canada, n = 7, United States, n = 2) and eight fathers (Canada, n = 7, United States, n = 1). Data were collected through one-on-one, in-depth, semi-structured, interviews lasting 45-120 minutes. Partners were interviewed separately. All interviews were audio-recorded and transcribed verbatim, and then analyzed using inductive thematic analysis in six phases based on the methods of Braun and Clarke (2006), thematic content regarding support for mothers emerged in the categories of (a) support needs; (b) support preferences; (c) accessibility to support; and (d) barriers to support.

Mothers’ Support Needs

Instrumental, Informational, and Emotional

Doucet et al., (2012) concluded that “all mothers reported the need for instrumental, informational, emotional, and affirmational support” (p. 238. Bottom line, the mothers needed good information about their illness, good information about taking care of an infant, and physical in home assistance.

Generic support of parenting needs included information on caring for newborn, and physical assistance with house cleaning and infant care. Following hospitalization for PP, the majority of participants described wanting 24-hour support at home. Some wanted help with physical needs of meal preparation, bathing, and assistance with confusion, disorientation, memory loss. Help with night feeding, holding, etc. were significant, as one mother noted:

It was helpful having people come over and play with him and take care of him, and if I am in that manic state I can just carry on and get it out of my system. (p.239)

Mothers reported needing reassurance that the cause of their illness was biological, that they would recover:

The turning point was when I talked to someone who had gone through the exact same thing as me. The fact that she turned out okay and went on to have a happy good life with other kids was reassurance that I could get through this. (p. 238)

Women also wanted specific information on PP including:

• treatment options
• medication safety when breastfeeding
• long term prognosis
• risk of relapse with future pregnancies
• community support

Mothers’ Support Preferences

Mothers wanted clinical information from professionals, and emotional, affirmational, and physical support from informal networks—such as peers, partners, and families.  There was a “strong preference” (p. 239) to receive physical help with baby from family, rather than formal sources such as in home nurses, etc.

All women wanted one-to-one, face-to-face support from a professional, at least once a week immediately after symptoms began. Once symptoms had improved, mothers reported preferring group support in face-to-face format, with mothers who had experienced postpartum mental health issues, and facilitated by someone with experience in PP, such as a professional, or a woman who had recovered from PP. They wanted to bring their babies to group sessions.

Access to Support

All mothers obtained access to a general psychiatric unit for immediate support with symptoms, but it is important to note they preferred a unit that specialized in postpartum mood disorders.

They felt they did not belong on a general unit, and did not receive specialized support. Most disturbingly, none of the women were able to see their infants, as is standard protocol in general psychiatric units, and found this extremely painful and hindered their recovery.

Barriers to Recovery

Barriers to recovery for the mothers in the study included the perception of health care providers as too clinical, uncaring, and having restricted their access to families. Isolation in the hospital, not seeing care provider, or feeling rushed in the appointment were also reported care-provider barriers. Family lack of knowledge about PP was reported as a barrier to recovery. One participant shared:

If my husband had a support group for new fathers to deal with a psychotic wife, it would have changed everything. He would have been far more compassionate had he known about my illness. He needed tools to deal with a mentally ill wife. (p. 241)

Finally, mothers in the study identified the lack of education regarding the differences between postpartum psychosis and other postpartum mood and anxiety disorders in family, peers and friends as a significant barrier to their own recovery. I think it is fair to offer considerations in approaching the topic so that together we will build a dialogue of difference, a conversation of consideration for how childbirth professionals process perinatal psychiatric illness, and learn to overcome fear through knowing.

In the next submission the findings from the fathers and partners will be reviewed, and considerations for childbirth professionals will be discussed.

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

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.

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.

About Walker Karraa

Regular contributor Walker Karraa is currently the President of PATTCh, an organization dedicated to the Prevention and Treatment of Traumatic Childbirth. Walker is a doctoral student at Institute of Transpersonal Psychology, a certified birth doula, freelance writer, and maternal mental health advocate.  She holds an MA degree in Clinical Psychology from Antioch University Seattle, and a BA and MFA degree in dance from UCLA.  Walker is a contributor to the Lamaze sites, www.givingbirthwithconfidence.org and www.scienceandsensibility.com.  She lives in Sherman Oaks, California with her husband, and two children.

Walker Karraa Depression, Maternal Mental Health, Maternal Mortality, Maternal Mortality Rate, New Research, Perinatal Mood Disorders, Postpartum Depression, Postparum depression, Pregnancy Complications, Prenatal Illness, Uncategorized maternal mental health, mental illness, partners, postpartum, postpartum depression, postpartum psychosis, PP, treatment for postpartum psychosis, Understanding Research, Walker Karraa

Preterm delivery, delivery before 37 completed weeks of gestation, has been shown to cause  significant morbidity in infants and to be a cause of lifelong health problems in these children. The World Health Organization (WHO) reports,

 

Preterm birth is a leading cause of neonatal and infant mortality as well as short- and long-term disability. Rates for preterm birth range between 6% and 12% in developed countries and are generally higher in developing countries. About 40% of all preterm births occur before 34 weeks and 20% before 32 weeks. The contribution of these preterm births to overall perinatal morbidity and mortality is more than 50%.”

