Lisa van Raalte Ph.D. | August 23, 2022
"It might not come as a surprise, but since the COVID-19 pandemic forced many into lockdown, there has been a surge in pregnancies in the United States. Initially, the onset of the pandemic resulted in a “baby-bust” where there were fewer pregnancies as compared to the previous year; those numbers have since reversed, however, and the U.S. has seen a rebound in pregnancy numbers.
Following the overturn of Roe v. Wade in June 2022, family planning has been a topic of conversation for a lot of households. For those who are already expecting, added stress to pregnancy can be harmful to the mother and child. Thankfully, romantic partners can help pregnant companions through massage.
Massages are a great way to reduce stress for both the receiver and provider. Not only does massage between romantic partners increase feelings of closeness, but this specific behavior also has several health benefits for mothers.
Here are four benefits of massage for pregnant women:
There's Now a Medical Textbook for Reproductive Mental Health—Here's What That Means
By Cassie Shortsleeve | May 20, 2022
"Ask any new birthing person about the realities of postpartum life or anyone post-menopausal about menopause and they'll usually say something along the lines of, "No one told me it was going to be like this."
There's a lot no one tells you about the way reproductive transitions impact mental health, say reproductive psychiatrists—doctors who specialize in the historically siloed field of mental health throughout the reproductive cycle, from adolescence through menopause.
People have long experienced reproductive transitions and the symptoms and conditions that come with those shifts—like postpartum depression (PPD), for example—but the medical community has not known much about them until recently. While the American Psychiatric Association (APA) has dozens of textbooks on all kinds of psychiatric topics, there has been no comprehensive textbook in reproductive psychiatry—until now.
In December, thanks to a volunteer effort by 80 authors from more than 30 different institutions around the country, the APA put forth a textbook: Textbook of Women's Reproductive Mental Health.
In the authors' words, it's "the first comprehensive text for understanding, diagnosing, and supporting the unique mental health needs of women and others who undergo female reproductive transitions during their entire reproductive life cycle."
Lucy Hutner, M.D., a reproductive psychiatrist in New York and one of the book's co-editors adds: "It's a flag-on-the-moon moment for women's mental health."
After all, when she was training to be a doctor, she was told that the field that she specializes in today didn't exist. As recently as the 1980s, doctors and research studies alike suggested falsehoods such as the idea that mood is protected in pregnancy or that "without exception" psychological changes after having a baby were positive.
It's ironic, Dr. Hutner says, considering that postpartum depression is the most common complication of childbirth. But when you have patients with symptoms of diseases that exist and a field that doesn't, it's more than just ironic; it's detrimental to the overall health and wellbeing of that population. A lack of legitimacy perpetuates shame, misinformation, silence, and stigma.
"This medical textbook is almost symbolically more important than anything else," says Dr. Hutner. "It sort of says, 'Hey, this is as important as any other aspect of medicine.' It validates people's voices. It says, 'We don't need to have this stigma anymore. We're done.'"
The Messy World of Reproductive Mental Health
There's nothing non-existent or niche about reproductive psychiatry. But today, if you find yourself with something like PPD or postpartum anxiety (PPA), one of your first touchpoints with the medical system is likely your six- or eight-week follow-up appointment with your OB-GYN or a few trips to the pediatrician.
If you're lucky, you might land in the office of someone like Dr. Hutner for specialized treatment. But too often new moms wind up in an OB-GYNs offices crying and reporting their symptoms with little to no guidance.
Just as this setup fails patients, it fails providers trying to care for those patients, too. The American College of Obstetrics and Gynecologists (ACOG), for example, recommends mental health screening at least once in the perinatal period. But as Dr. Hutner puts it, OBs may not always know what to do with positive screens, or may not know how to treat crying patients.
"The training, education, and dialogue around reproductive mental health have been ad hoc. There hasn't really been a standardized way of approaching it," says Dr. Hutner.
In short: Some physicians have training; some don't. Some are great at providing resources or spotting symptoms; some aren't. There are also big issues including systemic racism in medicine, as well as lack of awareness of queer health issues. This leads to a lot of patients who inadvertently wind up feeling invalidated and alone, without treatment.
Looking Ahead at Reproductive Mental Health
Most people recognize the importance of reproductive mental health, and doctors in training are eager to learn more about it. Lauren M. Osborne, M.D., one of the co-editors of the textbook and the director of the Johns Hopkins Center for Women's Reproductive Mental Health, has piloted a new curriculum designed to educate medical trainees in the field. She asked budding psychiatrists to rank six subspecialties of psychiatry—including reproductive psychiatry along with five officially recognized fields. Doctors ranked reproductive psychiatry in the top half, consistently outranking other specialties that are deemed essential knowledge for independent practice and board certification.
Yet because reproductive psychiatry isn't yet an official subspecialty of psychiatry, it currently lacks government funding for more post-graduate fellowship programs. And learning about widespread problems such as postpartum depression is elective, not a requirement. This contributes to a lack of faculty to teach reproductive mental health and a lack of providers to treat it."
By Sarah Griffiths | April 24, 2019
"Giving birth can be one of the most painful experiences in a woman’s life, yet the long-term effects that trauma can have on millions of new mothers are still largely ignored.
It’s 03:00. My pillow is soaked with cold sweat, my body tense and shaking after waking from the same nightmare that haunts me every night. I know I’m safe in bed – that’s a fact. My life is no longer at risk, but I can’t stop replaying the terrifying scene that replayed in my head as I slept, so I remain alert, listening for any sound in the dark.
This is one of the ways I experience post-traumatic stress disorder (PTSD).
PTSD is an anxiety disorder caused by very stressful, frightening or distressing events, which are often relived through flashbacks and nightmares. The condition, formerly known as “shellshock”, first came to prominence when men returned from the trenches of World War One having witnessed unimaginable horrors. More than 100 years after the guns of that conflict fell silent, PTSD is still predominantly associated with war and as something largely experienced by men.
But millions of women worldwide develop PTSD not only from fighting on a foreign battlefield – but also from struggling to give birth, as I did. And the symptoms tend to be similar for people no matter the trauma they experienced.
“Women with trauma may feel fear, helplessness or horror about their experience and suffer recurrent, overwhelming memories, flashbacks, thoughts and nightmares about the birth, feel distressed, anxious or panicky when exposed to things which remind them of the event, and avoid anything that reminds them of the trauma, which can include talking about it," says Patrick O’Brien, a maternal mental health expert at University College Hospital and spokesman for the Royal College of Obstetricians and Gynaecologists in the UK.
Despite these potentially debilitating effects, postnatal PTSD was only formally recognised in the 1990s when the American Psychiatry Association changed its description of what constitutes a traumatic event. The association originally considered PTSD to be “something outside the range of usual human experience”, but then changed the definition to include an event where a person “witnessed or confronted serious physical threat or injury to themselves or others and in which the person responded with feelings of fear, helplessness or horror”.
This effectively implied that before this change, childbirth was deemed too common to be highly traumatic – despite the life-changing injuries, and sometimes deaths, women can suffer as they bring children into the world. According to the World Health Organization, 803 women die from complications related to pregnancy and childbirth every day.
