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Kathy Morelli Shares Highlights from the 2014 Postpartum Support International Conference

July 15th, 2014 by avatar

Regular contributor Kathy Morelli attended the Postpartum Support International conference in Chapel Hill, North Carolina this past month.  In today’s post, Kathy shares her thoughts, some big take-aways and checks in with the keynote speakers, who share important messages on postpartum mood disorders with our S&S readers.  We all have a responsibility to increase awareness and treatment options for pregnant and postpartum women.- Sharon Muza, Science & Sensibility Community Manager.

PSI QuiltI want to shout from the rooftops that there are so many well-educated, caring and ethical professionals who are focusing on Maternal Mental Health! I was so fortunate to be able to attend this year’s Postpartum Support International 27th Annual Conference at the University of North Carolina (UNC) campus at Chapel Hill on June 18 – June 21, 2014.

PSI’s theme this year was “Creating Connections between Communities: Practitioners and Science: Innovative Care for Perinatal Mental Health.” It was a wonderful meeting where scholar-practitioners in the Perinatal Mental Health field met and exchanged information and best practices in order to hone their collective craft. Researchers, clinicians and identified survivors met and shared their professional and personal stories. PSI’s outgoing president, Leslie Lowell Stoutenburg, RNC, MS, reports that PSI had its largest attendance ever this year.

The keynote speakers were a group of experienced professionals, researchers and clinicians presenting on clinical, scholarly and advocacy topics: Dr. David Rubinow, of UNC Chapel Hill, Dr. Samantha Meltzer-Brody of UNC Chapel Hill, Dr. Marguerite Morgan, of Arbor Circle Early Childhood Services in Grand Rapids, Michigan, Ms. Joy Bruckhard of California’s 20/20 Mom Project, and Dr. Susan Benjamin Feingold, clinical psychologist, all presented about their work in the different aspects in the field of Maternal Mental Health. Advocate Katherine Stone of Postpartum Progress served as emcee at the Saturday night banquet.

Dr. David Rubinow presented on his team research regarding female hormonal fluctuations and the relationship to postpartum mood disorders in sensitive women. Dr. Rubinow is an internationally known expert in the evaluation and treatment of women with mood disorders that occur during periods of hormonal change. Regarding the team’s research, he states “Our data demonstrate that normal changes in reproductive hormones can produce affective disturbance in a susceptible group of women.” The study (Bloch et al, 2000) examined the role of endocrine factors in the etiology of postpartum depression (PPD) by comparing women with a history of PPD and without PPD. Progesterone and estriadiol was measured at baseline, addback, withdrawal, and folIow-up. 67% of the women who had PPD had a recurrence of significant affective symptoms, including a constellation of depressive and hypomanic affect, while none of the control group experienced significant affective symptoms. This indicates that women who suffer from PPD may have a trait vulnerability that isn’t present in women who do not suffer from PPD.

Dr. Susan Benjamin Feingold, the keynote speaker on Saturday evening, presented on her clinical work around the transformational nature of surviving postpartum depression, documented in her newly released book, Happy Endings, New Beginning: Navigating Postpartum Mood Disorders. Dr. Feingold presented inspirational journal entries from women in her clinical practice. She says: “ In my book, I focus on a new view of the postpartum experience and how this difficult time can be a catalyst for change, personal growth and positive transformation. Postpartum depression can be the opportunity for not only healing, but ultimately, it can be a life-changing event.”

Ms. Joy Bruckhard, MBA, of Cigna, presented on her advocacy work in as one of the founders of the Maternal Mental Health Care Collaborative in California called the 20/20 Mom Project. The 20/20 Mom Project is a national campaign and movement for moms and by moms to create specific pathways to treatment for maternal mental health disorders, to address barriers to mental health care. The 20/20 Mom Project has teamed up with Postpartum Support International, a sister non-profit to launch first-of-a-kind web-based training for clinical professionals with the aim of addressing the shortage of mental health and medical professionals who specialize in maternal mental health. Joy says: “I’m so honored to be a part of this important work. Three years ago, my worlds collided: my training through Junior League, my experience in health care working at Cigna and having had two babies myself (and perhaps mild postpartum depression), and some family experience with mental illness, I felt compelled to step up and do more.”

