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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 , , , , , , ,

Perinatal Mental Health and Childbirth Education: Professional Perspectives Part II

December 11th, 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.  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.  The first post in the series is here  Part III will appear on Dec 13th, 2012.– Sharon Muza, Community Manager.

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http://flic.kr/p/adyga

We have the opportunity to hear another expert perspective regarding the use of antidepressants, stigma, and the role childbirth education might play in the prevention of perinatal mood and anxiety disorders (PMAD). This installment features Nancy Byatt, D.O., MBA. Dr. Byatt is a perinatal psychiatrist and Assistant Professor of Psychiatry and Obstetrics & Gynecology at University of Massachusetts Medical School/UMass Memorial Medical Center.  Dr. Byatt’s research focuses on understanding and evaluating ways to improve depression outcomes for perinatal women and their children through health care system improvement.  Her current research aims to improve the uptake of evidence-based treatments for perinatal depression in obstetric settings.  I know I speak for Lamaze International in thanking Dr. Byatt for participating.

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

Dr. Byatt: Providing psychoeducation to women and their partners about the importance of perinatal mental health is a good first step.   Psychoeducation should aim to destigmatize depression and other perinatal mental health concerns and encourage women to engage in treatment.  Providing psychiatric resource and referral source guides may also empower women to seek treatment.  Childbirth educators could also be trained in motivational enhancement interventions that may inspire women to address their mental health concerns.  For example, providing information about health risks, wellness interventions, support groups, psychotherapy, medication options, and other mental health resources can encourage women to engage in treatment.

WK: How might childbirth professionals integrate perinatal mood disorders in classes? 

Dr. Byatt: Childbirth education classes are an excellent opportunity to prepare women and their partner or primary support for the emotional transition to the postpartum period.  Ideally, women should be taught how to take care of themselves both physically and emotionally during this vulnerable time period.  Women and their partners or primary support could be given information about the signs and symptoms of depression so they can recognize depression if it occurs.  It would also be helpful to destigmatize depression and review mental health resources.  Psychoeducation could also be provided about what factors may put women at higher risk for a perinatal mood disorder.

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

Dr. Byatt: Many studies have demonstrated that many women feel very ashamed of perinatal depression and as a result may be less likely to seek help.  More specifically, women may be afraid that they will lose parental or personal rights if they disclose psychiatric symptoms.  They may also fear feeling judged by perinatal health care professionals and/or friends and family.   Acknowledging depression symptoms can also negatively impact women’s view of themselves as a mother.   Unfortunately, these concerns may result is avoidance of mental health discussions.

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

Dr. Byatt: Women face many barriers to accessing and seeking help for perinatal depression. Stigma and shame have been consistently reported in numerous studies.  Studies also suggest that interactions with perinatal health care professionals may discourage help-seeking. Some women also report that their emotional needs are not addressed by perinatal health care professionals, perceiving them as unresponsive or unsupportive.  Women also perceive that perinatal health care professionals lack training in regards to perinatal mental health.  Available treatment resources are often limited for both perinatal women and obstetric providers and staff, creating both patient and provider barriers, respectively.

Some typical (but not all inclusive) symptoms of Postpartum Mood and Anxiety Disorders

  • Are you feeling sad or depressed?
  • Do you feel more irritable or angry with those around you?
  • Are you having difficulty bonding with your baby?
  • Do you feel anxious or panicky?
  • Are you having problems with eating or sleeping?
  • Are you having upsetting thoughts that you can’t get out
  • of your mind?
  • Do you feel as if you are “out of control” or “going crazy”?
  • Do you feel like you never should have become a mother?
  • Are you worried that you might hurt your baby or yourself?

Women note numerous factors that impede their ability access mental health treatment, including disconnected pathways to depression care.  Women’s interactions with mental health providers can also be perceived as a barrier to treatment. Women may find it hard to access mental health care due to long wait times or lack of available providers. Women may not know who to call or how to get help or have difficulty finding a mental health provider willing to see perinatal women.  

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

Dr.  Byatt: It is imperative to consider risk of untreated depression when considering medication or non-medication treatment during pregnancy.  Multiple studies have demonstrated that perinatal depression can negatively impact mother, infant, child and family.   Maternal depression has been associated with emotional and functional disability in children of depressed mothers.  Although risks have been reported with SSRI use in pregnancy, the preponderance of data is reassuring.

The risks and benefits of treatment with antidepressants should be weighed against the risks of untreated illness.  Does exposure to the antidepressant or untreated illness pose a greater risk?    If treatment with an antidepressant is indicated, then a discussion of the risks and benefits should take place before medication is prescribed.  Pharmacotherapy should be used judiciously and treatment should aim to maximize evidence-based non-medication treatments, such as psychotherapy, in order to maintain or reach remission of the maternal symptoms.

