24h-payday

Archive

Posts Tagged ‘maternal depression’

The Unexpected Project: Pre-eclampsia Researched, Revealed and Reviewed. Part II of an interview with Jennifer Carney

February 7th, 2013 by avatar

By: Walker Karraa

Regular contributor Walker Karraa wraps up her interview with Jennifer Carney, who became active with The Preeclampsia Foundation and the Unexpected Project after suffering from eclampsia while pregnant with her second child.  Have you had to answer any questions in your classes or with your clients and patients after the recent episode of Downton Abbey, where one of the characters developed eclampsia?  What have you shared with your pregnant families? Part one of Walker’s interview with Jennifer Carney can be found here. – Sharon Muza, Community Manager.  

Walker: What do you see are the common myths regarding pre-eclampsia?

JC: Common myths? Oh, there are so many. A lot of people seem to think they know what causes preeclampsia and how to cure it. There’s a whole faction of advocates who buy into the work of Dr. Tom Brewer, who in the 1960′s, devised a very high protein diet for mothers based on the idea that preeclampsia is caused by malnutrition. This isn’t supported by the current research, but it gets repeated all the time. Other people argue that preeclampsia is a so-called “lifestyle” disease – caused by obesity and poor prenatal care. Obesity is a risk factor, but it is only one of many and poor prenatal care can cause the disease to go undetected, but it will not cause it to happen in the first place. There are also a lot of people who think that the delivery of the baby will end the risk to the mother – and while it’s true that the removal of the placenta is essential, preeclampsia or eclampsia can still happen up to 6 weeks after delivery. There are other myths, but it strikes me that so many of these myths are rooted in a desire to control pregnancy. If we can blame preeclampsia on one central cause or on the women who develop it themselves, then we can reassure ourselves that we won’t develop it, too. There are risk factors that can increase a woman’s chances of developing the disease, but women without any known risk factors have developed it, too.

It’s not comforting to think that no one is safe, but with knowledge of the signs and symptoms – a woman can react to it promptly and receive the care that she needs. But this will only happen if women get the information and understand that it CAN happen to them. I am blown away by the ways in which preeclampsia and other serious complications are downplayed and dismissed in pregnancy books, online and even by some medical practitioners. Preeclampsia CAN happen to you – but you can deal with it IF you know the signs and the symptoms.

Walker: Can you share with our readers what you are doing with Anne Garrett Addison at The Unexpected Project?

JC: The Unexpected Project is a documentary, website, and book project that will examine the rate of maternal deaths and near-misses in the United States. Anne Garrett Addison, who founded the Preeclampsia Foundation, and I are both classified as near-misses due to preeclampsia. With Unexpected, we want to take a look at all maternal deaths regardless of the cause – preeclampsia, amniotic fluid embolism, hemorrhage, placenta previa, placental abruption, infection, suicide, and any other causes. We also want to look at the women who survived these complications because the line between surviving and dying is in these cases, often quite thin. Every case is different and there is no one factor to blame for the maternal death rate in the US. We will look at interventions and cesarean sections, but we will also look at the lack of information available to women and the tendency of some birth activists to minimize the dangers of serious birth complications.

Current Preeclampsia/Eclampsia StatisticsMaternal mortality and morbidity are, unfortunately, a part of the pregnancy and childbirth experience for women and their families in the US and the world.  While most (99%) of maternal mortalities occur in the developing world, the 1% that occur in developed countries like the US are still of concern to maternity care providers and advocates.  Indeed, U.S. still ranks 50th in the world for its maternal mortality rate (1).

More common than a maternal death, are severe short- or long-term morbidities due to obstetric complications (2).  Some estimate that unexpected complications occur in up to 15% of women who are otherwise healthy at term (2).  

In particular, hypertensive disorders of pregnancy, including elevated blood pressure, preeclampsia, eclampsia and HELLP syndrome are estimated to affect 12-22% of pregnant women and their babies worldwide each year. (3)  Adverse neonatal outcomes are higher for infants born to women with pregnancies complicated by hypertension.  

In the U.S., upwards of 8 percent or 300,000 pregnant or postpartum women develop preeclampsia or the related condition, HELLP syndrome each year. This number is growing as more women enter pregnancy already hypertensive (cite).  Preeclampsia is still a leading cause of pregnancy-related death in the US and one of the most preventable.  Annually, approximately 300 women die and another 75,000 women experience “near misses” – severe complications and injury such as organ failure, massive blood loss, permanent disability, and premature birth or death of their babies.  Usually, the disease resolves with the birth of the baby and placenta. But, it can occur postpartum–indeed, most maternal deaths occur after delivery.

