Posts Tagged ‘Postpartum Support International’

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.



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.


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?


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 , , , , , , , , , , ,

Part One in a Series: Perinatal Mental Illness for Birth Professionals

April 13th, 2012 by avatar

Stigma & Prevalence of Perinatal Mental Illness

Part One of this series of posts discusses the experience of public stigma and self-shame around perinatal mental illness. Part Two talks about risk factors and types of perinatal mental illnesses. Part Three about what you can do, Words & Actions that Heal and some resources. I hope you find this a useful addition to your knowledge base as a birth professional.

Woman to Woman Support

As a childbirth professional, how do you help women & families? Lamaze has a wonderfully constructive focus on birth as a normal and healthy process. Lamaze Six Healthy Birth Practices promotes positive empowerment of families. And, it is useful to be aware that the time around birth, pregnancy and postpartum is the time that a woman is most likely to (re) develop a mental illness (Nonacs, 2006).

Childbirth professionals are often the first point of woman-to-woman contact for new moms. Becoming educated about perinatal mood/anxiety disorders and having a list of resources available in your community and online is an effective way to be of help without overstepping your personal, certification or licensure boundaries.

You may be the first person she calls. You can help out by being positively aware, using Words that Heal, and providing a list of contacts in the community and online.

Fear and stigma around “postpartum mental illness”

The mentally ill are dealing with public and self-shame. In the observer, the stereotype of someone who has a mental illness is someone low-functioning, someone who can’t hold a job (Corrigan et al, 2010). Feelings of uneasiness and fear, rather than feelings of compassion bubble up (Corrigan et al, 2010). Think about your own reactions to the words “mental illness.”

So be aware that a mother who is feeling depressed, anxious or fearful is probably experiencing deep self-shame. She probably feels more shame than is expected and associated with a physical illness. She probably has erroneous beliefs about the nature of mental illness.

Some mothers believe they are weak, and “should” be able to control their feelings. Other moms might believe they are bad mothers because they are in such pain, like they are belittling the miracle of their new baby. Others might be afraid to admit the scary thoughts they are having. Yet others believe there is no effective treatment; they think they just can’t get better.

Postpartum mental illness exists on a spectrum. Postpartum mental illness conjures up images of a mom who hurts her children, of courtrooms, of a person who is hearing voices, a home that gets visited by Child Protective Services and a mom who ends up institutionalized (Puryear, 2007). This stereotype is extreme and erroneous, as there are different types of postpartum mental illnesses.

No public stigma? No self-shame? Take a look at these statistics.

The World Health Organization lists depression as one of the top two to four causes of disability (defined as the loss of productive life) worldwide today. Mental illness is more prevalent than many other more publicized illnesses, but as a society we are very quiet about it.

No public stigma? No self-shame? I wonder why is there no nationwide Walk for Depression? What color is the depression ribbon? Why does World Mental Health Day (World Health Organization sponsors this on October 10th ) come and go so quietly? (Well, PsychCentral did have a blog party that day…)

Depression in Women is More Common than Breast Cancer or Stroke (saaay what?)

One in four women suffers depression at some point in her life, and women are more likely to suffer depression during and shortly after pregnancy than at any other time (Nonacs, 2006). Ruta Nonacs, MD (2011), editor-in-chief of Massachusetts General Hospital’s Center of Women’s Mental Health’s website estimates annually in the US, there are about 4 million births, and about 950,000 to 1,000,000 mothers suffer from depression either during or after childbirth every year.

The good news is there are effective treatments for depression and postpartum depression. But the sad fact is less than 25 % of persons affected by depression receive any treatment at all (WHO, 2012). The top barriers to receiving proper treatment are the social stigma associated with mental illness (shame), lack of personal resources and the lack of trained clinicians (WHO, 2012).

So, think about that, only about 25% of those moms actually seek and receive help for perinatal depression. So many women cope all alone, managing their very real emotional pain while at the same time coping with an infant.

According to Postpartum Progress, there are more occurrences of perinatal depression annually than there are breast cancer diagnoses, occurrences of stroke in women, or diagnoses of diabetes. Postpartum Support International says that postnatal depression is the most common complication in childbirth today. Dr. Nonacs (2012) adds there are more occurrences of perinatal depression than pre-term labor or pre-eclampsia.