There are few official figures for how many women suffer from postnatal PTSD, and because of the continued lack of recognition of the condition in mothers, it is difficult to say how common the condition really is. Some studies that have attempted to quantify the problem estimate that 4% of births lead to the condition. One study from 2003 found that around a third of mothers who experience a “traumatic delivery”, defined as involving complications, the use of instruments to assist delivery or near death, go on to develop PTSD.
With 130 million babies born around the world every year, that means that a staggering number of women may be trying to cope with the disorder with little or no recognition.
And postnatal PTSD might not only be a problem for mothers. Some research has found evidence that fathers can suffer it too after witnessing their partner go through a traumatic birth.
Regardless of the exact numbers, for those who go through these experiences, there can be a long-lasting impact on their lives. And the symptoms manifest themselves in many different ways.
"I regularly get vivid images of the birth in my head,” says Leonnie Downes, a mother from Lancashire, UK, who developed PTSD after fearing she was going to die when she developed sepsis in labour. “I constantly feel under threat, like I'm in a heightened awareness.”
Lucy Webber, another woman who developed PTSD after giving birth to her son in 2016, says she developed obsessive behaviours and become extremely anxious. “I’m not able to let my baby out of my sight or let anyone touch him,” she says. “I have intrusive thought of bad things happening to all my loved ones.”
Not all women who have difficult births will develop postnatal PTSD. According to Elizabeth Ford of Queen Mary University of London and Susan Ayers of the University of Sussex, it has a lot to do with a woman’s perception of what they went through.
"Women who feel lack of control during birth or who have poor care and support are more at risk of developing PTSD,” the researchers write.
The stories from women who have developed PTSD after giving birth seem to reflect this.
Stephanie, whose name has been changed to protect her identity, says she was poorly cared for during labour and midwives displayed a lack of empathy and compassion. A particularly difficult labour saw her being physically held down by staff as her son was delivered. “He was born completely blue and taken away to be resuscitated and I was given no information on his condition for hours.”
By Stephanie Collier, MD, MPH, Contributor
"Pregnancy is an exciting time. You will soon become a parent to an adorable, tiny human. You may expect to experience the rollercoaster of emotions during pregnancy, or emotions may catch you off guard. Some women feel joy at every flutter or kick, marveling at their changing bodies. For other women, pregnancy is hard, giving no reprieve as it brings severe fatigue, mood changes, and constant worries. You may notice that with every passing month, your thoughts are spiraling out of control, affecting your performance at work and your relationships at home. But how do you manage your anxiety, and should you treat it?
What causes anxiety during pregnancy?
Worries during pregnancy are universal. Hormonal changes of pregnancy, prior heartbreaking miscarriages, and sleep difficulties may all contribute to anxiety for mothers-to-be. You may worry about how a baby will affect your relationships with friends or family members, the health of your future child, the delivery experience, or the financial burden of an additional family member. All of these worries are completely normal. For humans, a certain amount of anxiety is protective; how else could we motivate ourselves to complete our work or run away from a bear?
What are the symptoms of anxiety disorders during pregnancy?
Although it’s normal to be worried about the health of your baby, in some cases this worry becomes debilitating and may require further attention. Thoughts about the health of the baby may become obsessive, even when doctors are reassuring. Worries may also appear as physical symptoms, such as a rapid heartbeat, difficulty breathing, or panic attacks. If this is the first time you experience a high level of anxiety, this may be frightening in itself. When anxiety starts to interfere with your day-to-day functioning, relationships, or job performance, it may be classified as an anxiety disorder — if your doctor picks up on it.
Anxiety can occur at any time during pregnancy, or it may first appear after delivery (perinatal anxiety is the term used for anxiety during pregnancy and after delivery). The rates of generalized anxiety disorder appear to be highest in the first trimester, likely due to hormonal changes. The most common symptoms of anxiety include constant worrying, restlessness, muscle tension, irritability, feeling dread, an inability to concentrate, and difficulties falling asleep due to worries. Some women also experience symptoms as a result of other anxiety disorders, including panic disorder, obsessive-compulsive disorder, or post-traumatic stress disorder.
Unfortunately, two of the most common mental health screening tools in pregnancy (the Edinburgh Postnatal Depression Screen and Generalized Anxiety Disorder 7-item Scale) are not great at detecting anxiety in pregnancy. Although underdiagnosed, anxiety disorders during pregnancy and in the postpartum period are common, and may affect up to one in five women. Many women suffer in silence.
What are the effects of untreated anxiety on the fetus?
When thinking about management of anxiety, it is important to consider both the risks of treatment as well as the harms of untreated anxiety. Although less studied than depression, research suggests that anxiety may negatively affect both the mother and the fetus. Anxiety increases the risk for preterm birth, low birthweight, earlier gestational age, and a smaller head circumference (which is related to brain size).
What are some treatments for anxiety during pregnancy?
Fortunately, there are many treatments that can reduce anxiety during pregnancy and help you feel better. For many women, anti-anxiety medication is not an option during pregnancy, as there is little information on the safety of such medication on the fetus. Some women who had previously taken medications for anxiety may wish to discontinue medications during pregnancy for personal reasons.
Therapies such as cognitive behavior therapy (CBT) demonstrate promise in the peripartum period (the period shortly before, during, and after giving birth). CBT focuses on challenging maladaptive thoughts, emotions, and actions, and it uses anxiety management strategies such as diaphragmatic breathing (adapted to pregnancy).
If your anxiety is severe, medications may be an option for you. Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for depression and anxiety during pregnancy and after delivery. It does not appear that SSRIs are associated with an increased risk of major congenital malformations. However, SSRIs may be associated with transient neonatal symptoms such as jitteriness, tremor, crying, and trouble feeding, which resolve on their own in a few days.
The use of benzodiazepines such as lorazepam (Ativan) and alprazolam (Xanax) during pregnancy has long been a controversial topic. Although older studies showed an association between their use and an increased risk for cleft lip and palate, a more recent study looking at benzodiazepine use during pregnancy did not show this link when these medications were used alone (although there may be an increased risk when combined with antidepressants)."
By Melissa Willets | Updated August 22, 2021
"The term rainbow baby may not be familiar to people who haven't experienced a loss. But to those of us who have, it has a very deep and even life-changing significance.
So what is a rainbow baby? It's "a baby born after a miscarriage, stillborn, or neonatal death," says Jennifer Kulp-Makarov, M.D., FACOG. "It's called a rainbow baby because it's like a rainbow after a storm: something beautiful after something scary and dark."
She adds, "It's an extremely emotional and devastating experience to lose a pregnancy [or baby]. To create a life or bring a baby into the world after such a loss is amazing like a miracle for these parents."
I'm currently seven months pregnant with a rainbow baby, and indeed, I feel like I'm walking around with a miracle in my belly. There was a time when I never thought I could feel hopeful again. Just last year, we lost our beloved baby Cara at 23 weeks of pregnancy. The days, weeks, and months after she became our angel baby were the darkest of my life. But soon a dim hope flickered inside my heart, and eventually ignited a flame, that became my desire to try again, in part to honor Cara, and to find meaning in her loss.
Rainbow Babies Can Honor an Angel Baby
Moline Prak Pandiyan, a previous ambassador for March for Babies, March of Dimes Eastern North Carolina, knows this feeling well. She lost her son Niko when he was five months old due to complications related to his premature birth. "Although Niko lost his fight, his spirit lives on, and he continues to inspire many," she explains. Not only is this mama involved in fighting prematurity, but she was also inspired to conceive a rainbow baby.
