Postpartum Insomnia Series – Story 1: MRS. J

I want to thank Mrs. J for sharing her postpartum insomnia story with us.  She reached out to me via my blog a little over 2 months ago and we’ve corresponded via email since then.  Her twins are now just over 3 months old, and she is relieved and happy to report that she is well on her road to recovery and able to appreciate motherhood.  Mrs. J has had 4 other babies before and did not previously experience prenatal depression, postpartum depression (PPD) or postpartum anxiety (PPA).  Though, looking back, she thinks she might have had mild PPD before, now that she knows what having PPD is really like.  Like me, she was caught blindsided by insomnia, though hers really started before childbirth but was nevertheless what started her on her journey of perinatal illness.

Now, without further ado, here’s Mrs. J’s story.

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When Ivy asked me to share my story on her blog, I jumped at the opportunity. Had I found her blog before things escalated with me, I believe I would not have gotten as bad as I did.  Because of my experience, I want to offer hope to other moms who are suffering with PPD, PPA, and dreaded INSOMNIA that is one of the worst things anyone can ever go through, especially after just having had a baby….or in my case babies. That’s why I am sharing my story.

I gave birth to four healthy children before I found out I was pregnant a fifth time. At my 8-week ultrasound, the ultrasound tech looked at me and announced I was expecting twins. TWINS! Wow, that threw me for a really huge loop. After my initial shock wore off, I started to feel rather excited to take on this new experience.

My pregnancy was long but pretty uneventful up until my 7th month. I was diagnosed with gestational diabetes, which in itself is not too big of a deal.  You can control it with diet, which I was able to do. But I had been diagnosed with cholestasis during my last pregnancy, and it started rearing its ugly head again in this pregnancy. Cholestasis manifests itself with severe itching, usually on the palms of your hands and the bottoms of your feet. I started to have trouble sleeping when they tested me for cholestasis and during the 10-day wait for the test results. I couldn’t shut off my mind to the worry of having a vaginal twin birth (which was my hope!) and worry that I would have to be induced early for the cholestasis diagnosis and the negative impact it could have on the health of my babies.

I started to really have problems falling asleep. My doctor recommended I take Benadryl to help me sleep, and I was able to fall asleep and stay asleep for at least 6 hours the first two nights.  But on the 3rd night, I couldn’t fall asleep. I tried everything from warm baths with Epsom salt to drinking warm milk and avoiding television.  I wouldn’t touch caffeine with a ten foot pole. Everything you could read about “sleep hygiene” I tried. Nothing worked. I would pace the floors and move from my bed to the couch and back to my bed, all while my kids and husband were sleeping restfully. I called my OB office countless times and they wanted me to try Ambien. I was terrified to try Ambien, as I had never had to take a sleep aid before and I’d read horror stories of people doing things that they couldn’t remember doing while on Ambien. On the first night, I made my husband stay awake to make sure I didn’t start sleep walking and drive off into the night. I can now look back and laugh at this. I took the Ambien at 9:30 that night and was up by 4:00 in the morning. The second night I took it, I slept for maybe 4 hours. The third night I only got an hour of sleep. I was exhausted. I couldn’t nap during the day. I couldn’t sleep during the night besides a few hours here and there. I was calling and calling my OB office for help, but they couldn’t understand my desperation. My friends and relatives couldn’t understand either, but then again, how can you really understand such desperation until you’ve actually been there.  None of them have been through this before.

My OB suggested I go on Zoloft but I was having anxiety about taking an antidepressant while pregnant and I told her I wanted to try Prozac as I was on that before and it had helped with my General Anxiety Disorder. You see, I’m no stranger to anxiety and panic attacks but this was a whole different ball game. I never had trouble falling asleep like this in the past. It’s ironic that I am someone who’s always preached about how important sleep is to mental health….and yet I can’t sleep!  I have always needed a full night’s rest to feel good.  Why was this happening to me?!

Somehow, I managed to muddle through the last 3 weeks of pregnancy.  I was supposed to be induced at 36 weeks because my liver test results for cholestasis showed elevated levels. But 2 nights before I was to be induced, my water broke. Since I wasn’t 36 weeks yet, the hospital policy required me to be transferred to a bigger hospital.  The doctor on call there told my OB that he was going to perform a C-section. I was pretty devastated, as I wanted a vaginal birth and both my babies were head down on the ultrasound. Turns out, I progressed way too quickly and couldn’t be transferred.  Three hours after my water broke, I delivered two healthy little preemie boys. They didn’t need NICU time, thankfully.  But once I got back to my room, I started to hemorrhage.  I was terrified. My husband was in the nursery with my twins and not by my side when I started gushing blood. My OB was called in and was able to scrape all the clots out (ouch!).  To say I was exhausted at this point is an understatement. I probably looked like death. I certainly felt like I was on the brink of death.

Even after weeks of not sleeping, being up for 30 something hours straight, giving birth and then hemorrhaging, I only managed to sleep 4 hours the first night after giving birth.  I thought my body would shut down for hours from sheer exhaustion, but it didn’t. On the second night in the hospital, I asked for Ambien and I was able to sleep for about 6 hours.

