As I mentioned in my earlier post, I was going to write about the risk factors for PPD, which are among the many interesting things I learned during the past 4+ years while reading books to learn more about PPD for my own book. No one is 100% sure what causes postpartum depression (PPD) and why some women get it and some don’t. You need to keep in mind that every individual is unique in terms of life experiences and genetic makeup, and the way in which she reacts to things like fatigue, stress and lack of support is also unique. Although women with some of the risk factors listed below are more apt to get PPD than a woman with no risk factors, PPD can even strike women with no risk factors. As I’ve mentioned before, no woman is completely immune from PPD.
If you were to ask if there’s any way to know for sure whether you are at risk for PPD, the answer is No. So, how the heck can a woman know her risk for PPD? It is important to keep in mind that, if you already have the genetic predisposition for depression and/or PPD, you need to prepare for the possibility that you will experience antenatal depression and/or PPD. It seems that a combination of biological, psychological, and social factors increases your risk. You should also keep in mind that just because you may have some risk of developing PPD, it does not mean you will definitely develop it. And even if you’ve had PPD before doesn’t necessarily mean you will get it again, as every pregnancy is different and you may yourself be different physically, mentally and emotionally.
After childbirth, a woman’s body and the cells that make up the body need to repair themselves, and they usually do that through sleep. If they are unable to repair themselves through continuous lack of a complete sleep cycle (4-5 hrs at a time), the body and its functions will deteriorate. Needless to say, taking care of a newborn is quite an exhausting experience. It takes a lot of energy, both physically and mentally. Energy that a new mother will not have much of immediately after giving birth, which is why getting help is so important. If you’ve just gone through a long and difficult delivery in which you lost a lot of blood in the process, you must let the body recover with proper nutrition and rest. If the body (that includes the brain) cannot get the rest it needs, it will tend to be more susceptible to external stressors—like fear, loneliness and a sense of loss if there was a complication with delivery—that threaten its normal functioning and regulation.
Knowing what PPD is, what the symptoms are, and whether you’re at risk, as well as preparing for the possibility that you will develop it would be to your advantage. How’s that, you ask? Well, for one thing, if you were to develop PPD, you will be less likely to panic over what is happening to you, you won’t feel helpless and hopeless, and you will know to seek help immediately. The best way to prepare for the possibility or reduce the risk of PPD is to have a support network to provide practical and emotional support for you in the first 6-8 weeks postpartum. If everyone were to adopt this postpartum practice, I am confident that the PPD occurrence rate would drop.
BIOLOGICAL RISK FACTORS:
- Sleep deprivation from constant sleep interruptions during the night and inability to get a 4-5 hour block of sleep for an extended period of time can trigger PPD for certain women (it did for me). That’s why it is particularly important, in the first 6-8 weeks—since PPD usually begins 6-8 weeks postpartum (the first signs of my PPD started 46 days after childbirth)—for new mothers to get plenty of help with the baby and household chores, as well as encouragement and guidance from other women who have babies of their own. After the 6-8 weeks of a more vulnerable emotional state have passed and after receiving childcare advice, the new mother will feel stronger physically and emotionally and feel more ready to take on her new motherly responsibilities. This is probably why many societies today still observe a 40-day period during which women in the extended family take over all household chores and care of the mother to enable the new mother to recover from childbirth and focus on taking care of her baby. Sleep deprivation that begins during pregnancy arises from difficulty finding a comfortable position in which to sleep at night. With a huge belly, movement and sleep positions are much more limited. Limbs becoming numb, heartburn and difficulty breathing from the womb pressing up into the diaphragm can also make sleeping very difficult. Numb limbs and difficulty breathing were two of my challenges during pregnancy, but fortunately, I was able to sleep through the night. Some women aren’t so fortunate. RECOMMENDATION: It might be worthwhile to invest in a body pillow, as it helps many women get a better night’s sleep.
- Abrupt weaning/discontinuation of breastfeeding.
- The return of a woman’s menstrual period for the first time after childbirth.
- Difficult pregnancy/pregnancy complications, like preeclampsia, gestational diabetes, ruptured placenta, toxemia, hemorrhage, bed rest for the last few months of pregnancy, or being in pain and/or uncomfortable to the point of distress (like the painful pulling sensation I kept feeling in my diaphragm area, which I’m convinced to this day had something to do with my placenta accreta).
PSYCHOLOGICAL RISK FACTORS:
- Depression/anxiety during this pregnancy (antenatal depression/anxiety): Just like me, when you see the word “anxiety” listed as a risk factor, some questions will pop up in your mind. First and foremost, you will wonder what anxiety has to do with PPD, or for that matter, depression. I asked my doctor to explain the difference between anxiety and depression, and he had trouble explaining it to me. But what helps put it into perspective is Venis & McCloskey’s “Postpartum Depression Demystified: An Essential Guide for Understanding and Overcoming the Most Common Complication after Childbirth” (pg 59) following statement: “Even if you’ve never experienced a full-blown bout of depression or acute anxiety but have a tendency to get down or anxious during stressful or uncertain times, you may be more susceptible to depression when you’re expecting [and/or postpartum].” Being prone to anxiety when you are at your most vulnerable will increase your chances of developing PPD.
