Later this month, Science & Sensibility contributors will share their hopes for the year 2012: what we would like to see accomplished in the ensuing months on behalf of mothers, babies and families, and the maternity care industry as a whole. One of my hopes for the coming year(s) is that childbirth education organizations like Lamaze will increase their attention to issues revolving around maternal mental health; training birth professionals to screen, recognize, support and appropriately refer women with whom they work who may be suffering from one of the myriad perinatal mood disorders (PMDs)we now understand exists.
To that end, I’d like to share with you a study that recently crossed my desk (thank you, Walker Karraa) which assessed online resources pertaining to PMDs. Donna Moore and Susan Ayers published their findings from A Review of Postnatal Mental Health Websites: Help for Healthcare Professionals and Patients in the Archives of Women’s Mental Health in November of last year. The aim of the study was to conduct a systematic review on any and all current websites that maintain a primary purpose of discussing postnatal health with particular interest in the depth, breadth, quality and technological excellence of sites that specifically discuss postnatal mental health.
Studies show that 10–15% of new mothers are diagnosed with postnatal mental illnesses, and potentially one in four women may have significant distress without meeting criteria for a disorder.” (Baker et al. 2009a, b;Czarnoka and Slade 2000)… However, there is now increasing evidence that anxiety disorders are also prevalent in between 3% and 43% of women in the postpartum period (Glasheen et al. 2009).”
The four major search engines were employed (Google, Bing, Ask Jeeves and Yahoo) and the top 25 results for each key word entered were then analyzed.
Disappointingly, the publication of results does not list all sites scrutinized (I would like to see what their search results generated) but the authors did list the top five websites, according to their criteria for excellence which included accuracy of information, available resources for mothers, and website (technical) quality:
Table 1
*Table 1 re-purposed directly from publication
The websites were examined for their quality of information and navigability based on the basic criteria list above, as well as by the following sub-categories:
1. Accuracy of Information
a. symptoms (of postnatal mood disorders…not only PPD but anxiety, psychosis and PTSD
b. risk factors (psychosocial, medical history and additional factors)
c. impact (of postnatal mood disorders upon the mother, infant and her partner/family)
2. Available Resources
a. self-help
b. tools for mothers
c. support for mothers
d. additional resources.
3. Website Quality
a. authority
b. contact ability
c. up-to-date
d. navigation
e. presentation
f. advertisements (appropriateness or lack there-of, distracting, misleading…)
g. accessibility
As concluded by the authors:
Information was often incomplete and tended to be about symptoms, predominantly depressive symptoms, such as tearfulness. Coverage of other symptoms of anxiety, puerperal psychosis or PTSD was minimal. This could reinforce the misconception that postnatal mental illness is solely depression or simply an extension of the ‘baby blues’.”
What type of information, as certifying organizations, are we providing our educators? What kind of information are we, as childbirth educators, providing our clients? Are we providing information that is accessible (understandable), readily available (are we not shying away from difficult-to-discuss topics) and high quality (evidence-based)? Are we acknowledging that somewhere between ten and forty-three percent of the women we teach will end up suffering a postnatal mood disorder? Are we discussing risk factors and approaches to late pregnancy and birth that might help them avoid this outcome?
Invitation for reader feedback: How are YOU implementing postnatal (or perinatal) mood disorders into your curriculum?
Posted by: Kimmelin Hull, PA, LCCE, FACCE
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Sign in now[...] of late pregnancy and birth encourages waiting for the onset of spontaneous labor prior to 39, 40 0r 41 completed weeks of pregnancy, as opposed to encouraging early labor induction—an [...]
Thanks for addressing this critical topic. I don’t know how much longer childbearing women can pretend that current birth practices are not potentially harmful to both mothers and babies. I applaud your efforts to provide all women with information that encourages them to make the decision that is right for them without the ugliness that seems to dominate some other sites. Keep up the good work!
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Hello- I just wanted to note that the references for these articles do not work. I’m very interested in looking at the articles and would appreciate an active link.
Thanks!
Dear Ms. Turner-lee:
Thank you so much for your comments. Racial disparties in the health field are huge and will continue to be until cultural competency is widely spread throughout the medical community. So many preconcieved ideas, thoughts, sterotypes exist that it is amazing that healthy babies, youth, adults and pregnant women even exist..My daughter, who is African American, had health insurance, prenatal care, and education, and a job; the medical staff INSISTED that she be induced… even though she protested and did everything BUT walk out. ( the reason she didn’t walk out, I can only imagine is because we in this cultural-are taught that doctors know best,… so we disregard our own instincts and most times subcum to their pressure.. My daughter was obviously struggling with what to do and when I asked her if she trusted her doctor, ( an African American woman) she said yes…then I asked “so what’s wrong?”… she said ” I just don’t like their attitude”….
