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Exclusive Q&A with Rebecca Dekker – What Does the Evidence Say about Induction for Going Past your Due Date?

April 15th, 2015 by avatar

What does the evidence say about dueToday on Evidence Based Birth, occasional contributor Rebecca Dekker, Phd, RN, APRN, provides a comprehensive research review –  Induction for Going Past your Due Date: What does the Evidence Say?  I had an opportunity to preview the article and ask Rebecca some questions about her most recent project on due dates. I would like to share our conversation here on Science & Sensibility with all of you. Rebecca’s website has become a very useful tool for both professionals and consumers to read about current best practice.Consumers can gather information on the common issues that they maybe dealing with during their pregnancies. Professionals can find resources and information to share with students and clients.  How do you cover the topic of inductions at term for due date?  After reading today’s S&S post and Rebecca’s research post, do you think you might share additional information or change what you discuss?  Let us know in the comments section.- Sharon Muza, Community Manager, Science & Sensibility.

Note: if the Evidence Based Birth post is not up yet, try again in a bit, it should be momentarily.

Sharon Muza: Why did you decide to tackle the topic of due dates as your next research project and blog post?

Rebecca Dekker: Last year, I polled my audience as to what they would like me to write about next. They overwhelmingly said that they wanted an Evidence Based Birth article about Advanced Maternal Age (AMA), or pregnancy over the age of 35. As I started reviewing the research on AMA, it became abundantly clear to me that I had to first publish an article all about the evidence on due dates. This article on induction for due dates creates a solid foundation on which my readers can learn about induction versus waiting for spontaneous labor in pregnant women who are over the age of 35.

SM: When you started to dig into the research, were there any findings that surprised you, or that you didn’t expect?

RD: There were two topics that I really had to dig into in order to thoroughly understand.

The first is the topic on stillbirth rates. I began to understand that it’s really important to know which mathematical formula researchers used to calculate stillbirth rates by gestational age. It was interesting to read through the old research studies and letters to the editors where researchers argued about which math formulas were best. In the end, I had to draw up diagrams of the different formulas (you can see those diagrams in the article) for the formulas to make sense in my head, and once I did, the issue made perfect sense!

Before 1987 (and even after 1987, in some cases) researchers really DID use the wrong formulas, and it’s kind of funny to think that for so many years, they used the wrong math! In general, I thought the research studies on stillbirth rates by gestational age were really interesting…it raised questions for me that I couldn’t answer, like why are the stillbirth rates so different at different times and in different countries? Also, it was really clear from the research that stillbirth rates are drastically different depending on whether you are looking at samples that include or don’t include babies who are growth-restricted.

The other big breakthrough or “ah ha” moment I had was when I finally realized the true meaning of the Hannah (1992) Post-Term study. There was such a huge paradox in their findings… why did they find that the expectant management group had HIGHER Cesarean rates, when clinicians instinctively know that inductions have higher Cesarean rates compared to spontaneous labor? Since all of the meta-analyses rely heavily on the Hannah study, I knew I needed to figure this problem out.

There are a couple different theories in the literature as to why there were higher C-section rates in the expectant management group in Hannah’s study. One theory is that the induction group had Prostaglandins to ripen the cervix, while the expectant management group did not. However, in a secondary data analysis published by Hannah et al. in 1996, they found that this probably played just a minor role.

Another theory is that as women go further along in their pregnancy, physicians get more nervous about the risk of stillbirth, and so they may be quicker to recommend a Cesarean in a woman who is past 42 or 43 weeks, compared to one who is just at 41 weeks. This theory has been proposed by several different researchers in the literature, and there is probably some merit to it.

But in the end, I found out exactly why the C-section rates are higher in the expectant management group in the Hannah Post Term study (and thus in every meta-analysis that has ever been done on this topic). Don’t you want to know why? I finally found the evidence in Hannah’s 1996 article called “Putting the merits of a policy of induction of labor into perspective.” The data that I was looking for were not in the original Hannah study… they were in this commentary that was published several years later.

dekker headshotThe reason that Cesarean rates were higher in the expectant management group in the Hannah study is because the women who were randomly assigned to wait for spontaneous labor, but actually ended up with inductions, had Cesarean rates that were nearly double of those among women who had spontaneous labor. Some of these inductions were medically indicated, and some of them were requested by the mother. In any case, this explains the paradox. It’s not spontaneous labor that leads to higher Cesarean rates with expectant management… the higher Cesarean rates come from women who wait for spontaneous labor but end up having inductions instead. 

So the good news is that if you choose “expectant management” at 41-42 weeks (which is a term that I really dislike, because it implies that you’re “managing” women, but I digress), your chances of a Cesarean are pretty low if you go into spontaneous labor. But if you end up being one of the women who waits and then later on chooses to have an induction, or ends up with a medically indicated induction, then your chances of a Cesarean are much higher than if you had just had an elective induction at 41 weeks.

SM: What information do you recommend that childbirth educators share to help families make informed decisions about inductions and actions to take as a due date comes and then even goes, and they are still pregnant.

RD: First of all, I think it’s important for all of us to dispel the myth of the 40 week due date. There really is no such thing as a due date. There is a range of time in which most women will go into labor on their own. About half of women will go into labor by 40 weeks and 5 days if you’re a first-time mom (or 40 weeks and 3 days if you’ve given birth before), and the other half will go into labor after that.

The other thing that it is important for childbirth educators to do is to encourage families—early in pregnancy—to talk with their health care provider about when they recommend induction, and why.

There are some health care providers who believe strongly that induction at 39, 40, 41, or 42 weeks reduces the risk of stillbirth and other poor outcomes. There are parents who have the same preference. Then there are other health care providers who believe strongly that induction for going past your due date is a bad thing, and shouldn’t be attempted unless there are clear medical reasons for the induction. And there are parents who will tend to share that same preference. Either way, parents need accurate information about the benefits and risks of waiting versus elective induction at 41-42 weeks—because both are valid options.

But it’s probably best to avoid a mismatch between parents and providers. If parents believes strongly that they want to wait for spontaneous labor, and they understand the risks, but they have a care provider who believes strongly in elective induction at 41 weeks, then they will run into problems when they reach 41 or 42 weeks and their care provider disagrees with their decision.

Clearly, there are benefits to experiencing spontaneous labor and avoiding unnecessary interventions. But at the same time there is a rise in the relative risk of stillbirth starting at about 39 weeks, depending on which study you are looking at. However, the overall risk is still low up until 42 weeks. At 42 weeks, the risk of stillbirth rises to about 1 in 1,000 in babies who are not growth-restricted. The risk may be higher in some women who have additional risk factors for stillbirth. Women who experience post-term pregnancy (past 42 weeks) are more likely to experience infections and Cesareans, and their infants are more likely to experience meconium aspiration syndrome, NICU admissions, and low Apgar scores.

SM: Would you recommend that families have conversations about how their due date is being calculated, at the first prenatal with their health care providers. What should that conversation include?