 

Low birth weight—below 5 lbs 8 ounce (or 2500 grams)—is usually a consequence of preterm birth but is also a singularly significant cause of morbidity and mortality in neonates and children. According to the March of Dimes, 67% of preterm infants are low birth weight and in the United States, they estimate that about 1 in every 12 infants is born low birth weight.

 

Despite attempts to positively impact maternal health and nutrition, and aggressively treat preterm labor, the rates of preterm birth and low birth infants are still on the rise globally. Physicians and researchers continue to examine cases and studies trying to identify potential causes and treatments that could slow, halt and eventually reverse these trends. In 1996, Offenbacher et al first reported an association between periodontal disease and preterm birth. Since that time, evidence has been growing to support the idea that periodontal disease may be associated with preterm birth, low birth weight and other adverse birth outcomes.

 

Xu Xiong et al hypothesize in their article, Optimal timing of periodontal disease treatment for prevention of adverse pregnancy outcomes: before or during pregnancy?, that since periodontal disease treatment during pregnancy has not been shown to significantly reduce the rates of preterm birth and low birth weight, that preconception treatment (either in the year prior to conception in primiparas or between pregnancies in multiparous women) may be more effective.

 

Xiong and his colleagues reached this conclusion following a systematic review of the observational studies which showed that there is an association between periodontal disease and adverse birth outcomes (especially in lower socioeconomic populations), and meta analyses of randomized control trials (RCT’s); one in which preterm birth was the end point and one in which low birth weight was the end point. RCT’s performed in low to middle-income countries found a stronger link between treatment of periodontal disease during pregnancy and reduction in adverse pregnancy outcomes. RCT’s performed in high income countries such as the United States only showed that treating periodontal disease during pregnancy may reduce the rates of low birth weight. With these findings, Xiong and his colleagues present the following recommendations for future RCT’s to determine whether or not treating periodontal disease prior to conception can actually reduce the rates of preterm birth, low birth weight and other adverse pregnancy outcomes.

 

• Study participants would be women planning to conceive within one year and with documented periodontal disease
• Participants would be randomized to treatment vs. non treatment groups
• Treatment groups would receive intense periodontal therapies and use of antibiotics to aggressively treat and eradicate periodontal disease
• Endpoints of the studies would be delivery, and assessment of rates of adverse pregnancy outcomes would determine the efficacy of the intervention.

 

Xiong et al hypothesize that if preconception periodontal treatments reduce adverse pregnancy outcomes lowering infant morbidity and mortality, then improving oral health prior to pregnancy could be recommended, especially in low and middle income nations, as a means of reducing infant morbidity and mortality worldwide.

 

At face value Xiong’s hypothesis may seem like a lot of “ifs.” However, the presumed link between periodontal disease and adverse birth outcomes provides a simple portal for intervention and measurement of effect. While it may be more difficult to amass study participants as most women don’t receive preconception care, Xiong suggests recruitment within communities. He also suggests training of dental professionals so that the diagnoses and treatments of periodontal disease remain as uniform as possible worldwide.

 

I agree with Xiong’s hypothesis and proposed course of action. My concern is that here in the United States, many citizens are without dental coverage and will be unable to afford the preconception periodontal treatments should they become a standard of preconception care. While women may receive treatment during the study, how will low income and/or uninsured women receive such treatment once preconception treatment becomes a recommendation? Medicaid doesn’t cover dental procedures “for health” and preconception would need to be listed as treatment of overall health and that may prove a difficult task—at least initially. Medicaid is currently facing increasing budget cuts nationwide so adding another benefit may not be admissible, despite being effective in lowering other health care costs associated with the long term care of preterm and low birth weight infants.

 

While I hope that Xiong’s hypothesis is proven and preconception periodontal treatment is a solution to help reduce the rates of preterm birth and low birth weight infants, I fear that as a solution, it may not be available to many women, especially in the United States, due to costs. I hope that worldwide, if preconception periodontal treatment is effective in reducing adverse pregnancy outcomes, resources will be allocated for such treatment as it will reduce not only infant morbidity and mortality but also the burden of life long care costs for these children.

