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Mother’s Mental Health: Professional Perspectives and Childbirth Education Part I

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.

http://flic.kr/p/7oE1vk

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.

http://flic.kr/p/PYHj7

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

 

 

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 , , , , , , , , , , , , ,

  1. December 7th, 2012 at 04:33 | #1

    So important! I share a handout of the 6 things to know about post-partum depression from Postpartum Support International and basically a 2 minute description of what both of you share above — risk factors, moms might feel a little strange after birth but most of the time it will go away. If the partners feel like it isn’t, and the mom just doesn’t seem like who she was before it or it seems like she’s still in a funk, then for the partners to call someone — the mom’s ob, a counselor, they can even call me (but I share that I’m not an expert, but I could look into one). The partners who take my class (and there are a wide range of birth partners) get it.

    During this talk, I actually am mostly focused on the partners — that just seems intuitively right. I precede this talk with a couple minutes about attachment parenting (and a handout) and it’s followed by a new family support game that I created to give new families a way to think about the larger support they have and how best they might manage the support and love (and others’ expectations of helping!) surrounding them.

    And a really good book I’ve read is Depression After Childbirth. Seems to be a staple on this topic.

    Thanks to S&S for helping to address this topic! The more we Childbirth Educators can do to help prepare families for their new lives, the better for them and all of us.

  2. December 7th, 2012 at 11:53 | #2

    Thank you, Lucy for your offering. The PSI fact sheet is a great idea. How do you see organizations taking a more active role in providing instructors and doulas with good information and training?

  3. avatar
    Teri
    December 8th, 2012 at 00:45 | #3

    How about a discussion about formula use so that women who need to take medications after birth can continue them without fear that they are harming their babies? I can’t help but think that cases like Felicia Boots’ could have been avoided if we stopped demonizing formula and all who use it, making overblown claims about breastfeeding, and treating formula as if it alone carries all the risks in infant feeding, while breastfeeding has none.

    This article demonstrates quite clearly why we must approach infant feeding from neutral ground, not using women to push desired statistics or idealism about how babies should be fed. The current approach in the lactivist world is not working very well as it is, and it is causing tremendous harm to new mothers who feel caught between a two-ton rock and a very hard place.

  4. December 8th, 2012 at 15:12 | #4

    @Teri
    You said it all, Teri. And the lack of response here says much more.

  5. December 9th, 2012 at 13:40 | #5

    Like Lucy, I also give a handout and a talk about PPD and other mood disorders in class. I’ve also recently found a therapist who specializes in postpartum mood disorders who is going to lead a support group for me at Shining Light Prenatal Education. http://www.shininglightprenatal.com/programs/groups/#blue

    The more I work with women postpartum, the more I see it. By bringing awareness to the parents before birth, and having resources available to them, we will begin to bring this issue of mental health to the light.

    Continue your good work, Walker!

  6. avatar
    Lauren
    December 10th, 2012 at 12:51 | #6

    In response to Walker’s question re suggestions regarding how childbirth organizations can encompass perinatal mental health into training curriculum and practice, Dr. Frank notes “Widespread education in the use of efficient screening methods, particularly the PHQ 9 or the Edinburgh Postnatal Depression Scale would be a first step.”

    Did Dr. Frank mean to suggest that LCCEs might administer either of these screenings to women who attend their classes and then refer to local providers if the results warrant it? Is this within the LCCE’s scope of practice? I just wanted to get clarification regarding Dr. Frank’s recommendation.

  7. December 11th, 2012 at 16:11 | #7

    @Teri Bravo to you. I feel we have lost touch with the neutral ground and want you to know I appreciate your comment.

  8. December 15th, 2012 at 10:03 | #8

    Thank you, Walker, for increasing awareness of mother’s mental health. As a mental health advocate and overcomer of postpartum psychosis, I know first hand the toll postpartum psychosis has on a mother and her family. My family and I had no knowledge that postpartum psychosis even existed so we did not recognize any warning signs of its onset. I was initially diagnosed with postpartum depression, which often occurs in the case of postpartum psychosis.

    In my opinion, childbirth educators have a tremendous opportunity to educate women about perinatal mood disorders. Information should be given to all women and partners that attend classes. Doulas also have an important role as well. In my opinion, education, prevention and early intervention are the keys to improved outcomes and decreasing stigma.

  9. December 12th, 2013 at 12:37 | #9

    Your work with increasing awareness of this most stigmatized of mental health issues is so so appreciated. This area of study and support, for being so widespread in the disorders’ effect, is very under-studied and misunderstood – both by the public and by the healthcare profession in general.

    My work as a birth doula and RN had to broaden, by necessity and the startling realization that we are failing mothers as they go through pregnancy, birth, and postpartum transitions. I took my Postpartum Doula training through DONA International, and began partnering for education, screening, and support of pregnant and new mothers and families. I am currently developing a comprehensive Total Health Prenatal Class series which includes two 45-minute sessions on relationship building between couples with the focus of awareness of and supporting PPD and its accompanying forms of perinatal mood disorders. I will incorporate my RN and Postpartum Doula training into screening of my birth doula and prenatal class clients during pregnancy and again at 2 weeks, 1 month, and 3 months postpartum.

    I’ve recently been recruited by heart to volunteer with the Perinatal Mood Disorder Awareness Ltd of Canada to co-facilitate a support group for women, as well as to provide education and awareness to local RN training programs, to MD’s, and to the general community at large. We are attempting to partner with one of Canada’s primary DONA Postpartum Doula Trainers to include more information about perinatal mood disorders in the training, as well as to create advocates and support group facilitators.

    Canada is so far behind, and there is so much ground to break in this vital area! I did not realize that this would so quickly become a consuming passion – I am continuously trying to round up everyone I know to be alert and aware that these conditions exist and are very common and treatable – and that they need to be dealt with gently and without judgement. The founder of PMDA Canada, Tascheleia Marangoni, is a wonderful source of information and support, and she has big goals and hopes. I’m glad to be on her team.

    I have so much to learn! I feel overwhelmed by the need – and so thankful for sources of inspiration and mentors like you, Walker, to help us along!

  1. December 6th, 2012 at 08:43 | #1