RD: I would recommend asking these questions:

  • What is the estimated date range that I might expect to give birth—not based on Naegele’s rule, but based on more current research about the average length of a pregnancy?
  • Did you use my Last Menstrual Period or an early ultrasound to determine my baby’s gestational age?
  • Has my due date been changed in my chart at any point in my pregnancy? If so, why?

SM: The concept of being “overdue” if still pregnant at the due date is firmly ingrained in our culture. What do you think needs to happen both socially and practically to change the way we think about the “due date?”

RD: We need to start telling everyone, “There is no such thing as a due date.” To help women deal with the social pressure they may experience at the end of pregnancy, I’ve created several Facebook profile photos that they can use as their Facebook profile when they get close to their traditional “due date.” To download those photos, visit www.evidendebasedbirth.com/duedates

SM: How available and widely used are first trimester ultrasounds? If first trimester ultrasounds were done as the standard of care in all pregnancies, would it result in more accurate due dates and better outcomes? Do you think there should be a shift to that method of EDD estimation?

RD: I think the option of having a first trimester ultrasound definitely needs to be part of the conversation between a woman and her care provider, especially because it has implications for the number of women who will be induced for “post-term.” I could not find any data on the percentage of women who have an ultrasound before 20 weeks, but in my geographic area it seems to be nearly 100%, anecdotally.

If your estimated due date is based on your LMP, you have a 10% chance of reaching the post-term period, but if it’s based on an early ultrasound, you only have a 3% chance of reaching 42 weeks.

One strange thing that I noted is that ACOG still prefers the LMP date over an early ultrasound date. They have specific guidelines in their practice bulletin about when you need to switch from the LMP date to an ultrasound date, but the default date is still the LMP. I found that rather odd, since research is very clear that ultrasound data is more accurate than the LMP, for a host of reasons!

Before I published the due dates article, I reached out to Tara Elrod, a Certified Direct Entry Midwife in Alaska, to get her expert feedback as a home birth midwife. She raised an excellent point:

“It is of significant interest to me as a licensed midwife practicing solely in the Out-of-Hospital setting that ultrasounds done in early pregnancy are more accurate than using LMP. If early ultrasound dating was achieved, it’s thought that this would ultimately equate to less women being induced for post-term pregnancy. This is significant to midwives such as myself due to the scope-of-care regulation of not providing care beyond 42 weeks. While an initial- and perhaps arguably by some ‘elective’ ultrasound-  may not be a popular choice in the midwife clientele population, a thoughtful risk versus benefit consideration should occur, as to assess the circumstance of “risking out” of care for suspected post-dates. [In my licensing state, my scope of care is limited to 37+0 weeks to 42+0 weeks, with the occasional patient reaching 42 weeks and therefore subsequently “risking out,” necessitating a transfer of care.]” ~Tara Elrod, CDM

SM: What do you think the economic cost of inductions for due dates is? The social costs? What benefits might we see if we relied on a better system for determining due dates and when to take action based on being postdates?

RD: There are economic costs to both elective inductions and waiting for labor to start on its own. The Hannah Post-Term trial investigators actually published a paper that looked at the cost effectiveness of their intervention, and they found that induction was cheaper than expectant management. This was primarily because with expectant management, there were extra costs related to fetal monitoring (non stress tests, amniotic fluid measurements, etc.) and the increased number of Cesareans in the expectant management group.

But there are many unanswered questions about the cost-effectiveness of elective induction of labor versus waiting for labor to begin (with fetal monitoring), so I’m afraid I can’t make any definitive statements or projections about the economic and social costs of elective inductions. Here is a study that may be of interest to some with further information on this topic.

I do know that in a healthy, low-risk population, birth centers in the National Birth Center Study II provided excellent care at a very low cost with women who had spontaneous births all the way up to 42 weeks. I would love to see researchers analyze maternal and neonatal outcomes in women stratified by gestational age in the Perinatal Data Registry with the American Association of Birth Centers.

 SM: I very much look forward to all your research posts and appreciate the work  and effort you put into doing them. What is on your radar for your next piece?

RD: The next piece will be Advanced Maternal Age!! After that, I will probably be polling my audience to see what they want, but I’m interested in tackling some topics related to pain control (epidurals and nitrous oxide) or maybe episiotomies.

SM: Is there anything else that you want to share about this post or other topics?

RD: No, I would just like to give a big thank you to everyone who helped in some way or another on this article!! There was a great interdisciplinary team who helped ensure that the due dates article passed scrutiny—we had an obstetrician, family physician, nurse midwife, several PhD-prepared researchers, and a certified direct entry midwife all provide expert review before the article was published. I am so thankful to all of them.

References

Hannah, M. E., C. Huh, et al. (1996). “Postterm pregnancy: putting the merits of a policy of induction of labor into perspective.” Birth 23(1): 13-19.

Hannah, M. E., W. J. Hannah, et al. (1992). “Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. The Canadian Multicenter Post-term Pregnancy Trial Group.” N Engl J Med 326(24): 1587-1592.

 

 

 

Cesarean Birth, Childbirth Education, Evidence Based Medicine, informed Consent, Maternal Quality Improvement, Maternity Care, New Research, Research , , , , ,

Birth By The Numbers Releases New Video – Myth and Reality Concerning US Cesareans

March 19th, 2015 by avatar

birth by numbers header

I have been a huge fan of Dr. Eugene Declercq and his team over at Birth by the Numbers ever since I watched the original Birth by the Numbers bonus segment that was found on the Orgasmic Birth DVD I purchased back in 2008.  I was on the board of REACHE when we brought Dr. Declercq to Seattle to speak at our regional childbirth conference in 2010 and since then have heard him present at various conferences around the country, including most recently at the 2014 Lamaze International/DONA International Confluence, where Dr. Declercq was a keynote speaker.  I enjoy listening to him just as much now as I did back in 2008.  You  may also be familiar with Dr. Declercq’s work as part of the Listening to Mothers research team that has brought us three very valuable studies.

Birth by the Numbers has grown into a valuable and up to date website for the birth professional and the consumer, filled to the brim with useful information, videos, slide presentations and blog posts.  This past Tuesday, the newest video was released on the website: Birth By The Numbers: Part II – Myth and Reality Concerning US Cesareans and is embedded here for you to watch.  We shared Part I in a blog post last fall.


Also available for public use is a slide presentation located in the the “Teaching Tools” section of the Birth by the Numbers website designed to provide additional information, maps, data and resources for this new Myths and Reality Concerning Cesareans video. Included in this slideshow are notes and updates to help you understand the slides and share with others.  This material is freely given for your use.

© Birth by the Numbers

© Birth by the Numbers

This video explores how cesareans impact maternity care systems in the USA.  After watching the video and reviewing the slides, here are some of my top takeaways.

1.  The common reasons given for the nearly 33% cesarean rate in the USA (bigger babies, older mothers, more mothers with obesity, diabetes and hypertension, more multiples and maternal request) just don’t hold water when examined closer.

2. Many women feel pressure from their healthcare provider to have a cesarean, either prenatally or in labor.

3. The leading indicators for cesareans are labor arrest (34%) and nonreassuring fetal heart tracings (23%).

4. The rise in cesareans is not a result of a different indications.  Dr. Declercq quotes a 20 year old article’s title that could still grace the front pages today. “The Rise in Cesarean Section Rate: the same indications – but a lower threshold.”