 

 

Posted by:  Darline Turner-Lee, BS, MHS, PA-C

 

 

 

References

Stacy Beck, Daniel Wojdyla, Lale Say, Ana Pilar Betran, Mario Merialdi, Jennifer Harris Requejo, Craig Rubens, Ramkumar Menon & Paul FA Van Look

The worldwide incidence of preterm birth: a systematic review of maternal mortality and morbidity   Bulletin 37 World Health Organizaton 2010;88:31–38 | doi:10.2471/BLT.08.062554

 

The March of Dimes  http://www.marchofdimes.com/medicalresources_lowbirthweight.html

 

Steven Offenbacher, Vern Katz, Gregory Fertik, John Collins, Doryck Boyd, Gayle Maynor, Rosemary McKaig, and James Beck

“Periodontal Infection as a Possible Risk Factor for Preterm Low Birth Weight”

Journal of Periodontology October 1996, Vol. 67, No. 10s, Pages 1103-1113,

DOI 10.1902/jop.1996.67.10s.1103 (doi:10.1902/jop.1996.67.10s.1103)

 

Xiong X, Buekens P, Goldenberg RL, et al. “Optimal timing of periodontal disease treatment for prevention of adverse pregnancy outcomes: before or during pregnancy?” American Journal of Obstetrics and Gynecology 2011; 205:111.e1-6.

Darline Turner-Lee Pre-term Birth, Preconception Care, Prenatal Illness, Research Opportunities, Science & Sensibility, Uncategorized Darline Turner Lee, periodontal disease, prenatal periodontal disease, preterm birth, preterm birth prevention

 “There is no greater loneliness in the life of a human being than being alone with one’s own suffering; and no suffering is greater than the mental torture of impending agony from which there is no escape and of which there is no understanding.” Grantly Dick-Read, 1959, p.50

Grantly Dick-Read was right.  Suffering alone breeds a sense of inescapable despair for which there are few words, if any.  Lack of language is a kind of quintessential, ontological divide between a person’s experience and the observer’s understanding–what Biro (2011) noted as the starting point for change.  Language can “replace isolation with community” (Biro, 2011, p. 15).  This site is testimony to that!  Listening to mothers is both our privilege, our scientific premise (the landmark study by the same name), and our standard of practice as childbirth professionals.  In the spirit of listening to mothers, and learning to replace isolation with community–I would like to share a recent study regarding quite possibly the worst mental torture imaginable: suicidal ideation in pregnancy.

One of the first of its size and breadth, a recent study published in the Archives of Women’s Mental Health (2011) examined prevalence of suicidal ideation in a large sample of pregnant women.  Two objectives were presented: (1) examine the prevalence of suicidal ideation and comorbid psychiatric disorders during pregnancy; (2) identify the risk factors for suicidal ideation during pregnancy:

“Although our understanding of the prevalence and consequences of antenatal major depression has improved, our understanding of suicidal ideation—a common aspect of major depression—during pregnancy is limited.” (Gavin, Tabb, Melville, Guo & Katon, 2011, p. 244)

Comparing prevalence rates of suicidal ideation in a pregnant population with those in general, non-pregnant population could substantiate or refute the commonly held belief that pregnancy is a protective mechanism against thoughts of suicide (Zajicek, 1981; Kendell, Chalmers, & Platz, 1987), offering a fuller vocabulary regarding this rare, yet tragic suffering.  The authors built a strong rationale for their study by reviewing the scant literature that does exist, and its compelling evidence:

• “Suicide is a leading cause of death among pregnant and postpartum women in the United States” (Gavin, et al., 2011 p. 239; Chang, et al., 2005).
• The precursor to suicide in most cases is suicidal ideation, and the presence of major depression (Perez-Rodriguez, et al., 2008; Lindahl et al., 2005).
• Women of childbearing years are at greatest risk for depressive disorders (Perez-Rodriguez, et al. 2008).
• Pregnant women are less likely to be screened for suicidal ideation during pregnancy (Stallones, et al., 2007; Paris, et al., 2009; Gausia, et al., 2009; Copersino et al., 2005; Newport et al., 2007).
• Adverse outcomes experienced by women who did report suicidal ideation in pregnancy (Stallones, et al., 2007; Paris, et al., 2009;  Gausia, et al., 2009; Copersino et al., 2005; Newport et al., 2007; Bowen, et al., 2009; Eggleston, et al., 2009;  Chaudron et al., 2001).
• Suicidal ideation in pregnancy is a strong predictor for postpartum depression (Chaudron et al., 2001).
• Pregnant women with depressive disorders are less likely to receive treatment for depression (Vesiga-Lopez et al., 2008).
• Depressive disorders remain under-detected in prenatal settings because most women seeking prenatal care are not screened for depression (Kelly, et al. 2001).
• Most patients fail to tell care providers of suicidal plans or attempts (Isometsa et al., 1994).