Dr. Samantha Meltzer-Brody, a psychiatrist at UNC Chapel Hill, presented about the ongoing stigma about using psycho-pharmaceuticals during pregnancy and breastfeeding. She expressed frustration that other medications are readily accepted for use during pregnancy, but that there is an ongoing stigma against using medications that treat the mother’s mental health.

Dr. Marguerite Morgan, LCSW, presented on her successful program with African American women at the Arbor Circle Early Childhood Services in Grand Rapids, Michigan. She emphasized that she drops her “PhD-Dr” demeanor and constantly strives to connect at a human level with the people she serves. She is well versed in Christianity and quotes biblical passages about helping oneself during dark times, thus normalizing the experience of depression to her population in an accessible manner.

The psychodynamic approach to perinatal mood disorders was presented by Ms. Lorraine Caputo, LMFT, which addresses the mental health of women across the lifespan. Research and clinical practice indicates that a woman’s previous life experiences can have an impact on her transition to parenthood. On the lifelong care of a woman’s mental health, Ms. Caputo says: “I believe it’s crucial to help women with a history of trauma to make connections between the past and present in a way that psychodynamic treatment is uniquely poised to provide. The perinatal period is a natural time of enormous change, and in the best of circumstances will cause dysregulation, psychological transformation and re-identifications and dis-identifications with one’s own parents. And, given how entirely a pregnant woman and a postpartum mother surrenders her body to her child, childhood sexual traumas in the mother’s past can be triggered by this intense period of physical and emotional bonding with her baby. A psychoanalytic intervention that involves the development of a coherent narrative about how she was parented, and making connections between unrelenting anxiety, ruminations, self blame, and her past history can free a new mother from self doubt, guilt, and fear that she will not be a good mother. This work is done in a carefully paced way, using self reflection and the relationship with the therapist to help the mother feel safe and her powerful feelings contained and held by the therapist.”

Dr. Kelly Brogan, of Womens Holistic Psychiatry, discussed holistic clinical pathways to reproductive mental health.

Of note was the unique reproductive psychiatric sharing session, where reproductive psychiatrists came together to discuss clinical situations which they have encountered. This session was an extension of the collaborative professional LISTSERV that PSI hosts for clinical member reproductive psychiatrists.

Sessions on Healthy Postpartum Relationships were presented by both Ms. Elly Taylor and Ms. Karen Kleiman, LMFT, of the Postpartum Stress Center. Karen Kleiman has recently published her book, Tokens of Affection: Reclaiming Your Marriage after Postpartum Depression, informed from her extensive clinical experience with postpartum couples. Ms. Kleiman presented her overarching framework for treating distressed postpartum couples, identifying 8 tokens to be cultivated in the therapeutic encounter. One of the tokens she refers to as a “Token of Affection.” Ms. Kleiman notes: “Recovery from postpartum depression does not happen overnight, thus, creating a lag between the crisis and a sense of well-being for the couple. During this transitional period both partners are anxious to return to normal while they are simultaneously challenged by buried negative emotions and unmet expectations. Tokens of Affection are gift-giving gestures on behalf of the relationship. As a reparative resource, the Tokens lead the way toward renewed harmony and reconnection.”

Elly Taylor remarks: “It’s common for couples – even happily married ones – to find that the bond between them becomes stretched following the birth of their baby. This comes as a shock for most and increases the risk for perinatal mood disorders for some. But prepare for this, and its possible not only to protect the bond, but build on it as the foundation for family.” She has recently published her book about the postpartum couple’s experience called, Becoming Us, in the United States.

Included here are some closing thoughts from the incoming PSI president, Ann Smith, RN, MSN, CNM:

“PSI is the original and leading organization dealing with perinatal mood disorder which we now know affects approximately 1 in 7 moms. It’s the leading complication of childbearing. All women can be affected regardless of age, race, socioeconomic status and whether the pregnancy was wanted. When treated promptly and by someone who has familiarity with these disorders, moms get better quite quickly. PSI has training programs nationwide which train providers in evidence based treatments. Many women need a combination of medication and talk therapy to get better as quickly as possible. There are a number of medications which have been proven safe for pregnancy and breastfeeding. Support groups are also helpful.