Racism is alive and well in the medical institution as well as permeating all the other institutions here.
My daughter reluctantly agreed ( certainly NOT informed consent) to being induced with cytotec. Ten hours later both my daughter and granddaugher were dead. She is not the only case like this I am positive.
Thank you for your comments and insight…. hopefully the medical profession is listening…
Dear Ms. Oden,
I am SO sorry for your loss! This is a tragedy indeed. I could say many things but I think your story speaks volumes for itself. Again, so sorry for your loss and yes, let’s hope the medical community is listening.
Darline Turner-Lee
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I am a mother of 2 and have had two c-sections. The first in 2002 was an emergency section due to a placental abruption. Everything was fine after this then I had another c-section in 2007. I had a drain fitted after for a few days then after release from hospital I got an infection in my scar so had to go back in. After the section I was told there was a lot of scar tissue and if I had another section it would have to be done at 37 weeks to avoid any complications. After this there was a small hole left in the scar which bled with every cycle. After 10 months of this I finally had an operation in which they said they had found quite a lot of endometriotic tissue which they removed. Everything was fine for a couple of years then started to get pain in my scar. I went to the doctor and she referred me to a gynaecologist. I had a tissue scan which showed where the blood was apparently leaking from and where it was pooling. I was told that I could have surgery but advised against it because it would most probably come back, so at the moment I am running my Microgynon packs through and having a period every 3 months so I don’t get the pain as often and was told to take some Ibuprofen to ease the pain. Also, when I do get my period I only bleed for about a day and then nothing, but have the pain for about a week. I’m not sure if I should just carry on like this or try having keyhole surgery as I read this is the best way to get rid of the tissue. I haven’t had this done before because my scar was cut open in the last surgery.
Its great to read other stories and know that I’m not the only one suffering since a c-section! Any advice would be great thank you.
I am not a doctor or midwife, so I cannot give you specific advice, but I can tell you that the authors of all the medical journal articles I have read on cesarean scar endometriosis (also called “endometrioma”) agree that the only curative treatment is wide excision of the endometriotic tissue. Whether that can be done as a “keyhole” surgery is a question for your ob/gyn.
I always speak about baby blues and PPD in my prenatal classes where we discuss the need for good supports. Thanks for the websites…this is tremendous. We are hoping to start a PPD support group here and this will be a great resource.
In my discussions, we always discuss supports and attachment. We talk about birth as a continuum, not an event. And I am trauma informed, so my work reflects that–which I think cannot be over estimated!
There is PLENTY of room for improvement in my curriculum since I hardly acknowlege the possibility of postpartum depression prenatally except when discussing placenta encapsulation (which I do not personally offer). Talking about placentophagy with couples these past few years has been a way to discuss the hormonal changes and energy needs of new mothers and to reflect with them about the needs of some mamas for additional “nourishment” (emotionally, physically and spiritually) in the postpartum period. I think this has been my indirect way to approaching the subject and I’ll look forward to reading contributions from those of you who do this more directly! One aspect I do treat with more diligence (and may contribute overall to less problems for mamas)is what I call “who does what”. We review with detail who walks the dog, services the car, makes the appointments, takes out the trash, picks up the drycleaning, shops for food/housewares/gifts, and all the other gotta do’s of life NOW and then we anticipate that with the new baby there is going to be a redistribution of getting them done! A nice practical conversation begun during class with me then becomes their homework. Obviously this isn’t a panacea for the myriad reasons a women may feel overwhelmed or sad but it definitely reflects my reality as a mother whose husband traveled over half the time. I suppose we teach what we have lived no?
Also, like most experienced educators I have my “go to” list of local professionals if a family asks for help. I suppose my strength lies in “being there” for families in the days and weeks after the birth via visits, phone calls and emails. Mothers-to-be whose births I will be attending, come to my home in the final two months of pregnancy to form community with the other women who have already birthed. These mother baby gatherings occur every month and there is always time before and after the multi hour visit for a mama to approach me privately with a concern.If someone doesn’t attend then I call to find out why! I may not have the training of a psychologist but she has the confidence of knowing a very loving, experienced and interested person is listening. Finally, I can’t help but wonder if having experienced safe and respectful birth hasn’t gone a loooonng way in reducing the incidence of PPD in the women I have worked with over the years. Certainly I have never in 800 births had anyone who suffered post traumatic stress syndrome! That alone has to have reduced the number of PPD. Even as I write this short contribution I am reminded of the woman with whom I have nearly daily contact (since late November) whose baby died at 2 months. I was the doula for her first baby but was not available to accompany her for the recent birth. When her daughter died though, she wrote me immediately and called. Perhaps “mental health” wasn’t listed on the curriculum guide but the discussions, anectodal stories, and underlying belief system…you are important, you’re baby needs you whole, you may need additional support to meet this new lifestyle….contribute to forming a safety net what mother’s will seek when they need it. Certainly a baby’s death put her at risk of becoming seriously depressed and despondent and so far she is coping in healthy ways.
