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Placentophagy: A Pop-Culture Phenomenon or an Evidence Based Practice?

June 11th, 2013 by avatar

© Robin Gray-Reed, RN, IBCLC
mindfulmidwife.com

“Do women really eat their placentas?” I am asked this question in every Lamaze class I teach. This question is often accompanied by a raised eyebrow and a giggle. Many times, at least one mother will sheepishly avert her eyes and mention that she’s thinking about doing it because she’s heard of the amazing benefits that can be achieved by consuming her placenta. Our class discussion commences with differing opinions, theories, vague and distorted facts and many grunts of “ugh, gross!” It then becomes my job as the childbirth educator to sort this out and offer my students evidence based information with regards to placentophagy.

There’s been quite a bit in the news this last week or so about placenta eating.  Recently, Kim Kardashian, on her show, “Keeping up with the Kardashians,” queried her doctor about consuming her placenta after birth. She wanted to know if he thought that by consuming it, it would help keep her looking younger – a veritable fountain of youth. Don’t you think it makes you look younger?” Kim asks her doctor during the episode. “Some people believe in that,” her doctor replies. “There are cookbooks on placentas.”

In 2012, Mad Men star, January Jones let it be known that she consumed her encapsulated placenta after her baby was born, per her doula’s suggestion.  ”Jones’s secret to staying high energy through the grueling shooting schedule? ‘I have a great doula who makes sure I’m eating well, with vitamins and teas, and with placenta capsulation.’ “

Hollywood seems to have picked up on the trend. Locally, in Pittsburgh, were I practice, there are at least three placenta encapsulation specialists and a few others who dabble in it. Talking to one recently, she mentioned that she was busy enough that she needed to bring in a partner to help her. It would appear that the trend is indeed on the rise.

Let’s take an in-depth look into the modern practice of placentophagy and the evidence behind it.

 How can placenta be consumed?

  • Eaten raw
  • Cooked in a stew or stir fry, or other recipes
  • Made into a tincture
  • Dehydrated and put into smoothies
  • Dehydrated and encapsulated in pill form

Most modern mothers will choose to encapsulate their placenta. Taking it in a pill form seems to be most palatable for many women interested in consuming their placenta. The placenta is washed, steamed (sometime with other ingredients such as jalapeño, ginger and lemon), sliced, dehydrated, pulverized and encapsulated. Within 24-48 hours after birth, the mother has her placenta back in pill form and will ingest a certain number of pills each day.

Why would a woman want to take placenta capsules?

There are many claims made about the benefits of consuming placenta. The list below is from Placenta Benefits.info

The baby’s placenta, contained in capsule form, is believed to:

  • contain the mother’s own natural hormones
  • be perfectly made for that mother
  • balance the mother’s system
  • replenish depleted iron
  • give the mother more energy
  • lessen bleeding postnatally
  • been shown to increase milk production
  • help the mother to have a happier postpartum period
  • hasten return of uterus to pre-pregnancy state
  • be helpful during menopause

This is a rather amazing list. It would appear that consuming placenta postpartum is a bit of a magic bullet. This, in and of itself, makes me wary of the claims. There are a number of oft cited studies to back these claims up. However, my research turns up only studies in animals, anthropological studies and a recent survey of mothers who consume placenta.

© Bjorna Hoen Photography
bjornahoen.com

Animal studies are good preliminary research and may provide indication for further study in humans. In and of themselves, they provide insufficient information to recommend placentophagy in human mothers.

Anthropological studies are a fascinating peek into human evolution, history and practice. They may provide clues as to why humans, as a rule, do not consume placenta. Or for those limited cultures that did/do consume it, the rationale behind doing so may be revealed. However, as with animal studies, anthropology alone does not give us cause to say that we should or should not be participating in placentophagy.

There is ongoing research out of Buffalo, NY by Mark Kristal, as well as from the University of Nevada, Las Vegas by Daniel Benyshek and Sharon Young on placentophagy. I look forward to their further contributions and hope their work provides impetus for additional hard science.

To date, there is not one double-blind placebo controlled study on human placentophagy.

Although advocates claim that these nutrients and hormones assumed to be present in both the prepared and unprepared forms of placenta are responsible for many benefits to postpartum mothers, exceedingly little research has been conducted to assess these claims and no systematic analysis has been performed to evaluate the experiences of women who engage in this behavior. (Selander et al. 2013)

 A note on Selander, et al: Jodi Selander is the owner of Placenta Benefits LTD. Her financial conflict of interest is noted in the survey.

