Archive for the ‘PTSD’ Category

Series: Supporting Women When a VBAC Doesn’t Happen – Part Three: Supporting The Mothers

November 12th, 2015 by avatar

By Pamela Vireday

“Remember, no effort that we make to attain something beautiful is ever lost.” – Helen Keller

cbac part 3Today we conclude our three part series on Cesarean Birth after Cesarean, written by Pamela Vireday, who is an occasional contributor to Science & Sensibility.  In this series, Pamela examines the topic of women who experience a Cesarean Birth after a Cesarean. This is when families are planning for a vaginal birth after a prior cesarean, but the birth does not go as planned.  The experiences of women who have a CBAC are often negated and their emotional and physical well-being given short-shrift by both professionals and their social community of friends and family.  The research on this topic is slim and begs for exploration by qualified investigators.  Last week, Pamela discussed the unique grief that CBAC women may experience. Two days ago, Pamela examined the limited research available on CBAC births in part two.  Today, Pamela will provide information on how to support CBAC women in the absence of published research.  There is also great set of resources in the post to share with the families you work with or include in a CBAC Resource packet you provide after birth. You can also read a companion piece of Pamela’s own personal story, “Cesarean Birth after Cesarean, 18 Years Later” on her own website.- Sharon Muza, Community Manager, Science & Sensibility.

In the first post of our series –  Supporting Women When a VBAC Doesn’t Happen – Part One: A Unique Grief, we discussed how women who want and work for a VBAC but end up with a cesarean have a unique grief that is different from a primary cesarean or an elective repeat cesarean. Many women who have experienced a CBAC say they felt unsupported and isolated. They had nowhere to tell their stories, nowhere to process their anger, and got little sympathy from those around them.

In the second post – Supporting Women When a VBAC Doesn’t Happen – Part Two: The Forgotten Mothers, we examined what research there is on CBAC mothers and found limited wisdom to guide us. In the absence of research on how best to help CBAC mothers, we must rely on the words and experiences of CBAC mothers to tell us what they need.

In the final part of our series today, we suggest concrete ways that birth professionals can support CBAC mothers, based on suggestions made by CBAC mothers themselves. Keep in mind that each story and woman is unique, and the needs of one may be different than the needs of another. The best thing to do is to follow the lead of the CBAC mother; she will tell you in word and deed how best to support her.

Create a Safe Space for the Birth Story

One of the most important things that birth professionals can do to help CBAC mothers is to give them a safe space to tell their stories ― their full stories.

CBAC mothers often edit their stories for others, leaving out their disappointment or scary details because people only want to hear the happy parts. When they try to tell the full story, they may hear, “Just get over it already” or “Oh, we’re not going to talk about that again, are we?” CBAC mothers also often self-edit their stories in order not to discourage or scare other expectant mothers. But an untold story is one that weighs heavy on the heart.

Be the safe person to whom the full birth story can be told. Be truly present while listening. Don’t armchair-quarterback her story; suspend your judgment, put aside your own birth agendas, and focus only on supporting this woman, right now, in this situation. Eliminate distractions, use attentive body language, and really focus on the woman so that she truly feels like she is being heard.

Realize that she may need to tell the story multiple times; each time she tells it, she processes it on a new and different level. Ask her, “What do you need from me right now?” so she can tell you if she wants something more than just listening. If possible, check in with the woman’s partner, who may also need help processing or understanding why the mother is still coming to terms with her experience.

“Listen. Listen. And don’t contradict. Just listen. Don’t compare. Just listen. And don’t try to make me feel better. Just listen.”     – Kristina R.

Use Creative Support Techniques

Once the mother is ready to start processing the birth story further, use reflective listening techniques. Listen to what she says, seek to understand what seems most important to her, and paraphrase back to see if you understood her point. Don’t make assumptions about how she is feeling or add judgments. Ask open-ended follow-up questions that invite her to explore her feelings if she is ready. Give her the time and space to come to her own conclusions about her experience.

Many women find that journaling, making art, singing, writing poetry, and participating in rituals is helpful in processing their emotions. This can be particularly helpful for those who get stuck in a negative feedback loop or who need to process significant trauma. Don’t be afraid to refer to a good birth-supportive therapist in your area if needed.

Validate the Mother

CBAC mothers need to have their experiences and feelings validated. Mothers need to be reminded that their hard work and accomplishments during birth are still valid, however the baby was born. Acknowledge the amazing sacrifice she made in giving up her own dreams and bodily integrity for her baby.