PSI wants everyone to remember three things:

You are not alone, you are not to blame, with help you will be well.

For assistance, call the PSI Warmline at 800-944-4PPD or visit online

References

Bloch, M., Schmidt, P. J., Danaceau, M., Murphy, J., Nieman, L., & Rubinow, D. R. (2000). Effects of gonadal steroids in women with a history of postpartum depression. American Journal of Psychiatry157(6), 924-930.

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Babies, Birth Trauma, Childbirth Education, Guest Posts, Infant Attachment, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, PTSD, Trauma work , , , , , ,

Childhood Sexual Abuse as a Risk Factor for Postpartum Depression- Part 2: The Educator’s Role

June 5th, 2014 by avatar
© CC Smoochi: http://flickr.com/photos/smadars/4758708634

© CC Smoochi: http://flickr.com/photos/smadars/4758708634

Kathy Morelli, perinatal mental health expert and S&S contributor is sharing information about the impact of childhood sexual abuse on women during the childbearing year.  Tuesday, in Part 1,  Kathy discussed the brain changes that can occur as a result of such abuse and today, Kathy shares the impact during the childbearing year and the role of the childbirth educator.  - Sharon Muza, Community Manager, Science & Sensibility

How do these underlying biological changes affect a woman during the childbearing year?

Childhood sexual abuse (CSA) and a woman’s subsequent reproductive life, including menstruation, pregnancy, birth and ongoing sexuality, occur at different times, maybe even in different decades, in a woman’s life. Yet, in clinical practice and in the research, these issues are intertwined.

In general, the research indicates that women who experienced childhood sexual abuse have more emotional distress in pregnancy, which directly impacts their physical health, which then impacts their pregnancy and leads to more medical interventions (Lev-Weisel, Daphna- Tekoah, and Hallak, 2009).

The somatic, body-based feelings in pregnancy can be re-triggering to a woman who has deep, non-verbal somatic memories of childhood sexual abuse. It’s important that women receive sensitive reproductive care, both physically and emotionally. An unaccepting attitude from her healthcare providers can trigger deeply held feelings of helplessness, fear, low self-worth and shame and actual flashbacks, symptoms of post-traumatic stress disorder (Lev-Weisel, Daphna- Tekoah, and Hallak, 2009).

The obvious sexual themes resonate on multiple levels: body-based, emotional and psychological. Yet, there hasn’t been lot of research about how a history of childhood sexual abuse impacts a woman’s mental health during pregnancy and postpartum. However, what research exists, finds that women who suffered from childhood sexual abuse have an elevated risk of postpartum depression (Lev-Weisel, Daphna- Tekoah, and Hallak, 2009).

There are a lot of body-based feelings in pregnancy that could be re-triggering to a woman who has deep, non-verbal somatic memories of childhood sexual abuse, even if she is being treated with respect and kindness in the present day.

Pregnancy

Prenatally, simple things such as the position of a woman’s body as she lays on her to be checked vaginally can bring back non-verbal emotional memories of past abuse. The baby moving inside her body might cause intense joy, but might also create an underlying, non-verbal uneasiness.

Birth

Childbirth is an intense experience; a time of hormonal, physical and emotional exertion. Due to the pre-existing priming of early trauma memory networks – an intense distressful emotion, a particular scent, or a body position – can trigger flashbacks to earlier traumatic experiences. Feeling powerless, not heard, or disregarded by healthcare providers during childbirth, can activate the symptoms of post-traumatic stress disorder. Her present day feelings of powerlessness and fear are amplified by pre-existing traumatic memories (Beck, Driscoll & Watson, 2013).

Remember the disregard by the medical professionals may just be due to the rush of the medical team as they attend professionally to a medical emergency. The medical protocol doesn’t have a person assigned to talking and listening to the mother during the event, so she feels disregarded (Beck, Driscoll & Watson, 2013).