What we have is anecdotal evidence from mothers who have consumed placenta (Selander 2013). Care providers who witness the effects of placentophagy in the mothers have been noted as well. There are a number of studies in animals, both with regards to behavioral and, chemical and nutritional benefits.  There are a number of anthropological studies, as well as a recent survey (Selander 2013).

What we truly lack is a double-blind, placebo controlled human study of the affects of placentophagy.

“While women in our sample reported various effects which were attributed to placentophagy, the basis of those subjective experiences and the mechanisms by which those reported effects occur are currently unknown. Future research focusing on the analysis of placental tissue is needed in order to identify and quantify any potentially harmful or beneficial substances contained in human placenta… ultimately, a more comprehensive understanding of maternal physiological responses to placentophagy and its effects on maternal mood must await studies employing a placebo-controlled double blind clinical trial research design.” (Selander 2013)

 This leaves us with a few unanswered questions. 

  1. Is the benefit we see in the human mother after consuming placenta because she has consumed it, or is this placebo effect?
  2. Are their benefits or risks to consuming amniotic fluid after birth?
  3. If there is no biological imperative for human mothers to consume placenta, is there a reason for that? Is this a reason suggesting harm from eating placenta, a social norm, or something larger with regards to our need for bonding with our community of women during and after birth?

“This need for greater sociality during delivery then, in combination with the consequent pressure to conform to cultural norms, led to a strengthening of socials bonds and a reduction in the likelihood of placentophagia.” (Kristal 2012)

Coming full circle; how do we approach the topic of placentophagy in our Lamaze classes? Keep it simple. As of today, consuming placenta is not an evidence-based practice. Therefore, we cannot directly recommend it to our students.

However, to support our students’ autonomny, I believe a mother should be able to take her placenta home and do with it as she will. If your students wish to engage in this practice, I’d encourage them to speak to their care providers prenatally, to ensure safe handling of the placenta and to set appropriate expectations at birth.

References:

Kristal, M. B. (1980). Placentophagia: A biobehavioral enigma (or< i> De gustibus non disputandum est</i>). Neuroscience & Biobehavioral Reviews,4(2), 141-150.

Kristal, M. B., DiPirro, J. M., & Thompson, A. C. (2012). Placentophagia in humans and nonhuman mammals: Causes and consequences. Ecology of Food and Nutrition51(3), 177-197.

Selander, J. (2013), Placenta Benefits, placentabenefits.info. Retrieved June 09, 2013, from http://placentabenefits.info/index.asp.

Selander, J., Cantor, A., Young, S. M., & Benyshek, D. C. (2013). Human Maternal Placentophagy: A Survey of Self-Reported Motivations and Experiences Associated with Placenta Consumption. Ecology of food and nutrition52(2), 93-115.

Soykova-Pachnerova E, et. al. (1954)  “Placenta as Lactagagen” Gynaecologia 138(6):617-627

Young, S. M., Benyshek, D. C., & Lienard, P. (2012). The conspicuous absence of placenta consumption in human postpartum females: The fire hypothesis. Ecology of Food and Nutrition51(3), 198-217.

 

Childbirth Education, Depression, Evidence Based Medicine, Guest Posts, Maternal Mental Health, New Research, Perinatal Mood Disorders, Postpartum Depression, PTSD, Research, Uncategorized , , , , , , ,

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 , , , , , , , ,

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 , , , , , , , , , , ,

One in Three Suffers Posttraumatic Stress Disorder: A Look Behind the Headlines

August 21st, 2012 by avatar

by David White, MD CCFP, Associate Professor, Dept of Family & Community Medicine, University of Toronto

Dr. David White reviews the study “Postpartum Post-Traumatic Stress Disorder Symptoms: The Uninvited Birth Companion“ that made news headlines earlier this month.  This post,  is part two of a two part series. (Read part one here, where Penny Simkin discussed how the media created sensationalistic headlines from the study.) Dr. White demonstrates how important it is to go to the source,  and evaluate the study design for oneself.  I appreciate Dr. White sharing his  summary and review of the research behind the study. – SM

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Creative Commons Image by Horia Varlan

The dramatic headline caught my eye: “One in Three Post-Partum Women Suffers PTSD Symptoms After Giving Birth: Natural Births a Major Cause of Post-Traumatic Stress, Study Suggests.”[i] As a family doctor who provides maternity care, I was both puzzled and alarmed. Where were all these women? Each year, I care for about 50 women through pregnancy, birth and post-partum. Am I failing to recognize the 16 or 17 who develop PTSD? Are they suffering without proper care?

