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

November 14th, 2013 by avatar

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

Original Painting © Johann Heinrich Füssli

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

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

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

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

Definition 

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

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

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

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

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

Characteristics of Women Who Negate Pregnancy

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

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

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

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

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

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

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

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

Treatment

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

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

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

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

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

What birth professionals can do

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

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

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

Conclusion

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

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

References

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

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

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

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

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

About Kathy Morelli

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

 

 

 

 

 

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

Giving Birth after Battle: Increased Risk of Postpartum Depression for Women in Military

November 11th, 2013 by avatar

Today, November 11th is Veteran’s Day in the United States and Americans honor those who have served and continue to serve in the Armed Forces in order to protect our country.  Today on Science & Sensibility, regular contributor Walker Karraa, PhD, takes a look at the impact serving in battle has on women who go on to birth.  In an exclusive interview with expert Cynthia LeardMann, Walker shares with S&S readers what the study says and receives more indepth information that provides additional insight into just what women in the military face in regards to their increased risk of PPMADs.- Sharon Muza, Community Manager, Science & Sensibility

Introduction

The rate of postpartum mood or anxiety disorders in general US population for new mothers is 10-22%1-3.  Although approximately 16,000 active duty women give birth annually4, less is known regarding the prevalence of postpartum mood disorders in this population. In a striking finding, Do et al., (2013)5 recently reported “Service women with PPD had 42.2 times the odds to be diagnosed with suicidality in the postpartum period compared to service women without PPD; dependent spouses with PPD had 14.5 times the odds compared to those without PPD” (p.2)

Pixabay © David Mark. 2013

Furthermore, a recent study, Is military deployment a risk factor for maternal depression?6 , examined the relationship between deployment experience before or after childbirth, and postpartum depression in a representative sample of U.S. servicewomen.  The objectives included addressing the lack of research regarding maternal depression in military mothers.

I am honored to have had the opportunity to interview Cynthia A. LeardMann, MPH, Senior Epidemiologist at the Henry M. Jackson Foundation, Naval Health Research Center, and Department of Deployment Health Research regarding this important study. Particularly, I inquired as to how childbirth educators might integrate this data in practice, and how childbirth education might be suggested for future intervention.

Walker Karraa: Can you describe for our readers how the rate of maternal depression was found to be attributed to experiencing combat while deployed?

Cynthia LeardMann: In this study, the rate of maternal depression was highest among women who deployed to the recent conflicts and reported combat experiences.  Among women who gave birth, 16 to 17% screened positive for maternal depression who deployed and had combat-like experiences prior to or following childbirth. Rates were between 10 and 11% for women who did not deploy and between 7 and 8% for women who deployed and did not report combat-like experiences.

Moreover, we found that women who deployed after childbirth and experienced combat had twofold higher odds of screening positive for maternal depression compared with women who did not deploy after childbirth, after adjusting for prior mental health status, and demographic, behavioral, and military characteristics. However, this increased risk appeared to be primarily related to experiencing combat rather than childbirth experiences.

WK: Working with the Millennium Cohort Study7 benefitted the ability to investigate the relationship between military deployment and increased risk of maternal depression. Can you briefly describe the MCS and the process of working with it?

CL: Launched in the summer of 2001, the Millennium Cohort Study  is the largest longitudinal study of military service members, including active duty and Reserve/National Guard members from all services. The primary study objective is to evaluate the impact of military service on long-term health.  Since family relationships play an important role in the functioning and well-being of US military service members, in 2011 the Millennium Cohort Study was expanded to include spouses of military personnel. The overarching goal of this Family Study is to assess the impact of military service and deployment on family health.

Crisis line resources for active military and their familiesMilitary One Source1-800-342-9647

Crisis line resources for veterans and their families

Veterans Crisis Line

1-800-273-8255 (press 1)

Online chat is also available

WK: It was interesting that the rates were higher for women in the Army as compared to women serving in US Air Force or US Navy. Can you share the thinking around possible reasons for that difference?

CL: Women serving in the Army may be deployed longer and more frequently than those serving in the Air Force and Navy. In addition, there may be more ongoing imminent fear of deployment and while on deployment they may experience more intense or severe combat-like exposures, which may lead to increased risk of depression.

WK: How did you define combat-like exposure for your sample?