Pretty surprising statistics, no?

Any thoughts about why we are mum about maternal mental illness? I’d love to hear your comments.

Do you believe you can be a positive influence regarding maternal mental health? Or do you believe it is too specialized an area in which childbirth professionals to be knowledgeable?

Please share your views below. I love to hear from you!


 Corrigan, P.W., Morris, S., Larson,J., Rafacz, J., Wassel, A., Michaels, P., Wilkniss, S., Batia,. K., & Rusch, N. (2010). Self stigma and coming out about one’s mental illness. Journal of Community Psychology, 38(3), 259-275.

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

Massachusetts General Hospital (2012). Psychiatric disorders during pregnancy. Retrieved March 27, 2012 from http://www.womensmentalhealth.org/specialty-clinics/psychiatric-disorders-during-pregnancy/

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

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

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

 World Health Organization (WHO, 2012). Depression. Retrieved March 31, 2012 from http://www.who.int/mental_health/management/depression/definition/en/

Childbirth Education, Continuing Education, Depression, Do No Harm, Evidence Based Medicine, Lamaze Method, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, PTSD , , , , , , ,

Postpartum Support International: A Sensible Resource for Birth Professionals

December 23rd, 2010 by avatar

“Honesty is disarming.  It should set the stage for dialogue.” — Jane Honikman, M.S., founder, Postpartum Support International

One of the first written accounts of postpartum mood disorders was in 1436. Margery Kempe, mother of 14, wrote:

“Wherefore after that her child was born she, not trusting her life, sent for her ghostly father, as said before, in full will to be shriven of all her lifetime as near as she could. And, when she came to the point for to say that thing which she had so long concealed, her confessor was a little too hasty …and so she would no more say for nought he might do. And anon for dread she had of damnation on that one side and his sharp reproving on that other side, this creature went out of her mind and was wonderly vexed and labored with spirits half year eight weeks and odd daysi.”

Background to Postpartum Mood and Anxiety Disorders
In the quote above, from Out of her mind: Women Writing on Madness, Margery’s honesty is indeed disarming, and provides historical context to set the stage for future dialogue: perinatal mood disorders have been around a long time, and based on current evidence, they aren’t going away.

  • Suicide is the leading cause of death for women during the first year after childbirth.1
  • Depression is the second most common cause of hospitalization for women in the U.S.; the first being childbirth.2,3
  • Major and minor postpartum depression/anxiety estimates range from 5% to 25% for new mothers in US.4,5,6,7,8
  • There is a seven-fold increase in the risk of psychiatric hospitalization for women following childbirth.9,10,11
  • Reports show that PPMAD affects up to 48% of women living in poverty.12,13,14,15


The Role Stigma Plays
Statistically, over 500 years later, Margery would still be at risk largely due to the powerful social mechanism of stigma regarding motherhood and mental illness.  Just as stigma about mental health disorders silences women today, Margery was similarly silenced in 1436.16,17,18 It is the silent fear of stigma that likely causes nearly 50% of present-day, affected women to go untreated for perinatal mood disorders.19,20

In her 2010 book Within Our Reach: Ending the Mental Health Crisis21, former first lady (and life-long mental health advocate), Rosalynn Carter noted:


Stigma is the most damaging factor in the life of anyone who has a mental illness. It humiliates and embarrasses; it is painful; it generates stereotypes, fear and rejection; it leads to terrible discrimination. Perhaps the greatest tragedy is that stigma keeps people from seeking help for fear of being labeled, “mentally ill” (p. 1).

Raising Awareness

One of the ways to end stigma is to increase awareness. In my recent interview [KMH1] with Jane Honikman, M.S., founder of Postpartum Support International (PSI), she offered:

The causes of stigma include ignorance and denial about the importance of emotional wellbeing of childbearing women.  On the community, national and international levels this ignorance is being eliminated through educational awareness campaigns.   There is no excuse not to be educated about the range of emotional reactions during the perinatal period.  Denial is a personal issue and more difficult to confront.  It is impossible to know how one’s expectations of motherhood will be met.  The mythology that surrounds parenthood is another huge barrier.  Taboos need to be openly discussed.  Often there are conflicts between the woman and her partner. These need to be discussed.  It is difficult to parent alone. Family members should participate in supporting the new family.  It is important to have frank and honest conversations about opinions and expectations within the extended family unit during pregnancy and following the arrival of the baby.