The article claimed “Of the women who experienced partial or full post-trauma symptoms, 80 percent had gone through a natural childbirth, without any form of pain relief.”

On reflection, I became skeptical. So I read the original research paper.[ii] To their credit, the authors acknowledge, “Controversy remains whether childbirth should be included under the definition of a traumatic event that meets the criteria for post-traumatic stress disorder.” Unfortunately, their own study is so riddled with problems that it can only add confusion.

First, there is the matter of selection: 102 women agreed to participate, 89 completed the two assessments. There is no mention of how many women were approached, or how many women had births at the hospital during the study period. So there is no way to assess possible selection bias. Suspicion is warranted when a crucial methodological detail is omitted.

Then there is the issue of diagnostic criteria. The diagnosis of PTSD requires that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning (both DSM-IV-TR and ICD-10). The researchers administered their survey instrument within a few days of birth and again at one month post-partum. The latter just barely meets the criterion for duration. And could there be a cuing effect from administering an initial questionnaire within a few days of birth?

The findings report “full PTSD”, “partial PTSD” and “PTSD symptomatology”. However the tool used by the researchers, a self-administered questionnaire called Posttraumatic Stress Diagnostic Scale (PDS®), indicates only whether someone meets the DSM diagnostic criteria or not.[iii]

Now to the analysis, which piles questionable analysis onto this shaky diagnostic platform.  ”For processing the data we needed to select a group large enough to be statistically significant but homogenous enough to offer meaningful results.” So they lump together those missing one or two symptoms with those who actually have PTSD. The justification for this methodological legerdemain is that others have done it. They reference a study by Stein, Walker et al[iv] that is considerably more careful. It differs substantially in that it used telephone interviews, a different assessment tool and analyzed full and partial PTSD separately.

The results are reported in a way that even makes it difficult to determine what group they are analyzing. Is it the “full PTSD” (3) + “Partial PTSD” (7) = 10? No, it is 3 (“full) + 4 (“missing 1 or 2 symptoms”) =7. But look at Table 2, showing 5 in the row labeled “PTSD”. Table 3 has it back up to 7.

Table source: http://www.ima.org.il/imaj/ar12jun-02.pdf

The terminology for the groups seems variable. At times it is “PTSD group”, at others it is “women with PTSD symptoms” and the Tables simply apply the label “PTSD.”

Terminology problems continue: “control group” is used regularly to denote those who did not manifest PTSD symptoms, an odd usage for a study in which there is no intervention or randomization.

While studying Table 2, check out the mode of delivery: Natural 45, Cesarean 42 (20 elective), Instrumental 2. That indicates a Cesarean section rate of 47%. Could this be a biased sample?

More fun with numbers: the text reports that 80% of women with PTSD symptoms reported feeling very uncomfortable in the undressed state: Table 3 shows 3 out of 7 reporting this.

Table source: http://www.ima.org.il/imaj/ar12jun-02.pdf

And the figure that 80% of those with PTSD had gone through natural labour? It appears to come from Table 2, showing that 4 out of 5 women in the “PTSD” group had “Natural” childbirth. I scoured the tables and text in vain to find why the PTSD group is 5 in Table 2 and 7 in Table 3.

The definitions of mode of delivery should be more precise. The authors describe natural births as “non-interventional” but we really don’t know about analgesia use in this group. This matters, because they found “A significantly smaller number of women who developed PTSD symptoms received analgesia during delivery compared to the control group.” For this to make sense, it is essential distinguish vaginal births with and without effective pain relief.

This definitional and analytic fog leads to the conclusion that a lot of women have PTSD symptoms following birth. The authors don’t trouble themselves to explain why their numbers don’t square with the excellent community-prevalence study in the references, in which “The estimated prevalence of full PTSD was 2.7% for women and 1.2% for men. The prevalence of partial PTSD was 3.4% for women and 0.3% for men.”4

This study brings discredit to an admittedly difficult field, one in which researchers must address the criticism of medicalizing normal life experiences.

I’m a GP, not an expert in PTSD. But I think I can recognize “significant impairment in social, occupational, or other important areas of functioning.” The important issue for practitioners is whether we identify and help those at risk and who need assistance. Screening for post-partum depression is important. Adding a simple open-ended question such as “tell me about your birth” is likely to yield much more benefit in practice than this study.