CL: Deployed women were classified as having combat-like exposures if they reported personal exposure to one or more of the following in the 3 years prior to follow-up: person’s death due to war, disaster, or tragic event; physical abuse; dead and/or decomposing bodies; maimed soldiers or civilians; or prisoners of war or refugees.

WK: One of the recommendations from your study was the need for early intervention and reintegration programs for service personnel. What are some examples that you would hope to see in the future? What role do you see childbirth education playing in the prevention or early intervention of maternal depression in military personnel? 

CL: Currently there are some programs that focus on supporting service members and families before, during, and after deployments, such as the Yellow Ribbon Reintegration Program. This DoD (Department of Defense)-wide effort prepares Reserve and National Guard families for the challenges of deployment, educates them on programs that are available to help ease their concerns about reintegrating into the community, and provides information about seeking mental health care. While more services and programs are needed, these types of resources may successfully reduce the emotional and psychological impact of deployment. Childbirth education may play an important role as it may help couples understand and identify various feelings and symptoms related to mental disorders that may arise after childbirth. If educated, the mother or her partner may be more aware of certain symptoms and feel more comfortable seeking mental healthcare.

WK: The rate of comorbid PTSD in women who screened positive for depression was high (58%). Given what we know about the prevalence of PTSD following a traumatic childbirth in general population, what are your thoughts regarding how traumatic childbirth may have played a role? 

CL: We did not obtain any data on the childbirth experience itself, but it is possible that non-combat traumatic experiences, including traumatic childbirth, may have increased the risk for depression with comorbid PTSD.

WK: Would data on mode of delivery be useful in future studies?

CL: The Millennium Cohort Study does not currently obtain data on mode of delivery, but we could investigate mode of delivery among active service members using medical data records. We do not have current plans to examine mode of delivery, but it may be useful in future studies.

WK: What is the next phase of this important research?

CL: Currently, we are investigating the potential association between deployment and other related reproductive outcomes, like miscarriages and perceived impaired fecundity. We are also planning to examine depression among military spouses. We would like to better understand the inter-relationships and associations between service members and their spouses, including maternal depression and reproductive health outcomes.

WK: Many of our readers work with military families as childbirth professionals (doulas, lactation consultants, midwives, and childbirth educators). How would you recommend childbirth professionals integrate the findings in your study?

CL: The current findings add further evidence that screening and early intervention of depression among new mothers is critical, since parental depression can have a profound and lasting impact on children and families. In addition, the findings support the need for effective post deployment social support and reintegration programs, especially for women who have had combat-like experiences during deployment.

Conclusion

The service of the women in our military is a dedication for which I am grateful and humbled. The findings here underscore the critical need for better screening, intervention, and social support for childbearing women in the military who see combat during deployment.

As childbirth professionals, how do you see your role in supporting military women with mental health? And how might Lamaze become a champion in this area?

Acknowledgements

I would like to extend my appreciation to Ms. LeardMann for agreeing to the interview, and taking the lead in getting approval for its content.  Additional acknowledgement is extended to military personnel who participated in reading, reviewing and clearing the content for publication. And thanks to Sharon Muza for her continued support of the research regarding perinatal mood and anxiety disorders.

References

  1. Gaynes BN, Gavin N, Meltzer-Brody S, et al. (2005). Perinatal depression: Prevalence, screening accuracy, and screening outcomes. Evidence Report/Technology Assessment No.119. Rockville, MD: Agency for Healthcare Research and Quality, No. 05-E006-2.
  2. O’Hara MW, Swain AM. (1996). Rates and risk of postpartum depression: A meta-analysis. Int Rev Psychiatry,8, 37–54.
  3.  Peindl KS, Wisner KL, Hanusa BH. (2004). Identifying depression in the first postpartum year: Guidelines for office-based screening and referral. Journal of Affect Disord,80, 37–44.
  4. Rychnovsky, J. & Beck, C.T. (2006). Screening for postpartum depression in military women with the postpartum depression screening scale. Military Medicine,171, 1100-1104.
  5. Do, T., Hu, Z., Otto, J., & Rohrbeck, P. (2013). Depression and suicidality after first time deliveries during the postpartum period, active component service women and dependent spouses, U.S. Armed Forces, 2007-2012. Medical Surveillance Monthly Report, 20(9), 2-9.
  6. Nguyen, S., Leardman, C.A., Smith, B., Conlin, A. S., Slymen, D. J., Hooper, T. I., Ryan, M. A. K., & Smith, T. C. (2013). Is military deployment a risk factor for maternal depression? Journal of Women’s Health, 22(1), 9-18. doi: 10.1089/jwh.2012.3606
  7. Smith, T.C. (2009). The U.S. Department of Defense Millenium Cohort Study: Career span and beyond longitudinal follow-up. Journal of Occupational and Environmental Medicine, 51, 1193-1201