However, even if she is being treated in a kind way, your client’s body positioning or a scent can recollect something from her past trauma. In an uncanny and timeless way, her body and mind remember the past and take her back to feelings of fear and helplessness. She may wordlessly freeze or panic, for what seems to be no present day reason.

Postpartum

Postpartum, there are physical, emotional and psychological factors feeding emotional health. As has been noted over and over again, a pre-existing personal depressive or anxiety disorder (PTSD is in the spectrum of anxiety disorders) will set up the body up for another episode postpartum. Drs. Deborah Sichel and Jeanne Driscoll (2000) say the brain chemistry “remembers” its previous old depressive pathway and finds its way back there. Plus, there’s a major swing in hormonal activity in your body as you adjust from high levels of pregnancy and birth hormones to pre-pregnancy levels. This adjustment is different for all women, depending on whether or not they are breastfeeding and on their individual differences in metabolism and individual sensitivity level to their own hormonal shifts (Sichel and Driscoll, 2000).

For new parents who grew up in an abusive home, there’s the added challenge of the emotional and psychological work required to examine and modify negative repetitive childhood patterns. It’s not an easy task for your client as she evaluates her past behavioral, emotional and psychological patterns and replaces them with new and more positive patterns about family life and parenting. This adds another level of complexity to parenting a newborn, itself a major lifestyle adjustment.

Adjusting to a new lifestyle with an infant and baby care is physically and emotionally challenging. Feelings of frustration emerge as your client adjusts her schedule yet again to accommodate her baby plus the endless touching and carrying may leave her feeling like her body isn’t her own anymore. Breastfeeding may feel triggering to some women if it invokes past experiences.

A Childbirth Educator Can Help

Childbirth educators can play a key role in helping a woman who has survived childhood sexual abuse to proactively manager her experience of pregnancy, birth and postpartum.The good news is that, even with all these challenges, it’s important to realize that your client’s childhood sexual abusive does NOT define her. There are many aspects of the self that compose her constellation of self-definition.

The human mind and body are plastic, so the past isn’t destiny. Remember to factor in the resiliency of human nature. With patience and perseverance, human beings can move beyond survivorship, learn to bloom and move into the “thriving” phase.

However, learning to thrive is not an easy task. There are no “five steps” here! Managing the effects of an abusive childhood is an ongoing, deeply personal experience. It’s honorable life work, and highly individualized. As your client moves along her healing path, she’ll choose what feels right for her.

She can work positively on herself and experience post-traumatic growth. Post-traumatic growth is inner growth through personal development. It’s possible for her to experience this growth arising from her painful experience, with her own inner work.

Below are some positive ideas you may want to keep in mind as you teach your childbirth education curriculum to a diverse set of families. Your raised consciousness will help create an inclusive space for women survivors CSA to enhance her experience of pregnancy, birth and postpartum.

Be sensitive to the emotional aspects of working with someone recovering from CSA.

Help her honor the importance of pregnancy, childbirth and motherhood

  • Encourage women to honor their experience of childbirth as the important developmental life passage it is. CSA survivors may tend to dissociate and dismiss their experiences
  • Encourage women to interview some providers. Have a list of referrals of gynecologists/obstetricians/midwives that you know are open to and sensitive to working with women recovering from CSA
  • Encourage women to give themselves the respect of investigating the hospital or birth center where her provider practices
  • Allow women to have the freedom to have a personally honorable birth experience, in any manner that birth happens
  • Allow women to feel that they are not less of a woman or a mother, however the birth experience happens. Each woman gets to choose her path in childbirth. Not other people or the unseen, but felt, social pressures.
  • People heal individually at their own pace.
  • Don’t pressure women to use her childbirth experience as a healing ritual. Childbirth is a life-changing experience, and each woman gets to choose how to experience this. If she wants to explore the idea of birth as healing, encourage her to be open to many options. But birth is unpredictable, don’t put this out there as the only way to define healing. There are many paths to healing.
  • Help her by doing what you’re best at: demystify childbirth while accepting her choices. Don’t impose your personal agenda about what is right and wrong for her birth experience
  • If she has alot of anxiety about childbirth, honor her by encouraging her to put in the emotional work with a mental health professional. Childbirth education, while important, may not be enough to manage anxiety, depression and post-traumatic stress symptoms. Prenatal fear of childbirth increases the likelihood of postpartum depression.
  • Encourage her to develop a daily, holistic relaxation practice to counteract the effects of stress imbalance