Lack of prenatal depression screening, known risk factors for comorbid mood disorders and their adverse effects are noted:

“Given the risks associated with antenatal suicidal ideation to women and their offspring, identifying effective methods of detecting women with antenatal suicidal ideation is a paramount challenge.” (Gavin, et al., 2011)

Study Design

Authors employed a cross-sectional analysis design of data from a longitudinal study of 3,347 pregnant women receiving prenatal care at a single site university-based obstetric clinic (University of Washington) from January 2004 to 2010.   After exclusion, the final sample size was 2,159 women.  Study protocol mandated screening a minimum of two times, once in early second trimester, (16 weeks) and once in third trimester (36 weeks).  Suicidal ideation was measured using the Patient Health Questionnaire (PHQ-9)–a screening instrument that has demonstrated both high sensitivity (73%) and specificity (98%) for major depression (Spitzer, et al., 2009).   To examine suicidal ideation specifically, the authors measured women’s responses to item 9 of the PHQ-9:

“Over the last two weeks how often have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way?  0 = not at all, 1= several days, 2 = more than half the days, and 3= nearly every day.” (Gavin, et al., 2011, p. 241)

Participants self-reporting a score of 1 or greater (suicidal ideation several days a week in last 2 weeks), were considered positive for suicidal ideation.  With the protocol in place, authors then applied multiple covariate logistic regression analysis.

Study Results

Results demonstrated 2.7% of the 2,159 sample scored positive for suicidal ideation–similar to the prevalence rates for general, non-pregnant populations recorded in both the National Comorbidity Survey 1990-1993 (NCS) 2.8% ; and the National Comorbidity Survey Replication 2001-2003 (NCS-R) rate of 3.3% in general, non-pregnant population:

“The prevalence of antenatal suicidal ideation in the present study was similar to rates reported in nationally representative non-pregnant samples.  In other words, pregnancy is not a protective factor against suicidal ideation”.  (Gavin, et al., 2011, p. 239)

Of the 2.7% prevalence rate:

• 78.0% reported thoughts of suicide “several days” in last 2 weeks
• 15.3% reported thoughts of suicide “more than half the days” in the last 2 weeks
• 6.7% reported thoughts of suicide “nearly every day”
• 52.5% experienced comorbid antenatal depression
• 15.7% experienced comorbid antenatal panic disorder

Speak My Language

Consider for a moment a group of 2,159 women attending standard prenatal childbirth education classes at a local hospital over the course of several years.  Generalizing from this study and national statistics, 59 of them are having thoughts of ending their lives.  Of those 59:

• 48 (78%) have considered killing themselves several days in the last two weeks.
• 9 (15.3%) have considered suicide more than half of the week,
• 4 (6.7%) of those moms have contemplated killing themselves nearly every single day.

And those are the women who admit it.  The mothers who speak it. What do we do?  Final recommendations put forth by the authors here included “efforts to identify those women at risk for antenatal suicidal ideation through universal screening” (Gavin, et al., 2011, p. 239).

I think it is pretty fair to say that the majority of childbirth educators and doulas are trained to screen for difficulties in breast feeding.  When problems or risk factors present themselves, or a mom suffers from the agony of mastitis, we use language to help.  We lean over the void of suffering and listen to our mothers.

We speak the language of lactation quite easily,
and have organizational support and training to do so.
Yet, how many of us feel comfortable with the language of suffering alone in major depression? Go to your certifying organization’s website and look for resources for moms, or family members who feel suicidal.  Anything?   For you as a professional certified by that organization to offer emotional support to your clients, are there resources there for you to access, to help your clients?  Consider writing your certifying organization and request they update training for prenatal courses to include screening for depression.  Ask them to post suicide prevention materials for consumers. Your organization(s) should offer assistance in learning how to screen, referral sources in your area, and after care resources for your own healing should you need it.  Not doing so, not having public position papers, not speaking the language, in my mind is tantamount to silencing women’s suffering, and perhaps contributing to the loneliness of those who feel misunderstood. As David Biro (2011) states: “The consequences of silence are unacceptable…if we wish to relieve pain, we must first hear it” (p. 14).
“Listening to Mothers”…I’m in.

Posted by: Walker Karraa, MFA, MA

_____________________________________________________________

Resources

The Suicide Prevention Life Line offers free buttons, logos and links to add to your websites, and free downloads to give clients/students. You can also call them yourself to ask them how to talk to a mom about her symptoms.

Edinburgh Postnatal Depression Scale (EPDS)

PHQ-9

Postpartum Support International (PSI)

 

 

References

Biro, D. (2011). The language of pain: Finding words, compassion, and relief. NY: Norton.

Bowen, A., Stewart, N., Baetz, M., et al. (2009). Antenatal depression in socially high risk women in Canada. J Epidemiol Community Health, 63:414-416.

Brand, S. Brennan, P. (2009). Impact of antenatal and postpartum maternal mental illness: How are the children? Clinc Obstet Gynecol, 51:441-455.