About Walker Karraa

Walker Karraa, PhD is a perinatal mental health researcher, advocate and writer. She is currently a regular perinatal mental health contributor for Lamaze International’s Science and Sensibility,Giving Birth With Confidence, and the American College of Nurse-Midwives (ACNM) Midwives Connection.Walker has interviewed leading researchers and providers, such as Katherine Wisner, Cheryl Beck, Michael C. Lu and Karen Kleiman. Walker was a certified birth doula (DONA), and the founding President of PATTCh, an organization founded by Penny Simkin dedicated to the prevention and treatment of traumatic childbirth. Walker is currently Program Co-Chair for the American Psychological Association (APA) Trauma Psychology Division 56. She is writing a book regarding her research on the transformational dimensions of postpartum depression. Walker is an 11 year breast cancer survivor, and lives in Sherman Oaks, CA with her two children and husband.


Childbirth Education, Depression, Guest Posts, Maternal Mental Health, Postpartum Depression, PTSD, Research, Uncategorized , , , , , , , , ,

Postpartum Psychosis: Review and Resources Plus Additional PPMAD Resources

October 8th, 2013 by avatar

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

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

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

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

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

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

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

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

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

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

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

Prevalence

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

Symptoms

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

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

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

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

If left untreated, some dire potential outcomes include: 

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

Risk Factors

  • Women with history of bipolar disorder or previous postpartum psychosis

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

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

Suggestions for Educators:

Reflect/Remind/Review/Refer

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

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

Remind: PPP is Rare but Real

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

Review the Facts

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

Refer to Resources

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

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

Resources for Women and Partners Postpartum Progress

 Postpartum Psychosis Symptoms (in Plain Mama English)

Postpartum Support International 1-800-944-4PPD

 National Suicide Prevention Lifeline 1-800-273-TALK

Mother to Baby (formerly OTIS)

Medications & More During Pregnancy & Breastfeeding.

(866) 626-6847

Text-4-Baby Health Info Links

References

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

RX+DX= PPH Risk: What prescription dispensing data tells us about antidepressants and risk of postpartum hemorrhage.

October 1st, 2013 by avatar

 Regular contributor (and brand new PhD!) Walker Karraa shares a new study examining the relationship between antidepressant medication and postpartum hemorrhage.  Walker questions the lead researchers on other factors present during labor and birth that may have as much or more impact on the likelihood of PPH, as the influence of antidepressant medication and inquires if those factors were examined.  Read Walker’s assessment and interview and share in the comments section your thoughts on this research.  How might you respond to students, patients and clients who ask about this potential increased risk of hemorrhage?  - Sharon Muza, Community Manager, Science & Sensibility

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© www.revolutionpharmd.com

A recent study, Use of antidepressants near delivery and risk of postpartum hemorrhage: Cohort study of low income women in the United States (Palmsten, Hernándéz-Diaz, Huybrechts, Williams, Michels, Achtyes, Mogun, & Setogouchi, 2013) is described as:

“This study is the first to report an association between exposure to antidepressants at the time of delivery and risk of postpartum hemorrhage in a US population and in a population with a diagnosis of depression” (p. 6). Further inquiry into the study provides ample opportunity to consider the intersection of method, measurement and maternal mental health with regards to the use of antidepressant medication and potential risks.

RX: Prescription-dispensary records

The objective of this epidemiological cohort study was to “determine whether use of serotonin or non-serotonin reuptake inhibitors near to delivery is associated with postpartum hemorrhage” (Palmsten et al., 2013, p. 1). The methods involved analyzing pharmacy dispensing records of 106,000 women, ages 12-55, previously identified through Medicaid Analytic eXtract (MAX) who had live births between the years 2000 and 2007, and had been given a medically coded diagnosis of mood or anxiety disorder as defined by the ICD-9 codes (296.x, 300.x, 309.x, or 311.x). Outcome was identified as women who had received an ICD-9 code for postpartum hemorrhage (666.x), atonic postpartum hemorrhage (666.1x), and only inpatient postpartum hemorrhage (Palmsten, et al., 2013).