Increased awareness regarding prevalence, risk factors, and the need to screen has occurred at many levels. There has definitely been progress.  Jane further offered:

Awareness has increased tremendously since I first got involved nearly forty years ago.  The availability of accurate information, resources and referral networks is responsible for these changes.  The media has been our movement’s best friend.  For example, there are now free materials from the federal government, healthy start programs include maternal mental health curriculums, and states have active coalitions.  Insurance companies have eliminated barriers to receiving mental health coverage.  All of the major medical organizations have stepped forward offering educational seminars to their members.  The courts now consider mental health history when they encounter a crime. The internet has played an enormous role.  Postpartum Support International’s website www.postpartum.net has been a leader in this progress.

Further evidence of progress can be found in the published position papers related to maternal mental health of the following organizations:

Centers for Disease Control and Prevention (CDC)
The American Congress of Obstetricians and Gynecologists (ACOG)
The World Health Organization (WHO)
American College of Nurse-Midwives (ACNM)
Planned Parenthood
National Organization for Women (NOW)
The American Academy of Pediatrics (AAP)
National Alliance on Mental Illnesses (NAMI)
Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)
Children’s Defense Fund (CDF)
National Women’s Law Center
National Partnership for Women and Families (NPWF)
The U.S. Preventive Services Task Force
American Psychological Associatio(APA)
US Dept of Health and Human Services
March of Dimes
National Institute of Mental  Health(NIMH)
Healthy Mothers Healthy Babies
International Childbirth Educators Association (ICEA)

Postpartum Support International (PSI) has had a tremendous influence on raising awareness about postpartum mood and anxiety disorders. Given their successful leadership in advocating for maternal mental health using evidence-based research, it serves to look more closely at the organization’s structure and become familiar with the resources they provide all childbirth professionals.

Postpartum Support International Background
PSI was founded in 1987 by Jane Honikman in Santa Barbara, California. The purpose of the organization is to increase awareness among public and professional communities about the emotional changes that women experience during pregnancy and postpartum.  The non-profit organization’s greater mission is to promote awareness, prevention and treatment of childbearing-related mental health issues in every country worldwide. It is the vision of PSI that every woman and family will have access to information, social support, and informed professional care when needed.  PSI promotes this vision through advocacy and collaboration, and by educating and training the professional community and the public.  

How PSI Works
PSI is run and maintained by volunteers. According to Wendy Davis, Ph.D., PSI Program Director, there are currently 479 active members and of that number, approximately 50 of those are childbirth professionals (birth or postpartum doulas, childbirth educators, lactation consultants).  There are 145 PSI Support Coordinators in the United States, and 48 in other countries. Support coordinators provide support, information, and resources to anywhere from 2 to 20 families every month, and many of them lead free support groups. We also have specialized PSI Coordinators for military families, Dads, Spanish-speaking moms, and legal resources.

PSI maintains a warm line (1.800.944-4PPD) which is managed by 9 English speaking volunteers, and 8 Spanish speaking volunteers. On average, the English warm-line receives 90 calls a month, and the Spanish warm-line, 70 calls per month. The toll free number connects the caller with informed and caring PSI telephone support volunteers 7 days a week. What happens when an individual calls in? Dr. Davis explained:

The caller hears a greeting and then can leave a voicemail message in English or Spanish. The calls are usually returned within several hours; volunteers make every effort to connect with the caller within 24 hours at the most. The warm-line is answered live in English on Tuesdays and Wednesdays, during regular business hours, Pacific time. Warm-line volunteers offer non-judgmental support, information, and local resources. They will connect the caller with their area PSI Support Coordinator so they can find support or providers as close to home as possible.