Chang, J., Berg, C., Saltzman, L., et al. (2005). Homicide: a leading cause of injury and deaths among pregnant and postpartum women in the United States, 1991-1999. Am J Public Health, 95:471-477.

Chaudron, L., Klein, M., Remington, P., et al. (2001). Predictors, prodromes and incidence of postpartum depression.  Psychosom Obstet Gynecol, 22:103-112.

Copersino, M., Jones, H., Tuten , M., et al. (2005) Suicidal ideation among drug-dependent  treatment -seeking  inner-city women.  J. Maint Addict, 3:53-64.

Eggleston, A. Calhoun P., Svikis, D., et al. (2009). Suicidality, aggression, and other treatment considerations among pregnant, substance-dependent women with posttraumatic stress disorder.  Compr Psychiatry, 50: 415-423

Gausia, K., Fisher, C., Ali, M., et al. (2009). Antenatal depression and suicidal ideation among rural Bangladeshi women: A community-based study. Arch Womens Ment Health, 12:351-358.

Gavin, A., Tabb, K., Melville, J., Guo, Y., & Keaton, W. (2011). Prevalence and correlates of suicidal ideation during pregnancy. Arch Womens Ment Health 14(239-246).

Kelly, R., Zatzick, D., Anders, T. (2001). The detection and treatment of psychiatric disorders and substance use among pregnant women cared for in osbstetrics. Am J Psychiatry, 158:213-219.

Kroenke, K., Spitzer, & Williams, J. (2001).  The PHQ-9: Validity of a brief depression severity measure. Gen Intern Med. September; 16(9): 606–613.

Lindahl, V., Pearson, J., Colpe, L. (2005). Prevalence of suicidality during pregnancy and postpartum. Arch Womens Ment Health, 8:77-87.

Newport, D., Levey, L., Pennell, P., et al. (2007).  Suicidal ideation in pregnancy: Assessment and clinical implications. Arch Womens Ment Health, 10:181-187.

Paris, R., Bolton, R., Weinberg, M. (2009) Postpartum depression, suicidality, and mother-infant interactions. Arch Womens Ment Health 12:309–321

Perez-Rodriguez M., Baca-Garcia E., Oquendo M et al. (2008).  Ethnic differences in suicidal ideation and attempts. Prim Psychiatry 15:44–58

Spitzer, R., Williams, J., Kroenke,  K.,  et al. (2000). Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIME-MD patient health questionnaire obstetrics-gynecology study. Am J Obstet Gynecol 183:759–769

Stallones,  L., Leff,  M., Canetto, S. et al. (2007). Suicidal ideation among low-income women on family assistance programs. Women Health 45:65–83

Vesga-Lopez,  O., Blanco, C., Keyes, K., et al. (2008). Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry 65:805–815

 

Walker Karraa New Research, Patient Advocacy, Perinatal Mood Disorders, Prenatal Illness, Uncategorized antenatal depression, Archive's of Women's Mental Health, Grantly Dick Read, Perinatal Mood Disorders, PHQ-9, prenatal depression, prenatal depression screening, suicidal ideation in pregnancy

“Honesty is disarming.  It should set the stage for dialogue.” — Jane Honikman, M.S., founder, Postpartum Support International

One of the first written accounts of postpartum mood disorders was in 1436. Margery Kempe, mother of 14, wrote:

“Wherefore after that her child was born she, not trusting her life, sent for her ghostly father, as said before, in full will to be shriven of all her lifetime as near as she could. And, when she came to the point for to say that thing which she had so long concealed, her confessor was a little too hasty …and so she would no more say for nought he might do. And anon for dread she had of damnation on that one side and his sharp reproving on that other side, this creature went out of her mind and was wonderly vexed and labored with spirits half year eight weeks and odd daysⁱ.”

Background to Postpartum Mood and Anxiety Disorders (PPMAD)
In the quote above, from Out of her mind: Women Writing on Madness, Margery’s honesty is indeed disarming, and provides historical context to set the stage for future dialogue: perinatal mood disorders have been around a long time, and based on current evidence, they aren’t going away.

