Aspect Ratio

I can put myself in the labor bed for the birth of my third child.  I can see the scene unfold.  I can hear the conversations with my midwife.  I remember how, even at the height of contractions with delivery imminent, I still hadn’t come to grips with the fact that I was pregnant.

I remember thinking, but wait, I’m not ready.  I haven’t reconciled this with myself yet, with the universe.

The universe didn’t care.  Nature didn’t care.  My body and the baby didn’t care.  It was time – whether I was ready or not.

I think on a cellular level I knew that pushing out that child without owning the pregnancy would only lead to trouble.  The basest parts of the body do not lie.

I grew that baby with the utmost care.  Once she was this side of the womb, I was only attentive.

But my soul was squeezed by internal pressures; my own mind that couldn’t accept this path only because I hadn’t carved it.

And so, I was amazed by the wonder that accompanied an unplanned fourth pregnancy.  Simply bowled over by the joy that flooded me when they placed her on my breast.  While I had been afraid to plunge into the depth of my love for my third, for fear that someone would take her from me, it just happened with my fourth.

And yet, because any footprints make deep imprints on the psyche, a year later now, I look at my pregnant self and cannot believe that is me.  Was that my life?  Was that a mere year ago?  How can I reconcile that exhausted, frumpy, wallowing-in-her-own-skin IMG_20160430_150358162person with who I am just a year later?  I hate that I look so miserable when pregnant.  Because of my problems in the past, I look at any such photo and second-guess myself.  Was I feeling that same way then?  Struggling the same?  So paranoid, scared, to fall into that trough – even on a timeline that has already elapsed – I doubt what’s right in front of me.

My grey matter muscle memory worries that if I have a hard time measuring this last year of my newborn’s life, that I look at this picture of me a mere year ago and see an alternate reality – am I not in just as much denial this time as the last?  If I am still getting used to the idea of having a baby and she’s turning the corner to one year-old, doesn’t that mean I am putting up some of those same walls?

NO.

Will I forever be haunted by the dark feelings and stilted growth of my postpartum depression?  Yes.  Will it make me paranoid and second-guess myself?  Right now anyway.  Is it possible to have mind and heart blown during any childbearing and rearing experience – ‘normal’ or otherwise?  Yes.

It’s so easy to let past experiences form new fears and worries.  Just like losing it with the older kids or having a low day makes me worry I’m having a relapse.  Knowing the signs and how to help ourselves is key; expecting perfection and punishing ourselves is crap.

So maybe I’ll just look at those pregnant photos of me and say, no wonder I look like rough; growing a kid is rough work.  Maybe I’ll just seal them in her baby book and never look at them again.  I certainly need to stop looking at them trying to find signs of trouble.

Notice, though, that I haven’t even begun to look at the newborn photos for this go-round.

No More Smoke Screens

Last Wednesday, I had my six week follow-up appointment after the birth of my newest baby girl. The six weeks that had elapsed seemed like an eternity and yet instantaneous – like any spool of time surrounding a major life event does.

In the thick of summer vacation, I marched my older three girls into the office with me. Not ideal, but with the aid of electronic devices and some seats just outside the examination room door, I was able to avoid the embarrassment of an internal exam with the oldest two looking on and retching. I stationed my six year old’s chair full of crayons and coloring books at my head, the infant nestled in my chest.

Upon my arrival, the receptionist handed me the ubiquitous clipboard with the Edinburgh Postnatal Depression Scale. I knew it was coming. I was actually looking forward to it. I took it in hand almost giddily. There were a few reasons for this.

1. I didn’t need it.

Just a few days after the birth of my baby, a visiting nurse came to our house. Since it was a holiday weekend, we weren’t able to get an appointment with our pediatrician to check our breastfed baby’s weight and absence of jaundice so the hospital arranged for the home visit. While I expected the nurse to check the baby, she also looked after me, administering an EPDS. My score fell far below the range of danger for postpartum mood and anxiety disorders. Ever the overachiever, I joked with my husband that was a test I’d happily fail.

2.  But if I did, my answers to these questions would signal to my practitioners what sort of help I needed.

3.  If they gave the questionnaire to me, they gave it to all postpartum patients, which meant that all women had access to help if they were struggling.

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Jennifer Butler Basile

Still, when I handed the clipboard to the nurse in the examination room, and she followed up with questions like, ‘Have you ever thought of harming yourself or the baby?’, she asked them in a hushed voice. She apologized, saying she had to ask everyone.  Her tone insinuated it wasn’t me that was crazy, but it was her job to ask every mother in case one of them was. I knew part of her low volume was to spare my very aware six-year-old the world of suicide and psychosis, but I knew that wasn’t all of it. The apologies were born of shame, stigma; to separate me from those ‘tainted’ women, those we can’t speak of, for fear of ‘catching’ what they have.