5. When examining the distribution of cesarean births by states over time, it is clear that those states with the highest cesarean birth rate decades ago, still remain in those spots today.

6. “We are talking about cultural phenomena when we are talking about cesareans, not just medical phenomena.”

7. First time, low risk mothers who birthed at term and experienced labor had a 5% cesarean rate if they went into spontaneous labor and did not receive an epidural.  If they were induced and received an epidural, the cesarean rate was 31%.

8. The United States has the lowest VBAC rate of any industrialized country in the world.

© Birth by the Numbers

© Birth by the Numbers

While the video is rich (and heavy) in data laden charts and diagrams, the message, though not new, is clear.  The US maternity care system is in crisis.  We have to right the ship, and get back on course for healthier and safer births for pregnant people and babies. Take a look at this new video, and think about what messages you can share with the families you work with and in the classes you teach, to help consumers make informed choices about the care they receive during the childbearing year.

Please watch the video, visit the website to view the slides and let me know here in the comments section what you are going to use from this information to improve birth.

Babies, Cesarean Birth, Childbirth Education, informed Consent, Maternal Obesity, Maternal Quality Improvement, Maternity Care, Medical Interventions, New Research , , , ,

“Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth”, Part Three, Interview with Walker Karraa

March 17th, 2015 by avatar

By Cynthia Good Mojab, MS, LMHCA, IBCLC, RLC, CATSM

© Walker Karraa

© Walker Karraa

Last week, Cynthia Good Mojab provided Science & Sensibility readers with the first two parts of her three-part series on the book “Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth” by Dr. Walker Karraa. Today on the blog, Cynthia shares her recent interview with Karraa. Dr. Karraa provides additional insights on her research and discusses her thoughts on how the book has been received and can be beneficial to professionals and families alike. I recommend that you go back and read Part One and Part Two as well as today’s interview. – Sharon Muza, Community Manager, Science & Sensibility.

Cynthia Good Mojab: First, Walker, let me start with congratulations! I found your book to be a page-turner. I think what you’ve uncovered is very important. I’m so grateful that your book is now a resource for perinatal care providers, lay supporters, and new parents. Have you gotten reader feedback yet? 

Walker Karraa: I have gotten feedback. The feedback I’ve gotten has been very much like what you’ve just shared. People have said that it reads very quickly. I like that feedback because it says that it reads for clinicians and for lay people. It reads from the stories. I didn’t want to take out the literature review—I believe that it’s important for individuals and families that experience perinatal mood and anxiety disorders to have access to that information. I struggled with how to put context in and not have it be heavy. So, I’m glad to hear this. I did have one reader tell me that it was hard to read emotionally because the stories hit home. I think that it is a hard read. It certainly was hard to research. I didn’t see that coming. It was hard to hear the stories and be touched in my own experience of postpartum depression. I was so surprised by the stark, universal level of suicidal ideation. That was one of the most surprising things.

CGM: I think that the structure of the book, the writing style, and how statistics have been combined with real life experiences are very effective. That it’s a painful read is actually helpful because we need many more people to grasp postpartum depression at a deeper level so we can change whether we screen, how we screen, and what kind of services, support, and treatment we’re providing.

WK: I think that is what is different about my work—both in the approach I took to the research question and how I went in asking. I got answers that are that deep and that reveal a picture of postpartum depression experienced as trauma. And, that’s why it’s a hard read. I will always be thankful on a deep, profound, personal level to the twenty women who sat with me in those initial interviews and the women, another ten after, who shared the most difficult parts of their lives. So, I’m so thankful that they had that courage because it revealed that there’s more to the paradigm of postpartum depression than, how we think of it right now anyway, a form of depression with a pervasive sadness.

And, you know we all have social constructs of depression as lack of energy, sadness, incredible fatigue, sleeping too much, these kinds of general symptoms. There’s no diagnosis for postpartum depression [in the DSM-5]. It’s an onset specifier for major depression. So, we all look at these symptoms as depression. And, what the women in the study showed us is that their symptoms go beyond the symptoms of major depression. And that there’s something that happens within the context of having a major depressive episode and a new baby that is shattering to all that women have known prior to that to be things that they could count on in the world—all of those preconceived assumptions about what was predictable in the world were completely decimated. So, that collision and deconstruction of the self that they all shared is a trauma to witness, and they see it themselves; they watched themselves almost from a dissociative place. So, I do think and I hope that it offers the opportunity for everybody to have a larger conversation about how the effect of a mood disorder after the birth of a child can be traumatic.

CGM: Another thing that really struck me in your book, Walker, was how unprepared the women were when they experienced the onset of symptoms of postpartum depression. Tell me more about that.

WK: Even the women who had a history of mental health challenges were completely unprepared for the physical and psychological symptoms of postpartum depression. Their providers had not prepared them and their social world had not prepared them. So, when those symptoms hit, they had no context for being able to articulate to anyone what was happening. As a result, the “During” aspect of experiencing postpartum depression was unbelievable invisibility as the symptoms got worse and worse and worse because they had been so unprepared. Because perinatal care providers were not offering the feedback—I see you and you are feeling this way—the situation reached critical mass for all of them. And, what was so interesting to me is that every single participant was responsible for her own recovery. She alone found her way to help. They had all been asking for help….They weren’t shy—which was different than what we see in the literature. What we see in the literature is that stigma keeps women from talking. But, these women were saying “Hi, I want to die and you don’t see me.” Often a provider would say something like, “You’re telling me you want to die. Why don’t you try putting your iPod on when your baby cries.” And, what was it that made them decide to stay? I would say it was the love of their baby. And, that, no one has looked at in the research. All these women had a plan when they were nearest death. They all had suicidal ideation. They all had thoughts of harming themselves or others. They all were at that quintessential existential end of the rope when they then reached out to someone that they hadn’t yet reached out to, all on their own. And, they didn’t want to die. They wanted the symptoms to end. That is very important. And for some, treatment meant going to hospital. For some it meant getting medication. For some it meant both.

CGM: My clients also tell me that very few providers are screening them for perinatal mental health challenges or even asking a casual “How are you doing with this?” Or they tell me how they start trying to tell care providers how they feel and they will get the same kind of discounting response like what you’re describing. We have other research that shows how undetected perinatal mental health challenges are. It’s just so clear that we are collectively failing.

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

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

WK: I have a tremendous amount of respect for providers. I don’t think it’s their fault. I think that there is such stigma around mental illness—and in particular around mental illness in new mothers—that we’re blind. We are not receiving training to look at our own biases—to see that the elephant in the room is the belief that new mothers with mental illness are going to harm their babies. And we have Greek mythology and modern media to help support that belief. So, yes, it’s the primary responsibility of a care provider and that’s why women go to care providers because that’s who you go to when you say that you’re sick and you need help. But, the care providers themselves, including OBs, general doctors, ER doctors, psychiatrists, the whole realm of childbirth professionals…they haven’t been given the opportunity or the mandate to look at their own internalized and institutionalized stigma.