After two nights in the hospital everyone was healthy, so they sent us home. The first night home, I didn’t sleep at all. Not ONE minute. I was delirious. I was still taking Prozac at that point.  I called the OB and asked if I could be prescribed something besides Prozac and Ambien. She told me I needed to call my family doctor because she can’t prescribe anything other than the general sleep aid and antidepressant. I called my family doctor and got in the next day. He prescribed Xanax to take at night. So, here I thought this would solve my problems. It worked the first and second night, but by the third night (again!) I woke up after an hour of sleep and couldn’t fall back asleep. I didn’t understand how this medication would only help for a couple days but then it wouldn’t work anymore.  I’ve never experienced anything like this before.  Not knowing why I wasn’t sleeping even though I was exhausted added to my anxiety.

I thank God every day for giving me such a patient husband. He took care of the twins, and we sent our 4 other kids to stay with family. I started feeling desperate again, so I called my family doctor to see what he could do for me. His only suggestion was to double my Prozac dose.  The increased dosage didn’t help.  Now that I look back, I realize I wasn’t being as honest as I should have been. I should have told him that I didn’t think I could make it through another day.  On the ride home from that appointment, at every intersection I wanted a car to plow into us and just end it all. My husband and twins were in the vehicle and that didn’t matter to me. I had lost all will to live. I tried thinking of my kids and how much they needed a mother, but I still did not want to live anymore. I felt so hopeless and desperate.  It was on that ride home that I texted a friend to tell her that I think I needed to check myself into a psych ward. She texted back saying that if that’s what I felt I needed, it was the right thing to do. It was what I needed to hear, but it was the hardest decision I’d ever had to make in my life.

At that point, I didn’t know what I needed, I didn’t know who could help me, and I thought no one in the world has been where I was.  I just knew that I felt scared, alone and hopeless.

Once in the hospital, the first night was hell.  I was still on Xanax. I didn’t sleep at all. I wanted to die that night. And then to be in this strange place, with people yelling out all night long…..I’d never imagined I would ever need to be in a psych ward before. I wanted to disappear.  I didn’t want to exist anymore. I feared I would soon be hallucinating and hearing things. I reminded myself I was in a safe place. It was where I needed to be.

In the hospital you are exposed to all different kinds of mental health suffering. It was really frightening, eye opening and even fascinating. I had so much ignorance regarding mental health before that. In that psych ward I saw people with depression and anxiety like me, people having psychotic episodes, people addicted to drugs, old people with dementia, and war veterans with PTSD. It was so interesting to learn from the nurses, doctors, and other patients and see how much help people needed and can get for their mental health problems.

After 6 nights of trial and error I went home.  I was on the antidepressant Zoloft, the antipsychotic drug Seroquel as a sleep aid, and Vistaril on an as-needed basis for anxiety. I was terrified to go home and be in the same place where I had such horrible memories the month before. We sent the twins to stay with family. The only ones home with us were our two oldest children, as they had to go to school. I wore ear plugs, turned on the fans for white noise, and slept alone. I managed to sleep 5 hours….still not a full 6 or 7 hours like I would normally sleep, but it was so much better than before. I still felt like my life was never going to be “normal” again.

I remember hearing the train go by not far from our house.  I recalled the story of a mom suffering from PPD who threw herself in front of a train and killed herself. I felt I was going to do that.  My mind and body were so tired and I was in such a bad place that I could understand why she would carry out such an act of desperation.

After visits with a therapist, a new family doctor, and supportive friends and family, I slowly but surely started feeling better.  I started to have good minutes that would turn to good hours and finally turn to good days. Slowly but surely, I was able to sleep longer and longer stretches without waking.  If I did wake, I could fall back asleep.

I truly, truly, truly did NOT have any hope at all until I found Ivy’s blog and began reading her experience and the experiences of other moms in the same situation in the comment threads. It was such a blessing to read all of that and realize that there IS hope. THERE IS HOPE. I read about people who said that they felt hopeless and thought they would never return to their old selves again.  I FELT THE SAME WAY!  When you are in the midst of fighting dark hellish days, it is so hard to believe that life will ever return to a state of normalcy. But IT WILL. If you’re reading this and are experiencing dark days, please know that IT WILL GET BETTER. DO NOT LOSE HOPE and don’t be afraid to reach out for help.

My husband stayed home for 6 weeks to help me with the twins (once they came home) and the other two kids.  He also helped with the twins’ night feedings. But after he went back to work, I experienced a major setback. My comfort, my support, my rock was leaving and it felt terrifying. After he went back to work, my doctor upped my Zoloft dose and thankfully my mom stayed over the first week and helped with the twins at night.  A few family members helped with nights after my mom went home. It wasn’t until my twins were 13 weeks old that I felt confident enough to not only try taking on the night feedings with the twins but to also starting weaning off my sleep medication. Thankfully, as I write this, I am no longer dependent on my sleep medication! I am only on the Zoloft and I plan to stay on it for as long as necessary to make sure my brain chemical levels stabilize.

Just as Ivy’s husband feared at one point that she would never get better, my husband feared I would never recover. It was very tough for our husbands to watch us suffer and not be able to fix any of it. It was hard for our family members to watch us suffer and not know how to help us feel better.  If you are like me and have loved ones who do not understand the extent of our suffering, do not get frustrated with them. They can’t understand because they haven’t been through this kind of hell before.  They don’t understand that you are not being dramatic, and that you can’t just calm down, close your eyes and fall asleep.