Discuss postpartum planning in your curriculum

  • Have a babymoon/postpartum plan in place
  • Encourage women to practice self-love by allowing time to rest
  • Encourage women to gentle with themselves – pregnancy and childbirth puts body and mind through a lot of hormonal changes!
  • Educate her about hormonal changes. Hormonal balance takes at least three months to come back to pre-pregnancy levels. The hormonal adjustments are individualized; it also depends on if the mother is breastfeeding or not.
  • Educate women to protect her fourth trimester, and help her body shift to-wards balance:
    • Rest; develop the mindset of being, not doing
    • Practice good nutrition with whole foods and good supplements
    • Get help: If she can afford it, time with a postpartum doula or a baby nurse will help her achieve balance and rest
    • Don’t underestimate the power of sleep; discuss sleep planning
    • Practice mindfulness and relaxation to counteract the inevitable chal-lenges of caring for a new born and the emotional change of identity in motherhood
  • Complementary care is nurturing, safe touch helps rebalance the body and mind
  • Social support is important. Have resources available. Women who “Tend and Befriend” in real life and online help mothers feel supported, Women and birth circles are important resources.
  • Expect emotional ups and downs
  • De-stigmatize professional help; there’s a lot of professional help available. If she feels very sad or anxious, it’s ok to seek help.

As a childbirth professional, you can positively affect your clients and their families. Know that childhood sexual abuse,  though prevalent, doesn’t define people, they can work through it to experience positive personal growth, through resilience and post-traumatic growth.

References

Beck, C. Driscoll, J., and S. Watson (2013). Traumatic childbirth. New York: Routledge Press.

Lev-Weisel, R., Daphna- Tekoah, S., Hallak, M. (2009). Childhood sexual abuse as a predictor of birth-related posttraumatic stress and postpartum posttraumatic stress. Child Abuse and Neglect, 33, 877-887.
Perez-Fuentes, G., Olfson, M., Villegas, L., Morcillo, C., Wang, S. & Blanco, C., (2013). Prevalence and correlates of child sexual abuse: a national study. Comprehensive Psychiatry, 5(1), 16-27. http://www.ncbi.nlm.nih.gov/pubmed/22854279

Plaza, A., Garcia-Estave, L., Ascaso, C., Navarro, P, et al. (2010). Childhood sex-ual abuse and hypothalamus-pituitary-thyroid axis in postpartum major depression. Journal of Affective Disorders, 122, 159-163.

Sichel, D. & Driscoll, J. (2000).Women’s Moods. New York: Harper Paperbacka.

Yampolsky, L., Lev-Wiesel, R., & Ben-Zion, I. Z. (2010). Child sexual abuse: is it a risk factor for pregnancy?. Journal of Advanced Nursing, 66(9), 2025-2037. doi:10.1111/j.1365-2648.2010.05387.x

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

Childhood Sexual Abuse as a Risk Factor for Postpartum Depression – Part 1

June 3rd, 2014 by avatar

Childhood sexual abuse can play a key role as a risk factor for postpartum depression.  Kathy Morelli takes a look at the impact of this horrible childhood event on a woman during her childbearing year.  Today, in Part 1 – we learn how the brain actually undergoes changes as a result of the trauma experienced.  On Thursday, Kathy Morelli will discuss how the woman who has experienced childhood sexual abuse (CSA) and what affect that has on her during the childbearing year,(pregnancy, birth and postpartum)  along with information and tips  for what childbirth educators can do.  Join us on Thursday for Childhood Sexual Abuse as a Risk Factor for Postpartum Depression – Part 2. – Sharon Muza, Community Manager, Science & Sensibility.