I appreciate Dr. White’s analysis and wonder how many other professionals bothered to examine the research behind the headlines, in order to come to their own conclusions about the study design, assumptions and findings.  What do you think of this research?  Did you understand the terms being used or how the results were determined?  Do you think any journalists who wrote the sensational headlines took the time to look at the study themselves?  It is always important to be a critical thinker for yourself, examine the information and ask questions.  Sometimes, the research does not match up with the front page news, or the study may not have been well-designed.  Please share your thoughts, questions and comments here, with Dr. White, Penny Simkin, myself and Science & Sensibility readers. – SM

References

[i] American Friends of Tel Aviv University (2012, August 8). One in three post-partum women suffers PTSD symptoms after giving birth: Natural births a major cause of post-traumatic stress, study suggests. ScienceDaily. Retrieved August 14, 2012, from http://www.sciencedaily.com­ /releases/2012/08/120808121949.htm

[ii] Postpartum Post-Traumatic Stress Disorder symptoms: The Uninvited Birth Companion, Inbal Shlomi Polachek, Liat Huller Harari, Micha Baum, Rael D. Strous: IMAJ 2012; 14: 347–353, accessed at http://www.ima.org.il/imaj/ar12jun-02.pdf

[iii] The actual PDS® tool can be downloaded at (for a price): http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=PAg510&Mode=summary

A useful review of the PDS® is at: http://occmed.oxfordjournals.org/content/58/5/379.full.pdf+html

[iv] Stein, M. B., Walker, J. R., Hazen, A. L., & Forde, D. R. (1997). Full and partial posttraumatic stress disorder: Findings from a community survey. The American Journal of Psychiatry, 154(8), 1114-9. Retrieved from http://search.proquest.com/docview/220491145?accountid=14771

A useful overview of PTSD at

http://www.ptsd.va.gov/professional/pages/ptsd-overview.asp

A review of research issues in PTSD following childbirth:

Pauline Slade: Towards a conceptual framework for understanding post-traumatic stress symptoms following childbirth and implications for further research. Journal of Psychosomatic Obstetrics & Gynecology (January 2006), 27 (2), pg. 99-105, accessed at http://resolver.scholarsportal.info.myaccess.library.utoronto.ca/resolve/0167482x/v27i0002/99_tacffucaiffr

About David White

David White is a community-based family doctor in Toronto and Associate Professor of Family & Community Medicine at the University of Toronto. (DFCM, U of T). He currently serves as the Interim Director of UTOPIAN, the practice-based research network comprising all teaching sites affiliated with the Department of Family & Community Medicine at the University of Toronto.

He obtained his medical degree and completed residency in Family Medicine at the University of Toronto. He began clinical practice in 1977 at Sioux Lookout, working at the Zone Hospital and flying into remote First Nations villages in northwestern Ontario. In this setting he began a long-term affiliation with U of T. On returning to Toronto in 1980, he joined the Family Medicine Teaching Unit at Toronto Western Hospital, and later moved to Mount Sinai Hospital. In 1999 he was appointed Chief of Family & Community Medicine at North York General Hospital (NYGH).

His current academic activities include clinical teaching in his community office and in obstetrics, research in health care delivery, and mentoring of junior faculty. Contact Dr. White

Childbirth Education, Depression, Evidence Based Medicine, Guest Posts, Maternal Mental Health, Maternity Care, New Research, Perinatal Mood Disorders, Postpartum Depression, PTSD, Research, Uncategorized , , , , , , , , , , , , , , ,

Part Two in a Series: Risk Factors and Types of Perinatal Mental Illness for Birth Professionals

April 20th, 2012 by avatar

Read Part One in this series . . .

Risk Factors for Perinatal Mental Illness (saaay what – so many??)

Etiology: Bio-psycho-social

Current research does not give us a crystal clear cause for perinatal mood disorders. It seems that a convergence of biological, psychological and social (biopsychosocial) factors play a role in the intensification of anxiety and mood disorders during the childbearing year.

In other words, it is likely that a mixture of past mental health issues, hormonal changes and stressors from your current situation create a vulnerability to a mood disorders in the childbearing year (Kleiman & Wenzel, 2011; Kleiman, 2009; PSI, 2009; Puryear, 2007; Nonacs, 2006; Kendall-Tackett, 2005).

Listed below are some of the commonly acknowledged risk factors. I tried to group them into bio/psycho/social categories, but as you can see, there is much overlap.