Joni,
I really value your input, with your lengthy experience attending births, as a mother, and a birth professional working in a different setting (Mexico) than many readers of this blog site. The personal contact you describe both before and after a woman’s birth is HUGE in supporting her emotionally–and creates a bridge that is easier to walk across if/when she needs extra support.
Your discussion in class of the “who does what” is an excellent suggestion, and likely one that many first time expectant couples don’t recognize the need for. It is hard to explain to expectant parents all the ways life will change following baby’s arrival–implementing these types of conversations is so fruitful and hopefully just a starting point for couples to springboard off of.
Thank you for sharing!
@Snorkel
Um… no, it is NOT “clutching at straws” … it is factual to identify flaws in any study and consider them for what they are. Henci simply states that there IS the possibility of perinatal deaths due to congenital anomalies, which were NOT excluded in any setting.
Furthermore, we actually can not conclude (from the home birth transfer data) that poor perinatal outcomes after a home birth transport are a direct result of PLANNING a birth at home or beginning labor there. Risking women OUT of labor & birth and home is the entire point! We move to a higher level of care to safeguard the mother and baby. That doesn’t remove the risk as it then exists for that mother and her baby.
A midwife, for example, might identify fetal stress/distress during the course of labor and transport the mother appropriately, risking her out from further laboring/birth at home. That stress/distress event is not necessarily the CAUSAL factor in the actual outcome however. As we all know… some depressed babies will still do well, needing only close monitoring but require few other interventions and result in a healthy birth and baby; while others, despite closer monitoring and necessary interventions will continue to spiral precariously downward, requiring cesarean delivery to potentially safeguard their health (although C-sec does not guarantee a live, healthy baby is ANY circumstance)…
My point is… just because a home birth TRANSPORT OUTCOME ends in a perinatal morbidity or mortality does not MEAN that the DECISION to plan a home birth and begin labor at home is CAUSAL in the OUTCOME. If that were the case, then we could suggest we transport healthy, low risk, planned hospital birthing women to a birth center or home to birth and still use the same rationale “the decision and plan to birth in hospital” as CAUSAL in those hypothetical outcomes.
I believe that it is a serious FLAW in the study to base the OUTCOME of transports on the PLAN and ONSET of labor LOCATION as CAUSAL. You really can’t prove that.
Hello Henci, could you clarify the grammar in one of the sentences of this article? It is: “Confidence intervals overlapped, which means that differences were not statistically significant, i.e. unlikely to be due to chance.”
Does that mean differences WERE or WERE NOT “unlikely to be due to chance”? I was confused and this seemed important. Thanks!
Here’s a few more on this website http://mana.org/conf.html:
MANA Region 5: Feb 17-19 in Phoenix, AZ
MANA 2012: Sept 27-30 in Asilomar, CA
Int’l Breech Conference: Nov 9-11 in Wash DC
Thanks for the summary of Beck’s study and profound description of this alarming experience for women and families.
Dear Madam
I am a father form India. my wife underwent c section yesterday. i want mext birth vaginally naturaly. what precautions should my wife take for the same. how can we strngthen the uterus scar. also what information should i take from my doc right now hich shall be useful for future VBAC. thanking u in anticipation
Thank you, Annie. Your comment truly speaks to the value of qualitative research to give a woman’s experience voice in research. This is what Cheryl Beck has masterfully offered to the quantitative data on all perinatal mood and anxiety disorders.
Take care, Walker
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Thanks for sharing this research, Walker. I’m looking forward to reading the interview. It is encouraging to see qualitative studies on PPD. It’s kind of like counting the grains of sand that buried us, but it’s heartening, just the same. There’s solace (not just strength) in numbers.
Yes. Women know those grains of sand buried within. And we have knowing of the essence of the experience of them in others–this is where qualitative research feels like a gasp of air, an urgent inhale of reality while we all swim around in this ocean of quantitative science telling us about us! Measuring, counting, tabulating experiences… Empirical, quantitative science is the host for the majority of conversations about women’s bodies, and I often feel we assimilate just to survive, be heard, or earn a living.
I am so happy that women like Cheryl Beck have reached across the numbers and included, pragmatically, the voices of women in the research about the women.
Sorry about the double negative. “Statistically significant” means that a probability calculation shows that the difference between groups was unlikely to be due to chance. The difference in mortality rates was *not* statistically significant, which means it may have been due to chance. The thing with calculations of statistical significance, though, is that they never rule in or rule out chance absolutely. They just quantify how likely or unlikely it is that chance caused the difference.
wow, awesome blog article.Thanks Again. Will read on…
Hi Walker – Lovely review of Cheryl Beck’s qualitative research (I love qualitative research!). And looking way forward to your interveiw with Ms. Beck! thanks for keeping us posted!