I know you can’t help how you are feeling and you can’t control your anxiety levels or will yourself to sleep. In fact, the more you try to control it, the worse you feel. Just know that it will get better and you need to give your body time to adjust to your medication.  You WILL get better.  It just takes time, and I know that when you’re suffering, it feels like time is deliberately tormenting you by crawling so slowly.  Hang in there and try to avoid looking too far ahead.  Take one day at a time.  Once you get the right help, the days will go by quicker and easier.

I look back at these last few months and can now say I am thankful in many ways for going through what I went through. I have gained so much insight and have a whole new outlook on life and on mental health. I’ve learned that PPD and PPA are not due to some character flaw.  It’s not my fault I went through it.  I’m a survivor and you will be one too!

I am now enjoying motherhood and feeling so incredibly thankful for my two little twin boys.  They are such a joy and blessing!  I can now relax with my few cups of coffee during the day and not fear that darn caffeine will keep me up at night.

Hallelujah!

 

Blue Light and PPD

Just a short blurb today to share an interesting Huffington post article on the connection of blue light with melatonin secretion (the hormone that induces sleep) and thus postpartum depression (PPD).  The title of the article is “The Connection Between Blue Light and Postpartum Depression” by Matt Berical.

I’ve always been fascinated in the biology behind PPD, in particular insomnia as a symptom, hence here I am popping onto my blog this July 4th weekend ever so quickly to blog.  I had previously blogged about blue light in my post from 2 years ago titled “Sleep is So Important, Especially to the New Mom.”  If insomnia is plaguing you on a antepartum (or prenatal) or postpartum (or postnatal) basis, or if you are an expectant mom who just wants to be in the know to reduce the chances of PPD hitting you from left field like it does for so many moms, then please read the Huffington Post article and my previous blog post.

I had not known what depression and insomnia were like before I was hit from left field with both, so I’m always happy when I see information made available to the public to educate people.  An important word I’ve heard used before, just not in conjunction with something like PPD prevention, is prophylactic.   It’s a synonym, after all, for preventive measure, which in the case of pregnancy prevention comes in the form of a condom and/or the pill, but in the context of PPD prevention comes in the form of knowledge of symptoms, where/how to get treatment, lining up adequate social/emotional/practical support, and if you want to avoid disruption of sleep, orange-tinted sunglasses that can be effective in blocking blue light. These sunglasses are recommended for anyone that has to either stay up late on a regular basis, like teenagers studying and being on computers (which emit blue light), to expectant moms who have difficulty sleeping due to having to get up in the middle of the night to go to the bathroom and new moms who have to wake up every 2-3 hours to feed their babies.

Whether it’s the anxiety that comes with new mom challenges or the hormonal fluctuations and decrease in serotonin and/or melatonin–both of which are hormones critical for sleep–sensitivity to circadian rhythm changes are further aggravated by exposure to blue light, a biological trigger to wake up, which means that repeated exposure to it during the night can mess with our circadian rhythms and melatonin production.

And hence, insomnia, which for me was my very first PPD symptom.

Sleep is So Important, Especially to the New Mom

As soon as I saw the title of the conference slated for June 6th, “Sleep Matters: Effects on Maternal Mental Health & Infant Behavior,” I told myself I had to register for it.  And register for it I did.  The important of sleep–and the lack thereof during the first postpartum weeks–is a topic that is near and dear to my heart.  After all, insomnia was my first symptom that something wasn’t right.  That I was about to embark on a frightening postpartum depression (PPD) journey.

Dr. James Maas, one of the leading sleep experts, the author of Sleep for Success and the consultant to many a professional athlete/athletic team, was the first to speak.  And boy, was he one dynamic speaker…one of the best I’ve ever had the privilege of listening to!  He starts off confirming what we have probably all heard countless times before….that our society is comprised of sleep deprived individuals who don’t get the 8 hours of sleep a night recommended by the sleep experts; that those who sleep less than 6-7 hours a night are more prone to getting sick and have higher blood pressure due to higher cortisol levels.  Remind me to sleep more during the winter when the shorter days and resulting Vitamin D deficiency–not to mention, the greater number of people being sick, period–cause me to get sick on average once every other month.  The one main thing I took away from Dr. Maas presentation–other than the fact that I learned that Sara Hughes, 2002 ice skating gold medalist, attributes her gold medal win to his sleep advice–that as little as 15 LUX of blue light, like light emanating from smart phones, the iPad, e-readers, computers, and television, suppresses melatonin, the hormone that is critical to the regulation of your sleep-wake cycle.

Then there was Leslie Swanson, PhD and Roseanne Armitage, PhD, both from the University of Michigan.  A lot of the great information these subject matter experts covered in their separate presentations I already knew from the books and articles I’d read over the past years.  But what these presentations had in common with Dr. Maas’ presentation–which I wish I could’ve known BEFORE I had my daughter–was the importance of avoiding exposure to blue light within an hour of going to sleep, as blue light suppresses melatonin secretion (a hormone that induces sleep).  Exposure to blue light is best from the time you wake up in the AM and for the time you need to be up.  I had my daughter in December, which meant I had to spend my first postpartum weeks being exposed to the least amount of light of the year, with a 1/3 ratio of daylight (8 hours) to darkness (16 hours).  Yes, indeed, two reasons to hate winter:  cold and short days.  But I’m not sure a knowledge of blue versus red lights and how to use that information to help improve sleep would’ve helped me back when INSOMNIA hit me from left field when I didn’t even know what PPD was to begin with.