CGM: Like you said earlier, the stigma taps into our own fears. We’re afraid. It tugs on our own internal memories and experiences of when we’ve been vulnerable or someone significant in our life has been vulnerable.

WK: Yes. We are afraid. But women have been doing this for millennia. Most women get through it. And, this is what we need to help women know. The women in my book are just a tiny little window into the millions of women throughout the ages who have the fortitude, the skill, the strength, to be dragged through hell and survive. And not only survive, but be transformed. It’s beyond recovery. This is the trauma literature. This is the incredible literature from Tedeschi and Calhoun regarding posttraumatic growth that needs to be brought into the birth world. And, Viktor Frankl—the famous Viktor Frankl, Auschwitz survivor…. He endured that process. Every human being does that and women will do that. So we’re talking about what obstacles and paradigms are set against women. What I learned in the book is that women are more resourceful because of their attachment to their children—because of their unbelievable strength of love for their infant—than we know. I would even go so far as to say that, if I had a huge funding source, I would do a study on my hypothesis that women who have perinatal mood and anxiety disorders are more attached. We’re not less attached. We may have periods where we are less attached, but staying present while experiencing that makes us more connected.

CGM: Look at the love that it takes to feel so bad inside and still go and do these attachment building behaviors over and over and over again. The attachment is still being built even if parents can’t see it. And, the other thing I really appreciate about your work is that it’s such a refreshing focus on growth. Attending to growth is very effective and links well with cognitive behavioral therapy and solution-focused brief therapy. And, it makes me wonder, instead of what are all the risk factors, can we do some research on resiliency factors and on growth factors? What is it that helps parents grow through this and how can we nurture that?

WK: I hope more clinicians will read the book and think about these things. You know Tedeschi and Calhoun have a wonderful model for clinical intervention that’s growth based. And it’s only been used in situations that have already been identified as traumatic. But they have a really strong model for how to work with people who experience trauma, clinically, to develop more growth. And, I’m not a clinician. If I were, I would be interested in doing that kind of work. They were kind enough to let me use their scale. I found off the chart suicidal ideation. So, I asked them if I could use their posttraumatic growth inventory with the original sample and they obliged. And my wonderful original 20 women all took it. And they scored off the charts for growth. So then I interviewed somebody who is an expert in posttraumatic growth. And I also sent my result to Richard Tedeschi. I wanted some feedback: is this growth? And, they both said, well, it’s a small sample—it’s only 20—but yes. And, furthermore, they said that the level that I was getting off those scales is much higher than in other populations that they had looked at, such as people who had been through terrorist attacks or rape or surviving cancer. So, again, if I had money for research, applying that posttraumatic growth inventory to women who had been through a perinatal mood disorder would be really valuable on a larger scale.

CGM: I know it’s a small qualitative study, but what is your sense of how generalizable your findings might be?

WK: You know, generalizability in qualitative research is not necessarily a concern. Grounded theory would say that the generalizability of the findings has to do with if you’ve sampled well. And, theoretical sampling is about getting a condensed understanding. It’s like essential oil—you want the essence of it. I tell my doctoral students, who are just learning about the difference between qualitative and quantitative research, that quantitative research is like a fisherman casting a really wide net—huge—and you gather as much data in that net as far as you can go. And, that gives you information about the nature of the farthest reach of the ocean. Qualitative research goes straight down, plumbs straight down into the ocean—you know, a core area where the essence of that part of the ocean is. And, then you can take that and ask the same questions in other parts of the ocean. And, that would be the next part of the research.

CGM: Exactly. I know the whole purpose of your study was not to answer the question how generalizable transformation is but to explore the phenomenon of transformation. Your study design allowed you to do that. The question I have is: who do you think the women in your study are? Do you think they had characteristics that make them different than the big broad ocean? What did you notice about their membership in different social groups even though that was not the focus of your study?

WK: I have a couple of responses to that. First, it would be definitely an indication of the need for future research. In the demographics that I got, I would say that it was pretty diverse regarding race. And, socioeconomic status was all over the place. It was very diverse in terms of educational status. I had women with professional degrees and women with a high school education. But they were all English speakers. And when I say racially diverse, I will say that they identified as “American.” So, I didn’t have folks who were immigrants and that’s definitely something that should be looked at. Regarding whether there is some different quality in women who transform through postpartum depression, again I look at the research done by Tedeschi and Calhoun. They’re looking at that very issue. Are there personality characteristics that lend themselves more toward being able to grow through a traumatic event? What they have found is that people who are more optimistic are slightly more likely to experience growth through trauma than those who are not. But, it’s not set in stone. In other words, the numbers aren’t so high that we can go out and say that if you’re an optimistic person you’re going to have this amazing growth. There are so many variables involved with the quality of the growth, the characteristics of the person, access to time, and the circumstances. I think that there are probably shades of growth—that anybody who has ever been through a clinical mood disorder following the birth of a child probably experiences some amount of growth. And, this is just me shooting from the hip. I think there’s something inherent in being a parent. All of the research about having a child in the NICU, losing a baby, losing a baby in pregnancy…these are all traumas. Anything that’s a life or death experience is a trauma. And every human being grows. That’s just my personal belief. It’s just the human experience that we have the ability to grow—because we need to make meaning about these horrible things that happen. And, that meaning usually comes from making choices to believe in our ability as a parent. 

CGM: What is your number one take away? How do you think your findings can be applied by childbirth educators, doulas, midwives, and other perinatal care providers?

WK: I think that the take away is that it’s a call to action. At the very least 1 in 7 of your clients or your students is going to have this experience. What are you going to do about it? What kinds of information do you need to be able to help them? And then ask your organizations to give you that.

CGM: In my work as a clinician and an educator, I need tools and resources that I can point people to that I think are useful. So, I’m really excited about your book. I think it’s going to have a lot of ripple effect in terms of new research but also in supporting a shift in broadening our worldview of postpartum depression to include growth. So, I think your work is great. I’m so delighted that you did the research and you published it.

WK: Thank you so much for spending this time. It’s been a pleasure and a gift. I so appreciate it.

About Cynthia Good Mojab

cynthia good mojab headshot 2015Cynthia Good Mojab, MS Clinical Psychology, is a Clinical Counselor, International Board Certified Lactation Consultant, author, award-winning researcher, and internationally recognized speaker. She is the Director of LifeCircle Counseling and Consulting, LLC where she specializes in providing perinatal mental health care. Cynthia is Certified in Acute Traumatic Stress Management and is a member of the American Academy of Experts in Traumatic Stress and the National Center for Crisis Management. Her areas of focus include perinatal loss, grief, depression, anxiety, and trauma; lactational psychology; cultural competence; and social justice. She has authored, contributed to, and provided editorial review of numerous publications. Cynthia can be reached through her website

Book Reviews, Childbirth Education, Depression, Guest Posts, Infant Attachment, Maternal Mental Health, New Research, Perinatal Mood Disorders, Postpartum Depression , , , , , , , ,