Thank you, Walker, for this fine synopsis of Cheryl Beck’s first groundbreaking study of Postpartum Depression. Women’s words are extremely powerful in conveying the true meaning of their lived experiences. It’s interesting that when one woman’s words reach others who are going through something similar, they can be comforted to realize they are not alone and to begin healing by reaching out to others. And care providers who read their words with an open heart and mind will bring wisdom and empathy into their practices.
Here’s to the Queen of Qualitative Research, Cheryl Beck!
Thanks for your interviews Walker, introducing Cheryl to LI community is so appreciated. I hope I get to meet her in person someday! Looking forward to #3.
Hi Annie,
I was so struck by her insight that prevalence rates for PTSD could be as high as 18%. And the universal presentation and incidence globally while not shocking, is a good reminder of how desperately we need to prevent, screen, and treat PTSD following childbirth.
Walker and Cheryl, thank you for this fascinating and informative interview series.
With regard to PTSD: why are we not regarding transvaginal ultrasound as an aggravator? Word on the street is that women hate this; the device is like – excuse me – a dildo on a gun. Yet nobody’s taking feedback from patients. They’re told, ‘It’s best for your baby’ (despite lack of evidence. We should be adapting the technology to the patients, not forcing the patients to accept the technology. This is a form of institutional rape & has got to go. http://vaginal-ultrasound.com/
Such a great piece,Darlene.
History is an invaluable component to deeper understanding. The treatments of Silas Weir Mitchell dominated mental health as well. Confinement became the core theme in Foucault’s post positivist work on madness. Clearly there are so many links…thanks for a great article.
Thank you for this interview and clarification of the screening roles. I was quite concerned about the blurring of roles in this matter. I use EMDR for release of birth trauma, it is an evidence based psychotherapeutic method for PSTD and other trauma used by the Department of Defense for veterans and also endorsed by the Israeli and Irish governments.
Great article with many links and implications. Yes, why are women confined? A rhetorical question on my part and one with many levels.
Great feedback from all. Thank you. While I can’t speak for Cheryl, from my own experience, I agree completely with you Dr. Hikel regarding the intrusive nature of the transvag US. Particularly for women with hx of CSA–the mixed messages are so confusing and the emotional outcome deleterious.
Kathy, thank you for your input. I am hoping to bring an article/interview with Phyllis Klaus regarding her work with EMDR and birth trauma as well. Thank you for sharing your use as well. And I hear your concern regarding the blurring of roles and screening. I really appreciate Cheryl’s clarity, and hope we all engage in ongoing conversations about screening and prevention.
Tomorrow Cheryl shares about doing research (my favorite part) and it is so interesting. Hope you enjoy it.
we really do not have much to offer in terms of treatment for preterm labor, preeclampsia, vaginal bleeding, etc and so providers can feel that at least they are doing something, right!?
In researching this topic, it was amazing to see that there really is little to no scientific backing for bed rest. Pretty darn amazing given that 3/4 of a million are prescribed a baseless prescription annually! But like Judith has said, it may be that providers need to feel like they are doing something. But the NEED to feel like you are doing something and actually DOING something (i.e. effecting change and creating a positive outcome) are two very different things. Although the road is slow, there is research being done and hopefully more evidence based treatments for high risk pregnancy complications will be implemented in the near future.
This is a very interesting topic and I think the discussion will only increase as more women choose to delay parenting to concentrate on careers. As women rightfully gain more equal rights in the workplace, although this is a slow process, childbirth will be delayed. It’s positive to see that studies are being undertaken, so we can analyse the risks involved and avoid heartbreaking situations like miscarriage. However, we should take into account the circumstances of each study and analyse the merits of their findings. Some researchers may have predetermined ideas that they wish to portray through their data and that is something we should be wary of.
FYI: recent article. Women with preterm premature rupture of the membranes do not benefit from weekly progesterone
http://www.sciencedirect.com/science/article/pii/S0002937810010252
“data included in the study suggests a higher neonatal death rate (for both home and hospital births) compared to perinatal death rates. This, of course, is not possible as neonatal deaths ought to be included in the perinatal death numbers—therefore the data here are paradoxical in nature.”
Isn’t the definition of “neonatal death” a death occurring in the first month whereas “perinatal death” is death in the first week? If so, the neonatal numbers would be higher than or equal to the perinatal numbers and this isn’t paradoxical at all.
Another excellent prenatal yoga teacher program is Karen Prior’s Mamaste Yoga!
@Carla Harless Yes, she does have a good program. It was one of the ones I looked into when I was looking to take my prenatal teacher training.
Useful to know. Thanks for posting.
Not really interested in Yoga…but exercise is nice.