“CBAC women need validation. They need encouragement that every birth can be different. Above all, they need to be appreciated for the work they did both before and during the experience, the sacrifices made for their babies, and the special place inside themselves that now carries yet another scar.” – Teresa Stire

“Effort does not always equal outcome. Give yourself credit for that effort, and don’t boil it all down to the moment of birth alone.” -Melek Speros

Encourage Bonding

Bonding can be especially difficult after a physically or emotionally traumatic birth. Others may have stepped in to care for their babies, which can leave some mothers feeling incompetent or disconnected.

Start by encouraging more time with the baby. Promote as much skin-to-skin contact as possible; this helps produce more oxytocin and may help breastfeeding too. Some women find bathing or napping with babies to be very healing.

It can be helpful to compartmentalize grief behind an emotional door so women can focus on their baby’s immediate needs, on their older children, and on their own physical needs. However, it’s important that women schedule time periodically to take out the grief, actively work through it, and then put it away. Otherwise, grief may intrude on the bonding process.

Give the Mother Support Resources

Create a CBAC Resource Packet that you can email or hand out as needed. Include a list of CBAC support sites, CBAC brochures, and names of local postpartum doulas or birth therapists. Edit it to each woman’s unique situation.

The International Cesarean Awareness Network (ICAN) has a new brochure about CBAC, which will be available soon in its store, as well as a website dedicated specifically to CBAC, including an archive of CBAC stories. In addition, there is a closed ICAN support group on Facebook just for CBAC mothers.

Although not all CBAC mothers experience post-traumatic stress symptoms, having birth trauma resources in the CBAC Resource Packet puts the ball in the mother’s court and lets her decide the emotional ramifications of her experience. It also gives her concrete options for reaching out for further support, possibly even long after your working relationship with her is over.

Help Her Connect with Other CBAC Mothers

CBAC moms are their own best mentors. This may be the only place CBAC women find others who truly “get” what they are going through.

The unique feelings around CBACs may mean that birth groups, especially those centering on VBACs, could be uncomfortable for a while. Many CBAC mothers feel intensely jealous when hearing other women’s easy birth stories. They may need to insulate themselves for a bit. Taking a break from birth-related groups for a while can be healthy and self-protective; she can return when she is ready.

Of course, not every support resource is perfect. Encourage CBAC mothers to be careful about whom they seek support from. Many well-meaning people say hurtful things like, “Just be grateful you got a healthy baby,” or “You’re just lucky you didn’t die!” CBAC mothers need to find support that will not inadvertently trigger or hurt them more.

Acknowledge Unique Circumstances

Each CBAC is unique, and each may carry its own particular color of pain.

Some women had CBACs because their providers suddenly withdrew support for VBAC at the end of pregnancy or during labor. Some faced so many interventions and conditions during their labors that a CBAC seemed almost inevitable. Some experienced mistreatment and abuse during their experience.

On the other hand, some women had very supportive providers but still ended with a CBAC. Others felt they had a “prudent CBAC,” a difficult but sensible choice because of fetal distress, poor fetal position, rising blood pressure, or other complications. Some had an “empowered CBAC,” where there was powerful learning and healing to help balance the disappointment.

Some women have multiple CBACs, each with their own emotional resonance. Some have a VBAC and then a CBAC, which has its own particular pain. A few have had the bitter experience of having lasting physical and emotional damage from their CBAC, including uterine rupture, hysterectomy, or loss of their baby.

As always, each person’s experience is different, and each CBAC mother needs their unique experiences honored.

“Try on” a CBAC

“Trying on” a CBAC can help birth professionals have a deeper empathy for the unique grief of a CBAC mother.

Consider what it might feel like to have a CBAC. Let yourself feel what it might be like to hope and dream for a VBAC and then not have one, to have to tell everyone afterwards that you didn’t VBAC after all, to listen to the naysayers who believe your body really is broken and who tell you that you should have just scheduled a cesarean section, to listen to other women’s easy birth stories and feel envious all the time.

Walking in someone else’s shoes for a while gives people a better appreciation for the difficulties and the bittersweet feelings surrounding disappointing life events. More empathy for CBAC mothers is definitely needed in the birth community.

