Reducing Post-Partum Depression the Village Way

   the country was
shocked to learn how Andrea
Yates killed her children during
an episode of post partum
psychosis. The “eye for an
eye” folks wanted her electrocuted.
The “spare the rod,
spoil the child” folks wanted her punished
with a harsh sentence that would deter future
killings. The “there but by the grace of God
go I” folks wanted the world to wake up to
the reality of how postpartum mood disorders
(PPMD) can change a woman’s life.
In the aftermath the New York Times began
shedding light on the tragedy. Allegedly,
Andrea’s “controlling” husband limited her
free time to two hours per week (despite the
fact that she was isolated and also caring for
and later grieving for her Alzheimers-ridden
father), her church discouraged treatment and
encouraged baby-making, her psychiatrist
minimized her condition and failed to prescribe
an anti-psychotic medication, and
Andrea was previously discharged from clinics
prematurely because insurance wouldn’t
pay for extended services (i.e., “coverage
maxed out”). Knowing that these were things
we could change, everybody wanted to fix
the system so such tragedies would never
happen again.
HOW HAVE ATTITUDES TOWARD PPMD CHANGED
SINCE ANDREA YATES’ CASE?
Five years later people are still downplaying
the reality of PPMD and its impact on
children (see Julia’s vignette this issue). Just
three months ago a woman told me, “My husband
doesn’t believe post partum depression
is real. He thinks I should just get over it. You
know, ‘Just do it!’” How unfortunate because
PPMD generally responds to treatment (see
sidebar on PPMD). When family members or
professionals minimize a mother’s concerns,
or fail to acknowledge the reality of her
depression, a mother is hard-pressed to get
treatment. Rather than getting over it, individuals
with PPMD can easily spiral downward
in negative thinking that worsens their
condition and distances support. Consequently,
it is hard for them to give the attention
their infants need to be happy and to build
solid relationships (Field, 1997).
Five years later the “system” is still aggravating
PPMD rather than preventing it and
depriving women access to quality treatment.
Beck (2001) identified 13 significant predictors
of PPD (listed in order of effect size):
prenatal depression, low self esteem, childcare
stress, prenatal anxiety, life stress, low
social support, poor marital relationship, history
of previous depression, infant temperament
problems/colic, maternity blues, single
parent, low socioeconomic status, and
unplanned/unwanted pregnancy. Although
there is a subgroup of women who are vulnerable
to hormone changes during pregnancy,
radical hormonal changes did not make it to
the list. Rather, pregnancy seems to trigger
PPMD in women who have one or more of
these risk factors, half of which, if not more,
are affected by social policy (italicized items).
Social support is the factor that intrigues
me the most. We now have ample evidence
connecting it to PPMDs, even a causal role
(O’Hara 1985, Field et al. 1985; and Gotlib et
al. 1991). According to JAMA (2002), the
hormone oxytocin (produced during natural
labor and breastfeeding) “activates an
evolved biological system underlying mammalian
mother-infant attachment behavior…
However, under conditions of high
stress and inadequate support, this emotional
reactivity may increase vulnerability to
depression by rendering a woman more susceptible
to stress.”
The powerful impact of poor social support
following the birth of a baby leaves men
vulnerable to PPMD as well (see Hagen
1999). From an evolutionary perspective,
reduced social support increases the costs
borne by caregivers relative to the benefits of
offspring, especially when infants already
have problems. Reducing investment in the
child reduces the costs. Hence, PPMD is less
of an individual’s mental illness, and more of
a population dysfunction: community-based
interventions are needed.
CALL FOR IMPROVED FAMILY LEAVE POLICIES
The current federal Family and Medical
Leave Act protects parents against job loss
for up to three months after a baby’s birth.
However, protected leave is limited to individuals
who have worked at least 12 months
for a company with 50 or more employees.
For newly hired workers, workers with insecure
jobs or jobs lacking fringe benefits, or
workers who don’t meet the legal definition
of “family”, taking a leave often means quitting
and finding a new job later. Consequently,
most parents return to work well before
three months. Of families who wanted a
longer leave but did not take it, 88% would
have taken the time if income replacement
were available (Cantor, Waldfogel, Kerwin,
Wright, Levin, Rauch, Hagerty, & Kudela,
2001). In short, millions cannot afford to take
an unpaid leave when they need it the most.