Book Review – Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth – Part Two

March 12th, 2015 by avatar

By Cynthia Good Mojab, MS, LMHCA, IBCLC, RLC, CATSM

Dr. Walker Karraa has written an insightful book examining depression as a transformative event in the lives of women who have experienced it after the birth of a child. Cynthia Good Mojab, MS, LMHCA, IBCLC, RLC, CATSM, reviews Dr. Karraa’s book and interviews her in a three-part series on “Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth.”  Today, Cynthia examines two theories that relate to Dr. Karraa’s research and book and shares her commentary on the book’s findings.  Next week, Cynthia will share her interview with Walker Karraa, regarding her research and book. Find Part One of this series here. – Sharon Muza, Community Manager, Science & Sensibility.

walker book header

One of the many things I appreciate about Dr. Walker Karraa’s (2014) book, Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth, is its multidisciplinary mindset. Not only does she contribute to broadening our understanding of postpartum depression beyond a worldview focused on pathology, Karraa seeks to understand the bigger theoretical picture in which postpartum depression as transformation can be placed. This isn’t just analysis for the sake of analysis. When we understand how and why something happens, we become more able to seek out and identify factors that help it happen and that get in the way of it happening. Having a good framework for understanding transformation through postpartum depression will help guide future research and application of that research with a goal of improving identification of, support for, and treatment of new parents with postpartum depression. In this commentary, I share my thoughts about two theoretical frameworks that can aid in our understanding of growth after postpartum depression: posttraumatic growth and positive disintegration.

Posttraumatic Growth or Positive Disintegration?

In chapter 7, “Trauma and Transformation,” Karraa (2014) reviews several theoretical frameworks that might explain how postpartum depression can be experienced as traumatic and precipitate transformation. She ultimately settles, quite insightfully, on posttraumatic growth (Tedeschi & Calhoun, 2004; Tedeschi & Calhoun, 2004). She also acknowledges the historical understanding that people often grow through experiencing life’s challenges. How many of us have heard some version of Nietzche’s maxim, “What does not destroy me, makes me stronger”?

When I read Karraa’s book, the explanatory theory that came to mind was Dabrowski’s theory of positive disintegration (Mendaglio, 2008a), which predates the coining of the term “posttraumatic growth” (Tedeschi & Calhoun, 2004a, 2004b; Nelson 1989). Positive disintegration is a theory of personality development that has been extensively researched and applied in the fields of giftedness and gifted education though it encompasses the development of all people. I have found Dabrowski’s theory both personally and professionally helpful in understanding how people are and are not changed by difficult life experiences, including the experience of postpartum depression. The theories of posttraumatic growth and positive disintegration have notable parallels and connections (Tillier, 2014; Mendaglio & Tillier, in press). Furthermore, the growth that can be experienced after a traumatic event fits well within the broader scope of the theory of positive disintegration.

Dabrowski’s theory of positive disintegration posits that personality has the potential to be dynamic—a possible journey toward authenticity and altruism—and that negative emotions are essential, though insufficient, for its development (Mendaglio, 2008a). (The quality of the social environment, for example, can support or hinder development.) Therefore, depression and anxiety, which we experience as negative symptoms we wish to eliminate, can also be understood positively as precursors of growth. A full description of the theory—and related research, analysis, and applications—is well beyond the scope of this commentary (see Mendaglio, 2008a). And, it understandably takes time to become accustomed to the terminology used to describe the theory. But, in brief, Dabrowski theorized that personality is shaped over the lifetime through two developmental processes, disintegration and reintegration, that involve five levels of development (Mendaglio, 2008b, pp. 34-39). We begin life with a less developed mental organization that seeks to meet basic biological instincts, needs, and drives and conforms to unquestioned social norms. (This is called level 1, “primary integration.”) As we struggle with internal conflicts caused by developmental milestones and life crises, we experience intense emotions, like anxiety and despair, as well as uncertainty and confusion about our identity. When we find that what we know and believe does not help us cope with and make sense of a crisis, our mental organization becomes less fixed and our distress increases. (This is called level 2, “unilevel disintegration.”) At that point, we have three basic options in our developmental path: 1) we can stay in a state of unilevel disintegration (which holds risks like suicidality, psychosis, and traumatic stress reactions), 2) we can return to (reintegrate at) our prior level of mental organization, or 3) we can move toward the transcendence of our original level of mental organization (we can grow).

Another way of describing the disintegration seen with depression and the possibility of personality development is the experience of existential depression. In existential depression, we struggle with our lack of control in our lives as well as with the very meaning of life and ourselves within it:

“While not universal, the experience of existential depression can challenge an individual’s very survival and represents both a great challenge and at the same time an opportunity—an opportunity to seize control over one’s life and turn the experience into a positive life lesson—an experience leading to personality growth.” (Webb, 2008, pp. 1-2).

This is exactly what Karraa (2013, 2014) describes in her research: postpartum depression threatening a woman’s physical and psychological survival (thus qualifying as a traumatic life experience) and resulting in transformation to an entirely new way of thinking, feeling, acting, and being in the world (e.g., more authentic and altruistic). Karraa is describing posttraumatic growth as well as the even bigger picture of personality development through positive disintegration.

walker head shot 2In Dabrowski’s theory, moving toward greater personality development after experiencing unilevel disintegration involves three more levels (Mendaglio, 2008b, pp. 37-39). In the first of these, we spontaneously start to examine, challenge, and reject beliefs and understandings that no longer work for us. We begin to see the clash between the actual (how things are) and the ideal (how things should be). We develop more autonomy and authenticity toward ourselves and others. And, we experience great distress while engaging in this work. (This level is called “spontaneous multilevel disintegration.”) In the next level of moving toward greater personality development, we cultivate a stronger sense of social justice, empathy, and responsibility for others. We become active agents in our learning, growing, and healing. And, our daily behavior is more consistently guided by higher values that are increasingly aligned with our transforming ideals. (This is called “organized multilevel disintegration.”) The last level is the full development of our personality. Our behavior is in alignment with the hierarchy of values that we consciously constructed during our developmental struggles—rather than with unexamined values that are common in our society or with our basic needs and drives. Because of this alignment, we are able to live in harmony with ourselves. (This is called “secondary integration.”) This very brief description of Dabrowski’s theory of positive disintegration leaves out a great deal of nuance and detail. But, I hope that it conveys that positive disintegration offers a useful framework for explaining transformation after postpartum depression.

Clinical Experience with Positive Disintegration through Postpartum Depression

In my experience as a perinatal mental health care provider, parents coping with perinatal depression, anxiety, and trauma are often helped by Dabrowski’s positive reframing of their symptoms as potential harbingers of growth; they become less afraid of what they are going through as well as more hopeful about the future. The analogy I use is that sometimes we have to take something that isn’t working apart so that we can re-assemble it in a better way. Like a child knocking over a tower of blocks, we can build anew. And, this is what I often see in postpartum depression, particularly in the context of moderate to severe postpartum depression: something isn’t working at a very fundamental level. Our conscious and unconscious expectations may have been shattered by our experiences in pregnancy, birth, parenting, and/or life. We may grieve the loss of roles that were intertwined with our very identities. Our relationship to ourselves and to others may be jolted profoundly out of balance by the arrival of a completely dependent baby whose unrelenting needs chronically supersede our own in a widespread context of insufficient social support. Our very paradigm of who we are and how the world works may be challenged to the core right when sleep deprivation diminishes our capacity to even try to make sense of it all. Our lifeways may not support our experience of severe stress, creating an inflammatory response (Kendall-Tackett, 2007) and a diminished capacity to physiologically sustain our mental well being. And, the dominant culture in the US impossibly expects us to return quickly to our before-baby lives and selves as though nothing out of the ordinary has happened and without feeling anything negative because “having a baby is a happy event.”