- Personal history of depression, perinatal (antenatal, postpartum) anxiety/depression, premenstrual dysphoric disorder (PMDD), substance abuse, obsessive compulsive disorder (OCD), bipolar disorder, eating disorders (anorexia, bulimia, binging, purging), tendency to worry excessively, and/or tendency to experience mood changes while taking birth control pills or fertility medications.
- Family history of anxiety, depression, PMDD, substance abuse, OCD and/or bipolar disorder. One of the first questions my doctor asked me was whether I have a family history for anxiety or depression. If doctors are going to ask a question like that, it would be helpful if they helped define what constitutes a history of depression, like asking the question: “Have you ever felt depressed or down, most of the day, nearly every day, for more than 2 weeks at a time?” In several of the PPD stories I read (like Sylvia Lasalandra’s A Daughter’s Touch: A Journey of a Mother Trying to Come to Terms with Postpartum Depression), the woman’s mother also had PPD but failed to mention it until her daughter’s illness was well under way and already fairly serious. What a difference it would make if all PPD survivors were to share their experience with their daughters so they will know their risk for PPD before heading into pregnancy and prepare for it in advance!
- Unresolved issues/grief: Loss or separation from parent(s) at early age from death or divorce, dysfunctional relationship with mother, growing up with an alcoholic parent(s), and/or history of abuse (physical/sexual/emotional). Having a baby could stir up painful memories of what is was like to live in a dysfunctional household, causing extreme anxiety and distress, which may ultimately lead to PPD.
- Difficult/traumatic/disappointing birth experience–e.g., obstetrical complications leading to a traumatic birth experience, emergency caesarian (especially after having had no pain relief and enduring many hours of labor), premature birth, baby going into distress during or after delivery, inability to see or hold the baby immediately upon birth, extremely difficult and long labor, baby requiring surgery to correct a serious congenital defect, last-minute change in OB/GYN delivering your baby. The type of delivery you have (c-section or vaginal), whether you have an epidural or not, your overall satisfaction with the care you received during delivery (including quality of staff and hospital services), and whether you experience any complications during delivery – all of these may increase your risk for PPD. Many women long, hope and prepare for a natural childbirth experience. In other words, no medical intervention of any sort. A vaginal delivery with no epidural, no forceps, nothing. Just plain endurance, willpower and heavy-duty breathing exercises. What they don’t plan for—baby in breach position or other unforeseen medical emergency for the mother and/or baby—are the times an emergency caesarian or other medical intervention may be required. For these women, not being able to have the birth experience they had hoped for can cause a tremendous sense of loss, disappointment, grief and/or utter lack of control in birth experience. RECOMMENDATION: This is why it’s best to adopt a realistic attitude of hoping for the best but expecting the worst. It’s best going into labor and delivery not knowing what to expect (like me), since you won’t be setting yourself up for disappointment if you went into it with certain expectations.
- Feeling less attractive from weight gain, not being able to fit in your pre-pregnancy clothes, and/or not having time to maintain your appearance.
- Abrupt weaning can impact a woman’s maternal sense of competence.
- Negative life events related to childbearing–e.g., history of and unresolved grief associated with pregnancy loss (previous stillbirth, abortion, miscarriage); multiple failed IVF cycles. There is a lot at stake emotionally with the baby that is conceived after years of trying, possibly with the help of IVF and after failed attempts/cycles and perhaps even miscarriages. See previous post on this for more info.
- Low self esteem; pessimism; tendency to worry; tendency for perfection/control and to have everything “just so”/high standards/expectations of self (including need for structure and consistency in day-to-day life); controlling personality (fear of losing conrol). Studies have shown that pessimistic women (those who tend to interpret events negatively) are more likely to become depressed after negative events. There is a correlation between a woman’s self esteem and how confident she feels at mothering and how high her expectations are for herself based on perfectionist tendencies and being misguided by literature supportive of the myths of motherhood (disappointment in gap between reality and expectations). Caring for a newborn is a huge responsibility that challenges even the healthiest woman’s self-esteem and sense of identity, so entering this situation with self-esteem and identity issues can make the postpartum period a very difficult time. Being a first-time mother, you learn the ropes as you go. Practice makes perfect. But for those mothers with perfectionistic or control freak tendencies, they find it particularly hard to adapt to the fact that much of their motherhood experience is one in which mistakes will be made and it isn’t possible to have control of your life when you have an infant to take care of. Those who set high expectations and have specific thoughts of how their childbirth and motherhood experiences should be are setting themselves up for disappointment when their expectations are not met.