Recent statistics from Christine Morton, PhD.

The trend toward “normal” or “natural” birth does not seem to allow a lot of space for our stories to be heard or to be told. This has the effect of making survivors feel marginalized – as though their experience is somehow too far outside “normal” to be a part of the overall conversation. The one constant of all of our stories is that none of us expected to become statistics. Our birth plans did not include emergency cesarean sections, seizures, ICUs, blood transfusions, strokes, hysterectomies, CPR, prematurity, PTSD, depression, or death. No one was more surprised than us. This isn’t about assigning blame – this is about finding answers, improving birth for ALL moms to come, and learning to live with the unexpected.

Walker: How did you get involved with researching for the Preeclampsia Foundation?

JC: I started out volunteering with the March of Dimes in the spring following my son’s birth. I started a walk team and raised money, hoping that I would be able to meet other moms who had been through something similar. I felt very alone in the months following his birth. I was dealing with postpartum depression (PPD) and post-traumatic stress disorder (PTSD) symptoms and struggling to feel normal again. I had a premature infant – which meant sleeping through the night was a problem for a long time. When I returned to work, I was greeted by a coworker who declared that she now no longer wanted to have children because of what I had gone through. This weighed heavily on me – and I felt like I was the cautionary tale, the one bad pregnancy story that everyone knows. I know I had never heard a story as bad as mine – so I felt deflated, flattened by the whole thing.

With the March of Dimes, I found moms to help me deal with the preemie part of it. As he matured and grew out of the preemie issues, I found that I still had a lot of issues to deal with regarding my own health – both physically and mentally. I decided to volunteer with the Preeclampsia Foundation after they merged with the HELLP Syndrome Society.  The Preeclampsia Foundation is much smaller than the March of Dimes, which allowed me to be much more active as a volunteer. I was able to use my writing and editing skills to work on the newsletter – and when I suggested that someone do a review of the available pregnancy literature based on how well they cover preeclampsia, I was given the opportunity to conduct that research and write the report myself. This was something I had been doing informally in bookstores for a while anyway, so it felt good to be able to look at the literature and confirm that the information really is severely lacking if not downright misleading in a large number of so-called comprehensive books. It really isn’t my fault that I missed the symptoms.

This year, I am coordinating the Orange County, California Promise Walk in Irvine as part of the foundation’s main fundraising campaign on May 18. I am hoping to bring a mental health expert from the California Maternal Mental Health Collaborative out to the walk to talk to the moms about dealing with the emotional impact of their birth experiences.  Many of these moms lost babies, delivered preemies, or suffered severe health issues of their own. Our community as a whole is at a very high risk for mental health issues, myself included.

It wasn’t until this year – 6 years after the birth of my son – that I finally sought professional help dealing with the PTSD from the very difficult birth experience. I feel that the volunteer work helped fill that spot for the past 6 years and brought me to the point where I can now process the trauma in a healthy way. I am not happy that I had eclampsia, but I am beyond grateful for all of the great people that it has indirectly brought into my life.

Closing Thoughts

To have to wait 6 years to receive the vital treatment for PTSD is a travesty. We are so thankful that Jennifer survived both the initial trauma, but endured its legacy of traumatic stress that lingers today. Unfortunately, PTSD subsequent to traumatic childbirth is growing in prevalence, and under-recognized by the majority of women’s health and maternity care providers.  I have learned a great deal from Jennifer and look forward to the work she and her colleagues will continue to do for the benefit of all women.

References

1.  WHO. Trends in maternal mortality: 1990 to 2008 estimates developed by WHO, UNICEF, UNFPA and The World Bank, World Health Organization 2010, Annex 1. 2010. http://whqlibdoc.who.int/publications/2010/9789241500265_eng.pdf. Last accessed:January 3, 2011.

2. Guise, J-M.  Anticipating and responding to obstetric emergencies.  Best Practice and Research Clinical Obstetrics and Gynaecology. 2007; 21 (4): 625-638

3. American College of Obstetricians and Gynecologists. Diagnosis and management of preeclampsia and eclampsia; ACOG Practice Bulletin No. 33. Obstetrics & Gynecology. 2002;99:159-167. 

