Author Archive

Book Review: Traumatic Childbirth and an Interview with the Author – Cheryl Beck

January 9th, 2014 by avatar

By Walker Karraa, PhD

It is thought that traumatic childbirth affects up to 34% of all birthing women, but frequently there is inadequate prenatal preparation for what to do if an individual woman has this experiences and scant resources for women seeking support and help.  The experiences are minimized and our society creates a fence of isolation that women with birth trauma are surrounded by.  Today, Walker Karraa, PhD reviews a new book geared for professionals and interviews the author, Cheryl Beck, DNSc, CNM, FAAN,  so that we can be better prepared to recognize trauma, support women and provide resources. What are you doing as a birth professional and childbirth educator to help women who may be at risk or or who have experienced birth trauma? – Sharon Muza, Science & Sensibility Community Manager

 …a fascinating and full-bodied presentation of the emerging understanding of the impact of traumatic childbirth on mothers, fathers/partners, and providers.

Traumatic Childbirth1 should be required reading for any birth professional. The trifecta of midwife, pre-eminent researcher and Distinguished Professor at the School of Nursing, University of Connecticut, Cheryl Tatano Beck, clinical nurse specialist in psychiatry, psychotherapist and author Jeanne Watson Driscoll, and survivor, activist and founder of TABS Sue Watson, provides the most comprehensive resource on traumatic childbirth for health professionals to date.

© Cheryl Beck

© Cheryl Beck

Since Cheryl Beck’s ground-breaking research, Birth trauma: in the eye of the beholder2 (2004a), health providers, researchers, and birth professionals have applauded the relevance and strength of Cheryl Beck’s research regarding traumatic childbirth. Her research has covered PTSD following traumatic childbirth3-4, the experience of the anniversary of birth trauma5, breastfeeding after a traumatic birth6, subsequent birth after a previous traumatic birth7, secondary trauma experienced by labor and delivery nurses exposed to traumatic birth8, and multiple publications on research methods and birth trauma 9-12.

In 2006, Cheryl and Jeanne Watson Driscoll (co-author of the landmark Women’s moods: What every woman must know about hormones, the brain, and emotional health13) collaborated on what is still considered a clinical tour de force in perinatal mood and anxiety disorders, Postpartum mood and anxiety disorders: a clinician’s guide14.

TABS (Trauma and Birth Stress) was founded by Sue Watson and colleagues in 1998 and continues to offer current resources and support regarding traumatic childbirth.

In Traumatic Childbirth, Cheryl, Jeanne, and Sue offer their individual expertise as researcher, clinician, and activist and combined wisdom of nearly two decades of work in the field. The result is a compelling read and review of current literature. The case studies are profound examples of the lived experiences of traumatic childbirth. Additionally, after each case Jeanne and Sue offer their own perspectives. It is a fascinating and full-bodied presentation of the emerging understanding of the impact of traumatic childbirth on mothers, fathers/partners, and providers.

I am honored to have had the opportunity to ask Cheryl some questions for Science and Sensibility regarding how childbirth professionals might use Traumatic Childbirth in practice. I know that you will find her insights both useful and encouraging.

Walker Karraa: How has the definition of traumatic childbirth evolved since you began your work?

Cheryl Beck: In the beginning of my research traumatic childbirth was viewed as an event that occurs during labor and delivery that involved actual or threatened serious injury or death to the mother and or her infant. After my first 2 studies on birth trauma and its resulting PTSD what I learned was that traumatic childbirth can also occur even if a woman does not perceive that she or her infant is at risk for serious injury or death. Women can perceive their birth as traumatic if they perceive that they were stripped of their dignity during the birthing process.

WK: How does loss of dignity play a role in the traumatic birth?

CB: One of the most frequent phrases I hear mothers using to describe their traumatic their birth to me was “I felt raped on the delivery table with everyone watching and nobody offering to help me.” Some women shared that they felt like a piece of meat on an assembly line. Women did not feel cared for by the obstetrical team. To me this lack of caring stripped women of a protective layer during their labor and delivery and left them prime to perceive their birth as traumatic.

WK: How important is it for childbirth professionals to understand the subjective experience of childbirth trauma when working with clients?