Not that she previously knew the meaning of the term "rainbow baby." "I remember the feeling that I had when I first heard [it]," says Pandiyan. "It was perfect. I so much wanted to make sure that Niko wasn't forgotten, and the term so eloquently acknowledges the babies who we've lost, while also celebrating the joy of our babies who do survive."
Prak Pandiyan is now a proud mom of a little girl, her rainbow, who truly informs her parenting philosophy. "My husband and I always wondered what life would have been like if our son could be discharged and come home with us," she says. "When we welcomed our rainbow baby into this world, our perspective as parents shifted. Whenever things get hard—feeding challenges, sleeping challenges, mild illnesses—we always make it a point to step back and remember that things could be so much worse."
Parenting a Rainbow Baby May Feel Different
Mama Stephanie Sherrill Huerta, who has one daughter, is also expecting a rainbow baby, via adoption, after several miscarriages and failed adoption attempts. She too acknowledges that parenting her rainbow baby will be different, telling Parents.com, "We will love him a little differently than our daughter because we went through so much grief and pain before meeting him. He will truly be the light at the end of the tunnel, the pot of gold under the rainbow, and the rainbow after our storm."
That same spirit has encouraged me to enjoy my current pregnancy more than before. Morning sickness and heartburn can't take away my gratitude for the chance to carry a healthy baby.
Elizabeth Lorde-Rollins, M.D., MSc, OB-GYN at CareMount Medical says this is normal. "For parents who have experienced the loss of a child, whether that loss occurs before or after birth, the life adjustments associated with pregnancy are accompanied with an acute sense of gratitude even when they are uncomfortable," she notes. "And although most of us have the great fortune of being wanted babies, parents tend to have a special, and in many cases incredibly sharp, sense of being blessed when they are expecting and then giving birth to a baby that follows loss."
By Jessica Zucker, Ph.D. | April 22, 2021
"Elisha M., 31, a clinical research coordinator for oncology clinical trials living in New Jersey, can hardly put into words the joy she felt the moment she held her rainbow baby in her arms. Having previously experienced a pregnancy loss, she says she felt "so grateful and excited" to finally have her baby earthside, healthy and thriving.
But her son was also fussy and hard to soothe, and before the two were discharged from the hospital, Elisha found herself appreciably overwhelmed and crying nonstop. "By the end of the first week with him, I knew the emotions I was having were more than just the 'baby blues,' because I felt like I wanted to give up. I didn't want to be a parent anymore," Elisha tells me. "I loved him so much, but I also wanted out."
According to Centers for Disease Control and Prevention (CDC) research, one in eight experience symptoms of postpartum depression (though it's believed the rate is even higher, given the lack of reporting, education, and support resources available to postpartum women). In a country saddled with mental health care and health insurance crises—to say nothing of the pervasive systemic racism within the healthcare system that makes support even more unattainable for Black and brown postpartum people—treatment can be prohibitively expensive, if not completely out of reach.
"By the time I spoke to someone about the way I was feeling, counseling was pretty much off the table for me," Elisha says. "I started to have thoughts of hurting myself." Elisha says she took four to five months off from work so that she could work on herself and be mentally present, and recalls her insurance being billed nearly $1,000 for a single visit to simply speak to a doctor.
"We couldn't necessarily afford for me to be out of work, but my husband really encouraged me to do whatever it was that I felt like I needed and he would figure out everything else," she explains. "It did set us back financially for some time, which I think added another strain on our relationship in addition to the strain postpartum depression was already having on us as a couple."
I wanted to give up. I didn't want to be a parent anymore.
On average, mental health providers practicing in major U.S. cities charge anywhere between $75 to $150 per 45-minute session, though rates in places like New York City, for example, can be upwards of $300 per session. And while costs of certain postpartum depression and anxiety medications can vary widely and depend on insurance coverage, the recent $34,000 price tag for a postpartum depression one-time infusion drug that's said to provide "fast relief" highlights just how expensive the cost of postpartum depression can be—and how unattainable it is for those who are not affluent. In 2017 alone, the cost of maternal depression was an astounding $14.2 billion—an average of $32,000 per mom.
Arden Cartrett, 28, who works in real estate and recently started a miscarriage doula business, says she paid anywhere from $150 to $200 per session with a mental health professional after realizing she was struggling with postpartum depression.
"When my son turned exactly 6 months old, I felt a shift," Cartrett tells me. "I had struggled with anxiety, feeling alone, and worrying about the pandemic, and honestly wasn't sure what would be considered normal or abnormal. Physically and mentally, I felt foggy and was having a really hard time keeping up with life."
Still, due to the high cost of care, Cartrett says she spaced out her therapy sessions—to the detriment of her mental health.
"I do have insurance, but it's a high deductible plan, which means I basically pay out-of-pocket expenses until I reach a certain amount (which is high), so I am having to pay hundreds out of pocket per session which unfortunately limits how often I can use that resource," she explains. "However, medication-wise, I'm on a common medication that is reasonably priced."
Of course, the cost of postpartum depression isn't just limited to a person's finances, nor does it only occur when a person experiences a live birth. In my book I Had a Miscarriage: A Memoir, a Movement, I outline the many costs of postpartum depression that exist with or without a baby in your arms—and those costs are physical, mental, emotional, and financial.
Kayte de la Fuente, 41, a California administrative assistant going to school to become a preschool teacher, says she and her husband have spent upwards of $100,000 between postpartum depression treatment, acupuncture, blood tests, medications, chiropractor visits, and IUI and IVF treatments. She has experienced three pregnancy losses in the last five years.
How does one continue to power through postpartum depression and the various ways it affects a life...while also managing the financial toll?
"It wasn't until we had done more rounds of IUI and having them not work that I really started to recognize the depression that I was in because of that [initial] miscarriage and all of the unsuccessful treatments," de la Fuente tells me. She says that she sought out "unconventional treatments" as well, including a 12-week program provided by a friend of a friend that focuses on finding your inner child, and an infertility support group as well. The program cost $1,200 and the group cost $200 for eight-week sessions—none of which was covered by insurance.
"Of course, because you're looking at all of the bills and you're trying to figure out what your next steps are because you already have all of this financial burden," she says. "Do you keep going?" How does one continue to power through postpartum depression and the various ways it affects a life—symptoms such as mood swings, sadness, anxiety, guilt, loss of interest or pleasure in activities, irritability, restlessness, reduced concentration, feeling overwhelmed, trouble sleeping, or all of the above—while also managing the financial toll?
It's a question anyone who identifies as a parent and who is struggling, whether they've had a live birth or not, has to ask themselves: How do I keep going? Can I keep going? How do I find a way to keep going?"
By Loren Kleinman | May 12, 2021
"The day Lily was born, my husband, Joe, took pictures, murmured soft words, and held her every moment he could. "I want to stay home with her for her first year," he said. "I read it's important for their development."
Luckily, he was able to as he was honorably discharged from the Navy. But despite my three-month maternity leave, I wanted to go back to work.