If this doesn’t qualify as a developmental milestone—as well as a life crisis—with the potential to trigger what Dabrowski calls “unilevel disintegration,” I don’t know what does! No wonder so many new parents experience postpartum depression. When our depression is on the more severe end of the spectrum, we disintegrate. We fall apart. We are shocked by the onset, magnitude, and nature of the symptoms of our devastation (Karraa’s “I Was Shattered;” Dabrowski’s “disintegration”). We experience this disintegration as a threat to our survival—meeting the definition of a traumatic event. If we stay in a prolonged state of disintegration, we may become suicidal, experience psychosis, or live with the debilitating symptoms of traumatic stress. Or, our recovery can return us to our prior level of functioning (Karraa’s “Getting Better;” Dabrowski’s reintegrating at the level of “primary integration”). Or we may instead take control of our development and healing, intentionally choose higher values to guide our behavior, increase our empathy and authenticity, and experience transformation and reintegration at a higher level of personality development (Karraa’s “I Was a Different Person” and “Metamorphosis;” Dabrowski’s “organized multilevel disintegration” and “secondary integration”).

Perinatal researchers and clinicians whose worldview is solely a medical model of postpartum depression may not recognize its developmental potential (Karraa’s “posttraumatic growth;” Dabrowski’s “positive disintegration”), viewing the goal of treatment only as the elimination of “negative” symptoms rather than as the facilitation of transformation. But individual experience, clinical experience, and now Karraa’s research show that both recovery and transformation are possible.

Whose Voices Were Heard?

The goal of Karraa’s research was to deeply explore the nature of transformation through postpartum depression—something that had not yet been studied. Her qualitative approach matches this goal perfectly. In a small qualitative study, it’s not surprising that she did not collect much demographic data related to the social group membership of the 20 women who participated in her study. She does report ascertaining their occupations (e.g., mental health care provision, marketing, finance, higher education, computer science, volunteer), which suggest that many participants had at least a middle class socioeconomic status (SES). Speaking English and having access to internet, email, and phone communication were inclusion criteria for the study. So, overall, the reported demographic data hint that many participants had access to resources, opportunities, and power that are disproportionately available to members of dominant social groups (e.g., white, at least middle class SES, cisgender, heterosexual, able-bodied).

I am left wondering: whose voices were included and whose were excluded in this initial research? If they were not included in this small study, what would we learn from the voices of depressed new mothers who cannot afford to attend college or to volunteer; who live in the chronic stress of poverty (Isaacs, 2004); and/or who do not have equitable access to culturally competent mental health care, support, and information? If they were not included in this small study, what would we learn if we had heard the voices of depressed new parents of a variety of gender identities/expressions and sexual orientations (Abelsohn, Epstein, & Ross, 2013) who live with intergenerational trauma (Graff, 2014) and the trauma of inescapable, ongoing racism (Bryant-Davis & Ocampo, 2005), cisgenderism (Mizock & Lewis, 2008), classism (Collins et al., 2010), ableism (Browridge, 2006), and/or other systems of oppression?

Dabrowski’s theory of positive disintegration recognizes the role of a variety of factors on personality development, including the effect of the social milieu (Mendaglio, 2008a). Do those who live as members of social groups targeted by systems of oppression have equitable access to experiencing postpartum depression as both suffering and recovery, much less as growth? Are there circumstances in which the human spirit is so persistently crushed that transformation after postpartum depression cannot occur even when the potential for growth exists? Or would the resiliency that can manifest even amidst chronic stress and trauma (Mullings & Wali, 2001) allow growth to still be possible? Further research and analysis is needed to uncover 1) how growth is and is not experienced by depressed new parents who hold membership in a wide variety of social groups, 2) what social factors support or undermine transformation after postpartum depression, 3) what kind of information, support, and treatment best supports growth after postpartum depression in a variety of social contexts, and 4) how perinatal organizations, care providers, and lay supporters can contribute to the dismantling of institutional oppression that creates inequitable access to resources and services that support recovery and growth from postpartum depression. And, then we need to take action to provide effective support and treatment that is equitably accessible to all new parents.

Conclusion

That people have the capacity for growing through life’s challenges has long been recognized. Karraa’s (2014) book, Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth, offers a moving account of such transformation in the context of postpartum depression. The fact that the women in her study experienced physical and psychological symptoms that threatened their survival led Karraa to insightfully frame their transformation as an example of posttraumatic growth. Transformation through postpartum depression can also be understood through the lens of the theory of positive disintegration—a theory which subsumes and is broader than the experience of growth after trauma. Positive disintegration explains the possible outcomes of 1) transformation through a traumatic experience of postpartum depression, 2) recovery without transformation, and 3) remaining in a prolonged state of disintegration (e.g., suicidality, psychosis, traumatic stress reactions). Both theories offer hope to new parents experiencing the devastation of moderate to severe postpartum depression. Postpartum depression is more than pathology; it can lead to deeply meaningful transformation. Regardless of which theoretical framework is used to explain growth after postpartum depression, Dr. Karra’s findings are a compelling invitation for further exploration and application. I hope that her work will inspire more multidisciplinary research and analysis of the development that can come from postpartum depression so that more new parents will have access to the information, support, and treatment that they need to recover—and possibly even to be transformed.

References

Abelsohn, K., Epstein, R., & Ross, L. (2013). Celebrating the “other” parent: Mental health and wellness of expecting lesbian, bisexual, and queer non-birth parents. Journal of Gay & Lesbian Mental Health, 17(4), 387-405.

Browridge, D. (2006). Partner violence against women with disabilities: Prevalence, risk, and explanations. Violence Against Women, 12(9), 805-822.

Bryant-Davis, T. & Ocampo, C. (2005). The trauma of racism: Implications for counseling, research, and education. Counseling Psychologist, 33(4), 574-578.

Collins, K., Connors, K., Davis, S., Donohue, A., Gardner, S., Goldblatt, E., Hayward, A., Kiser, L., Strieder, F., & Thompson, E. (2010). Understanding the Impact of Trauma and Urban Poverty on Family Systems: Risks, Resilience, and Interventions. Baltimore, MD: Family Informed Trauma Treatment Center.

Graff, G. (2014). The intergenerational trauma of slavery and its aftermath. Journal of Psychohistory, 41(3), 181-97.

Isaacs M. (2004). Community Care Networks for Depression in Low-Income Communities and Communities of Color: A Review of the Literature. Washington, DC: Howard University School of Social Work and the National Alliance of Multiethnic Behavioral Health Associations.

Karraa, W. (2013). Changing Depression: A Grounded Theory of the Transformational Dimension of Postpartum Depression. (Doctoral dissertation). Retrieved from ProQuest/UMI. (3607747.)