CB: It is essential for childbirth professionals to hear and really listen to the voices of mothers as they describe what it was about their labor and delivery that was so traumatic. As the title of my first research study tried to impress upon health care providers, birth trauma is in the eye of the beholder. What one woman perceives as a traumatic birth may be viewed quite differently through the eyes of obstetric staff that may see it as a routine birth.

WK: What are some of the ways childbirth educators, doulas, and lactation consultants might use Traumatic Childbirth in developing curriculum or direct service to clients?

CB: Childbirth educators, doulas, and lactation consultants can use the various chapters in Traumatic Childbirth to develop a series of classes for education. Examples of some of these chapters in the book include:

  • Risk factors for postpartum posttraumatic stress
  • Assessment and diagnosis
  • Instruments to screen for PTSD
  • Impact of traumatic childbirth on breastfeeding
  • Anniversary of birth trauma
  • Subsequent childbirth after a previous traumatic birth
  • Treatment methods for PTSD
  • Fathers and traumatic childbirth

WK: As doulas are increasingly becoming a part of birth team, they too are exposed to traumatic births that may lead to distress, impairment and disability in their work. Given the findings in your recent study11 regarding secondary traumatic stress for labor and delivery nurses, I wonder what your thoughts are regarding how doulas might prepare, or even prevent secondary trauma for themselves using Traumatic Childbirth?


© Cheryl Beck

© Cheryl Beck

CB: In 1989 Charles Figley15  first wrote about the “cost of caring” for supporters of traumatized victims. He called it secondary traumatic stress or compassion fatigue. Doulas who have built up such a close relationship with the women they are supporting through labor and delivery certainly are at risk of developing secondary traumatic stress. Continuing education is a must for doulas to learn about their risk of secondary traumatic stress and the symptoms they should be watching. Self-awareness of these symptoms is essential so that doulas can get the help they need. Doulas need to learn how to nourish their mind-body-spirit. Debriefing sessions, support groups, and opportunities for doulas to share the traumatic childbirths they have been present for are necessary.

WK: I so appreciate the inclusion of fathers in your book. When I was practicing as a doula I had several fathers who they themselves had risk factors for traumatic stress due to experiences in military or law enforcement. Knowing that upfront, we were able to strategize labor and birth in ways to mitigate exposure to triggers (i.e. < seeing too much blood, not being able to see an open door, etc.). How could Traumatic Childbirth help childbirth educators include partners in the conversation about traumatic childbirth?

CB: Researchers are finding that fathers can also develop posttraumatic stress symptoms as a result of being present at their partner’s traumatic childbirth. This possibility for fathers should be address in one of the childbirth classes. As one father in a research study of mine and Sue Watson’s shared “I am on an island watching my wife drown and I don’t know how to swim! I not only do not know how to swim but I was drowning myself. But I am a man, I do not need help-John Wayne, you know. I was fooling myself at the expense of my wife and myself.” This quote impresses on childbirth educators their responsibility to also be helping the fathers and support them if he and his partner have experienced a birth trauma.

WK: One of the things I note is that we don’t yet have support systems within childbirth organizations to help our childbirth educators and doulas seek support for themselves, or colleagues who suffer extreme distress after attending traumatic births. This is particularly devastating for new doulas who may not know their own risk factors, or the signs and symptoms of traumatic stress following exposure to traumatic childbirth. What are some ways childbirth organizations such as Lamaze can use Traumatic Childbirth to inform policy and prevent secondary traumatic stress in doulas and childbirth educators?

CB: At the annual conferences of these organizations, workshops, sessions, or keynotes on secondary traumatic stress due to traumatic childbirth are a must. The first step in helping to prevent this or minimize secondary traumatic stress is education. Breakout sessions at the conferences could be offered by a mental health care professional for doulas, lactation consultants, and childbirth educators to provide an opportunity for them to share their traumatic experiences.


For those who have followed the research on traumatic birth, this book has been a long time coming! Traumatic Childbirth is a highly readable, compelling and comprehensive collection of research, practice, and perspective that speaks to the birth professional’s sensibilities. I highly encourage the discussion of implementing this material as required reading, and instituting the suggestions of debriefing workshops for professionals. I look forward to hearing your thoughts on this, as well as the book!