DX: Connecting diagnosis to depression

Citing a 2000 Canadian epidemiological study (West, Richter, Melfi, McNutt, Nennstiel & Mauskopf), the authors determined that being given the medical code with one of the aforementioned diagnoses was a reasonable predictive measurement of maternal depression. Palmsten et al., (2013) stated “The positive predictive value for depression with these codes was 77%, indicating that most women in this subcohort likely had depression” (Palmsten, et al., 2013, p. 2).

Measuring exposure to antidepressants was addressed by dividing the women of this large cohort into four groups based on their pharmacy dispensing data: (a) current, or antidepressant dispensing supply that overlapped with the delivery date, (b) recent, or antidepressant dispensing supply on at least 1 day in the 1-30 days before delivery date, (c) past, or antidepressant dispensing supply ending between 1-5 months before delivery date, and (d) a reference group with “no exposure”, or no record of antidepressant dispensing supply in the five months before delivery.

I am very grateful to the study’s lead author, Dr. Kristin Palmsten, and senior author, Dr. Soko Setoguchi for taking the time to unpack the pharmacoepidemiological methodology used in this study, and offer suggestions for how childbirth professionals can address findings in practice.

WK: Can you explain the use of prescription dispensing data with regards to estimating exposure at the time of delivery in lay terms?

KP and SS: In our study, we had information on the date a woman was dispensed an antidepressant prescription, the type of antidepressant received, and the number of days for which the prescription was intended to cover. Using this information, we estimated whether a woman had antidepressants available near the time of delivery. Because women may not have taken antidepressants on the days we assumed, there will be some error in our measurement of the exposure. However, this is the best available measurement for drug exposure in studies with large numbers of women like ours.

WK: How does a prescription dispensing data collection measure blood serum platelet levels of exposure? Given that prescription dispensing data is an epidemiological estimate, what would you suggest is the best language to use when describing estimated, relative, or actual risk of postpartum hemorrhage if a woman is taking an SSRI or a non-SSRI prior to delivery?

KP and SS: The risk for postpartum hemorrhage was 2.8% for women not using antidepressants and it was 3.9% for women who were exposed to antidepressants near the time of delivery. We did not have biologic samples available to assess antidepressant exposure.

Given the breadth of the study and potential implications of assumed causality, I then asked the authors for feedback on their following concluding statements (Palmsten, et al., 2013):

• “Although we cannot rule out residual confounding, our study indicates that there might be
about one excess case of postpartum hemorrhage for every 80 to 100 women using antidepressants near the time of delivery, if we assume causality” (p. 6);
• “Our study suggests that all classes of antidepressants are associated with an increased risk for abnormal bleeding” (p. 6);
• “The absolute increase in risk associated with antidepressant exposure in the month before delivery is small, but women and their physicians should be aware of the potential risks when making treatment decisions near the end of pregnancy” (p. 6).

WK: Based on these statements, how would you recommend childbirth educators respond to women’s concerns regarding the use of SSRI and non SSRI in pregnancy?

KP and SS: Our study found that women who use SSRI or non-SSRI antidepressants near the time of delivery had an increased risk for postpartum hemorrhage. We could not exclude the possibility that other factors associated with antidepressant use might actually have caused postpartum hemorrhage, and it is important to remember that the increase in risk of postpartum hemorrhage among antidepressant users is small. In our study, the risk for postpartum hemorrhage was 2.8% for women not using antidepressants and it was 3.9% for women using antidepressants near the time of delivery. These findings as well as the harmful effects of untreated depression should be considered in decisions regarding antidepressant use during pregnancy.

WK: How do you see the risk of exposure to “all classes of antidepressants” in consideration of the literature demonstrating the adverse effects of untreated perinatal mood and anxiety disorders on fetal development, birth, and postpartum health and wellness of mother and baby?

KP and SS: Practitioners and pregnant women should consider and balance the potential risks of antidepressants and the harmful effects of untreated depression and depressive relapse on maternal and offspring health.

WK: How would you address the impact of the underlying disorder in the assessment of risk? For example, depressed women are more likely to be overweight/obese, which is also associated with hemorrhage. (Blomberg, 2011).