Biological / Psychological

  • A personal history of a mental illness in her lifetime, ie, depression anxiety, PTS/PTSD, OCD or bipolar disorder (may have been diagnosed & treated or was undiagnosed & untreated) (previous PPD history increases risk to 50 – 80 % risk of recurrent PPD, as compared to 10- 20% risk w/o a prior episode)
  • A familial history of depression or anxiety disorders, etc (undiagnosed/diagnosed)
  • Premenstrual syndrome/disorder. A woman with a heightened sensitivity to her hormonal cycle, may be more vulnerable to the hormonal changes of pregnancy & birth.
  • A heightened sensitivity to hormonal fluctuations of pregnancy and childbirth.
  • Going through a traumatic birth. Traumatic birth occurs on a continuum from disappointing care to painful natural birth to life rescue efforts during the birth (huge topic)
  • Her infant is born premature (both the birth and the NICU experiences can be traumatic)
  • A history of extensive infertility treatments, trauma from necessary medical procedures
  • A history of previous miscarriages (can accompany infertility tx or not)
  • Unresolved feelings about termination of an earlier pregnancy
  • Her infant is born with a disability.
  • Her infant is stillborn, or a history of previous stillbirth

Social / Psychological

  • Poverty is a big risk factor for the development of perinatal mental illness.
  • Lack of social support: geographical move, a non-supportive family structure (alcoholism, etc), or a major change in job (ie, from career to SAHM).
  • Unhealthy current family dynamics: Occurs on a continuum from feelings of disconnect, poor communication & relationship skills, different parenting styles, bullying, to domestic violence
  • Domestic Violence creates a complex history of trauma/PTS/PTSD
  • Personal history of sexual abuse or sexual assault creates a complex history of trauma/PTS/PTSD.
  • Past family dynamics: Unresolved issues from childhood regarding parenting and being parented interferes with the transition to parenthood (huge topic -can cause major anxiety and depression)
  • Major life stressors, such as an accident or death in the family.

Differential Types of Perinatal Mental Illness

An accurate diagnosis?

I’ve gotten feedback (thank you Lara!) that I need to acknowledge not all sadness and stress in new mothers should be considered pathological, ie, needing diagnosis and treatment. So I’d like to publicly say that being a mom, caring for a newborn, can be overwhelming and that sleep deprivation can be a big factor in destabilizing a person emotionally, and some support for a new mom such a hard job can go a long way. Debra Flashenberg, CD(DONA), LCCE, wrote an article for Lamaze about her friend’s personal experience with a perinatal mood disorder.

The thing about any mental illness is that it exists on a broad continuum from “adjustment” behavior to varying degrees of “abnormal” behavior, where the person becomes so disorganized in their daily living that it does warrant treatment, Where that line is, is not always obvious, and requires discernment and sensitivity to individual needs.

The clinical presentation of the diagnoses below often overlap and/or co-occur. Diagnosis is sometimes not simple, and may be confounded by a prior history of depression, anxiety, post-traumatic stress influenced by previous life experiences.

Simpler depression and anxiety can be diagnosed and treated in primary care. A psychiatric consult is necessary for more complex cases. Licensed mental health professionals can diagnose and treat a broad range of mental disorders. Optimal treatment is usually a combination of medication, therapy and social support, tailored to individual needs.

Not all of the following categories of perinatal mental illnesses are recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM). But, many practitioners in perinatal mental health, including authors of the references to this article, recognize these differential diagnoses in clinical practice.. There is currently an active discourse in creating these new diagnoses.

Rates of perinatal mood disorders occurrence:

  • 85% suffer baby blues
  • 15% suffer depression
  • 10% suffer postpartum anxiety
  • 3 – 5% postpartum OCD
  • .1% postpartum psychosis
  • 1 – 6 % postpartum (birth) trauma – PTSD

Alphabet soup: BB, PPD, PPA/PPOCD, PP, PTSD/CB

These categories may seem confusing, but, as a childbirth educator, you don’t have the burden of diagnosis, this is for educational purposes.

BB – Baby Blues. Not a mental illness. The baby blues self-resolve and are normal. Occurs in the first two weeks or so after birth, goes away by itself. Not a mild form of postpartum depression.

PPD – Postpartum Depression.

Symptoms: If weepiness, sleeplessness, low self-esteem, change in appetite, feelings of being abandoned, alone, anger (rage), listlessness continue past two – three weeks, may be indicative of PPD. May have thoughts of self-harm or of harming the baby. In general, women who are depressed after birth who actually attempt and commit suicide are those who have histories of previous psychiatric events or previous suicide attempts. But, whenever harming behaviors are mentioned, please take it seriously. Some specialists believe PPD can overlap BB and can occur anytime in the first year. If the sad feelings are dragging on past the two-three week delimiter, it is best to seek help, rather than continue to suffer painful debilitating symptoms while also caring for an infant.