© CC Michelle Brea: http://flickr.com/photos/itsallaboutmich/451493421

© CC Michelle Brea: http://flickr.com/photos/itsallaboutmich/451493421

Woman to Woman Support

As I’ve said in my previous articles about Perinatal Mental Health, Lamaze childbirth professionals are very often the first point of contact for pregnant and new mothers. You’re an important resource in your community about pregnancy and childbirth, so becoming educated about the signs of perinatal mood/anxiety disorders and having an awareness about the prevalence of childhood sexual abuse (12% -20% of women) is an important aspect of your knowledge base. This article is meant to:

  • Increase awareness about the emotional aspects of surviving childhood sexual abuse (CSA)
  • Present a broad overview about the research regarding CSA
  • Present how CSA impacts a woman holistically, over her lifespan
  • Present how CSA impacts a woman specifically during childbearing
  • Discuss the complex recovery process from CSA
  • Generate ideas about whom to add to your community resource and referral list
  • Encourage being effective and supportive while preserving your own personal, certification and/or licensure boundaries

Remember, you may be the first person with whom she feels safe enough to discuss her personal history, even before her healthcare provider and sometimes even before her family. You can help out by being positively aware, being appropriately supportive and providing a list of contacts in the community and online.

Holistic View of a Woman’s Emotional History

Whenever a woman comes into my office for help for feelings of emotional and somatic distress during her pregnancy, childbirth experience and postpartum, I look at her life holistically, across her lifespan. I don’t assume, but I wonder, if she might be in that estimated 12% – 20% of women who have been sexually abused in their lifetime.

Is there a likelihood that past abuse affects how a woman feels about herself during pregnancy and childbirth and can be an underlying causative factor for antenatal depression or anxiety?

The research literature about the link between a woman’s past childhood sexual abuse and distress during pregnancy is scarce, but emergent research does show a connection.

How does a history of childhood sexual abuse (CSA) intersect with postpartum depression? This is a complicated question, but I’ll try to list some influential factors.

The HPA Axis is Modified: Fear and panic of CSA alters internal stress response

In general, research shows us that people who suffered from childhood sexual abuse (CSA) have a higher incidence of emotional, psychological and social distress, in addition to post-traumatic and physical, or somatic, symptoms. Specifically, research shows us that adult survivors of CSA suffer from higher rates of diabetes and cardiovascular symptoms (Plaza et al, 2010).

Women who have suffered past childhood sexual abuse suffer more unexplained gynecological symptoms, such as recurrent pelvic pain and more painful periods and sexual dysfunction than women who don’t have a traumatic sexual history (Lev-Weisel, Daphna- Tekoah, and Hallak, 2009). The stress and fear from childhood abuse manifests later on in adult life on all levels: body, mind and spirit.

What are some of the physical processes underlying this distress on the body and mind levels?

Researchers believe that long-term negative emotions, such as fear, panic and pain, cause an over-activation of the neural pathways in the brain associated with these strong emotions. The internal production of neurotransmitters, which affect mood, is affected. So chronic emotional stress impacts brain health.

The brain communicates with the pituitary and adrenal glands via the feedback loop called the Hypothalamus-Pituitary-Adrenal Cortex Axis (HPA Axis). The pituitary and adrenal glands are responsible for hormone production, which, in turn, affects the brain and our emotional state (Plaza et al, 2010).

During long-term childhood sexual abuse, the HPA Axis is continually activated and, with overactivation, the stress response becomes chronic, persisting throughout a lifetime. Thus, the chronic over-activation of the fear and pain response underlies anxiety disorders and chronic pain syndromes across the lifespan (Plaza et al, 2010).

During pregnancy and postpartum, hormonal changes are very dramatic, so there’s an additional adjustment for the mind and body to cope with. Thus, the hormonal changes during pregnancy also impact brain health via the pituitary and adrenal glands feedback loop.