But when we returned home from the hospital, I unraveled. No time to shower, eat, or pay a bill. Our lives revolved around Lily. Everything I imagined about motherhood exploded. Dreams of gardening with my daughter in a Snugli on my chest were replaced with her unrelenting cries and endless diaper changes.
Yet to Joe, she was just a baby. "What did you think having a baby would be like?" he asked.
"Not like this," I snapped, taking off my spit-up covered shirt and replacing it with a clean one.
It wasn't just the dirty shirt. I had thoughts of hurting myself and my baby, an alarming desire to drive us both off the road. I hated myself for these thoughts, but I hated her more. I hated that she never slept, and resented that I couldn't, either. I hated breastfeeding, which was not magical as I'd pictured, but painful and lonely.
I missed our date nights, coming and going as I pleased, and clean clothes.
Darkness settled over me, unlike any depression I'd experienced. I began experimenting with cutting myself just to feel something other than exhaustion, spending long minutes in the bathroom, my only escape. With each cut came relief from the burden of this new, agonizing life.
"You were in there a long time," Joe teased me.
Low spirited, I replied, "I wish I never had to come out."
He reached out to console me and saw the cuts on my arm. I didn't hide them. I didn't care. But Joe called his therapist, who told him about a clinic for women with postpartum depression.
"He doesn't even know me," I argued.
"You're going," a frazzled Joe said. "Today."
My First Dose of Postpartum Depression Treatment
We arrived to find a room filled with infants, dads, and moms, many of the latter red-faced and crying, while their husbands stood by, holding babies. I was amazed to see so many men like my husband, cradling their little ones, in solidarity with their wives, as the women went one by one to meet with a psychiatrist.
When it was my turn, I looked back at Joe and Lily. A concerned smile dusted his face. "We'll be right here when you're done."
During my intake, I asked flatly, "Will I ever love her?"
"This is a classic postpartum depression question. You will love her," the psychiatrist assured me. "But I have to ask, do you have any plans to kill yourself?"
Without hesitation, I said, "I want to drive off the road." Then I wept.
I wasn't allowed to drive until further notice, and if I didn't abide, the psychiatrist warned, "We'd have to consider hospitalization."
Joe ferried me to and from the clinic every day, no matter how many times he'd been up with Lily the night before. On weekends, Joe tended to me and to Lily, making sure we both ate and slept, as his parents flew out from Washington State to lend a hand, a relief to both of us.
For the first time, I felt some hope.
Every week, I attended weekly dialectical behavior therapy sessions (DBT), learning skills for coping with my anxiety and insomnia like radical acceptance and positive self-talk.
Things Only Got Worse
Then, one night, after Joe put Lily to bed, we sat on our back porch, me with my usual glass of wine, him with his Coke and ice.
"Are you OK?" he asked, as I stared, glassy-eyed, into the trees.
Before coming outside, I'd already washed down a handful of Tylenols, along with sedatives and a few glasses of wine.
"I can't live like this anymore." I paused. "Lily deserves a mom, not me."
Joe sighed and said, "I'm calling the clinic's emergency line."
The therapist on duty advised Joe to bring me to the hospital immediately, even though I protested. But I had no choice. I confessed my desire to kill myself, so I could go voluntarily or in an ambulance.
Joe stayed with me for nine hours in the emergency room, until there was a bed ready in the psychiatric unit. His parents watched Lily at home.
"Please don't let them take me away," I called out to Joe, as a nurse led me to the unit.
"I'll see you in the morning," Joe answered back. "You will be OK."
When he arrived the next day, I pleaded with him to get me out.
"Someone tried to kill themselves last night," I cried. "I don't belong here."
"Can you give it a chance?" he begged.
I sat back in my chair and folded my arms. I resented Joe for bringing me here. At the beginning of our relationship, I'd been the strong one, helping him through his own hardships. But Lily changed everything.
"I have to get back," he said. "Focus on getting better, not getting out."
When Joe leaned in to give me a kiss goodbye, I stopped him. "I want a divorce when this is over," I whispered.
He teared up and said, "You've said some of the meanest things anyone has ever said to me."
I felt no remorse. Before the baby, we never went to bed angry. Now, I loathed him for keeping me here. I was determined to punish him, and I did, lashing out constantly, but he kept visiting and taking my phone calls. He never stopped trying.
I was discharged after five days. Joe and I argued for the entire ride home. When we arrived at the house, I imploded: "I can't take this anymore!"
I threw chairs and baby toys, wailing, and punching the wall. Joe couldn't calm me, so he took Lily and his parents to the farthest part of the house.
The next morning, Joe gave me a choice: "You either go to your parents' house and take a break, or you go back to the hospital."
I chose the first option.
A few days later, Joe called me. "I told my therapist what happened. He called Child Protective Services," he said matter-of-factly.
"They're going to take Lily away?" I asked.
Shocked, I suddenly realized how much I wanted her."
By Paige Glidden | May 07, 2021
"During TheBlueDotProject's Maternal Mental Health Awareness Week, it's time to focus on the mental health of mothers—especially during a life-changing pandemic. The most recognized maternal mental health disorder is postpartum depression, but there are other common mental health concerns to look out for.
Juggling societal and familial expectations is a heavy burden for anyone. But when you add a new baby into the mix (during a pandemic!), it can become overwhelming. Sleepless nights, hormones, and new emotions all feed into overwhelm after the birth of a baby, not to mention that maternal anxiety and depression are the most common complications of childbirth, impacting up to 1 in 5 women.
The first week of May serves as Maternal Mental Health Awareness Week, bringing to light the challenges that moms face and the reality of postpartum depression and anxiety. Maternal Mental Health Disorders (MMHDs) include a range of disorders and symptoms, including depression, anxiety, and psychosis. Although often referred to more commonly as "postpartum depression," there are several different types of postpartum mental health disorders that affect new moms.
Symptoms can occur during pregnancy and/or the postpartum period (together often referred to as the perinatal period). These illnesses can affect anyone—and they are far more common than you'd think. Although an estimated one in five women have a maternal mental health disorder, most cases go undiagnosed, leading experts to believe that the number should be much higher. New parents also experience the baby blues, which is not formally considered an MMHD—up to 80 percent of women suffer from this in the initial two to three days postpartum, according to Bridget Frese Hutchens, Ph.D., CNM, RN, CNL, PHN.
What's worse is that only 30 percent of women who screen positive for depression or anxiety seek or receive treatment. When left untreated these disorders can cause devastating consequences for moms, babies, families and communities. The good news is that risk for both depression and anxiety can be reduced (and sometimes even prevented), and with treatment, women can recover.
It can be hard to identify some of the symptoms of postpartum mental health challenges, but it's worth paying attention to. Here are five types of maternal mental health conditions to look out for:
Common Maternal Mental Health Disorders
1. Postpartum Depression
Pregnancy and Postpartum Depression (PPD) is a mood disorder that can begin during pregnancy or in the first three weeks after having a baby, according to ACOG, the American College of Obstetricians and Gynecologists. Symptoms can range from mild sadness, trouble concentrating, or difficulty finding joy in once-loved activities to severe depression, and mothers with pre-existing depression prior to or during pregnancy are more likely to experience postpartum depression, according to The Blue Dot Project. While there is no single cause for PPD, experts attribute it to the drop in hormones estrogen and progesterone following childbirth and general stressors which increase during pregnancy and the postpartum period. With proper mental health care, PPD is treatable and the risk of severe depression can also be prevented.