Karraa, W. (2014). Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth. Amarillo, TX: Praeclarus Press.

Kendall-Tackett, K. (2007). A new paradigm for depression in new mothers: The central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health. International Breastfeeding Journal, 2(6), 1-14.

Mendaglio, S. (Ed.) (2008a). Dabrowski’s Theory of Positive Disintegration. Scottsdale, AZ: Great Potential Press.

Mendaglio, S. (2008b). Dabrowski’s theory of positive disintegration: A personality theory for the 21st century. In S. Mendaglio (Ed.), Dabrowski’s Theory of Positive Disintegration. Scottsdale, AZ: Great Potential Press.

Mendaglio, S. & Tillier, W. (2006). Dabrowski’s theory of positive disintegration and giftedness: Overexcitability research findings. Journal for the Education of the Gifted, 30(1), 68-87.

Mendaglio, S. & Tillier, W. (in press). Discussing Dabrowski: Has the time come to emulate Jung? A response to Piechowski’s most recent rethinking of the theory of positive disintegration: I. The case against primary integration. Roeper Review.

Mizock, L. & Lewis, T. (2008). Trauma in transgender populations: Risk, resilience, and clinical care. Journal of Emotional Abuse, 8(3), 335-354.

Mullings, L. & Wali, A. (2001). Stress and Resilience: The Social Context of Reproduction in Central Harlem. New York: Kluwer.

Nelson, K. (2004). Dabrowski’s theory of positive disintegration. Advanced Development Journal. 1989; 1:1-14.

Tedeschi, R. & Calhoun, L. (2004a). Posttraumatic growth: A new perspective on psychotraumatology. Psychiatric Times, 21(4), 1-4.

Tedeschi, R. & Calhoun, L. (2004b). Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry, 15(1), 1-18.

Tillier, W. (2014). Dąbrowski 201: An Introduction to Kazimierz Dąbrowski’s Theory of Positive Disintegration [PDF document]. Retrieved from http://www.positivedisintegration.com/Dabrowski201.pdf

Webb, J. (2008). Dabrowski’s theory and existential depression in gifted children and adults. The Eighth International Congress of the Institute for Positive Disintegration in Human Development. Calgary, Alberta, Canada.

About Cynthia Good Mojab

cynthia good mojab headshot 2015Cynthia Good Mojab, MS Clinical Psychology, is a Clinical Counselor, International Board Certified Lactation Consultant, author, award-winning researcher, and internationally recognized speaker. She is the Director of LifeCircle Counseling and Consulting, LLC where she specializes in providing perinatal mental health care. Cynthia is Certified in Acute Traumatic Stress Management and is a member of the American Academy of Experts in Traumatic Stress and the National Center for Crisis Management. Her areas of focus include perinatal loss, grief, depression, anxiety, and trauma; lactational psychology; cultural competence; and social justice. She has authored, contributed to, and provided editorial review of numerous publications. Cynthia can be reached through her website.

 

 

Birth Trauma, Childbirth Education, Depression, Guest Posts, Maternal Mental Health, New Research, Parenting an Infant, Perinatal Mood Disorders, Postpartum Depression, Trauma work, Uncategorized , , , , , , , , ,

Book Review – Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth, Part One

March 10th, 2015 by avatar

 By Cynthia Good Mojab, MS, LMHCA, IBCLC, RLC, CATSM

transformed cover

Walker Karraa, PhD, a former contributor to Science & Sensibility, has authored a new book, Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth, that speaks to what lies on the other side for the 20 women she interviewed about their experiences with postpartum depression. Cynthia Good Mojab, MS, LMHCA, IBCLC, RLC, CATSM, who specializes in supporting people with postpartum mood and anxiety disorders and birth trauma presents a three-part series related to Dr. Karraa’s book. Today on the blog, Cynthia outlines the books content and its implications for practice. On Thursday, Cynthia shares her commentary on some of Dr. Karraa’s research and conclusions. Next week we are offered a glimpse into the person behind the book, when an interview with Dr. Karraa is shared with blog readers. Follow all three parts of this series on “Transformed by Postpartum Depression.” – Sharon Muza, Science & Sensibility Community Manager.

 In the last several decades, our awareness and understanding of postpartum depression have steadily increased. A wealth of research now exists regarding its prevalence, risk factors, prevention, symptoms, consequences, and treatment. Organizations, like Postpartum Support International and Postpartum Progress, champion the needs of families touched by postpartum depression and other perinatal mental health challenges, counter stigma, and contribute critical support and information to the safety net that all new families need and deserve. Many states in the United States have enacted legislation or developed projects related to public education, screening, and/or treatment for perinatal mental health challenges. And, at the national level in the US, the 2020 Mom Project seeks to remove institutional barriers that prevent depressed new mothers from being identified and accessing treatment.

In spite of this progress, we do not see the prevalence of postpartum depression dropping. Globally, it is as high as 82.1% when measured using self-reported questionnaires and as high as 26.3% when measured using structured clinical interviews (Norhayati, Nik Hazlina, Asrenee, & Wan Emilin, 2014). In fact, we see that depression during pregnancy and after birth routinely goes undetected and untreated (Miller et al., 2012). How is that possible? And, beyond the statistics that we have now amassed, what is it really like to experience postpartum depression, come out the other side, and make meaning from the experience?

Posttraumatic Growth after Postpartum Depression

In her new book, Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth, Walker Karraa, PhD (2014) invites readers to join her in a touching and thought provoking exploration of the potentially transformative nature of postpartum depression. Her book, which is based on the findings of her dissertation research (Karraa, 2013), brings to light both the suffering and development that women can experience on this journey. In fact, her book is one of the fruits of her own transformation through her experience of severe postpartum depression. Parents, lay supporters, and perinatal care providers who appreciate the blend of research and women’s voices found in books like Depression in New Mothers: Causes, Consequences, and Treatment Alternatives (Kendall-Tackett, 2010) and Traumatic Childbirth (Beck, Driscoll, & Watson, 2013) will also appreciate Karraa’s book. It should certainly be considered “required reading” for perinatal care providers and lay supporters.

walker karraa head shot 2015Karraa begins with a brief review of the literature, including what postpartum depression is, who develops it, and its global prevalence, risk factors, and consequences. These facts and figures help orient the reader to the general nature and scope of a veritable global mental health pandemic. They also serve to illustrate the foundation of the dominant discourse regarding postpartum depression: an allopathic worldview that frames mental illness as pathology. The following five chapters, however, contribute to an expansion of that view by illustrating how postpartum depression can be experienced as a long and painful journey culminating in positive change.

In the course of conducting her qualitative research, Karraa used grounded theory to analyze the answers of 20 women to four questions (Karraa, 2013) about their experience of postpartum depression:

  • How would you describe your process of transformation through postpartum depression?
  • In what ways did you experience the process of transformation through postpartum depression?
  • What were the ways you saw yourself transforming?
  • How do you experience this transformation currently?