KP and SS: We cannot rule out the possibility that obesity, alcohol use, drug use, or other factors related to maternal depression or the severity of the depression; contribute to the higher risk of postpartum hemorrhage among women who use antidepressants during pregnancy. This uncertainty of our results should be a part of the antidepressant treatment decision by practitioners and pregnant women.

WK: Regarding potential mediators, your study included delivery characteristics of short labor, long labor, forceps or vacuum extraction and induced labors. For induction, was protocol considered? For example, use of Cervadil or not, or the length of time and levels of Pitocin given prior to delivery? How might you look forward to including data like this in future analyses?

KP and SS: We did not have information on the type or duration of induction. Further studies are needed to confirm our results and these would be important factors to consider in future studies.

WK: How do you perceive the relationship between these findings and pain management in labor and delivery?

KP and SS: We did not assess the role of pain management in this study, but pain management and epidural use are important factors to consider in future studies.

WK: Childbirth educators are often interested in the relationship between outcome measures and hospital labor and delivery protocol. Many hospitals have protocols regarding external fetal monitoring (EFM) that requires being in bed, and not eating or drinking in labor. For a woman who is also on an SSRI or non SSRI, how might either or both of these practice protocols confound exposure and risk of postpartum hemorrhage stated in this study? (Particularly because serotonin receptors in the gut involved in metabolizing SSRIs?)

KP and SS: Many factors influence bioavailability of antidepressants and birth outcomes. We did not have information on EFM in our study and we cannot speculate how EFM interact with antidepressants and postpartum hemorrhage.

WK: How might APGAR scores of infants be considered within this discussion?

KP and SS: While we did not have APGAR scores in our database, the impact of maternal mood and anxiety disorders and maternal antidepressant use on infant outcomes is another critical piece to be considered in the balance of antidepressant treatment decisions around the time of pregnancy.

WK: Unfortunately, many medical care providers do not screen for perinatal mood and anxiety disorders in pregnancy, despite validated and available short tools available (such as PH-Q-9 or PHQ-2). In assessing exposure to antidepressant medication and increased risk for postpartum hemorrhage, how do you see your data potentially bridging that gap?

KP and SS: We hope this study and others on antidepressant safety during pregnancy underscore the importance of maternal mood and anxiety disorders on pregnancy outcomes, the complex treatment decisions that women with mood and anxiety disorders face, and the importance of discussing treatment options before, during, and after pregnancy with patients.

Conclusion

The opportunity to create cross disciplinary dialogue connecting reader with research, researcher with reader creates the causes for future collaboration, increased understanding, and growth in the field. Given the findings posited in this study, the scope and limitations of the prescription dispensing epidemiological methods—there is much to learn regarding the issue of antidepressants and postpartum hemorrhage. Pharmacy dispensing records cannot measure the exposure perfectly, as having a prescription does not insure consuming the prescription. As noted by the authors, bioavailability of blood serum was not a resource. Controlling for timing, dosage, frequency, missed doses, or titration cannot be measured through prescription records, yet the authors concluded the records and analyses of the records estimate a likelihood of exposure and conclude risk of increased chance of postpartum hemorrhage.

As increased awareness of maternal mortality brings our understanding of the significance of further research into preventing PPH, critical analysis of the relationship, or lack of relationship, between perinatal mood and anxiety disorders and psychopharmacological treatment must continue to develop. I look forward to seeing the next phase of research that emerges from the work of this team, and thank them for their contribution to the discussion.

Correspondence regarding this research paper may be directed to the lead author, Dr. Kristin Palmsten.

References

Blomberg, M. (2011). Maternal obesity and risk of postpartum hemorrhage. Obstet Gynecol,118 (3):561-8. doi: 10.1097/AOG.0b013e31822a6c59.

Palmsten, K., Hernándéz-Diaz, S., Huybrechts, K. F., Williams, P. L., Michels, K. B., Achtyes, E. D., Mogun, H. & Setogouchi, S. (2013). Use of antidepressants near delivery and risk of postpartum hemorrhage: Cohort study of low income women in the United States. BMJ, 347:f4877 doi:10.1136/bmj.f4877.

Salkeld, E., Ferris, L. E., & Juulink, D. N. (2008). The risk of postpartum hemorrhage with selective serotonin reuptake inhibitors and other antidepressants. Journal of Clinical Psychopharmacology, 28, 230-234.