But I was like them. I had what they had. I was just six years out.

Six years earlier, I would’ve been scared off by whispers like that. I wouldn’t have answered truthfully, if I’d thought it would smear me with that shame. Not because I didn’t need help. Not because I wasn’t having irrational thoughts. Not because I knew how to fix it myself. Because I felt that saying yes would be submitting to defeat.

I’m not trying to pin the shortcomings of postpartum care on this one nurse. If anything, this one nurse’s demeanor only shows just how difficult it is to discuss these matters. But the only reason I didn’t face these struggles this time is because someone asked the tough questions. Because a friend, a mother who had gone through the same struggles insisted I get help. And because once I healed, I knew how to prepare and preempt the struggles this time.

So wave the clipboard proudly. Answer the questions honestly. Ask for help loudly.

Mental health screenings should elucidate symptoms, not throw up smoke screens.

When does a perinatal mood disorder start?

Please read on to pinpoint when you or a woman close to you will begin to see signs of a perinatal mood and/or anxiety disorder.

  • When two lines appear on the pregnancy test
  • When pregnancy is unexpected
  • When pregnancy is finally achieved
  • When pregnancy is not achieved
  • When the mother loses the baby
  • When the mother chooses not to have the baby
  • When the adoption falls through
  • When the drastic changes in lifestyle that having a baby will induce begin to occur:
    • nausea
    • extreme exhaustion
    • no more wine with dinner or beer after a rough day
    • limited mobility
  • When the hormones at flux in the pregnant body affect thought processes
    • heightened anxiety at the amazing responsibility of growing and then caring for a baby
    • fear of the unknown or varied outcomes of gestation, labor, delivery, and aftercare
    • ambivalence over the new self the mother must create or become
    • mourning the loss of the former self
  • When medication regimens must be altered due to unknown effects of routine prescriptions on the fetus
  • When mother worries and feels guilty about continuing medication and its effects on fetus
  • When mother suffers a loss during pregnancy
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    postpartumpathways.com

    • death of a loved one
    • separation from partner
  • When the mother has no partner or support person
  • When a drastic transition occurs during pregnancy
    • moving homes and/or locations
    • away from support network
    • loss of own or partner’s employment
  • When labor and/or delivery does not go as planned or expected
  • Traumatic labor and/or delivery
    • physical trauma
    • emotional or psychological trauma
  • Complicated recovery from labor and/or delivery
    • infection
    • injury
  • When adoption is complete
  • Unexpected medical condition in infant
  • Loss of infant
  • Difficulty feeding infant
    • breastfeeding
    • colic
    • reflux
    • allergies
    • tongue tied
  • Extreme fatigue recovering from labor and caring for newborn around the clock
  • No routine
  • No schedule
  • No down time – constantly being needed, touched, suckled
  • Disappointment at real life not matching imagined version of motherhood
  • Hormones further thrown into flux after baby-growing part of process complete
  • Stress
  • Too much interference and advice from others
  • Not enough support and help from others
  • Isolation
  • Weaning child from breast (days, weeks, years after birth)
  • Being sole caregiver for a fragile, totally dependent being

After reading this list, it should be an incredibly simple and precise process to pinpoint exactly when you or a woman close to you will exhibit signs of a perinatal mood disorder. Diagnosing and treating it should be even simpler. And recovery? Piece of cake.


Hopefully it is quite obvious that the way I’ve chosen to frame this list is tongue in cheek. The individual items on the list are anything but. They are varied; some mutually exclusive and many overlapping – to show that there is no one road map for predicting, preventing, diagnosing, or treating perinatal mood disorders. Perinatal mood disorders come in many different forms with many different time lines. The one surefire tool to helping yourself or a woman close to you who is suffering is awareness. Awareness of the myriad possible causes and many symptoms that can present. And then reaching out.

To her. To your physician. Midwife. OB. GYN. Pediatrician. Counselor. Therapist. Psychologist. Psychiatrist. Friend. Mother. Partner. Neighbor.

With an illness this insidious, multi-faceted, and far-reaching, silence is not an option. The lives of our mothers, babies, and families depend upon it.

If it’s Monday, it must be . . .

After my third pregnancy, it felt like I saw every specialist under the sun. Midwife, general practitioner, physical therapist, behavioral therapist, chiropractor, podiatrist. It took a lot of work to put me back together physically and mentally.

My schedule hasn’t changed much this time around, except I’m starting my visits prenatally rather than post. And I haven’t hit everyone on the laundry list yet – which is probably a good thing, given I’m already having continuity of care issues.

Today I saw my general practitioner.