 

Birth Trauma, Childbirth Education, Depression, Guest Posts, Maternal Mental Health, Maternal Mortality, Maternity Care, News about Pregnancy, Postpartum Depression, Pre-eclampsia, Pre-term Birth, Pregnancy Complications, PTSD , , , , , , , , , , ,

Serve and Return: Deconstructing the Language of Maternal Mental Health

February 17th, 2011 by avatar

My professional curiosity lies in the power of language to limit, or liberate the lived experience of the childbearing woman—particularly those with perinatal mental health concerns.

Maternal Depression Can Undermine the Development of Young Children (2009) illustrates the positive strides being made to increase awareness of perinatal and postpartum mental health. This Harvard University working paper was a joint effort of the National Forum on Early Childhood Program Evaluation, and the National Scientific Council on the Developing Child, and published by the Center on the Developing Child at Harvard University.  As a psychologist, Ph.D. student in Transpersonal Psychology, birth doula, and mother managing the disease of major depression, I fully recognize that my personal experience influences my professional view.

Maternal Depression Can Undermine the Development of Young Children offers insights as to how childhood development experts view and describe maternal depression.  Increasing awareness of PPMAD (perinatal, postpartum mood/anxiety disorders) in all aspects of family care is crucial to making changes to prevent and treat it. However, the terminology used in the paper, and omission of the full spectrum of PPMAD demonstrate how casual use of language perpetuates stigma and stereotypes regarding maternal mental health.


Titles Are Important

The title, Maternal Depression Can Undermine the Development of Young Children reads, to me, as something I would hear on cable news, rather than a professional paper. Moreover, the term “maternal depression” is the primary descriptor used throughout the paper, rather than the more accurate “perinatal”, or even the somewhat outdated “postpartum” maternal depression.  Not using a puerperal adjective removes context of recent birth.  There is a difference.

“Because chronic and severe maternal depression has potentially far-reaching harmful effects on families and children, its widespread occurrence can undermine the future prosperity and well-being of society as a whole.” (p. 1)

Wow. Not only do depressed mothers hurt children; apparently we also have power to take down all of civilization!  I picture myself the ultimate evil villainess, “depressed mom” in my lair. In my never ending desire to undermine the future prosperity and well-being of society as a whole, I send out my far-reaching harmful effects to terrorize civilization in search for Zoloft. Children and family be damned! I have society to ruin.

The mental health of our mothers is a crucial component to healthy families and communities. But unless we unpack this kind of language, we perpetuate an unconscious belief that “mentally ill” mothers are dangerous mothers.


What is Maternal Depression?

“Characterized by a low mood and loss of interest in usually enjoyable activities, depressive symptoms include difficulty sleeping and concentrating, loss of appetite, feelings of worthlessness or guilt, and low energy. In the face of major clinical depression, the drive, energy and enjoyment needed to build and maintain positive family relationships recedes.”

Set within the prose of the article opinion, leaves symptoms in the realm of the murky. I hate to say it but for much of science, if it isn’t codified, it doesn’t exist.  If the reading audience is not medical professionals, all the more reason to be extremely clear with how medicine describes the disorder. Omitting the full DSM-IV-TR, or ICD 10 diagnostic criteria is a subtle invalidation.  It remains a “mood”/emotional/mental disorder. Furthermore, it is not an accurate representation of the actual diagnostic criteria.  There is no indication of time of onset, duration of symptoms, co-morbidities, symptoms of anxiety with depression, differential diagnosis, or how many symptoms need to present simultaneously to fit criteria.  (Go here for complete list of criteria.)

Prevalence and Effects
According to the authors, in the section subtitled: What Neuroscience and Developmental Research Tells Us, the majority of research on this subject is on maternal postpartum depression.  This is Harvard University. The power of that should not be diminished. When a group holding academic status defines something, we believe it, we repeat it to others.  Not having included all perinatal and postpartum mood/anxiety disorders (PPMAD) in the literature review missed the opportunity to recognize the research that has been done in PTSD after childbirth, and perinatal anxiety disorders.

Furthermore:

“About one in eleven infants will experience their mothers’ major depression in their first year of life”.

This wording suggests mothers doing something to the infant. It personalizes a medical condition. That the relation to the object for our attachment theory readers, WILL be negative. I doubt a public health paper would say, “About one in eleven infants will (powerful word) experience their mother’s diabetes in their first year of life”.

“When raised by a chronically depressed mother, children perform lower, on average, on cognitive, emotional, and behavioral assessments than children of non-depressed caregivers….such patterns forecast difficulties later in adult life across a variety of important domains”.