West, S.L., Richter, A., Melfi, C.A., McNutt, M., Nennstiel, M.E., & Mauskopf, J. A. (2000). Assessing the Saskathchewan database for outcomes research studies of depression and its treatment. Journal of Clinical Epidemiology, 53, 823-831.

Childbirth Education, Guest Posts, Maternal Mental Health, New Research, Postpartum Depression , , , , , , ,

Professional Perspectives Part III: Advocacy, Postpartum Doulas and Childbirth Education

December 13th, 2012 by avatar

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.  Today, Walker interviews Jennifer Moyer, an expert in the field of postpartum psychosis who is an active mental health advocate, and has had personal experience with postpartum psychosis after her son’s birth. Here you can find Part I and Part II of the series.– Sharon Muza, Community Manager.

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“Childbirth professionals have a unique opportunity to reach a tremendous number of women and families as most pregnant women participate in some type of childbirth class.” —Jennifer Moyer


 

http://flic.kr/p/Tx5rm

As many of you know, I am a big proponent of qualitative research methods. The lived experience of a phenomenon offers a depth of data that objectivist methods simply cannot collect. Researchers in women’s reproductive health have been on the forefront of the understanding and implementation of research that listens to mothers. In the same way, I wanted to offer Science and Sensibility readers the voice of a mother, postpartum doula, and advocate who has lived it—experienced postpartum psychosis (PP) and not only “survived”, but transformed the adversity into a path to helping others.

Jennifer Moyer has unique insight into mental health as a recovered mom herself. She overcame postpartum psychosis, a life threatening mental illness, which she was struck with when her son was eight weeks old. She has focused her efforts on being a mental health advocate in the area of perinatal mental health in order to help others experiencing mental illness related to childbearing.

Jennifer also has experience as a postpartum support and education consultant, a certified postpartum doula and a speaker on mental health issues.

WK: The recent Felicia Boots tragedy in the UK has brought media attention to the dangers of untreated perinatal mood disorders, specifically postpartum psychosis (PP). What are your thoughts as to the multiple factors that contribute to a tragedy such as this? 

Jennifer Moyer: I believe there are several factors that contribute to tragedies associated with perinatal mood disorders.  One of the factors is the ignorance about the difference between postpartum depression and postpartum psychosis, which is usually the disorder associated with infanticide.  In my experience with postpartum psychosis, I was completely unaware that postpartum psychosis even existed despite having an educated and proactive pregnancy.  I think many mothers are in the same situation.

Another contributing factor is that providers often do not provide education on the warning signs or risk factors of perinatal mood disorders making it difficult for a mother or her loved ones to recognize what is happening.  Of course the lack of preventative screening also causes a mother at risk from receiving early intervention.

There are other factors as well but I believe these are the primary obstacles contributing to unnecessary tragedies.

WK: Can you describe the sequelae of postpartum psychosis (PP)? 

Jennifer Moyer: An aftereffect or secondary result of postpartum psychosis is different for each mother but, in general, I have found that it changes the mother forever.  In my case, postpartum psychosis came on sudden and unexpectedly.  Once I was stabilized, the trauma I had experienced prior to my diagnosis left me with serious post-traumatic stress.  It also shattered the positive and strong bond I had with my son prior to the onset of postpartum psychosis.  It caused me to question my ability has a mother for a very long time.  The lack of understanding about my condition as well as lack of support from someone, who had experienced postpartum psychosis, lengthened my recovery and made it much more difficult.

Postpartum PsychosisPostpartum Psychosis is a rare illness, compared to the rates of postpartum depression or anxiety. It occurs in approximately 1 to 2 out of every 1,000 deliveries, or approximately .1% of births. The onset is usually sudden, most often within the first 4 weeks postpartum.Symptoms of postpartum psychosis can include:

  • Delusions or strange beliefs
  • Hallucinations (seeing or hearing things that aren’t there)
  • Feeling very irritated
  • Hyperactivity
  • Decreased need for or inability to sleep
  • Paranoia and suspiciousness
  • Rapid mood swings
  • Difficulty communicating at times

The most significant risk factors for postpartum psychosis are a personal or family history of bipolar disorder, or a previous psychotic episode.

source: Postpartum Support International

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

Jennifer Moyer: I believe education on perinatal mood disorders should be included in every childbirth class.  In fact, when I worked as a Postpartum Support and Education Consultant, I did a presentation on perinatal mood disorders in every childbirth class conducted at a hospital in my area.  By educating the mother and her partner about the risk factors, symptoms and proper treatment, early intervention occurred when a case did occur.  My involvement helped educate the childbirth professionals, which led to them ultimately address perinatal mood disorders on their own in their classes.  To me, the goal is to educate as much as possible so that the information can be passed on to women and their families.  Childbirth professionals have a unique opportunity to reach a tremendous number of women and families as most pregnant women participate in some type of childbirth class.