I know I speak for so many in thanking Cheryl Beck for her input, and to both Jeanne Driscoll and Sue Watson for their tremendous contributions in Traumatic Childbirth, and their dedication to the prevention and treatment of traumatic birth.


  1. Beck, C. T., Driscoll, J.W., & Watson, S. (2013). Traumatic childbirth. New York, NY: Routledge.
  2. Beck, C. T. (2004). Birth trauma: in the eye of the beholder. Nursing research, 53(1), 28-35.
  3. Beck, C. T. (2004). Post-traumatic stress disorder due to childbirth: the aftermath. Nursing Research, 53(4), 216-224.
  4. Beck, C. T. (2011). A metaethnography of traumatic childbirth and its aftermath: Amplifying causal looping. Qualitative Health Research, 21(3), 301-311.
  5. Beck, C. T. (2006). The anniversary of birth trauma: failure to rescue. Nursing research, 55(6), 381-390.
  6. Beck, C. T., & Watson, S. (2008). Impact of birth trauma on breast-feeding: a tale of two pathways. Nursing Research, 57(4), 228-236.
  7. Beck, C. T., & Watson, S. (2010). Subsequent childbirth after a previous traumatic birth. Nursing research, 59(4), 241-249.
  8. Beck, CT, & Gable, RK (2012). A mixed methods study of secondary traumatic stress in labor and delivery nurses. Journal of Obstetric Gynecological and Neonatal Nursing, 41, 747-760. doi:10.1111/j.1552-6909.2012.01386.x
  9. Beck, C. T. (2005). Benefits of participating in Internet interviews: Women helping women. Qualitative health research, 15(3), 411-422.
  10. Beck, C. T. (2006). Pentadic cartography: Mapping birth trauma narratives. Qualitative Health Research, 16(4), 453-466.
  11. Beck, C. T., Gable, R. K., Sakala, C., & Declercq, E. R. (2011). Posttraumatic Stress Disorder in New Mothers: Results from a Two‐Stage US National Survey. Birth, 38(3), 216-227.
  12. Beck, C. T. (2009). Critiquing qualitative research. AORN journal, 90(4), 543-554.
  13. Sichel, D., & Driscoll, J. W. (1999). Women’s moods: What every woman must know about hormones, the brain, and emotional health. New York: William Morrow.
  14. Beck, C. T., & Driscoll, J. (2006). Postpartum mood and anxiety disorders: A clinician’s guide. Jones & Bartlett Learning.
  15. Figley, C. R. (Ed.). (1989). Treating stress in families (No. 13). Psychology Press.




Birth Trauma, Book Reviews, Childbirth Education, Guest Posts, Trauma work , , , , , ,

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

November 11th, 2013 by avatar

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


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

Pixabay © David Mark. 2013

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

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

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

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

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

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

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

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

Crisis line resources for veterans and their families

Veterans Crisis Line

1-800-273-8255 (press 1)

Online chat is also available

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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


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


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

About Walker Karraa

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

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

Postpartum Psychosis: Review and Resources Plus Additional PPMAD Resources

October 8th, 2013 by avatar

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

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

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



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

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

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

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

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

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

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


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


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

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

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

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

If left untreated, some dire potential outcomes include: 

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

Risk Factors

  • Women with history of bipolar disorder or previous postpartum psychosis

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

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

Suggestions for Educators:


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

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

Remind: PPP is Rare but Real

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

Review the Facts

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

Refer to Resources

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

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

Resources for Women and Partners Postpartum Progress

 Postpartum Psychosis Symptoms (in Plain Mama English)

Postpartum Support International 1-800-944-4PPD

 National Suicide Prevention Lifeline 1-800-273-TALK

Mother to Baby (formerly OTIS)

Medications & More During Pregnancy & Breastfeeding.

(866) 626-6847

Text-4-Baby Health Info Links


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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

October 1st, 2013 by avatar

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


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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.


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.


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


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.


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)


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)


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.


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. 


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!


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.


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 , , , , , ,

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