• Suicide is the leading cause of death for women during the first year after childbirth.¹
• Depression is the second most common cause of hospitalization for women in the U.S.; the first being childbirth.^2,3
• Major and minor postpartum depression/anxiety estimates range from 5% to 25% for new mothers in US.^4,5,6,7,8
• There is a seven-fold increase in the risk of psychiatric hospitalization for women following childbirth.^9,10,11
• Reports show that PPMAD affects up to 48% of women living in poverty.^12,13,14,15

 

The Role Stigma Plays
Statistically, over 500 years later, Margery would still be at risk largely due to the powerful social mechanism of stigma regarding motherhood and mental illness.  Just as stigma about mental health disorders silences women today, Margery was similarly silenced in 1436.^16,17,18 It is the silent fear of stigma that likely causes nearly 50% of present-day, affected women to go untreated for perinatal mood disorders.^19,20

In her 2010 book Within Our Reach: Ending the Mental Health Crisis²¹, former first lady (and life-long mental health advocate), Rosalynn Carter noted:

 

Stigma is the most damaging factor in the life of anyone who has a mental illness. It humiliates and embarrasses; it is painful; it generates stereotypes, fear and rejection; it leads to terrible discrimination. Perhaps the greatest tragedy is that stigma keeps people from seeking help for fear of being labeled, “mentally ill” (p. 1).

Raising Awareness
One of the ways to end stigma is to increase awareness. In my recent interview [KMH1] with Jane Honikman, M.S., founder of Postpartum Support International (PSI), she offered:

The causes of stigma include ignorance and denial about the importance of emotional wellbeing of childbearing women.  On the community, national and international levels this ignorance is being eliminated through educational awareness campaigns.   There is no excuse not to be educated about the range of emotional reactions during the perinatal period.  Denial is a personal issue and more difficult to confront.  It is impossible to know how one’s expectations of motherhood will be met.  The mythology that surrounds parenthood is another huge barrier.  Taboos need to be openly discussed.  Often there are conflicts between the woman and her partner. These need to be discussed.  It is difficult to parent alone. Family members should participate in supporting the new family.  It is important to have frank and honest conversations about opinions and expectations within the extended family unit during pregnancy and following the arrival of the baby.

Increased awareness regarding prevalence, risk factors, and the need to screen has occurred at many levels. There has definitely been progress.  Jane further offered:

Awareness has increased tremendously since I first got involved nearly forty years ago.  The availability of accurate information, resources and referral networks is responsible for these changes.  The media has been our movement’s best friend.  For example, there are now free materials from the federal government, healthy start programs include maternal mental health curriculums, and states have active coalitions.  Insurance companies have eliminated barriers to receiving mental health coverage.  All of the major medical organizations have stepped forward offering educational seminars to their members.  The courts now consider mental health history when they encounter a crime. The internet has played an enormous role.  Postpartum Support International’s website www.postpartum.net has been a leader in this progress.

Further evidence of progress can be found in the published position papers related to maternal mental health of the following organizations:

Centers for Disease Control and Prevention (CDC)
The American Congress of Obstetricians and Gynecologists (ACOG)
The World Health Organization (WHO)
American College of Nurse-Midwives (ACNM)
Planned Parenthood
National Organization for Women (NOW)
The American Academy of Pediatrics (AAP)
National Alliance on Mental Illnesses (NAMI)
Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)
Children’s Defense Fund (CDF)
National Women’s Law Center
National Partnership for Women and Families (NPWF)
The U.S. Preventive Services Task Force
American Psychological Associatio(APA)
US Dept of Health and Human Services
March of Dimes
National Institute of Mental  Health(NIMH)
Healthy Mothers Healthy Babies
International Childbirth Educators Association (ICEA)

Postpartum Support International (PSI) has had a tremendous influence on raising awareness about postpartum mood and anxiety disorders. Given their successful leadership in advocating for maternal mental health using evidence-based research, it serves to look more closely at the organization’s structure and become familiar with the resources they provide all childbirth professionals.

Postpartum Support International Background
PSI was founded in 1987 by Jane Honikman in Santa Barbara, California. The purpose of the organization is to increase awareness among public and professional communities about the emotional changes that women experience during pregnancy and postpartum.  The non-profit organization’s greater mission is to promote awareness, prevention and treatment of childbearing-related mental health issues in every country worldwide. It is the vision of PSI that every woman and family will have access to information, social support, and informed professional care when needed.  PSI promotes this vision through advocacy and collaboration, and by educating and training the professional community and the public.  

How PSI Works
PSI is run and maintained by volunteers. According to Wendy Davis, Ph.D., PSI Program Director, there are currently 479 active members and of that number, approximately 50 of those are childbirth professionals (birth or postpartum doulas, childbirth educators, lactation consultants).  There are 145 PSI Support Coordinators in the United States, and 48 in other countries. Support coordinators provide support, information, and resources to anywhere from 2 to 20 families every month, and many of them lead free support groups. We also have specialized PSI Coordinators for military families, Dads, Spanish-speaking moms, and legal resources.