PPA/PPOCD – Postpartum Anxiety/OCD – PPA/PPOCD.

Some research suggests that some women who develop PPA/PPOCD have a heightened sensitivity to hormonal levels, in particular oxytocin, and this sensitivity may over-stimulate natural maternal behaviors, thus increasing maternal behaviors to over-protectiveness (Driscoll and Sichel, 1999). Other researchers believe the pre-existence of perfectionistic/rigid thinking styles may predispose a woman to PPA / PPOCD (Kleiman & Wenzel, 2011).

Symptoms: A pervasive anxiety that expresses itself as over-concern for the baby, over concern about germs, cleanliness, sleep arrangements, parenting skills and the normal attachment process. The mom becomes hyper-vigilant. She may bring baby to the hospital or doctor over and over again. She may develop checking behaviors such as checking to see if the blankets around the baby are folded properly, checking to see if the baby is breathing over and over again. She may engage in checking and counting rituals (counting the ceiling tiles, right angles, etc), which help her feel safe & soothed. She ay have scary thoughts about harming the baby or herself may occur. As in PPD, these must be taken seriously.

PP – Postpartum Psychosis. Separate disorder from PPD/ PPA/PPOCD

Most significant risk factor for PP is previously (un)diagnosed bipolar disorder, a previous psychotic episode or a family history of schizophrenia. Healthcare provider screening and prevention is extremely relevant to PP. Women are most susceptible in the first thirty days after childbirth. Postpartum psychosis is a psychiatric emergency. Get help immediately.

Symptoms:

Not sleeping for a few nights in a row, delusions, speaking about nonsensical beings, thoughts about evil beings, death, intense fear, mumblings, robotic movements, acting as if she can hear words coming from somewhere else (command language), staring, flat affect, deflated speech, one word answers, catatonia, staring, paranoia. You cannot talk a person out of their psychotic delusions. Best to nod your head, say, “I understand” or “Must be hard” and GET HELP IMMEDIATELY. The person is very ill and needs help, not ridicule or fear.

Post-traumatic Stress Disorder (PTSD) Secondary to Childbirth -PSTD/CB.

Walker Karraa has written many articles about trauma and childbirth for Science and Sensibility. Like all emotional experiences, trauma is experienced on a continuum. There are two recognized diagnoses: post-traumatic stress (PTS) and post-traumatic stress disorder (PTSD), with PTSD having more long-term symptoms.

Symptoms of PTS are considered normal reactions to a traumatic event. PTS symptoms are the same as PTSD, but present to a lesser extent: dissociation, avoidance, numbing, flashbacks, hypervigilance, anxiety, depression. Normal response to trauma is considered a normal survival response, our mindbody’s way of integrating traumatizing events slowly, in small chunks. This way of ignoring things to get by, to a normal extent, is sometimes called “coping ugly.” PTS symptoms are self-limiting, and most people recover from it.

 Ayers (2004) reports 1/3 women in western world consider their birth to be traumatic and ten percent report severe symptom of traumatic stress. Dr Ayers (2004) says difficult birth experiences affects psychological health, but for majority it is self-resolved. 1% – 2% develop clinical post-traumatic stress symptoms which need treatment.

“Part Three” coming up is a guide to positive helping and suggested resources.

Do you believe you can be a positive influence regarding maternal mental health?

Do you believe it is important to be aware of perinatal mental illness?

Please share your views below. Love to hear from you!

References

Ayers, S. (2004). Delivery as a traumatic event: Prevalence, risk factors, and treatment for postnatal post-traumatic stress disorder. Clinical Obstetrics and Gynecology, 47(3), 552-567.

Driscoll, D. and Sichel, J. (1999). Women’s moods: What every woman must know about hormones, the brain, and emotional health. New York: HarperCollins

Kendall-Tackett, K. (2005). Depression in new mothers. New York: Haworth Press.

Kleiman, K. (2009). Therapy and the postpartum woman. New York: Routledge Press.

Nonacs, R. (2006). A deeper shade of blue. New York: Simon and Schuster.

Postpartum Support International (2009). Components of care. Seattle: PSI

Puryear, L. J. (2007). Understanding your moods when you’re expecting. New York: Houghton Mifflin Company.

Twomey, T.M. (2009). Understanding postpartum psychosis: A temporary madness. Westport, Ct.: Praeger Publishers.

Babies, Childbirth Education, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, PTSD , , , , ,