The PSI website
provides consumers and professionals with current research, and resources.  According to Dr. Davis:

The hallmark of our website is our Support Map Page that lists PSI support coordinators, free support groups, and events in every U.S. state and 35 other countries. Childbirth professionals can be assured that they can find volunteers in their own area who are available to help them and the families they serve. Our Coordinators are trained to provide support, information, and local resources as well as phone or email support to families as needed. The website also includes current evidence-based information on the range of pregnancy and postpartum mood disorders, tips for coping, resources for moms, partners, and professionals, educational materials like brochures and posters in English and Spanish, new research articles, and a bookstore. There is one page that just lists information and links in non-English languages, and one section of the website has been translated to Spanish. We update the website constantly to keep it current, adding new research and resources daily.

One of the additional resources she described is the PSI Free Chat with an Expert:

PSI hosts free, live phone sessions every week facilitated by licensed professional experts in perinatal mental health. There is a session for moms and their helpers every Wednesday and for Dads on the first Monday of each month. These sessions provide a forum to share, listen to others, and talk with a PSI expert about resources, symptoms, options and general information about perinatal mood and anxiety disorders. You can learn more about the facilitators and call schedules [here].  

Sensible Resource: How to use PSI in Practice
How can childbirth professionals best utilize PSI for their clients? Dr. Davis suggested:

  • Find your local PSI Coordinator on the Support Map so that you can connect clients with them.
  • Create links to PSI website in the resource section of your websites, provide basic facts about perinatal mental health in educational materials, include information about pregnancy and postpartum mental health in prenatal education.
  • Have PSI brochures or posters available.
  • Use the 13-minute PSI educational DVD with clients. You can see a preview of the DVD, and one for fathers on the PSI website here.

How could childbirth organizations best utilize PSI for their professionals?  Again, Dr. Davis shared great ideas:

Come to PSI trainings, use the PSI website, join PSI and be part of our listserve for PSI members who are doulas, contact local coordinators or the PSI office with questions, provide educational materials and training for their students and members. The PSI Professional trainings, offered in several places around the country and at the PSI annual conference every year, are designed to include childbirth professionals. PSI 2011 trainings are scheduled for Los Angeles in January, Michigan and Kentucky in March, Indianapolis in May, and in Sept 2011 the 25th annual PSI conference will be held in Seattle in conjunction with PSI-Washington, which has a long history of involvement with childbirth professionals. You can keep track of trainings on the website here. http://postpartum.net/Professionals-and-Community/Trainings-Events/Trainings-and-Conferences.aspx

My heartfelt hope is that the information shared here will provide childbirth professionals evidence-based resources for their practice and clients.

Thank you for reading the article.

Still, I keep thinking about Margery Kempe: over 500 years later, why are depression and childbirth the two top reasons for a woman to be hospitalized2,3?

I extend an invitation to all childbirth professionals to honestly examine current positions, or lack thereof, regarding maternal mental health. What are current positions regarding perinatal mood disorders?  Are we, as childbirth industry professionals, comfortable discussing mental health issues with our clients?  Do we  know how to screen?  Do we know how to refer to local resources in our local communities?

Ask yourself this:  What help do you need in becoming comfortable discussing mental health issues with your clients? Let your organizations hear from you.

Professionally, let’s examine if our organizations have mental health resources on their websites, blogs, training materials, and fact sheets. Given that suicide is the leading cause of death in the first year following childbirth1, I would offer that having suicide prevention information on websites might be a place to start.

USA National Suicide Hotlines
Toll-Free / 24 hours / 7 days a week

**View Walker’s complimentary post over at Giving Birth With Confidence where she expands further on her interview with Jane Honikman**

I would like to extend my gratitude to Jane Honikman, M.S., for her contribution to this article, and for her steadfast commitment to women everywhere. Jane…I will pass my heart to you any day.  And thanks, as always, to Wendy Davis, Ph.D., for working until 3AM to help me with this article. Also, thank you to both Cara Terreri, and Kimmelin Hull for giving me the opportunity to write for their sites, and to Lamaze International for their support. The full content of my interview with Jane Honikman can be found at www.fullydilated.net

Posted by:  Walker Karraa, MFA, MA, CD (DONA)

iKempe, M. (1436). The book of Margery Kempe. In Shannonhouse, R. (Ed.) (2003). Out of her mind: women writing on madness. New York: Modern Library. pp. 3-7.