What’s a conference on perinatal mood disorders without the esteemed Kathleen Kendall-Tackett, IBCLC, a health psychologist, board-certified lactation consultant, La Leche League Leader?!  I’ve had the privilege of hearing her at practically every Postpartum Support International conference I’ve been to.  Like the previous presenters, Kathleen talked about bright light therapy. She wrote this Bright Light Therapy for Depression article for the Texas Tech University Health Sciences Center, for which she is clinical associate professor of pediatrics.   Among all the data she shared with us was the result of a study that showed that depression tended to occur at 3 months among mothers who had less than 4 hours of uninterrupted sleep.

What I also wish I had known BEFORE I had my daughter is that:

  1. sleep and depression are intimately connected,
  2. sleep deprivation is a risk factor for PPD, and
  3. getting 4-5 hours of uninterrupted sleep is critical especially to the new mother at high risk (in my case I was high risk due to the events leading up to the 6th week postpartum, especially when it comes to my childbirth complications, my being starved for 7 days, and inability to get uninterrupted sleep even from day one at the hospital because the staff was constantly waking me up through the night).

It’s reasonable to believe that sleep deprivation in a society of super-achieving mothers–mothers who feel they should be able to do it all (take care of baby, cook, keep up the house and round-the-clock breastfeeding) with very little to no help and inadequate amounts of sleep–has caused PPD to crop up in 1 out of 8 new moms!  This also applies to moms with no family nearby to help with the baby, as I previously wrote about in my post on the historical perspective on social support.

I can tell you from my experience that, and I’m confident many other moms feel the same, before my daughter was able to sleep through the night, when she was waking every 2-3 hours or in highly irregular intervals (she was not a great sleeper in the beginning until we determined she had to sleep upright for the first month or so, so we kept her in her car seat, and she had to sleep tightly swaddled–both of these things we had to learn through trial and error as I had mentioned in prior posts), my apprehension that at any minute, I would have to be checking on the baby and/or feeding her prevented me from feeling truly at ease and able to fall asleep as easily as my husband did each and every night for the first few weeks.  Had there been guilt-free care (i.e., no need to worry about my husband getting enough sleep because he had to work the next day) and an assurance that there was someone there to do the night time feedings each and every night until she could sleep through the night, I could’ve very well have prevented my PPD onset entirely.  That would only have been possible, however, if we had known enough to hire a doula ahead of time to spend the evenings with us for the first couple of months.

Speaking of apprehension, I had mentioned in my book how fatigue, depression and stress are highly interrelated in that sleep deprivation can trigger the stress response, which results in the production of stress hormone (i.e., cortisol).  Cortisol, in turn, causes a decrease in the level of the neurotransmitter serotonin.  A decrease in serotonin usually leads to insomnia.

I’d like to wrap up this post with a little yelp of excitement in that Kathleen Kendall-Tackett bought a copy of my book!  This woman has written more than 300 articles, authored/edited 22 books, was a founding editor for two scholarly journals, and served on the editorial boards of five others.  First Jeanne Watson-Driscoll, and now Kathleen Kendall-Tackett.  I wonder who’s next?

How anyone could think that PPD isn’t real is beyond me

Postpartum depression (PPD), and depression for that matter, is an imaginary, or make-believe illness, a state of mind that can be changed at will, a means to get attention, an excuse to take medication to escape from reality, a sign of weakness or self indulgence, an excuse to avoid the reality of motherhood.

Yeah, get a grip on reality–and get educated while you’re at it–for crying out loud.  These statements couldn’t be further away from the truth.  In this day and age, how anyone can believe any of this BS (especially other women) is beyond me.   Why can’t women be supportive of each other instead of being so critical and competitive with each other?!   That includes being supportive of and contributing toward efforts that will help mothers experiencing PPD rather than impeding those efforts (those people, by the way, should be ashamed of themselves).  Why women have to be so feline (note:  my #2 anger trigger is feline behavior, after my #1 anger trigger of behavior & remarks made out of ignorance/racism/condescension) is beyond me!

Skeptics will claim that, since PPD isn’t necessarily detectable via blood work nor a growth or wound or handicap that is visible to the naked eye, that it must not be real.   And please don’t say this is a recent phenomenon or that women have been giving birth thousands of years and we’ve only seen a rise in PPD awareness–and thank goodness for that–in the past decade, so it must be a new invention made up by women in today’s generation because they can’t cut it like the tougher women of previous generations.  Right.    Anyway, this “recent phenomenon” is thanks to the women out there (you go girls!)–plus celebrities who are finally gaining the courage to speak up more about a condition that has been documented as far back as the days of Hippocrates.  Scientists have not been spending years on research on treatments, detection, determination of risk factors, etc. for lack of anything better to do.

People out there scoff at the idea of PPD and claim to know all about it, when in fact they don’t.  Why?  Because they never suffered it themselves…duh.  They’ll claim that all new mothers experience mood shifts after childbirth.  Hello, you’re thinking of the blues, which happen within the first couple of weeks postpartum and resolve on its own.  They’ll claim that there is no scientific evidence that PPD exists.   They’ll claim that insomnia, a classic symptom of PPD, is merely sleep deprivation and fatigue that all new moms experience.  They’ll also claim that having a panic attack is the same thing as anxiety that comes from difficulties in transitioning to motherhood and being a first-time mom.  Now, had these people actually experienced real PPD, including real insomnia and real panic attacks, they would understand what it’s like to have PPD,  insomnia and panic attacks.   Until then, they should keep their ridiculous claims to themselves.  I’m not going to tell these skeptics to do their reading because no amount of facts will change these peoples’ minds…unless perhaps they experience any of these conditions for themselves.   It’s really a shame, isn’t it, that people insist on maintaining their stubborn beliefs, regardless of how ridiculous they are.