PSI maintains a warm line (1.800.944-4PPD) which is managed by 9 English speaking volunteers, and 8 Spanish speaking volunteers. On average, the English warm-line receives 90 calls a month, and the Spanish warm-line, 70 calls per month. The toll free number connects the caller with informed and caring PSI telephone support volunteers 7 days a week. What happens when an individual calls in? Dr. Davis explained:

The caller hears a greeting and then can leave a voicemail message in English or Spanish. The calls are usually returned within several hours; volunteers make every effort to connect with the caller within 24 hours at the most. The warm-line is answered live in English on Tuesdays and Wednesdays, during regular business hours, Pacific time. Warm-line volunteers offer non-judgmental support, information, and local resources. They will connect the caller with their area PSI Support Coordinator so they can find support or providers as close to home as possible.

The PSI website provides consumers and professionals with current research, and resources.  According to Dr. Davis:

The hallmark of our website is our Support Map Page that lists PSI support coordinators, free support groups, and events in every U.S. state and 35 other countries. Childbirth professionals can be assured that they can find volunteers in their own area who are available to help them and the families they serve. Our Coordinators are trained to provide support, information, and local resources as well as phone or email support to families as needed. The website also includes current evidence-based information on the range of pregnancy and postpartum mood disorders, tips for coping, resources for moms, partners, and professionals, educational materials like brochures and posters in English and Spanish, new research articles, and a bookstore. There is one page that just lists information and links in non-English languages, and one section of the website has been translated to Spanish. We update the website constantly to keep it current, adding new research and resources daily.

One of the additional resources she described is the PSI Free Chat with an Expert:

PSI hosts free, live phone sessions every week facilitated by licensed professional experts in perinatal mental health. There is a session for moms and their helpers every Wednesday and for Dads on the first Monday of each month. These sessions provide a forum to share, listen to others, and talk with a PSI expert about resources, symptoms, options and general information about perinatal mood and anxiety disorders. You can learn more about the facilitators and call schedules [here].  

Sensible Resource: How to use PSI in Practice
How can childbirth professionals best utilize PSI for their clients? Dr. Davis suggested:

• Find your local PSI Coordinator on the Support Map so that you can connect clients with them.
• Create links to PSI website in the resource section of your websites, provide basic facts about perinatal mental health in educational materials, include information about pregnancy and postpartum mental health in prenatal education.
• Have PSI brochures or posters available.
• Use the 13-minute PSI educational DVD with clients. You can see a preview of the DVD, and one for fathers on the PSI website here.

How could childbirth organizations best utilize PSI for their professionals?  Again, Dr. Davis shared great ideas:

Come to PSI trainings, use the PSI website, join PSI and be part of our listserve for PSI members who are doulas, contact local coordinators or the PSI office with questions, provide educational materials and training for their students and members. The PSI Professional trainings, offered in several places around the country and at the PSI annual conference every year, are designed to include childbirth professionals. PSI 2011 trainings are scheduled for Los Angeles in January, Michigan and Kentucky in March, Indianapolis in May, and in Sept 2011 the 25^th annual PSI conference will be held in Seattle in conjunction with PSI-Washington, which has a long history of involvement with childbirth professionals. You can keep track of trainings on the website here. http://postpartum.net/Professionals-and-Community/Trainings-Events/Trainings-and-Conferences.aspx

Conclusion
My heartfelt hope is that the information shared here will provide childbirth professionals evidence-based resources for their practice and clients.

Thank you for reading the article.

Still, I keep thinking about Margery Kempe: over 500 years later, why are depression and childbirth the two top reasons for a woman to be hospitalized^2,3?

I extend an invitation to all childbirth professionals to honestly examine current positions, or lack thereof, regarding maternal mental health. What are current positions regarding perinatal mood disorders?  Are we, as childbirth industry professionals, comfortable discussing mental health issues with our clients?  Do we  know how to screen?  Do we know how to refer to local resources in our local communities?

Ask yourself this:  What help do you need in becoming comfortable discussing mental health issues with your clients? Let your organizations hear from you.

Professionally, let’s examine if our organizations have mental health resources on their websites, blogs, training materials, and fact sheets. Given that suicide is the leading cause of death in the first year following childbirth¹, I would offer that having suicide prevention information on websites might be a place to start.

USA National Suicide Hotlines

Toll-Free / 24 hours / 7 days a week

1-800-SUICIDE 1-800-784-24331-800-273-TALK 1-800-273-8255

**View Walker’s complimentary post over at Giving Birth With Confidence where she expands further on her interview with Jane Honikman**

I would like to extend my gratitude to Jane Honikman, M.S., for her contribution to this article, and for her steadfast commitment to women everywhere. Jane…I will pass my heart to you any day.  And thanks, as always, to Wendy Davis, Ph.D., for working until 3AM to help me with this article. Also, thank you to both Cara Terreri, and Kimmelin Hull for giving me the opportunity to write for their sites, and to Lamaze International for their support. The full content of my interview with Jane Honikman can be found at www.fullydilated.net

Posted by:  Walker Karraa, MFA, MA, CD (DONA)

ⁱKempe, M. (1436). The book of Margery Kempe. In Shannonhouse, R. (Ed.) (2003). Out of her mind: women writing on madness. New York: Modern Library. pp. 3-7.