2. Dysthymia, Persistent Depressive Disorder
Dysthymia is defined as a low mood occurring for at least two years, along with at least two other symptoms of depression. According to the Mayo Clinic, people with dysthymia may lose interest in normal daily activities, feel hopeless, or have overall feelings of inadequacy. Women with pre-existing dysthymia may be at a higher risk for severe symptoms/depression during the perinatal period, according to The Blue Dot Project.
3. Pregnancy and Postpartum General Anxiety
It might seem normal to worry before or after having a baby, but if your anxiety is more than just the baby blues and you can't get these worries out of your brain, you might be suffering from pregnancy or postpartum related generalized anxiety . Around 10 percent of women will develop anxiety during pregnancy or after childbirth, according to the American Pregnancy Association. Anxiety is treatable during pregnancy and postpartum.
Symptoms often include restlessness, racing heartbeat, inability to sleep, extreme worry about the "what if's"—questions like "what if my baby experiences SIDS" or "what if my baby has autism," and extreme worry about not being a good parent or being able to provide for her family, according to The Blue Dot Project."
By: Lindsay Dolak | Editor at Aaptiv | August 6, 2020
"No matter how fit you were before and even during pregnancy, postpartum exercise presents a unique set of challenges. Your body is still healing from delivery, and with a newborn in the house, you might be feeling more tired than ever. But finding time to fit in fitness is amazing for both your body and mind—it can be just what you need to get back to feeling like your pre-pregnancy self. No, we’re not talking about “getting your body back.” We’re talking about a boost to your energy, self-confidence and physical strength. Plus, you’re bound to sleep better too. Do we have your attention now? Here, two trainers from Aaptiv—a fitness app offering trainer-led, music-driven audio workouts—break down why you should start a postnatal fitness routine, and how to do it.
Benefits of Postpartum Exercise
Postnatal exercise brings a host of positive benefits to your body, but also for your mood and stress levels. Fitness not only helps your body heal but also provides an outlet to recenter and focus on yourself—something that might feel a bit out of reach now that you’re caring for another tiny human. “Postpartum exercise gives moms back that feeling of being in control,” says Aaptiv trainer Candice Cunningham, an ACE-certified personal trainer and Fit For Birth pre- and post-natal corrective exercise specialist. “It’s a huge stress-reliever and also gives new moms something to really focus on for themselves.”
Aaptiv trainer and mom Jaime McFaden, an ACE-certified pre- and post-natal fitness specialist and health coach, agrees, adding that consistent exercise post-baby provides a huge boost in not only physical strength, but mental strength as well. “You just went through so many changes—things have shifted. Exercise helps you heal from the inside out,” she says.
In addition to the many mental and emotional benefits, postnatal fitness can lead to weight loss, improved strength (carrying around a baby all the time is no joke), better sleep and more balanced hormones—a must after nine months of ups and downs.
When to Start Postpartum Exercise
First things first: Don’t jump into a postpartum exercise routine without your doctor’s approval. Many doctors recommend waiting six to eight weeks after birth before starting trying any type of exercise, but it often varies. Some women may experience complications during pregnancy or labor that might set them back a few more weeks. For example, a mother who had a vaginal birth will likely have a different timeline than one who had a c-section. And others may even be able to work out sooner than six weeks.
According to McFaden, working out during pregnancy may help when it comes time to start exercising again. “Your body’s muscle memory will kick in and you’ll have an easier time getting back into it after birth,” she says. “You still want to give your body time to recover, though. Never push yourself too hard post-baby. Patience is key.”
No matter what, it’s crucial to work with your doctor to find out exactly when is right for you and your body. “Every mom is different and it’s important to pay attention to stresses the body may undergo post-pregnancy,” Cunningham says. “A doctor will be able to check for an indication of diastasis recti (the separation of the abdominals) and be able to recommend the appropriate physical work to heal that or any other side effects of childbirth.”
There’s no real reason to rush back into exercising early anyways. In fact, it can cause you more harm than good down the line. It might be hard for women used to high intensity workouts or long runs, but taking it slow is key.
When you’re ready, start by adding walking and low-impact bodyweight exercises at first. Aaptiv’s fourth trimester program meets new moms where they are and focuses on building back up to regular workouts. It covers core, strength training, outdoor walking and elliptical, and places special emphasis on healing the pelvic floor muscles and not aggravating a diastasis recti—both of which are crucial for new moms with recovering bodies. Don’t worry, you’ll gradually work your way back to sprints and burpees in no time.
Best Postpartum Workouts
Before you starting working out again, it’s important to temper your expectations. Your body is different now and you won’t immediately be as strong as you once were. Start with simple, functional exercises you can ultimately build on. To get you started, we asked McFaden and Cunningham to share some of their favorite postpartum exercises to work your entire body."
Medically reviewed by Lynn Starr, RNC-OB — Written by Shannon Conner on September 9, 2015
"Most moms-to-be spend a lot of time worrying about their developing baby. But remember, it’s just as important during the next nine months to tune in to someone else’s cues: your own.
Maybe you’re exceedingly tired. Or thirsty. Or hungry. Maybe you and your growing baby need some quiet time to connect.
Your doctor or midwife may say, “Listen to your body.” But for many of us, that’s followed by, “How?”
Meditation can help you listen to your voice, your body, that small heartbeat — and help you feel refreshed and a bit more focused.
What Is Meditation?
Think of meditation as some quiet time to breathe and connect, be aware of passing thoughts, and to clear the mind.
Some say it’s finding inner peace, learning to let go, and getting in touch with yourself through breath, and through mental focus.
For some of us, it can be as simple as deep, in-and-out breaths in the bathroom stall at work as you try to focus on you, your body, and the baby. Or, you can take a class or retreat to your own special place in the house with pillows, a mat, and total silence.
What Are the Benefits?
Some of the benefits of practicing meditation include:
Moms who have high levels of stress or anxiety during pregnancy are more likely to deliver their babies at preterm or low birth weights.
Birth outcomes like those are a pressing public health issue, especially in the United States. Here, the national rates of preterm birth and low birth weight are 13 and 8 percent, respectively. This is according to a report published in the journal Psychology & Health.
Prenatal stress can also impact fetal development. Studies have shown that it can even affect cognitive, emotional, and physical development in infancy and childhood. All the more reason to squeeze in some meditation time!"
BY ANNE LORA SCAGLIUSI | May 25, 2021
"Jen Schwartz, mental health advocate and CEO of Motherhood Understood, first experienced perinatal depression a day after giving birth. “The biggest red flag was that I was having scary thoughts about wanting to get hurt or sick so I could go back to the hospital and not have to take care of my baby,” she says. “I had no interest in my son. I thought I had made a huge mistake becoming a mother and I couldn’t understand why I was failing at something that I believed was supposed to come naturally and that all other women were so good at.”
According to the World Health Organization, about 10 percent of pregnant women and 13 percent of new mothers will experience a mental disorder, the main one being depression. Without appropriate intervention, poor maternal mental health can have long term and adverse implications for not just these women, but their children and families, too. In most cases, however, women may not be aware of the help available or even that they might need it.