Many of these skeptics of PPD are also skeptical of depression, in general.  They’ll claim that depression is a matter of mind over matter.  They’ll claim that anyone can snap out of depression on their own accord.  Well, wake up!  The ability to will or wish away depression is a myth.  You can’t overcome it by just putting your mind to it.  PPD is a real illness with a biological cause, just like diabetes and heart disease.  You can’t just “snap out of it” any more than you could if you had an ulcer, diabetes or heart disease.  Until I experienced PPD, I thought depression is just a state of mind.  I used to say things like “I’m depressed” whenever I felt sad.  Now, I’m careful to not use the word “depressed” in the context of sadness.  I believe the majority of folks out there mistakenly think that being depressed is the same thing as being sad, feeling down or feeling blue.   People, particularly OB/GYNs,  need to stop getting these two very distinctly different conditions confused with each other because by doing so, they are preventing women with PPD from getting the help they need right at the beginning.  Not to mention, perpetuate the misconceptions about PPD.

With PPD, the longer you wait to seek help, the harder it is to recover from.  But why wouldn’t you get the help that you need to get better and enjoy motherhood sooner?  Why suffer longer than you have to?   There are many possible reasons, though high up at the top of the list would be 1) mistakenly thinking that this is just the way it is with being a first-time mother who is trying to cope but just going through a rough patch (because they don’t know any better due to lack of education about PPD and their doctors’ misdiagnosis as blues) and 2) fear from the stigma associated with mental illnesses and what others would think/say and.    All too many women will unnecessarily struggle with toughing it out or self medicating with alcohol or other substances.

My best piece of advice to you moms out there is to not give a damn what other people think.  Now, if I could take a dose of my own medicine, that would solve one of the biggest habits—or weaknesses, that is—I’ve had so much trouble kicking over the course of my lifetime!  Your priority should be the wellbeing of you and your family.  The best thing you can do for yourself and for your baby—in fact, for your whole family—is to seek help as soon as you experience three of more of the symptoms described in my post “Baby Blues is NOT the Same as PPD!”  Don’t wait until you are crippled by the effects of PPD like I was.    Prolonged and untreated depression can not only negatively affect your marriage and your baby’s cognitive and social development, it can unnecessarily strain your relationship with your partner.  Worse yet, untreated PPD can lead to such feelings of hopelessness that ending your life may seem like the only way out of the pain.  Don’t try to tough it out, thinking what you’re experiencing will pass on its own just as quickly as it developed.  Don’t try to tough it out because others around you are trying to convince you that this is all part of the process of transitioning to motherhood, that every new mom experiences sleep deprivation and anxiety (see previous post on the difference between that and true insomnia, a very common PPD symptom if it is experienced 3 weeks or later after childbirth).

Though the symptoms and their severity may be unique to every woman, PPD is debilitating to all those who suffer from it.  Depression–and there are thousands in this country today that are afflicted with it– affects people physically, not just mentally.  It is a physical illness that is the result of a chemical imbalance.   Hormonal changes are responsible for perinantal (during pregnancy and postpartum)—and even premenstrual dysphoric disorder (PMDD)—mood disorders and an imbalance in brain chemicals called neurotransmitters.  Serotonin is one such neurotransmitter.  Research shows that serotonin dysregulation is a primary cause of PMDD and PPD.  A sudden and huge drop in estrogen levels immediately after childbirth contributes to a decrease in serotonin availability in the brain.  Since serotonin promotes normal mood, a decrease in serotonin availability in the brain is associated with anxiety/depression.  This is why medications such as selective serotonin reuptake inhibitors (SSRIs), which increase serotonin availability in the brain, have in many cases been effective in the treatment of PPD.   An SSRI was effective for me.

Let me explain something here, lest the words “medications” and “SSRIs” trigger a violent reaction among the anti-pharma faction out there.  I am not advocating medication for everyone.  Different treatments will work for different women.  A woman must be informed enough to be able to make a decision that she feels is right for herself.   Being informed means having ready access to information about PPD, its symptoms, where to go for help, what treatments are available, what medications are usually prescribed and their side effects and risk of being passed to the baby via breastfeeding, etc.   It also means having a doctor that is adequately trained to detect, diagnose and treat perinatal mood disorders.  But many doctors are still not adequately qualified to do any of that, plus lack adequate tools and resources.  This is why awareness about PPD and preventive measures (like lining up adequate social support and getting 5 hours of interrupted sleep as much as possible in the first 6-8 weeks postpartum) are so, so critical to everyone who plans on having a baby. 

I’d like to close with this piece of advice to the skeptics.  Without knowing the full story (or without ever experiencing PPD or any other illness directly) one should NEVER pass judgment on the situation of others.   Women with PPD do not need to be scoffed at, doubted and criticized.  They need support and understanding.  If you were in their shoes, would you want to be on the receiving end of these negative or–shall I say–tasteless behaviors?