Brain Development is Modified: Fear and panic of CSA can inhibit encoding of memories

Research shows that chronic fear and stress in childhood can actually inhibit the growth of some brain structures. In fact, some parts of the brain, such as the hippocampus, which is in charge of memory, are smaller in CSA survivors than people who were not abused in childhood. So, recollection of childhood memories is impaired.

In addition, brain imaging shows brain development is hindered in that there are less robust connections between the emotional part of the brain and the upper part of the brain (Plaza et al, 2010).

How do these underlying biological changes affect a person’s emotional health?

Survivors of childhood sexual abuse survivors are known to suffer from post-traumatic stress disorder, which has a constellation of symptoms on many levels: depression, anxiety, panic attacks, somatic pain, flashbacks and dissociative episodes.

Events that occured long ago in a woman’s life can still play a large role in her mental and physical health when she is pregnant, birthing and in the postpartum period. Join us on Thursday for Childhood Sexual Abuse as a Risk Factor for Postpartum Depression- Part 2: The Childbirth Educator’s Role.- SM

References

Beck, C. Driscoll, J., and S. Watson (2013). Traumatic childbirth. New York: Routledge Press.

Lev-Weisel, R., Daphna- Tekoah, S., Hallak, M. (2009). Childhood sexual abuse as a predictor of birth-related posttraumatic stress and postpartum posttraumatic stress. Child Abuse and Neglect, 33, 877-887.
Perez-Fuentes, G., Olfson, M., Villegas, L., Morcillo, C., Wang, S. & Blanco, C., (2013). Prevalence and correlates of child sexual abuse: a national study. Comprehensive Psychiatry, 5(1), 16-27. http://www.ncbi.nlm.nih.gov/pubmed/22854279

Plaza, A., Garcia-Estave, L., Ascaso, C., Navarro, P, et al. (2010). Childhood sex-ual abuse and hypothalamus-pituitary-thyroid axis in postpartum major depression. Journal of Affective Disorders, 122, 159-163.

Sichel, D. & Driscoll, J. (2000).Women’s Moods. New York: Harper Paperbacka.

Yampolsky, L., Lev-Wiesel, R., & Ben-Zion, I. Z. (2010). Child sexual abuse: is it a risk factor for pregnancy?. Journal of Advanced Nursing, 66(9), 2025-2037. doi:10.1111/j.1365-2648.2010.05387.x

Childbirth Education, Depression, Guest Posts, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, Uncategorized , , , , , , ,

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

October 1st, 2013 by avatar

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

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© www.revolutionpharmd.com

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

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

RX: Prescription-dispensary records

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

DX: Connecting diagnosis to depression

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Conclusion

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

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

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

References

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

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

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

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

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

Perception of Social Support and Increased Risk of PPD in Cities: Research Review

August 27th, 2013 by avatar

Today, regular Science & Sensibility contributor Walker Karraa shares a study that came out earlier this summer examining the incidence of postpartum depression and place of residence (rural vs urban.)  Women living in urban areas were more likely to suffer from PPD.  Are you surprised?  Why do you think that might be?  Take a look at the information Walker shares and join the conversation in the comments section.  If you work in an urban setting, are you doing everything you can to help mothers with this increased risk? Let us know. – Sharon Muza, Community Manager

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A new Canadian study has examined the relationship between place of residence and risk of developing postpartum depression (PPD) based on population-based sample. Vigod, Tarasoff, Bryja, Dennis, Yudin, & Ross (2013) presented Relation between place of residence and postpartum depression in the early release at Canadian Medical Association. The study is a comprehensive and complex analysis of the statistical indicators related between where women live and the risk for developing postpartum depression (PPD.) For childbirth professionals who practice in urban settings, the findings here underscore the need for heightened awareness of the issues of support and awareness regarding maternal mental health in pregnancy and postpartum.

source: futurity.org

An overview of the study objectives, design, methods, and results has been compiled. Finally, a brief discussion as to the role of childbirth professionals is offered, and resources are provided.