1 Oates, M. (2003). Suicide:  The leading cause of maternal death.  The British Journal of Psychiatry, 183, 279-281.

2 Gold , K., Marcus, S., (2008). Effect of maternal mental illness on pregnancy. Expert Review of       Obstetrics & Gynecology, 3 (3), 391-401.

3 Blenning, C., Paladine, H. (2005). An approach to the postpartum office visit. American Family Physician, 72(12), 2491-2496.

4 Gaynes, B., Gavin, N., Meltzer-Brody, S., Lohr, K., Swinson, T., Gartlehner, G., et al. (2005).   Perinatal depression prevalence, screening accuracy, and screening outcomes: Summary, evidence report and technology assessment, No. 119. AHRQ Publication No. 05-E006-1.

5 Onunaku, N. (2005). Improving maternal and infant mental health: Focus on maternal depression. National Center for Infant and Early Childhood Health Policy at UCLA.

6 Knitzer, J., Theberge, S., Johnson, K. (2008). Reducing maternal depression and its impact on young children: Toward a responsive early childhood policy framework. National Center for Children in Poverty, Project Thrive Issue Brief 2.

7 Yonkers, K., Chantilis, S. (1995). Recognition of depression in obstetric and gynecology practices. American Journal of Obstetrics and Gynecology, 173(2), 632-638.

8 Gavin, N.I., Gaynes, B.N., Lohr, K.N., Meltzer-Brody, S., Garlehner, G., Swinson, T. (2005). Perinatal depression: A systematic review of prevalence and incidence. American Journal of Obstetrics and Gynecology, 106(5 Pt 1), 1071-1083.

9 Harlow, B.L., Vitonis, A.F., Sparen, P., Cnattingius, S., Joffe, H.,  Hultman, C. M. (2007). Incidence of hospitalization for postpartum psychotic and bipolar episodes in women with and without prior prepregnancy or prenatal psychiatric hospitalizations. Archives of General Psychiatry, 64(1), 42-48.

10 Manisha, S. (2005). The role of state public health in perinatal depression. Fact sheet. Association of State and Territorial State Officials.

11 Postpartum Mood Disorders. The Jennifer Mudd Houghtaling Postpartum Depression Foundation Website. Retrieved May 1, 2009 from http://www.ppdchicago.org/.

12 Onunaku, N. (2005). Improving maternal and infant mental health: Focus on maternal depression. National Center for Infant and Early Childhood Health Policy at UCLA.

13  Knitzer, J., Theberge, S., Johnson, K. (2008). Reducing maternal depression and its impact on young children: Toward a responsive early childhood policy framework. National Center for Children in Poverty, Project Thrive Issue Brief 2.

14 Position statement: Screening for  prenatal and postpartum depression. (n.d.). Perinatal Foundation and Wisconsin Association for perinatal Care. Retrieved April 9, 2009 from http://www.perinatalweb.org.

15 Isaacs, M. (2004). Community care networks for depression in low-income communities and communities of color: A review of the literature. Submitted to Annie E. Casey Foundation and the Howard University School of Social Work and the National Alliance of Multiethnic Behavioral Health Associations (NAMBHA).

16 Knitzer, J., Theberge, S., Johnson, K. (2008). Reducing maternal depression and its impact on young children: Toward a responsive early childhood policy framework. National Center for Children in Poverty, Project Thrive Issue Brief 2.

17 Ibid.

18 Abrams, L.S., Dorning, K. (2007). Bridging the gap: Barriers to service use among low-income women with postpartum depression. Funded by the Center for Vulnerable Populations Research at the UCLA School of Nursing and the UCLA Faculty Senate in cooperation with the Public Health foundation Enterprises WIC program.

19 Maternal Depression Making a Difference Through Community Action: A Planning Guide (n.d.). Mental Health America, Substance Abuse and Mental Health Services Administration (SAMHSA). Retrieved March 4, 2009 from: http://www.mentalhealthamerica.net/go/maternal-depression.

20 Ramsay, R. (1993). Postnatal Depression. Lancet, 314, 1358.

21 Carter, R. (2010). Within our reach: Ending the mental health crisis. New York, NY: Rodale, Inc.

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