How Hospitals/Docs and Magazines/Books on Pregnancy/Motherhood Can (and Should) Increase Public Awareness on a New Mom’s Need for Sleep

Let me start with how I believe OB/GYNs and hospitals–not to mention books and magazines on motherhood and pregnancy– can and should most definitely do more in terms of increasing public awareness of postpartum depression (PPD), which should start with this….the importance of sleep and getting adequate support to help reduce the risk of PPD rearing its ugly head.   OB/GYNs and/or hospitals should put right up at the top of the childbirth education curriculum–short though it usually is (a couple of hours…what a shame!)–the importance for new mothers to get at least 5 hours of uninterrupted sleep as much as possible during the first 6-8 weeks postpartum

What should be included in the education: 

1) the fundamentals of adult sleep, including what is considered “normal” sleep

2) sleep cycles

3) what to expect during late pregnancy and postpartum in terms of their impact on sleep

4) strategies for sleep management during late pregnancy and postpartum

5) effects of sleep deprivation

6) facts about newborn/infant sleep

Granted, for the greater majority of mothers out there a) the husband has to work full-time during the week and it is highly unlikely he could work the same hours and do the late-night feedings all week, and b) they lack the financial ability to hire a baby nurse, postpartum doula or nanny to help with late-night feedings.  What that means is, for most mothers out there, it is highly unlikely the mom can get the 5 hour block of sleep at night that she needs.  That shouldn’t, however, deter the OB/GYN from providing the simple fact that a minimum of 5 hours of uninterrupted sleep is imperative to the healthy functioning of an adult (more so for a woman who has just given birth), and depression is one possible consequence for the brand-new mother–hormones all outta whack and all–who fails to obtain that over the course of weeks following childbirth, a time in which she is at her most vulnerable. 

Awareness + Preparation = Keys to a better postpartum experience and reducing the risk of PPD (Note:  You may not be able to prevent PPD if you are at risk, but it certainly doesn’t hurt to be prepared to have a better postpartum experience):

  • While you are still pregnant, reach out to friends and family members to provide practical support (like help watching the baby, cooking, laundry, housework, errands) and emotional support (someone who can listen to you, provide advice and be empathetic and nonjudgmental) after the baby arrives.  Believe me, after the baby arrives, you will have neither the time nor the energy to search and coordinate.  If family and friends are not options, consider hiring a baby nurse and/or a doula to help during the first couple of months, if you can afford it.    Having a baby nurse to help with nighttime feedings will enable you to get the sleep you need to take care of the baby the whole rest of the day while your husband is at work, and your husband to get the sleep he needs to go to work each day.  
  • Resist temptation to use your baby’s nap time to try to catch up on housework, do laundry, address birth announcements, write thank-you notes, or handle other projects.  I know it’s so much easier said than done. I would suggest you scope out the wording and pick out the birth announcement you want to order (and thank-you cards) before having the baby.  That way, you won’t be stressed out finding the perfect one to send after the baby has already arrived, worry about not getting them out within a month after the baby’s born and hustling to get thank-you cards out within 30 days of receiving a gift.  

What happened to me I wouldn’t want to see happen to you…..

I thought I could handle taking care of the baby, cleaning up, finding announcements, addressing them and mailing them out, etc. since I typically thrive on multi-tasking and I never thought it would be any different after having a baby.  And believe me, the word thrive doesn’t come close to describing how much I try to squeeze in in a day’s time.  Silly me had failed to realize that I had just had a baby, which is a very big deal physically.  And that’s on top of the 7 days of hell I spent at the hospital, not to mention the multiple surgeries, daily blood work, MRIs, loss of 4 units of blood, and constant hunger (see previous post for details of my hellish hospital stay). 

I returned home from the hospital fully expecting to resume my old routine in addition to taking care of the baby.  Every time my mother or mother-in-law suggested I lie down or sit down, put my feet up and relax, I waved them off, saying that I was A-OK and didn’t need to nap.  Now that I’ve actually experienced insomnia and PPD, I know that my mother’s and mother-in-law’s advice was excellent advice.  Relaxing/resting is beneficial, even if you can’t fall asleep.  Problem is, I’m neither a napper nor a rester.  I’ve always considered napping a waste of valuable time that could be spent doing something productive.  For as long as I can remember, at least from the time I was 13 years old, napping was never my thing.  I wasn’t about to nap now. 

Don’t feel guilty for napping instead of doing something productive.  Now is not the time to feel compelled to try to impress others or try to fit the mold of what in your mind is how a perfect mother should be like.  After all, no one is going to expect that your house be spotless with a new baby to take care of.   Don’t worry if your house isn’t spotless and neat for visitors.  I know that’s easier said than done.  My house is messy on a normal day sans baby in the picture, let alone with baby (and exhaustion) in the picture.  It didn’t help that I resisted the idea of hiring a cleaning lady because I was brought up to clean my parents’–and now my own–house, so why pay someone else for the work I can do myself, even if it is for the sake of convenience?   I have issues with privacy and trust in hiring a stranger to come into the house (same reason I couldn’t hire a nanny).   

Don’t be like me, letting yourself get caught up in one hell of a vicious cycle:  If you don’t clean, you are less willing to have visitors, so you will feel more lonely and isolated than ever, which makes your PPD worse….