Objectives

The objectives of this study were as follows:

  1. To compare the risk of PPD among Canadian women living in rural and urban areas
  2. To identify factors that could explain any associations between place of residence and risk of postpartum depression (Vigod, et al., 2013, p. 1)

Design

Sample: Women who had recently given birth and responded to the 2006 Canadian Maternity Experiences Survey through the Public Health Agency of Canada and the Canadian Perinatal Surveillance System were contacted. The study is a comprehensive and complex analysis of the statistical indicators related between where women live and the risk for developing PPD.

Stratified sampling by province or territory ensured sample size and a simple random sample without replacement was pulled from each stratum.  Inclusion consisted of women age over 15 who had singleton birth and were living with their child at the time of the interview. Response rate of 78% were collected via telephone and computer assisted interview resulting in 6421 of 8244 women contacted, representing 76, 500 Canadian women nationally. The final sample was 6126.

Outcome Measure: All women were administered the Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden, Sagovsky, 1987). Risk of PPD was operationalized as anyone with a score of < 13 points.

Definitions of populations. The authors defined the types of populations as follows:

  • Rural: populations outside the settlements of 1000 or more people or outside areas with a population density of 400 more inhabitants per square kilometer (p. 2)
  • Semi-rural: population <30,000
  • Semi-urban: population 30,000-499,999
  • Urban: > 500,000

Additionally, the authors implemented a metropolitan-influence component in defining and compartmentalizing different populations:

To separate the women with the most potential for social isolation from those with less potential for isolation, we further divided women living in rural and small town areas by ‘metropolitan-influenced zone’. These zones indicate the percentage of residents who commute to urban centers. The zones are designated as strong (> 30% residents commute to urban core), moderate (5%-29% commute), weak (> 0%, but <5%) or no (0%) metropolitan influence. (Vigod, et al., 2013, p. 2)

Methods

A thorough panel of covariates was administered to data analysis, including: age, parity, marital status, SES, educational status, and country of birth, recent immigration (within 5 years), and distance travelled to birth. In addition, history of depression, substance/alcohol use and life stressors such as interpersonal violence, abuse, and social support during pregnancy and postpartum period were factored.  Medical covariates of complications during perinatal period included preterm birth, birth weight, NICU, and cesarean section. All data were analyzed through SAS version 9.3.

Findings

We found that Canadian women who lived in large urban areas (i.e., population > 500,000 inhabitants) were at higher risk of postpartum depression than women living in other areas. The risk factors for postpartum depression (including history of depression, social support and immigration status) that were unequally distributed across geographic regions accounted for most of the variance in the rates of postpartum depression. (Vigod et al., 2013, p. 5)

The authors noted that immigration status, interpersonal violence, and self-perceived health and social support were responsible for the variance. For example, in the area of perceived social support in pregnancy and postpartum, the following findings were noted in the table below. 

 Conclusions

The authors noted that modifiable risk factors included social support in pregnancy and postpartum. Childbirth professionals working in cities can provide invaluable social connectivity and access to key resources targeting this issue.  Issues of dislocation, immigration status, and domestic violence are risk factors for higher incidence of PPD that need to be addressed in education, training and curriculum. Resources for domestic violence and legal advocacy have been provided.  Each professional can create ways to offer the material to students and clients that remains within a scope of practice as defined by their certifying organization, and that resonates with h/her personal style and community needs. Please feel free to add to the list of resources!

 Resources

Postpartum Support International (resources in Spanish as well)

Interpersonal violence resources

National Domestic Violence Hotline: Staffed 24 hours a day by trained counselors who can provide crisis assistance and information about shelters, legal advocacy, health care centers, and counseling.

1-800-799-SAFE (7233); 1-800-787-3224 (TDD)

Domestic Violence Fact Sheets

Domestic Violence State Hotlines

Learn more for your own continuing education at the Department of Justice Office of Violence Against Women.

References

Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. The British journal of psychiatry, 150(6), 782-786.

Vigod, S. N., Tarasoff, L. A., Bryja, B., Dennis, C. L., Yudin, M. H., & Ross, L.E. (2013).  Relation between place of residence and postpartum depression. Journal of Canadian Medical Association. doi:10.1503/cmaj.122028.

 

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