“Most of the time, they mistakenly think they are failing at parenting,” says Wendy Davis, executive director of Postpartum Support International (PSI). “They don't realize they are going through a temporary, treatable experience that many others have gone through.”
To find out more during World Mental Health Awareness Month, Vogue speaks to a range of global mental health experts and women who have experienced perinatal depression.
What is perinatal depression?
"Perinatal depression is the experience of depression that begins during pregnancy [prenatal depression] or after the baby is born [postpartum depression]. Most people have heard of perinatal depression, but what’s equally common for mums to experience is perinatal anxiety either separately, or with depression,” explains Canadian therapist Kate Borsato. Perinatal depression does not discriminate. “Some people are surprised when I tell them that I experienced postpartum anxiety, because of my job as a therapist for mums. But mental illness doesn’t really care who you are or what you know.”
While anyone can experience it, there are some known risk factors that increase women’s chances of developing mental health difficulties in the perinatal period. According to Australia-based social worker and founder of Mama Matters, Fiona Weaver, these include a “previous history of depression or anxiety, those who have limited support networks, have experienced birth or pregnancy trauma, infertility or who may be genetically predisposed to it.”
What are the signs and symptoms to look out for?
Symptoms differ for everyone, and may include feelings of anger, anxiety, fatigue, neglecting personal hygiene and health or surroundings, fear and/or guilt, lack of interest in the baby, change in appetite and sleep disturbance, difficulty concentrating/making decisions, loss of enjoyment or enthusiasm for anything, and possible thoughts of harming the baby or oneself.
Women can also develop postpartum obsessive-compulsive disorder, and postpartum psychosis. Copenhagen-based content creator Clara Aatoft was diagnosed with severe postpartum depression and psychosis months after becoming a new mum. “For the first three months, I didn't sleep at all. I was constantly aware of my daughter’s needs. She was later diagnosed with colic. When I gave up breastfeeding and switched to the bottle, my depression and psychosis went full-blown.” She continues, “I started thinking that my daughter was a robot that someone placed a chip inside at the hospital. I attempted suicide and ended up in the psychiatric ward. I’m very well now, still medicated on antidepressants. But my daughter and I have the best relationship.”
By: Centers for Disease Control and Prevention | April 19, 2021
"Mental health of children and parents —a strong connection
The mental health of children is connected to their parents’ mental health. A recent study found that 1 in 14 children has a caregiver with poor mental health. Fathers and mothers—and other caregivers who have the role of parent—need support, which, in turn, can help them support their children’s mental health. CDC works to make sure that parents get the support they need.
A child’s mental health is supported by their parents
Being mentally healthy during childhood includes reaching developmental and emotional milestones and learning healthy social skills and how to cope when there are problems. Mentally healthy children are more likely to have a positive quality of life and are more likely to function well at home, in school, and in their communities.
A child’s healthy development depends on their parents—and other caregivers who act in the role of parents—who serve as their first sources of support in becoming independent and leading healthy and successful lives.
The mental health of parents and children is connected in multiple ways. Parents who have their own mental health challenges, such as coping with symptoms of depression or anxiety (fear or worry), may have more difficulty providing care for their child compared to parents who describe their mental health as good. Caring for children can create challenges for parents, particularly if they lack resources and support, which can have a negative effect on a parent’s mental health. Parents and children may also experience shared risks, such as inherited vulnerabilities, living in unsafe environments, and facing discrimination or deprivation.
Poor mental health in parents is related to poor mental and physical health in children
A recent study asked parents (or caregivers who had the role of parent) to report on their child’s mental and physical health as well as their own mental health. One in 14 children aged 0–17 years had a parent who reported poor mental health, and those children were more likely to have poor general health, to have a mental, emotional, or developmental disability, to have adverse childhood experiences such as exposure to violence or family disruptions including divorce, and to be living in poverty.
Fathers are important for children’s mental health
Fathers are important for promoting children’s mental health, although they are not as often included in research studies as mothers. The recent study looked at fathers and other male caregivers and found similar connections between their mental health and their child’s general and mental health as for mothers and other female caregivers.
Supporting parents’ mental health
Supporting parents, and caregivers who act in the role of parent, is a critical public health priority. CDC provides parents with information about child health and development, including positive parenting tips, information and support when parents have concerns about their child’s development, or help with challenging behavior. CDC supports a variety of programs and services that address adverse childhood experiences that affect children’s and parents’ mental health, including programs to prevent child maltreatment and programs that support maternal mental health during and after pregnancy. CDC also examines issues related to health equity and social determinants of health, including racism, that affect the emotional health of parents and children. More work is needed to understand how to address risks to parents’ mental health.
To help parents and other adults with mental health concerns in times of distress, CDC funded the web campaign How Right Now as a way to find resources and support. CDC is also funding the National Academies of Science, Engineering, and Medicine to develop an online resource for parents to learn skills to cope with emotions and behavior using evidence-based approaches to improving mental health, which will be released this summer."
By Christin Perry | February 25, 2020
"Almost as soon as those two pink lines pop up on a pregnancy test, your hormones get the message that something's different at mission control. Progesterone and human chorionic gonadotropin (hCG) begin pumping to signal your body to halt production on your next menstrual period, and begin forming that cluster of cells into a mini-you instead. As you probably already know, as these hormones get to work, you'll experience an onslaught of early pregnancy symptoms like nausea, fatigue, and breast tenderness.
As pregnancy progresses, our bodies produce extraordinary amounts of estrogen and progesterone, says Aumatma Shah, fertility specialist and naturopathic doctor at the Bay Area's Holistic Fertility Center. "These two steroidal hormones are key to creating dopamine and serotonin, two neurotransmitters in the brain that are important in feeling calm and happy. This is why a lot of women feel amazing when pregnant: Pregnancy offers a surge of hormones and neurotransmitters that help us feel great."
But what happens to those feel-good pregnancy hormones once your baby is born? "Unfortunately, immediately postpartum and the week following delivery, estrogen and progesterone will both plummet. Simultaneously, there will be a surge in prolactin and oxytocin," says Shah.
These wildly swinging hormones are to blame for those crazy emotions you'll experience after giving birth. Here's a closer look at what happens to your hormones postpartum and when so you know what to expect—and so you know the loony emotions you're feeling are all completely normal.
What Happens to Hormones Immediately After Giving Birth?
The birth of your sweet bundle of joy is undoubtedly one of the most exciting moments of your life. No matter how long you labor or what time you give birth—yes, even if it's at 3 a.m.—you'll likely feel an amazing, indescribable high when you meet your baby for the first time, or shortly thereafter. But those surging hormones will plummet over the next few days. Here's what's going on:
Postpartum Hormones at 3 to 6 Weeks
After those first few weeks pass, you may start to feel those rollercoaster-like emotions start to regulate a bit as you begin to get into the groove of caring for baby and get used to the lack of sleep. Ashley Margeson, a naturopathic doctor says, "the first three months are a bit of a whirlwind of sleep loss and emotions as your system runs mostly on adrenaline to move you through the day."
Around the six-week mark, she says, symptoms of postpartum depression may begin to show as those positive post-birth hormones continue to fade. "The changes you should look for closely are not wanting to shower or focus on hygiene, being afraid of leaving your baby with someone else, not being able to sleep fully due to continually checking on baby, and lack of desire for common tasks like eating, drinking, being around people, and leaving the house."