¹ Oates, M. (2003). Suicide:  The leading cause of maternal death.  The British Journal of Psychiatry, 183, 279-281.

² Gold , K., Marcus, S., (2008). Effect of maternal mental illness on pregnancy. Expert Review of       Obstetrics & Gynecology, 3 (3), 391-401.

³ Blenning, C., Paladine, H. (2005). An approach to the postpartum office visit. American Family Physician, 72(12), 2491-2496.

⁴ Gaynes, B., Gavin, N., Meltzer-Brody, S., Lohr, K., Swinson, T., Gartlehner, G., et al. (2005).   Perinatal depression prevalence, screening accuracy, and screening outcomes: Summary, evidence report and technology assessment, No. 119. AHRQ Publication No. 05-E006-1.

⁵ Onunaku, N. (2005). Improving maternal and infant mental health: Focus on maternal depression. National Center for Infant and Early Childhood Health Policy at UCLA.

⁶ Knitzer, J., Theberge, S., Johnson, K. (2008). Reducing maternal depression and its impact on young children: Toward a responsive early childhood policy framework. National Center for Children in Poverty, Project Thrive Issue Brief 2.

⁷ Yonkers, K., Chantilis, S. (1995). Recognition of depression in obstetric and gynecology practices. American Journal of Obstetrics and Gynecology, 173(2), 632-638.

⁸ Gavin, N.I., Gaynes, B.N., Lohr, K.N., Meltzer-Brody, S., Garlehner, G., Swinson, T. (2005). Perinatal depression: A systematic review of prevalence and incidence. American Journal of Obstetrics and Gynecology, 106(5 Pt 1), 1071-1083.

⁹ Harlow, B.L., Vitonis, A.F., Sparen, P., Cnattingius, S., Joffe, H.,  Hultman, C. M. (2007). Incidence of hospitalization for postpartum psychotic and bipolar episodes in women with and without prior prepregnancy or prenatal psychiatric hospitalizations. Archives of General Psychiatry, 64(1), 42-48.

¹⁰ Manisha, S. (2005). The role of state public health in perinatal depression. Fact sheet. Association of State and Territorial State Officials.

¹¹ Postpartum Mood Disorders. The Jennifer Mudd Houghtaling Postpartum Depression Foundation Website. Retrieved May 1, 2009 from http://www.ppdchicago.org/.

¹² Onunaku, N. (2005). Improving maternal and infant mental health: Focus on maternal depression. National Center for Infant and Early Childhood Health Policy at UCLA.

¹³  Knitzer, J., Theberge, S., Johnson, K. (2008). Reducing maternal depression and its impact on young children: Toward a responsive early childhood policy framework. National Center for Children in Poverty, Project Thrive Issue Brief 2.

¹⁴ Position statement: Screening for  prenatal and postpartum depression. (n.d.). Perinatal Foundation and Wisconsin Association for perinatal Care. Retrieved April 9, 2009 from http://www.perinatalweb.org.

¹⁵ Isaacs, M. (2004). Community care networks for depression in low-income communities and communities of color: A review of the literature. Submitted to Annie E. Casey Foundation and the Howard University School of Social Work and the National Alliance of Multiethnic Behavioral Health Associations (NAMBHA).

¹⁶ Knitzer, J., Theberge, S., Johnson, K. (2008). Reducing maternal depression and its impact on young children: Toward a responsive early childhood policy framework. National Center for Children in Poverty, Project Thrive Issue Brief 2.

¹⁷ Ibid.

¹⁸ Abrams, L.S., Dorning, K. (2007). Bridging the gap: Barriers to service use among low-income women with postpartum depression. Funded by the Center for Vulnerable Populations Research at the UCLA School of Nursing and the UCLA Faculty Senate in cooperation with the Public Health foundation Enterprises WIC program.

¹⁹ Maternal Depression Making a Difference Through Community Action: A Planning Guide (n.d.). Mental Health America, Substance Abuse and Mental Health Services Administration (SAMHSA). Retrieved March 4, 2009 from: http://www.mentalhealthamerica.net/go/maternal-depression.

²⁰ Ramsay, R. (1993). Postnatal Depression. Lancet, 314, 1358.

²¹ Carter, R. (2010). Within our reach: Ending the mental health crisis. New York, NY: Rodale, Inc.

Walker Karraa Doula Care, Healthy Care Practices, Patient Advocacy, Practice Guidelines, Prenatal Illness, Research, Science & Sensibility, Uncategorized Jane Honikman, postaprtum education training maternials, postpartum depression resources, postpartum mood and anxiety disorders, Postpartum Support International, Roselyn Carter, Walker Karraa, Wendy Davis