She uncovered five stages of transformation through postpartum depression: before, during, ending, after, and beyond. That the women described 1) feeling shocked by the nature and magnitude of their symptoms, 2) enduring physical and psychological disintegration to which care providers seemed oblivious, and 3) slowly finding a path toward recovery will strike a familiar chord for lay supporters, perinatal care providers, and individuals who have worked and/or lived with postpartum depression. What might not be familiar to all readers are the last two stages that Karraa identified: 4) an increase in self-care, self-confidence, authenticity, and compassion; improved relationships; and alteration of perception of self and purpose in the world; and 5) coming to view postpartum depression as resulting—paradoxically—in a profoundly positive transformation.

In her 7th chapter, Karraa gives the reader a thoughtful tour of her consideration of several theories that might explain her research participants’ experiences of transformation through postpartum depression. Ultimately, she recognized that the prolonged endurance of threat to their physical and psychological survival was so great that the women experienced postpartum depression as a traumatic life event and that the transformative nature of their experience of postpartum depression is, thus, an example of posttraumatic growth: “positive psychological change experienced as a result of the struggle with highly challenging life circumstances” (Tedeschi & Calhoun, 2004).

In chapter 8, Karraa shares the confirming feedback of four experts in the field of postpartum depression, including the illustrious Cheryl Tatano Beck, Jane Shakespeare-Finch, Karen Kleinman, and Jane Honikman. Then she closes with a chapter acknowledging that her work has revealed a connection that has been right under our noses waiting for us to formally notice and describe: postpartum depression is one of the adversities of life that can precipitate growth. Karraa researched, recognized, and named that connection. Naming an experience honors it. It also provides a language for new parents, lay supporters, perinatal care providers, and researchers to use as they seek to express, understand, provide support for, treat, recover from, and/or grow from the life-altering experience of postpartum depression. And, perhaps most importantly, it offers hope to those who are fighting their way back from the devastation of postpartum depression. Not only can recovery be found at the end of the darkest tunnel; transformation may await.

Care Provider Failure: A Call to Action

The power of Karraa’s book continues in its appendices, where she describes an informal survey that serves as an(other) urgent call to action for all of us: in spite of the high prevalence of postpartum depression and its negative consequences when untreated, we are collectively failing to help those who are experiencing it. Because so many women in her qualitative study reported that their care providers had failed to help them, Karraa conducted the Changing Depression Survey (n=486). When asked who was most responsible for their getting help for postpartum depression, 65.4% of her participants selected “Self,” 23.0% selected “Partner,” 16.9% selected “Family Member,” 11.7% selected “Medical Care Provider” (which includes OB/GYN, Midwife, General or Family Physician), 8.8% selected “Other (Friend),” and 6.6% selected “Therapist.” When asked who was least helpful in getting them help for postpartum depression, 43.2% of her participants selected “Medical Care Provider,” 21% reported “Family Members,” 20.6% reported “Partner,” 19.3% reported “Self,” and 6.8% reported “Therapist.”

While this is, admittedly, an informal survey, the patterns seen here match clinical experience as well as research findings that only a fraction of new mothers with postpartum depression are identified and treated (Milgrom & Gemmill, 2014). My own clients, who are new parents, frequently report finding me after seeing a series of care providers who did not formally screen or refer them for perinatal mental health challenges, did not informally ask them about how they are coping with new parenthood, and/or did not respond with sensitivity, validation, or assistance when they tried to share their struggles. A delay in diagnosis, support, and treatment can both worsen and prolong suffering for new parents struggling through postpartum depression. Karraa’s research suggests that, in some cases, it may also delay the experience of posttraumatic growth.

This call to action must be heard and effectively responded to by individuals as well as by institutions. Yes, perinatal care providers and lay supporters will benefit from reading Karraa’s book. But, reading the book is not the same as developing the skills to apply the book’s insights in practice. Her research is an invitation for organizations and credentialing institutions in the diverse fields that provide services to new families (e.g., childbirth education, doula care, midwifery, obstetrics, pediatrics, family practice medicine, lactation education, lactation consulting, counseling, social work, psychiatry, naturopathic medicine) to develop, offer, and require training related to perinatal mental health, including:

  • how to reduce stigma and increase awareness by educating expectant and new parents about perinatal mental health issues
  • why, when, and how to screen and refer
  • how to effectively provide care to new parents struggling with perinatal mental health challenges—including using approaches that incorporate an understanding of postpartum depression as potential transformation to be nurtured, not just as pathological symptoms to be eliminated.

Conclusion

Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth consistently engages the reader with the poignant and inspiring stories of 20 women, as well as with the intriguing insights of the author and four experts in the field. The moving narratives and cogent analysis effectively describe the women’s experience of postpartum depression as traumatic and the transformation of their suffering into growth. The book also invites us to transcend the dominant view of postpartum depression as pure pathology and to learn how to take effective action to keep new parents struggling with perinatal mental health challenges from falling through the cracks. I congratulate Dr. Karraa on authoring a book that makes such a meaningful contribution to our understanding of postpartum depression and, refreshingly, offers a significant focus on recovery and development. Join me here on this blog on Thursday to read my commentary regarding frameworks that might explain her findings as well as my hopes for future research.

References

Beck, C., Driscoll, J., & Watson, S. (2013). Traumatic Childbirth. New York: Routledge.

Karraa, W. (2013). Changing Depression: A Grounded Theory of the Transformational Dimension of Postpartum Depression. (Doctoral dissertation). Retrieved from ProQuest/UMI. (3607747.)

Karraa, W. (2014). Transformed by Postpartum Depression: Women’s Stories of Trauma and Growth. Amarillo, TX: Praeclarus Press.

Kendall-Tackett, K. (2010). Depression in New Mothers: Causes, Consequences, and Treatment Alternatives. New York: Routledge.

Milgrom, J. & Gemmill, A. (2014). Screening for perinatal depression. Best Practice & Research Clinical Obstetrics & Gynaecology, 28(1), 13-23.

Miller, L., McGlynn, A., Suberlak, K., Rubin, L., Miller, M., & Pirec, V. (2012). Now What? Effects of On-Site Assessment on Treatment Entry After Perinatal Depression Screening. Journal of Women’s Health, 21(10), 1046-1052.

Norhayati, M., Nik Hazlina, N., Asrenee, A., & Wan Emilin, W. (2014). Magnitude and risk factors for postpartum symptoms: A literature review. Journal of Affective Disorders, 175C, 34-52.

Tedeschi, R. & Calhoun, L. (2004). Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry, 15(1), 1-18.

About Cynthia Good Mojab

cynthia good mojab headshot 2015Cynthia Good Mojab, MS Clinical Psychology, is a Clinical Counselor, International Board Certified Lactation Consultant, author, award-winning researcher, and internationally recognized speaker. She is the Director of LifeCircle Counseling and Consulting, LLC where she specializes in providing perinatal mental health care. Cynthia is Certified in Acute Traumatic Stress Management and is a member of the American Academy of Experts in Traumatic Stress and the National Center for Crisis Management. Her areas of focus include perinatal loss, grief, depression, anxiety, and trauma; lactational psychology; cultural competence; and social justice. She has authored, contributed to, and provided editorial review of numerous publications. Cynthia can be reached through her website.

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