Contact the Mother Periodically to Check In

CBAC is a bit of an emotional rollercoaster and feelings will change over time. The way the mother feels immediately after a CBAC will probably not be the same as a few months or a year later. Check in with her periodically to see how she is feeling about everything and whether there is any way you can support her further. This is especially important for CBAC mothers who have experienced a major trauma.

It’s not unusual for CBAC mothers to experience emotional upset around the six month mark, on the child’s first birthday, or even later. A quick check-in can affirm that someone remembers and cares about what she is going through.

Discuss Future Pregnancies

Another common point of emotional crisis for CBAC mothers is when the mother considers having another child. At that time she revisits her fear and trauma from past births, decides whether to have more children, and if so, may be torn over whether to choose a repeat cesarean or another VBAC trial of labor (TOL).

Although conventional medical wisdom holds that once a woman has had a CBAC, she has shown she cannot birth vaginally, the reality is that a number of CBAC women go on to have a VBAC in future pregnancies, and the American College of Obstetricians and Gynecologists (ACOG) is supportive of VBAC after two cesareans. Women who choose a TOL in this situation may need particularly strong emotional support as they work through their fears and concerns from both a primary cesarean and a CBAC.

However, it’s also important to remember that sometimes a VBAC is truly medically contraindicated, the woman is done having children, or does not wish another TOL. Although VBAC is no longer an option, that doesn’t mean these women are at peace with past or future CBACs. They may still need support too. Little research has been done on how to support this group as they integrate their experiences into their lives. In particular, information is needed on how to support women who experienced significant emotional trauma during birth (Beck and Watson, 2010).

Believe That Healing Can Be Had

Life gives us all disappointments and sometimes these remain bittersweet forever. As with other griefs, you never truly “heal” from a CBAC; the disappointment and loss of that birth is always there, and it never goes away. However, birth professionals need to communicate that – with time and distance – women often come to some sort of peace with the experience.

If given the chance to process their feelings thoroughly, women eventually have enough distance from it to not grieve as sharply, to find lessons or growth in the experience, and to be able to integrate the disappointment of it into their lives.

Some transform the power of the CBAC experience into advocacy, becoming health care workers themselves or advocates in birth-related fields. Others practice micro-advocacy by informally helping birthing women they encounter in their personal lives.

Women don’t have to ever be grateful for their CBACs, but in time they can recognize that good things can spring from difficult things, and that great trauma can lead to great growth. The process is not quick or facile, but it can happen. And birth professionals can be a vitally important part of that process.

“My joy [in my births] has gradually returned. I am learning now to honor my experiences…We are not failures, we are no less brave than the women who accomplish the VBAC goal. I keep reminding myself that I will never climb Mount Everest, either, and will probably not accomplish some of the other things I think I want in my life. Maybe this missed childbirth opportunity is just that ─ another missed opportunity ─ and maybe we can find some other accomplishments/ life experiences to compensate. Maybe.”       -K

“Today, 12.5 years after my first CBAC, I can honestly say how much growing and learning came from it and for that I am grateful.” -Teresa Stire

“My CBAC made me the compassionate advocate I am today.” -Melek Speros

Resources for CBAC Mothers

Here are a few select resources that may be helpful to CBAC mothers. If you know of more, please add them in the comments section.

CBAC Resources

CBAC Support Groups

General Birth Trauma Support Organizations

Articles on CBAC Recovery

Birth Trauma Articles



Beck CT, Watson S. Subsequent childbirth after a previous traumatic birth. Nurs Res 2010 Jul-Aug;59(4):241-9. PMID: 20585221

About Pamela Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Image from Wikimedia Commons.

Pamela Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 20 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.


Cesarean Birth, Childbirth Education, Guest Posts, Maternal Mental Health, Maternity Care, Medical Interventions, PTSD, Series: Supporting Women When a VBAC Doesn't Happen, Vaginal Birth After Cesarean (VBAC) , , , , , , ,

Kathy Morelli Shares Highlights from the 2014 Postpartum Support International Conference

July 15th, 2014 by avatar

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

PSI wants everyone to remember three things:

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

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


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


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

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

June 11th, 2013 by avatar

© Robin Gray-Reed, RN, IBCLC

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

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

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

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

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

 How can placenta be consumed?

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

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

Why would a woman want to take placenta capsules?

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

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

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

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

© Bjorna Hoen Photography

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

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

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

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

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

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

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

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

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

 This leaves us with a few unanswered questions. 

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

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

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

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


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

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

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

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

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

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


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

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