- Any feelings of loss: It is only natural for such a major life transition as having a baby to result in changes to the way you live your life, which causes you to experience a range of thoughts and feelings. RECOMMENDATION: Rather than feeling bad about these thoughts and feelings, acknowledge, accept and most importantly, share them with a nonjudgmental listener.
- Loss of baby inside you – Some women may even grieve over, or have difficulty adjusting to, the transition of happily carrying a baby for nine months to no longer carrying a baby.
- Loss of one’s old self (e.g., pre-pregnancy body, lifestyle, social life, routine).
- Loss of control/predictability – Particularly challenging to first-time parents is the adjustment to the lack of control and unpredictability of having to care for a newborn baby. Your daily routines will no longer be predictable, revolving around your baby’s feeding, sleeping and diaper changing schedules.
- Loss of structure/stimulation – There are those whose lives are all about routine and the comfort such routine brings to the person’s life. Going from such a structured life to one in which each day is totally different from one day to the next (due to the unpredictable nature of having an infant that depends completely on you for everything), many days of which are lacking adult conversation and interaction, can only contribute toward a loss of touch with reality.
- Loss of freedom/spontaneity/mobility – Realization that there are three of you now, and you’ve lost your freedom to go wherever you want whenever you want (vacations, movies, shopping, road trip, or even just errands), without having to pack up everything you need for the baby or look for a babysitter. Realization that for many years to come your world will revolve around the baby. Realization that you are now fully responsible for another human life for the rest of your life (at least up he/she becomes an adult) who will be completely helpless up to the first year and completely dependent on you for several years more. Gone are the days that you could do whatever you wanted to do whenever you wanted. Gone are the days you could sleep in and do basically nothing except watch television on the weekends.
SOCIAL RISK FACTORS:
- Poor support system–i.e., not having enough support (emotional and practical help from husband, mother, mother-in-law, other relatives, friends, neighbors, doula, nanny, midwife, housekeeper). Isolation, or the feeling of being alone, is not necessarily about not having any, or insufficient, company. It’s a perception that you are alone in your feelings and experiences.
- Major life stressors–e.g., death/serious illness of loved one, marital problems (divorce, separation), financial difficulties, unemployment, relocation, mourning loss of your old (pre-baby) self and lifestyle. Any kind of change—even a change in lifestyle due to baby’s presence or change in husband/wife relationship—can cause stress, particularly if you have difficulty coping with changes to begin with. And having a baby is one of the most significant life changes you’ll experience in a lifetime. RECOMMENDATION: Since adapting to new surroundings is only adding another element of stress and something else to feel insecure about, you should avoid moving during pregnancy or in the first year postpartum.
- Childcare stress, such as health issue for baby–e.g., preterm birth, difficult infant temperament, hyperviligance, high anxiety levels, feelings of helplessness from a baby that cries a lot or cries inconsolably (i.e., a colicky baby). These can cause a mother to question herself and eat away at her self-esteem as a parent.
- Being a first-time mother: Lack of prior experience in taking care of a baby and setting high expectations based on motherhood myths play a role in setting the stage for PPD. First-time mothers are particularly at risk for higher levels of anxiety from the uncertainty that comes with never having experienced pregnancy, labor and delivery before. It certainly makes sense, in direct correlation to the fact that all too many mothers are led to believe that the transition to motherhood is a snap—the anxiety levels of a new mother are often sky high when they realize that, lo and behold, they now have 24/7 responsibility for a completely helpless newborn without so much as any hands on training of any sort. I can personally identify with the following trend: with women being more career-oriented and having children later, and with families being smaller nowadays, women generally have little experience caring for other peoples’ babies and being around women who are having babies. Lack of experience with babies doesn’t help a mother feel warm and fuzzy about her mothering capabilities.
- Myths of motherhood: Certain women go into pregnancy with the intent to carry out their dream of motherhood down to the last detail they’d envisioned, with breastfeeding at the top of the priority list. Not being able to successfully breastfeed can be a devastating blow to the mother who had envisioned doing so for the first few months, and not being able to live out that dream is, needless to say, a huge disappointment and a crushing blow to her self-esteem.
- Being a single mother: It’s tough enough when you’re married having to take care of a newborn let alone a single mom who is on her own with no spouse to help with childcare, financial support, and housework, etc. Unless you have a very good support network of family, friends, neighbors, community programs, etc. the stress of having a baby to care for in addition to a job (or even multiple jobs), housework, etc. can easily put you at risk for PPD.
- Low socioeconomic status.
- Unwanted or unplanned pregnancy: Those who did not plan or expect to have their babies at this point in their lives are at even greater risk, whether it’s the married woman who has children and wasn’t prepared to have another, the married woman who wasn’t ready to start a family yet, the single woman who isn’t prepared to support a child on her own, or the teenager who is but a child herself and the least emotionally prepared to have a baby out of all these examples.