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

Jennifer Moyer: The stigma of perinatal mental health disorders prevents women from getting help when they need it.  Often because of the stigma and lack of understanding, women are often afraid they will lose their child (children) if they do seek help.  The stigma of perinatal mental health disorders is devastating to families and communities. When families and the community are not educated about perinatal mental health disorders, it makes it difficult for the disorders to be properly addressed, treated and prevented.  I have heard of way too many cases of the mother losing her children because of the lack of understanding and education of perinatal mental health disorders in the community.

WK: What do you see as the most significant barriers to treatment for women with PMADs?

Jennifer Moyer: I believe the most significant barrier is the lack of proper education and training of health care professionals.  Another barrier is the failure of the providers, who are not properly trained, to refer the women to perinatal mental health resources or if no resources available in the area, to consult with an expert in perinatal mental health.  So many women are improperly treated.  I know of many cases where the woman contacted her doctor for assistance and were only prescribed an antidepressant, often over the phone, and received no further direction or support.  So it goes back to education or, in the case of the primary barrier, the lack of education.

WK: 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) attracted attention regarding the safety of using SSRI medication in pregnancy. Would you like to respond to the study directly?

Jennifer Moyer: I am not a medical professional so I cannot respond in depth but from a lay person’s perspective, this information can cause many pregnant women from seeking help, if they are experiencing any perinatal mental health issues.  My understanding is there is always a risk/benefit analysis when it comes to medication so education about options is so important.  In my opinion, it seems that medication is often the only intervention presented rather than a more complete and balanced plan of treatment, which may include medication when necessary. Educating women about their options should always be a priority but if the health care professionals are not properly educated in perinatal mental health, how can they educate anyone else?

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

Jennifer Moyer: Offering and requiring specific training on perinatal mental health for all members would increase awareness, education, treatment and most importantly prevention.  Offering continuing education and ways of implementing mental health into their practice would help eliminate stigma and, when necessary, increase referral and treatment to perinatal mental health professionals.

WK: What can we do to increase the understanding that a woman’s mental health is part of maternal health?  

Jennifer Moyer: Although the old saying “if mom is not happy, no one is happy”, puts pressure on moms, it does stress the importance of maternal health.  The health of mothers is critical to society and communities everywhere.  The more mental health is talked about, the better understanding will occur.  As you probably have realized from my previous responses, I am a huge proponent of education.  I believe it is the key to decreasing stigma and bringing about positive changes in the health of women both mentally and in general.

Next Steps

In what ways can childbirth educators participate in bringing about positive changes within this paradigm? How can health care professionals learn more about how the role mother’s mental health plays in so many of the dynamics of the new mother and child(ren). Would you be interested in a webinar on this topic?  Where do you as a birth professional go for more resources, information and teaching tools on the topic of postpartum mental health?

About Jennifer Moyer

Jennifer Moyer has various media experience including her personal story being published in the February 2002 issue of Glamour Magazine resulting in a guest appearance on CNN’s The Point. She was also interviewed for an article appearing in the December 2002 issue of Psychology Today. Jennifer is a member of the National Perinatal Association, the National Alliance on Mental Illness, Mental Health America, The Marcé Society, the National Association of Mothers’ Centers and Postpartum Support International. Jennifer is also now a member of the International Association for Women’s Mental Health.

Please contact Jennifer through her website or by emailing her at jennifer@jennifermoyer.com. Jennifer blogs at: www.jennifermoyer.com/blog

Walker would like to thank Jennifer Moyer, Nancy Byatt, D.O., MBA, and Julia Frank, MD, and the Listserv of the Marce Society for their assistance with this article.

Childbirth Education, Depression, Guest Posts, Infant Attachment, Maternal Mental Health, Newborns, Perinatal Mood Disorders, Postpartum Depression , , , , , , , ,