After Birth

Notes: If the plea to the CDC for guidance last week resonated, I wrote a bit more about it in The Atlantic, here.

My oldest child is 10 and when I think back on the first days with her there are moments which stand out brightly — the first time through the door with the carseat, when our friends Aude and Matt brought canele to the hospital — but a lot of it is a blur. I know a lot of it was hard, but it’s distant enough now that I forget quite how hard.

But a lot of people who read this newsletter are in these first day and weeks, or about to be there, and I was reminded the other day of just how hard and isolating that period can be. As I put it in Cribsheet: “Before the baby, you’re a vessel to be cherished and protected. After the baby, you’re a lactation-oriented baby accessory.” Many people, and I include myself here, are fundamentally unprepared for the physical consequences of the period after birth. And even if one understands in the abstract that emotional ups and downs are common, postpartum mental health is a minefield. I can only assume this is even more true for those of you who are giving birth during a pandemic.

I write a lot about this in Cribsheet, including what to expect physically after birth. The tearing and bleeding and needing of help to get to the shower and what happens the first time you poop. (My college roommate, Tricia, made me put a disclaimer in the chapter that people who already lived through it might want to skip it.) Today, though, I wanted to extract a bit of the portion of the chapter on mental health, in case it is of use to anyone.

The extract is below. But let me say here: if this resonates with you, if you’re suffering, please get help. Your OB can help, or a therapist if you have one, or there are many local resources. One place to start if you can’t access any of these is PSI.

Mental Health, After Birth

Let’s start with the basics: although we do not discuss it enough, postpartum depression, postpartum anxiety and even postpartum psychosis are common. In the first days and weeks after you baby arrives, you will experience a wave of hormones.

Most women find they are emotionally sensitive during this period. I spent our first visit to friends crying in a spare bedroom for an hour for no reason (they didn’t bat an eye, gave me a hug and brought me food on a tray. Lesson: only visit friends like this).

This early experience is sometimes referred to as the “baby blues” and is self-limiting in the sense that the hormone surge is worst in the first couple of days after giving birth and has died down by a couple of weeks later.

But true postpartum depression or other postpartum mental health conditions can crop up in this period. They can also arise later, even months later. Many women discount later-onset depression, thinking postpartum depression only happens right after the baby arrives. This is not the case.

The prevalence of postpartum depression, even if we focus only on diagnosed cases, is high. An estimated 10 to 15 percent of women who give birth will experience it.  The data suggest that about half of these women actually experience the onset of depression during pregnancy; post-pregnancy, diagnosis is most typical in the first four months after birth.

There are some important risk factors for postpartum depression. These fall into two categories: predisposition and situation. By far the biggest risk factor for postpartum depression is predisposition, or prior experience of depression. If you’ve had episodes of depression before, they are more likely to crop up again in the pregnancy or postpartum period.

The other risk factors are largely about situation. Some of these factors are modifiable, some are not. New parents who have less social support, who experience difficult life events around this time, or whose baby has medical or other problems are more likely to be depressed. And the baby itself can also play a role; people with babies who are poor sleepers are at greater risk for depression, almost certainly due to the fact that they, in turn, get less sleep.

How is postpartum depression diagnosed? Ideally, every woman is screened for this using a short questionnaire at their six-week postpartum visit. The most widely used questionnaire is probably the Edinburgh Postnatal Depression Scale, though a few others are common. You can access the full questionnaire with instructions here, and for good measure I’ve put it in below.

The scaling of this is simple: each question is scored from 0 to 3, with the worst category (the top one for most questions, the bottom for 1, 2 and 4) getting a 3. Doctors will typically use a cutoff of 10 or 12 as a signal of mild depression, and a value of 20 or more as signaling a more serious depression.

Evidence suggests using this screening tool can be extremely effective. Researchers have shown improvements in detection (and therefore treatment) from using this questionnaire—as much as a 60 percent reduction in depression a few months later.

If you are the birth-giving person, your doctor will almost certainly give you this questionnaire at 6 weeks. In my view, though, this is probably not sufficient. It captures only a point in time, and it focuses only on the birth-giving person, not any of the other adults in the household. In my view, it would be a good idea to have every adult in the household do a depression screen a few weeks after the baby is born, and then periodically after that. This could pick up more cases early, and accelerate treatment.

Treatment for postpartum depression proceeds in stages. For mild depression, the first approach is to try to treat without drugs. There is some evidence that exercise or massage can be helpful. Or perhaps most important, sleep. For new parents, in particular, lack of sleep can be a huge contributor to mild depression. This shouldn’t be that surprising. Even when you don’t have an infant, if you have a few nights of poor sleep, it can be hard to enjoy things. Now add together many, many nights of interrupted sleep—it’s not surprising this could contribute to emotional exhaustion and depression.

Obviously it is hard to treat lack of sleep when you have a newborn (although I will note here that I also talk through sleep training in Cribsheet and one of the strong arguments in favor of it is improvements in maternal depression rates). But there are ways to try to improve things a little. Get help for a night or two—or more—from a grandparent or friend. Hire a nighttime doula if possible. Divide the night duties with a partner so you can each get at least one uninterrupted stretch of sleep. It may be helpful to remind yourself that addressing depression is valuable for your baby, too, not just some kind of selfish personal indulgence.

Beyond sleep, some type of cognitive behavioral therapy, or other talk therapy, is a usual first-line treatment for many people. This focuses on reframing negative thoughts and focusing on positive actions.

For more severe depression—sometimes defined as a score above 20 on the standard depression screen—antidepressants are more widely used. Although antidepressants are passed through breast milk, there is no evidence of adverse consequences (there is also more on this in Cribsheet). This means there is no need to choose between getting help and breastfeeding.

Much of the literature, and popular discourse, focuses on postpartum depression. But not all postpartum mental health issues take the form of depression. Postpartum anxiety is also common. Many of the symptoms are similar to postpartum depression, and indeed, it is common to diagnose postpartum anxiety using the same screening tool. But women with postpartum anxiety also tend to find themselves fixated on terrible things that could happen to the baby, unable to sleep even if the opportunity is there, and engaging in obsessive-compulsive behaviors around infant safety. This can be treated with therapy or, in more severe cases, with medication.

With anxiety, it can be hard to know where the line is between normal parental worry and obsessive worry. If anxiety is interfering with your ability to enjoy spending time with your baby, if it is occupying all your thoughts and preventing you from sleeping—that is over the line.

Less common but much more severe is postpartum psychosis. This affects an estimated 1 to 2 in 1,000 women and is much more likely to develop in women with a history of bipolar disorder. Postpartum psychosis usually manifests in hallucinations, delusions, and manic episodes. It will very likely need inpatient treatment, and should be taken extremely seriously.

There are many issues in the pre-pregnancy, pregnancy, and post-pregnancy world that we do not talk about enough. When I was writing about pregnancy, the thing that struck me in this category was miscarriage. So many women have had miscarriages, yet they are rarely talked about—until you have one and then it turns out many women you know have also miscarried.

Postpartum mental and physical health have the same pattern. You have a new baby—shouldn’t you be happy and feeling great? When people ask how you are, everyone wants to hear, “The baby is great! We’re so thrilled!” Not “I’m depressed and anxious and I’m dealing with third-degree vaginal tears.” The fact that these things are not talked about makes many of us feel like we are the only ones dealing with them, or should just get over it.

This simply isn’t true, and I think the more we talk about this, the more we do a service to other women. It’s time to have a more honest conversation.


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