By Wendy Wisner | Medically reviewed by Carly Snyder, MD |Updated on June 14, 2021
"What Is Prenatal Depression?
Prenatal depression, also called perinatal depression, is depression experienced by women during pregnancy. Like postpartum depression, prenatal (or perinatal) depression isn’t just a feeling of sadness—mothers who experience this mental health disorder may also feel anxious and angry.
You've likely heard of postpartum depression—and that's a good thing. The more that postpartum depression is talked about and understood, the more mothers will seek the help they need so that they can feel better and live full and healthy lives as new moms.
But prenatal depression is a maternal mood disorder that hasn’t gotten nearly as much attention as it should. While prenatal depression can be treated, many expecting mothers don’t even know that it’s a “thing” and therefore don’t seek treatment for it.
Many feel ashamed to even share how they are feeling. After all, you are supposed to be overjoyed and excited when you are expecting a baby, right? It’s easy to feel guilt and shame when you are feeling the exact opposite.
Here’s what you should know about prenatal depression, including how common it is, what to look for in terms of symptoms, and most importantly, how to get help.
How Common Is Prenatal Depression?
Like postpartum depression, which impacts as many as 1 in 7 new moms, prenatal depression is actually quite common.
According to a journal article by Maria Muzik, MD, and Stefana Borovska, published in Mental Health in Family Medicine, 13% of pregnant moms experience depression.
As the authors note, perinatal depression (both prenatal and postpartum) is even more common among mothers facing adverse experiences, such as a history of depression or economic hardship.
“The prevalence of perinatal depression is even higher in vulnerable groups with certain risk factors,” the authors explain. “Young, single mothers, experiencing complications, with a history of stress, loss or trauma are far more likely to succumb to depression. Furthermore, one study found that up to 51% of women who experience socioeconomic disadvantage also report depressive symptoms during pregnancy.”
It's important to note prenatal depression doesn’t discriminate: You can experience it whether or not you have pre-existing risk factors. Always remember there is no shame in experiencing a serious bout of depression during pregnancy, and you are not alone.
Similar to postpartum depression, experts can’t pinpoint one particular cause of prenatal depression, but have hypothesized that it’s likely caused by a confluence of factors—a “perfect storm” of triggers that come to a head for some mothers during their pregnancies.
Either way, it’s important to note that whatever caused your prenatal depression, it most certainly wasn’t your fault. There was nothing you did wrong, and you are not a bad mom (or going to be a bad mom).
“Depression and anxiety during pregnancy or after birth don't happen because of something you do or don't do—they are medical conditions,” notes the Academy of American Pediatrics (AAP).
“Although we don't fully understand the causes of these conditions, researchers think depression and anxiety during this time may result from a mix of physical, emotional, and environmental factors,” they add.
Prenatal depression manifests differently for every mom—you may even experience it differently from one pregnancy to another. It’s important to understand that anytime you feel overwhelmed by your emotions, unable to function in your day-to-day life, or just “off,” you should reach out to discuss your feelings with a trusted loved one or medical provider.
Here are some of the most common symptoms of prenatal depression:
For more mental health resources, see our National Helpline Database."
Depression During Pregnancy Affect Infant’s Brain Anatomy, But No Change with Prenatal Exposure to SSRIs
By MGH Center for Women's Mental Health | June 22, 2021
"When a woman comes in for a consultation regarding the use of medications during pregnancy, we spend most of our time reviewing the potential risks of exposure to medications during pregnancy. However, we must also include a discussion of the effects of untreated psychiatric illness in the mother on the developing child, for there is a growing body of literature which demonstrates that what happens in utero, while the fetus is developing, may have effects on the child that persist into adulthood.
A number of recent studies have examined the brain anatomy of infants born to depressed mothers. Neuroimaging has revealed changes in connectivity between the amygdala and the prefrontal cortex (reviewed in Duan et al, 2019), and it is hypothesized that these alterations are responsible for the children’s increased vulnerability to anxiety and depression.
In a recent study Sethnaa and colleagues add to this literature, using MRI to compare regional brain volumes in 31 3-to-6-month-old infants born to women with a diagnosis of major depressive disorder (MDD, confirmed using the SCID) and 33 infants born to women without a current or past psychiatric diagnosis. The study recruited women during the second and third trimesters of pregnancy from antenatal clinics and perinatal psychiatric services in South London.
MRI assessments were conducted in infants between the ages of 3 and 6 months. Compared to infants born to non-depressed mothers, infants born to mothers with depression during pregnancy have larger subcortical grey matter volumes and smaller midbrain volumes. This finding persisted after adjusting for potential confounders, including medication use during pregnancy, postpartum depressive symptoms, and infant sex.
These findings are consistent with other studies looking at different types of insults, such as hypoxia and substance use, suggesting that these subcortical structures are particularly susceptible to changes in the in utero environment. The authors note that this finding of an association between maternal antenatal depression and midbrain development is not surprising given the midbrain’s role in stress regulation."
By: Robin Elise Weiss, PhD, MPH | June 14, 2021
"Affirmations are statements that you use intentionally to instill a sense of positivity and purpose in your mind about a particular subject. You can use these short phrases and sentences to help yourself focus on and accept a positive message that you wish to remember.Affirmations are an example of using positive thinking to set an intention and increase the likelihood of positive results. Even better, they are simple to do, free, and accessible to all.
Why They Work
While there is no guarantee that affirmations will actually change the outcome of your pregnancy, some studies suggest that affirmations can reduce stress and anxiety—which can make it easier to rest, eat, and avoid issues such as headaches and fatigue. Plus, positive thoughts tend to cultivate positive feelings, which may help to make your pregnancy experience more enjoyable and relaxed.
Studies show that using positive affirmations impacts brain pathways, increasing activity in the areas of the mind responsible for self-worth, self-regulation, and core values. Researchers believe that making a regular practice of saying affirming statements can effectively shift your focus from negative emotions or stressors to your own expansive capacity to cope, bolstering your confidence and bringing you new ideas, strategies, energy, and hope for the future.
Write Your Own
The beauty of positive affirmations is that you can write your own to use whenever you like. They can be said out loud or silently in your head, quietly whispered to yourself, or written down. In lieu of writing your own, you can also use one you have read or heard elsewhere. If it makes you feel strong, positive, and hopeful, then you're on the right track.
Remember, your affirmation should be in the present tense, as if what you wish to happen is already occurring. For example, someone who is worried about coping with childbirth might say, "I am strong." A person who is trying to get pregnant and having difficulty might say, "I am a good parent to my child."
This person might decide to repeat the affirmation every morning as a reminder of their goal and to foster their hope for this desired outcome. During infertility treatments, they might visualize this affirmation while undergoing procedures and tests, as well. During pregnancy, daily pregnancy affirmations may serve to enhance the mother's bond to their growing baby while also alleviating the worry that something might go wrong.
How to Do It
Anything that speaks to you can work as an affirmation. If you're unsure, brainstorm statements that connect to the feelings, values, and intentions you want to affirm. If you have a specific worry or negative thought that keeps coming to mind, try flipping it around to a positive one.