It was to be a followup after my visit to a psychiatrist. Shortly before my pregnancy, I’d started with this GP. When discussing my mental health history and current condition, she suggested I get a specific diagnosis from a psychiatrist since what initially presented as postpartum depression was persisting. I’d been continuing care with a LICSW I’d been seeing. Thanks to hospital systems and network nightmares, I’d need to go through 12 CBT sessions at his facility before even seeing the psychiatrist – even though that’s what I’d been doing for years with my own therapist. Already spooked by the red tape and thought of strong psychotropic drugs, I put it all on hold once I found out I was pregnant. I couldn’t start on new meds anyway and didn’t need any additional stress.

Through the guidance of my LICSW and midwife, I decided the benefits of continuing my low dose of meds were greater than the risk of harm during pregnancy. That’s not to say the decision was made lightly. I cut out mostly everything questionable when pregnant. I’d always felt guilt for taking meds in the first place. But after weighing all my options – and a few bad days of trying to wean – the meds stayed.

Now, my GP didn’t know any of this.

When I tried to verify my protocol and discuss my midwife’s suggestion to possibly wean toward the end of pregnancy so the baby would not suffer any possible ill effects of the drug as a newborn, she wondered whether she would’ve advised taking meds at all had she found out earlier in my pregnancy. She said that’s why she wanted the input of the psychiatrist, especially now with a pregnancy, to know exactly with what we were dealing.

Now, this GP is solid. She did not shy away from discussing different prescription therapies. She wanted me to see the psychiatrist to get to the origin point at the bottom of my pit. She is candid, empathetic. Today, however, I felt the doubt and guilt over taking meds during pregnancy try to push up. The doubt that I’m not getting the best possible prenatal care cropped up when she suggested I see an OB in my group rather than only a midwife; her reasoning being that should my situation become critical I would need someone to assess and intervene immediately.

She is following due process. She is looking out for the best interests of me and my baby. She is talented, trained, and professional.

And yet there are gaps in her knowledge of perinatal mood disorders and their treatment.

My midwife, fully aware there is no definitive research saying meds are 100% risk-free during pregnancy, also knows the research that an anxious and/or depressed mother can also have ill-effects on a developing fetus.

My LICSW knows the mental anguish I put myself through in making this decision and that I can’t hang without the meds.

All three are looking out for the best interests of me and my baby. All three are experts in their fields. And yet, at times, all three have told me something different.

Where is the continuity of care in the perinatal period? Yes, the knowledge base is growing. Yes, awareness is spreading. Yes, some practitioners are training themselves to be experts in this ever-growing area. But there isn’t enough widespread know-how. There are gaps in which women can and will fall through.

I haven’t met any of the OBs in the group I visit, but seeing one doesn’t guarantee me swift and effective intervention in the postpartum period. Not taking meds doesn’t guarantee a perfectly formed baby. Taking meds doesn’t even preclude mood disorders.

There is always some mystery involved in making and growing a baby. Insert mood disorders and mental health issues and the lines are blurred even further. Unfortunately, it still falls primarily to the mother to advocate for her own health amidst all the conflicting care.

Though still haunted by the postpartum experience in my previous pregnancy, I feel that I can advocate for myself this time. Knowing the danger signs, the markers, the despair, I feel equipped to request and access care as soon as it’s needed. I know who to ask and how to get it. However, that doesn’t mean that all of my helpers will be on the same page. One perinatal hand may very well have no idea what the others are doing – just as I don’t know which specialist I’m seeing unless I know which day it is.

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Help Yourself

“If you do become depressed there are several things you can do to help yourself and make the illness as short-lived as possible.”*

I read this in a book preparing women for pregnancy and childbirth. It is meant well. It introduces a section on self-care and avoiding or alleviating depression (including medical help), which goes on to dispel the myth of the ‘perfect mother’, but the tone of this statement rankled me.

Self-advocacy, expectation, and positive outlook do play an important role in mental health, but they only go so far.

If a woman is clinically depressed, no amount of happy thoughts will pull her out. No amount of pampering will soothe her. Strong and mighty though she may be, bent but not broken, she still needs more. Some sort of medical and/or therapeutic intervention.

Statements like this perpetuate the feeling of failure that women suffering from mental illness already feel. That there is something they failed to do, some step they missed or didn’t push hard enough to save themselves. To embrace life and joy.  And the idea that they’ve prolonged their misery by not making it as ‘short-lived as possible’ – argh!

Maybe I’m just cranky because it didn’t work for me. I know I’m reading this not as an objective observer or researcher, but as a severely chipped shoulder. But a lot of the literature I’ve found reads like it’s written by someone who’s too objective, like someone who views depression as a clear-cut, easily addressed condition.

Like someone who’s never been there.

from I’m Pregnant by Lesley Regan, MD; no disrespect to the author, this post represents my own subjective opinion on the topic.