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

Dr. Byatt: Clinical decisions should be based on the risks, benefits and alternatives to medication treatment.  Untreated maternal illness and the potential risks of psychotropic medication must be considered.  It is vital to consider women’s treatment preferences, illness severity, and the risks of no treatment and under-treatment.  Discontinuation of an effective medication often poses more risk than continuation because it carries the risk of relapse and/or in utero exposure to a second antidepressant.

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

Dr. Byatt: A combination of staff training, structured screening programs, and community resource guides may help childbirth education organizations encompass perinatal mental health training into their curriculum and practice.  Training childbirth educators in mental health can allow them to feel more confident discussing perinatal mental health, which in turn may mitigate women’s fears and concerns and activate them to seek treatment.

Conclusion:

I wonder about the perception of lack of training in childbirth education courses as a part of the barrier to treatment noted by Dr. Byatt. Disconnected pathways to care seem a call to action for childbirth professionals. Where women and families find lack of education, empathy, and acceptance –childbirth professionals could provide pathways to better treatment merely through community resource lists.  Training, structured screening programs and community resource guides are good suggestions to not only optimize care for women, but to optimize practices for educators.

If you took inventory of the training and resources you have been given regarding perinatal mental health—what would you find? Do you know what resources are available from your certifying organization for you to use in your classes? Have you read Kathy McGrath’s article on the Lamaze.org website on Baby Blues? What are some of your favorite resources and activities that you use in class to cover these topics? How do you envision your childbirth organization creating or growing pathways in the future to support continued education on this topic?

Check

About Nancy Byatt, DO, MBA

Nancy Byatt, DO, MBA:  Dr. Byatt’s clinical, educational and research efforts have been led her numerous publications and awards including the Briscoli Award for Resident-Faculty Academic Collaboration and APA/APIRE Junior Investigators Award.   She recently submitted a Career Development Award Proposal to the NIH/NIMH (National Institute of Health/National Institute of Mental Health) in order to develop and evaluate a new low-cost program that aims to improve the delivery of depression care in outpatient obstetric settings.  Her recent publications include:

1. Byatt N, Biebel K, Lundquist R, Moore Simas T, Debourdes-Jackson G, Ziedonis D.  Patient, Provider and System-level Barriers and Facilitators to Addressing Perinatal Depression:  Perspective of Obstetric Providers and Support Staff. Journal of Reproductive and Infant Psychology.  Link to article:  http://dx.doi.org/10.1080/02646838.2012.743000

2. Byatt N, Biebel K, Debourdes-Jackson G, Lundquist R, Moore Simas T, Weinreb L, Ziedonis D.  Community Mental Health Provider Reluctance to Provide Pharmacotherapy May Be a Barrier to Addressing Perinatal Depression: A Preliminary Study. Psychiatric Quarterly, 2012; ePub ahead of print DOI: 10.1007/s11126-012-9236-0.

3.  Byatt N, Moore Simas T, Lundquist R, Johnson J, Ziedonis D. Strategies for Improving Perinatal Depression Treatment in North American Outpatient Obstetric Settings. Journal of Psychosomatic Obstetrics & Gynecology. 2012 Dec;33(4):143-61. doi: http://www.ncbi.nlm.nih.gov/pubmed/23194018

4. Byatt N, Deligiannidis K, Freeman M.  Antidepressant Use in Pregnancy:  A Critical Review Focusing on Controversies and Risks. Acta Psychiatrica Scandinavica. In Press.

 

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

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

December 6th, 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.  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 , , , , , , , , , , , , ,

Support Needs of Mothers Who Experience Postpartum Psychosis and Their Partners: A Qualitative Research Review

July 31st, 2012 by avatar

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

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

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

Creative Commons Image: Pamela Machado

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

Postpartum Psychosis: Some Background               

Prevalence

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

Symptoms

Symptoms of postpartum psychosis are sudden in onset, usually occurring within 48 hours to 2 weeks following birth. PP represents “psychiatric emergency and warrants hospitalization” (Beck & Driscoll, 2009, p. 47). If left untreated, some dire potential outcomes include:

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

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

Study Review

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

Mothers’ Support Needs

Instrumental, Informational, and Emotional

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

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

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

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

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

Women also wanted specific information on PP including:

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

Mothers’ Support Preferences

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

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

Access to Support

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

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

Barriers to Recovery

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

About Walker Karraa

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

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