Insomnia versus Sleep Deprivation in new moms (yes, there is a difference between the two)

Here, finally, is my post on sleep (as a follow-up to my post “Some Postpartum Advice for New Moms-Part I”) ….or actually, insomnia.  Just what is insomnia?  Equally frustrating as explaining the difference between the baby blues and postpartum depression (PPD) is explaining the difference between having insomnia and not having the ability (or lack of opportunity/time) to sleep.  Insomnia is when you can’t sleep at night and can’t nap during the day no matter now exhausted you are.  I’m not talking about sleep deprivation, which is what ALL new parents experience in the first 3 months postpartum.  I’m not talking the lack of opportunity or time, either.  To be perfectly clear, a person with insomnia has difficulty falling asleep and/or difficulty staying asleep, even when the baby sleepsInsomnia is one of the most common symptoms of PPD. In fact, it has been shown that early severe fatigue predicts depressive symptoms at 1 month postpartum.  For me, insomnia was my very first symptom of PPD and I wholeheartedly believe that the constant sleep interruptions that started during my week-long stay in the hospital charted a course that was headed for PPD.

You need sleep to stay healthy and to be able to take care of your baby day in and day out.  I had it bad.  You’d think that sleep deprivation would cause exhaustion which would cause me to fall asleep readily and at first opportunity.  That couldn’t be further from the truth in my case.  I couldn’t fall asleep, even when the baby was sleeping.  I couldn’t nap during the day, even with someone taking care of the baby for a few hours.  When I told my doctor I couldn’t sleep at night, he instructed me not to take naps, to which I said “That’s not an issue because I can’t nap either…I can’t sleep at all.”

I encourage you to try one or more of the following to try to switch gears and condition your body out of this situation.  The key is to have the patience to stick it out for at least a couple of weeks.  I know with PPD it can be really hard to do, but please try your best.  Things don’t happen overnight.

  1. If you can’t fall asleep within 30 minutes, stop trying to sleep.  The more I couldn’t fall asleep, the more I was unable to fall asleep.  This effect is referred to as conditioned insomnia where your mind doesn’t expect you to fall asleep, which in turn, keeps you from falling asleep. Lying there waiting to fall asleep but not succeeding will only eat at you and make you more and more frustrated.  It will do you no good.  The harder you try to sleep, the more anxiety you will experience, and that anxiety will keep you from falling sleep—a vicious cycle.  The key in those situations, it seems, is not to expect to fall asleep.  If you fall asleep, great.  Just relax and try to blank out your mind from any thoughts.  Sounds so easy, but is so hard to do.   So many people warned me that the last thing I should do is toss and turn in bed for more than half an hour at a time.  Instead, I should get out of bed and go into another room to watch TV or listen to some quiet music before trying to fall asleep again (this is to interrupt the conditioned insomnia).  Of course I didn’t heed their advice because I was stubborn.  In my mind, sleeping was the only thing I should be doing in the middle of the night.  Plus, I should be exhausted and able to fall asleep instantly.  But after 2 hours of tossing and turning, I was in a state of anguish beyond words.  Had I known at the time that PPD was behind this all, it never would’ve gotten this bad.
  2. Avoid looking at the time.  Move your clock(s) out of the room, if necessary, as watching time go by will only serve to make you feel even more anxious about not being able to fall asleep.
  3. Get a headphone noise canceller or white noise generator to use while getting your 5 hours of uninterrupted sleep.  This is, by the way, just if you have someone like your husband or relative staying with you and helping to care for the baby at night.  My husband had suggested getting me a headphone noise canceller or white noise generator in terms of helping me not to overreact to my daughter’s noises and his snoring (which I could hear even when he was in the den or living room downstairs).  I swear back then I could hear a pin drop, I was so attentive to every little sound that was made in the house!
  4. Have your husband or whoever might be staying with you to give you a back/shoulder massage right before bed.  Ordinarily, a back/shoulder massage right before bed feels so good and is so relaxing, I would fall asleep immediately.  Needless to say, my husband’s massages when I was already sick with PPD didn’t help me one smidgeon.
  5. Establish a bedtime ritual:  Much like trying to condition your baby to associate a bath, reading a book and/or humming a lullaby with going to bed, you should try to recondition your mind to associate drinking warm milk (if you’re not lactose intolerant) and eating something high in complex carbs that can promote drowsiness like bread, taking a hot soothing bubble bath or listening to relaxation music (the kind that would be played during a massage) with going to bed.  I never realized that the reason why so many people suggest warm milk to help you sleep is because it contains tryptophan, which increases serotonin, promoting sleep.
  6. Avoid exercising within 2 hours of going to bed.  My doctor suggested exercise anytime during the day except for within 2 hours of your bedtime may burn off excess energy/reduce jitteriness and promote sleep.  I tried but couldn’t keep this up.
  7. Avoid napping during the day.  My doctor suggested that I avoid napping during the day, as it may charge me up to the point and increase the likelihood that my body will feel less tired at the end of the day.
  8. Do a wind-down routine.  My mother suggested I do a wind-down routine, similar as I would do for my daughter, every night before going to bed.  I should avoid exerting myself or watching stimulating television shows or read books that require too much thinking.  She gave me some information about Chinese relaxation techniques that have been used for centuries.  I tried that, but that night, I ended up having my first anxiety attack from failing to fall asleep after 3 hours of doing that relaxation exercise.  She also suggested I try breathing exercises and visualize positive things when I’m in bed, so as to facilitate sleep.  But try as I might, it was to no avail.  The harder I tried, the more I expected to be able to sleep, and the more agitated/panicked I felt that I would never fall asleep without medication for the rest of my life.  A friend told me that counting backwards in three’s helps her sleep.  I tried that too, but with no success.  It actually drove me crazier.
  9. Reserve your bedroom for sleeping only.  There’s a reason behind the saying “Mothers know best.”  But nearly half the time, I dismiss my mother’s advice as “old wives’ tales.”  Well, when my mother advised me to reserve the bedroom for sleeping only and not do anything like read, watch TV or write in bed, I waved off her advice saying “Uh huh whatever you say, mom.”  Then, I read in “Postpartum Depression Demystified“ by Joyce Venis, RNC and Suzanne McCloskey (pg 41) that you should “Make your room your sleep sanctuary.  In other words, don’t watch TV, read, or play with your baby there.  Your bedroom should be only for sleep.” So, mom really does know best, after all.
  10. Stay away from caffeine.  For me, caffeine wasn’t a factor, since I was totally caffeine free all of my pregnancy and continued to be caffeine free postpartum.
  11. If within a week all the above suggestions fail–provided you don’t experience tremendous anxiety from not being able to fall asleep–then it’s time to see your doctor.  Don’t wait or you could you find yourself going down the same road I traveled—in other words, experiencing high anxiety and panic attacks from not being able to fall asleep.  Don’t wait.  You could go from bad to worse very quickly, and I wouldn’t want you to experience what I experienced (or worse).  Do see a doctor for an evaluation to help determine what is causing your insomnia.  Be honest about all your symptoms when talking to your doctor.  No question is a stupid question when you are a patient.  Doctors are paid to provide medical care, which includes consultation about your diagnosis and treatment.  Leaving out key details will only impede your recovery.  Also, do not let your doctor try to convince you that this is temporary and is experienced by all new mothers.  If you find that your doctor doesn’t know the difference between the blues and PPD, it’s time to find another doctor.  If you don’t know where to find a doctor that can help, reach out to your state PSI coordinator.