Work in(g on) Progress

When I started this blog chronicling my survival as a mother postpartum, I sought out other blogs with a similar focus.  My research took me all the way to South Africa.  I found Lebogang and her blog, For His Love.  A woman living a totally different life in a totally different part of the world felt the exact same way as me.  I was so glad to read my story on her pages with a different set of characters and timeline, especially since she was further along in her story, which meant I, too, would make it.  After all, that’s what the badge in the bottom right hand corner of her page said:

I survived postpartum depression.  You can too.

This image was like a magic talisman to me.  I clicked on it, half-expecting, I think, the spontaneous appearance of the how-to handbook for solving all my problems.  This mythical handbook did not appear – but Postpartum Progress did, which is, really, the next best thing.

Postpartum Progress is the brainchild of Katherine Stone.  She has built and branded a maternal mental health empire.  It started, as she says, with the blog, then a conference, and is now building its nonprofit status.  But while it started with Stone and her own struggle with postpartum OCD, its success is in the amazing community she’s created for women who all-too-often feel completely alone.

Simply their social media feed is enough to inspire hope, with affirmations, informational tidbits, and links to in-depth articles.  The blog and website offer a wealth of information and resources, that would help any woman while away the wee hours of the panicked postpartum morning before the doctor’s office opens.  And that may be precisely the point that Postpartum Progress exists.  To offer a voice and ear 24/7 to a struggling population whose problems do not adhere to office hours and are not as cut and dry as a short symptom list.

A disclaimer on all their pages states that the information and advice is not a substitute for professional care and consultation.  However, it is a place to start the journey and a companion throughout it.  It offers a place for women who have no vocal allies in their everyday lives, due to stigma, to find friends and examples of success despite struggle.

It is organizations like Postpartum Progress that give me hope for the empowerment, validation, and vindication of all women suffering from perinatal mood disorders.  Even ones like me, who are post postpartum.

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Into the Depths

It’s become an all-too-familiar image associated with postpartum depression.  A mother, out of her mind due to internal and external stresses, drives her children into a lake.  The reasons vary.  She may think she’s protecting them from an unseen spectre lurking at every turn.  She may be trying to protect them from any harm she might inflict as an unfit mother.  Whatever the motivation, the stories usually stem from some sort of irrational attempt at ‘saving’ the children under her care.

Last week, the body of water was the Atlantic Ocean rather than the ubiquitous lake.  A pregnant South Carolinian woman attempted to drive her minivan and three children into the ocean on Daytona Beach.  Bystanders sprung into action, pulling the children from the van, while the mother, still trying to head into the waves, apparently said, “We’re okay, we’re okay, we’re okay.”  Thankfully, in the end, they all were.

While reports of a diagnosis have not yet been made, I knew instantly this woman’s actions must have stemmed from some sort of perinatal mood disorder.  Of course postpartum was the first thing to pop into my mind, but then I learned she was pregnant.  Not outside the realm, people.  It’s not as if these mood disorders and psychoses obey that post determination like the flip of a switch.  The machinations that power the beast start churning before the baby pops out.

Indeed, this woman’s sister called police requesting a ‘well-being check’, knowing her sister was having difficulty.  The police suspected that as well upon speaking with her, but “conclud[ed] she couldn’t be held under a Florida law that allows for detention of people believed to be impaired by mental illness and who possibly pose a risk of harm.”  They did arrest her after her release from the hospital later that day, however.  With three counts of aggravated child abuse and a charge of attempted murder.

I do not condone the maltreatment of children and most definitely anything that could lead to their deaths.  However, the charges brought against this woman chill me to the bone.  Simply hearing the story – before any facts – I knew she could not be able to exercise right judgment.  Her sister recognized it.  The police officer who interviewed her earlier that day recognized it.  And yet, she is slapped with such a charge?

There are other issues at play.  She came to her sister in Florida to escape a supposedly estranged husband back in South Carolina.  She said she didn’t want him near the children.  The sister said she spoke of demons.  But then she also told police, “she’s … having psychosis or something or postpartum.”  Volusia County Sheriff, Ben Johnson, said “one goal of charging her was to make sure she gets help for any possible mental issues.”

“This is a tragic event. And our goal is to get her into the system so that we can protect the children and take whatever action we need to help her, too,” he said.

I certainly agree that she needs help, help needed so badly she cannot even recognize it.  But is this the way we help those with mental illness?  By charging them criminally?

And what do we tell the children?  The children reportedly told officers, “Mom tried to kill us.”  No child should have to go through such an ordeal.  But I certainly hope all the support staff that come into contact with these children temper their words.  I hope they avoid judgment and stick to the facts: their mother needs help.

Resources (all info and quotes come from the following articles):

http://www.cnn.com/2014/03/08/justice/florida-mother-minivan-ocean/

http://www.cnn.com/2014/03/07/justice/florida-mother-minivan-ocean/

 

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