Some readers may find this language suggests that depressed mothers are bad mothers, and cannot take care of children. This is myth.  Depressed women are not inherently incapable women.  Depressed mothers are not inherently incapable mothers; they are suffering a medical condition that challenges some of their current capabilities but is also completely amenable to proper treatment. I would encourage readers to read my interview with Katherine Stone at www.givingbirthwithconfidence.org for an example of resiliency.

Ping Pong and Problematic Parenting
The Paper authors acknowledge the evidence-based, substantive data demonstrating a correlation between “maternal depression” and fetal, neonatal, and early childhood development.  They are spot on to bring this data to the forefront of child development. However, word choice is extremely important when approaching an issue that has a history of stereotyping, particularly when describing it to professionals who may not be familiar with the issue. The data cited in the Harvard paper:

  • Chronic depression can manifest itself in two types of problematic parenting patterns that disrupt the “serve and return” interaction essential for healthy brain development: hostile or intrusive, and disengaged or withdrawn.
  • Children who experience maternal depression early in life may experience lasting effects on their brain architecture and persistent disruptions of their stress response systems.
  • Maternal depression may begin to affect brain development in the fetus before birth.
  • Depression often occurs in the context of other family adversities, which makes it challenging to treat successfully.

And, while not in bold-face, authors use the serve and return metaphor throughout the paper:

“When caregivers are sensitive and responsive to young child’s signals, they provide an environment rich in serve and return experiences, like a good game of tennis, or Ping-Pong.”

Sports analogies for the intimate interaction between mother and child are at best not creative, at worst insulting.  Perhaps one of the flaws of working papers is the assumption that readers can’t intellectually handle the material, and in an attempt to be understood, unfortunate metaphors are employed.


Suggestions and “Other Serious Adversities”

Hidden in all of the rhetoric, however, is good data. Shuffled off  in footnotes, there are wonderful studies referenced that offer serious contributions to what we are learning about the effects of untreated maternal mood and anxiety disorders. It is a shame in a way, as the second half of the paper offers learning opportunities around looking at program evaluation, policy, and implications for the future. But one has to weed through this kind of language to find the fruits of knowledge. A few more examples for our discussion:

Authors examine outcomes of current programs addressing “maternal depression” and conclude important issues regarding prevention and early intervention. Prevention is key. Early intervention is incredibly important. Treatment is essential and challenging. Here is their interpretation:

Prevention:Given the potential negative consequences of depression for both mothers and their children, a variety of interventions have been designed to prevent and treat it as well as to buffer children from its harmful effects.”

What is your reaction to this finding, and then to the wording?

Early intervention: “ It is not commonly understood that even young children are likely to be affected by their mother’s depression and these effects may be lasting. Moreover, ongoing depression after childbirth is linked to patterns of parenting that may disrupt the normal “serve and return” interactions between an infant and mother, thus potentially harming the child’s developing brain architecture and emerging skills.  By intervening early, before these effects can accrue, we increase the likelihood that children of depressed mothers will grow into healthy, capable, fully contributing members of society.”

Reflect on your reactions to this wording.

Treatment: “Intensive intervention efforts that focus specifically on mother-child interactions have shown promising results in several recent studies.

Wonderful information has emerged in studies showing improved cognitive behavior when mother-infant interaction is coached in brief sessions, over the first year of baby’s life.  Some of the best information the paper offers, and leaves wonderful questions about the efficacy of our current intervention paradigms.

“Research indicates that various combinations of psychotherapy and educational treatments focused exclusively on adults can be effective in reducing depressive symptoms in mothers but appear to have limited impacts on the development of their children. These findings have led several researchers to argue that therapies should not only treat the mother but should also focus on the mother-child relationship.”

I hold a deep belief in the potential of communities of women to facilitate tremendous growth through inclusive, expansive, and multiple levels of consideration and consciousness. Five studies are cited here, the most citations for any one single conclusion in the paper. Interestingly, the citations come from research in the disciplines of psychiatric, psychology, and infant mental health, in contrast to the traditional medical fields supporting first half of the paper (epidemiology, orthopsychiatry, neurobiology, biology, and immunology). The language is less of the uni-directional, mother-based disorder speak.  Traditional treatment paradigms are challenged. Here is where we can all become inclusive and expand professional and societal understanding of perinatal mood disorders. Cleaner language lends itself to learning.

Now, back to the crazy mommy bat cave to complete my mission to undermine civilization with mood swings, crying jags, coma-like responses to my children, and bad tennis.


Posted By: Walker Karraa, MFA, MA, CD

Patient Advocacy, Perinatal Mood Disorders, Research, Science & Sensibility, Uncategorized , , , , , , , , , ,