Additional Suggestions

Here are some of the things we did to help my daughter sleep through the night, which may be helpful to you:

  1. If you are breastfeeding without any difficulties, you may want to consider having the baby sleep in your room in a co-sleeper so you can pull the baby into bed with you for nighttime feedings without ever having to get up.
  2. If you aren’t breastfeeding, it would help to prepare bottles of pumped milk or formula in advance and have your husband take turns with you in terms of nighttime feedings.
  3. By 3 months if you haven’t done so already, have the baby sleep in her crib in her own room so you will not constantly be disrupted, especially if the baby tends to make a lot of noise while sleeping.  My daughter started sleeping in her own room at 6 weeks because her noises kept us from sleeping during the night, which I know contributed toward my insomnia and PPD.  I had every intention of keeping her in our room through the 2nd month.  Avoid setting this expectation, as it will only let you down harder if you are unable to follow through.  The fewer expectations you have and the more open-minded/flexible you are, the better off you will be.
  4. Keep a clear distinction between night and day as bed time and awake time, respectively.  Keep the room completely dark and quiet at night and bright during the day, with constant noise and hustle and bustle of activity (even when the baby naps during the day).  Doing this consistently can contribute toward your baby’s sleeping through the night earlier.  Every baby is different, I realize.  Fortunately, our daughter was sleeping through the night within 2 months.
  5. Establish a bedtime ritual for your baby, like reading a book or humming a lullaby so she associates bedtime with them.  My daughter used to hum and then drift off to sleep.  So she clearly associated humming with sleeping.  In fact, at four years old, I can still tell when she’s tired because she would all of a sudden start humming/singing to herself.
  6. At 3 months, you may want to start trying to avoid immediately going to your baby when she cries during the night or as you put them to bed.  It’s tough to not immediately go to your baby when they cry.  A minute can feel like an eternity when you hear your baby crying.  At first, you may want to give it 5 minutes before going to her.  If you can’t last 5 minutes, try 3 minutes at first and work your way to 5 minutes.  And then over time, stretch the interval to 10-15 minutes before going into her room, calming her down and letting her cry another 10-15 minutes.  To calm her, you can try humming a lullaby or talking to her, avoiding picking her up, and then walking out of the room.  Repeat this until she falls asleep on her own.  Pick her up and comfort her (or feed her if necessary) only when all else fails.  Keep this up…it will work.

 We found that for 1-2 weeks at a time while she was teething, and even after she learned how to go back to sleep, she would wake up every night at around 2:30 AM crying.  She needed our comfort during that time to fall back asleep.  So we’d pick her up, hold her while sitting in the rocking chair, and sometimes hum her back to sleep.  After about 5-10 minutes, we’d put her back in her crib whether she was asleep or not.  At first, we feared she had regressed.  But it was only temporary.  You may find this will happen to your baby while they are sick, teething or have an ear infection.  A baby who is teething and/or has a fever and/or is not feeling well should be comforted immediately.

 By 4 months, in order to teach her to fall asleep in her crib while she is still awake, begin putting your baby to bed at night while she is still awake.  If your baby will only fall asleep if you rock, nurse and/or hum a lullaby, she will come to depend on being rocked, nursed and hummed to in order to fall asleep, so that when she wakes up in the middle of the night, she won’t know how to fall back asleep without your intervention.

Stay tuned for my next post that continues on this topic, specifically in relation to awareness of the importance of sleep and setting up a support network before you have your baby as being the key to prevention of insomnia (and PPD).

Risk Factors for PPD

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:

  1. 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.
  2. Abrupt weaning/discontinuation of breastfeeding.
  3. The return of a woman’s menstrual period for the first time after childbirth.
  4. 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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. Low socioeconomic status.
  8. 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.