Current family leave policies don’t offer
families ample time to recover and support
each other following a birth. A leave gives
the mother time to physially recover and
adapt to her infant. It gives parents time to
adjust their relationship, balance family
chores, recover from sleep loss, integrate the
baby into the family, learn their baby’s cues
and patterns, and feel effective in soothing
their baby and organizing her day. Three
months is too short for many families to
accomplish these tasks let alone give their
babies’ development solid grounding. Most
infants are not socially responsive until three
to four months of age, and many parents need
longer to feel the rewards of parenting. Most
infants do not have the capacity to sleep
through the night until four months of age,
and parents need time to make up lost sleep.
Early return to work can disrupt the
adjustments that families must make after the
birth of a child. When a mother is at risk for
depression, early return to work, especially
when caring for a child with special needs,
could push her into depression. Developmental
research shows that shorter leaves are
associated with increased depressive symptoms
in mothers and with more negative
affect and behavior toward infants at 4
months. When a family has a significant
stressor (e.g., depression, poor physical
health, infant with special needs or difficult
temperament), longer leaves are associated
with increased positive affect, sensitivity, and
responsiveness and decreased negative interactions
toward infants at four months of age
(Clark, Hyde, Essex, & Klein, 1997; also see
Julia’s vignette this issue).
It is unacceptable that employees feel
lucky if they have a few weeks of paid leave
after a baby’s birth. Ask your state representatives
to support flexible equal-opportunity
family-work policies that recognize individual
differences and vulnerabilities in families’
needs and values. Consider pushing for
HB 3470, the Illinois Family Leave Insurance
Program (FLIP), which has been sitting
in the House Rules Committee since March
2005 (see sidebar), or the socialist models
used in Scandinavia (see sidebar on page 6).
PUSH FOR FAMILY SUPPORT PROGRAMS
In several places around the world women
are pampered for 40 days after they give
birth. Usually the grandmother comes to
make special soups that will replenish the
mother’s blood supply and to tend to household
tasks so the mother can sleep and bond
with her baby. In the US, many women give
birth in a community far from family or
friends who might be willing or able to stay
by their side for 40 days. Unless a woman is
wealthy enough to hire a post-partum doula,
she likely spends long hours at home alone
with her infant. This lack of social support is
the last thing she needs.
Recently I asked a local mother who lives
with her spouse and two children, a 4-year-old
and 3-month-old, how she spends her day. She
told me that on the six days per week when her
husband works, she spends 10 hours/day alone
with her children (not counting night-time
feedings while her husband sleeps), because,
as she said, “Most of the people around me
work during the day and my husband takes our
car so it’s hard to get out.”
In a 2002 survey, 35% of women reported
feeling isolated in the months following birth
(childbirthconnection.org). Isolation prevents
early detection and deprives women of the
support they need to combat stress. Our current
solution: wait for depression to happen
and train pediatricians to screen women for
PPD during well-baby visits. There are more
proactive approaches.
Individuals could mobilize their neighborhoods
to take care of their families with
new babies (checking on them, helping them
laugh, offering respite, connecting them with
other families, listening to their stories, and
referring them to the Crisis Nursery, Family
Service, Healthy Families, or http://helpbook.
prairienet.org when necessary). Early
Childhood Care and Education providers
could join the Strengthening Families Illinois
network (strengtheningfamiliesillinois.
org) to learn how to care for families, not just children. Hospitals and public health officials could add programs like the
Nurse-Family Partnership (www.nursefamilypartnership.org) that send highly educated
nurse home visitors or infant mental health specialists to visit families bi-weekly
during pregnancy and the first two years after birth. These programs can save 4
times the money spent on them by improving the lives of mothers and their children
up to15 years down the line (including reduced arrests and negative adjudications).
PUSH FOR UNIVERSAL ACCESS TO QUALITY HEALTH CARE
In my recent search for health insurance I discovered that many health care packages
do not offer maternity care, let alone coverage for pregnancy related conditions
like PPMD. Policies with maternity care come at a very high premium and/or are difficult
or impossible to add after a woman becomes pregnant. Texas, where Andrea
Yates lives, ranks near the bottom in the U.S. for mental health care
(healthyplace.com). A doctor referenced on this site said that even though “improved
drug therapy and outpatient care have reduced the need for long hospital stays…the
time authorized by most managed care plans, often just 10 days…still isn’t nearly
enough” (also see Julia’s vignette this issue). “Managed care selectively and deliberately
cut the funding and the benefits for people with mental illnesses and addictive
disorders in this country,” says Dr. Peel. “It’s deliberate corporate practice….resulting
in drive-by hospitalizations.”
To bolster these programs let your representatives know that you want to invest your
tax dollars in wrap-around programs for families with infants instead of funding things
like war. Shared responsibility for family care cycles back so that children, families,
employers, workers, and citizens all benefit. It really does take a village to raise a child.