If you catch yourself thinking, "I can't do this," counter that with, "I can do this." "Childbirth is scary" becomes "childbirth is beautiful." Simple is good. Setting your positive intention can literally change your mind.
To help you get started writing your own affirmations, consider beginning with phrases like the following:
By MGH Center for Women's Mental Health | June 10th, 2021
"When we meet with women for perinatal psychiatry consultations, we now ask about vaccinations. It’s not something we typically do, but after the last year, we are now getting involved in their decisions regarding vaccination against COVID-19. Just as we counsel women to avoid alcohol and to consistently take their prenatal vitamins, providing information on the COVID-19 vaccine is an important aspect of promoting the health of pregnant and postpartum women.
Considering a growing body of evidence indicating that pregnant women are more likely to have certain manifestations of severe COVID-19 illness, including admission to the ICU and mechanical ventilation, the American College of Obstetricians and Gynecologists (ACOG) has urged the CDC’s Advisory Committee on Immunization Practices to include pregnant and lactating women in the high-priority populations for COVID-19 vaccine allocation. ACOG clearly states that all pregnant and lactating people should be allowed to receive the vaccine, and that their decision to do so should be based on a careful discussion of risks and benefits with their healthcare provider.
From our vantage point, there are other benefits to the COVID-19 vaccine. During the past year, before the vaccination was available, we watched as pregnant and postpartum patients undertook the most extreme forms of lockdown. Many of these women were literally housebound: never leaving the house and cutting off contact with friends and family, while at the same time taking on more childcare responsibilities as outside care providers and day care centers were no longer available. And all the while wondering what would happen if they or a member of their family felt ill?
We are yet to fully appreciate the impact of the COVID-19 pandemic on perinatal women, but preliminary studies indicate that during the lockdown, pregnant and postpartum women reported higher levels of stress, loneliness, depression, and anxiety. And this is not really a surprise. So many of the things we typically recommend to reduce stress and social isolation, such as exercising regularly or spending time with friends and family, vanished.
While it might seem like the pandemic is fading into the distance, the resurgence of the pandemic in places like India and Brazil where immunization rates are low, we cannot be so sure about this. So far the most successful way to avoid becoming seriously ill with COVID-19 is to get vaccinated.
A recent article in Medscape, however, suggests that mothers appear to be less likely to get vaccinated than others in the general population. According to a recent poll from Morning Consult, about two-thirds of adults in the US have either already been vaccinated against COVID-19 or plan to do so. In contrast, mothers are the most likely to be hesitant about the vaccine. In this study, 51% of the mothers reported that they are unwilling to get vaccinated or are uncertain about getting vaccinated, at 51% (compared to 32% of other women and 29% of fathers)."
Sleep and Pregnancy
By familydoctor.org editorial staff.
"The amount of sleep you get while you’re pregnant not only affects you and your baby, but could impact your labor and delivery as well. Lack of sleep during pregnancy has been tied to a number of complications, including preeclampsia (a serious condition that affects your blood pressure and kidneys). This condition could result in pre-mature birth. Now is the time to take sleep seriously.When you become pregnant, one of the first symptoms you may notice is being overwhelmingly tired, even exhausted. Sleep will be irresistible to you. You can most likely blame your changing hormones for this, especially the extra progesterone that comes with being pregnant. In the beginning, pregnancy also lowers your blood pressure and blood sugar, which can make you feel tired.
Shortly after the first trimester, your energy should return. Sometime during the third trimester, you’ll begin to feel tired again. Some of this feeling can be blamed on the sheer physical exhaustion that comes from growing a baby and the stress that it puts on your body. However, your weariness during this time is in direct relation to your inability to get a good night’s sleep.
Even if you’ve never had trouble sleeping before, you may find it much more difficult while you’re pregnant.
Path to improved health
Sleep should never be seen as a luxury. It’s a necessity — especially when you’re pregnant.
In fact, women who are pregnant need a few more hours of sleep each night or should supplement nighttime sleep with naps during the day, according to the National Institutes of Health.
For many pregnant women, getting 8 to 10 hours of sleep each night becomes more difficult the farther along they are in their pregnancy. There are many physical and emotional obstacles to sleep in this stage. Anxiety about being a mom or about adding to your family can keep you awake. Fear of the unknown or about the delivery can cause insomnia. Plus, there is the getting up every few hours to go to the bathroom. It also can be difficult to find a comfortable position in bed, especially if you are a former stomach sleeper.
If any of the following is keeping you awake at night, try these strategies for getting a good night’s sleep.
At some point in their pregnancy, most pregnant women suffer from heartburn, which is a form of indigestion that feels like burning in your chest and throat. Heartburn can wake you up in the middle of the night and ruin a good sleep. Minimize the chance for this by avoiding spicy foods. Also, cut down on rich foods for dinner.
Restless leg syndrome
Few things are more distracting than restless legs syndrome (RLS), especially when you are trying to go to sleep. While you can’t take traditional RLS medicines when you are pregnant, you can try to reduce the feelings of RLS with a good prenatal vitamin that includes folate and iron.
Morning sickness — at bedtime
Despite the name, morning sickness can occur any time and is often worse later in the day. Try eating a few crackers at bedtime and keep a stash in your nightstand in case a wave of nausea hits as you are trying to go to sleep.
There are many ways insomnia can creep in and compromise your sleep time. Often, it’s just about being able to shut down your brain. Most medicines for insomnia should not be taken while you are pregnant. Instead, try journaling some of the things you are anxious about. Write down what is stressing you and try to let it go as you go to sleep. Also, stop drinking caffeine by early afternoon. Try not to take long naps during the day. Doing any — or all — of these things can help ease you back into sleep at a reasonable bedtime.
Not many things can wake you as quickly and painfully as a leg cramp. Sometimes called a charley horse, these cramps are usually a contraction of your calf muscle. Less frequently, they can occur in your thigh or your foot. These can plague you in pregnancy because of a lack of minerals, especially calcium and magnesium. They also are more common if you are dehydrated. To guard against leg cramps, make sure that you continue to take your prenatal vitamin and drink plenty of water and other fluids during the day.
Finding a comfortable position
As your body grows, sleep becomes a little harder to come by, especially in the third trimester. It’s difficult to get comfortable. It’s harder to move around and shift positions in bed. If you’ve been a stomach or back sleeper, it can be hard to adjust to sleeping on your side. The best position to sleep in when you’re pregnant is on your left side. This improves blood flow and, therefore, nutrient flow to your baby. Try lying on your left side, knees bent with a pillow between your knees. It also helps to tuck a pillow under your stomach, as well, for extra support.
Frequent bathroom breaks
With the baby pushing down on your bladder, you likely can’t make it all night without waking at least once to go to the bathroom. You can help minimize nighttime bathroom trips by cutting down on how much you drink in the evenings. Just be sure to get adequate hydration during the day. Bright lights can make it harder for you to fall back asleep, so use nightlights so that you will not need to turn on the lights when you get up to go to the bathroom.
In addition to minimizing the common obstacles to getting a good night’s sleep, there are also ways to encourage good sleep habits. This is called good sleep hygiene.
Things to consider
Sleep is essential to health. Lack of sleep is associated with many chronic diseases, including type 2 diabetes, obesity, depression, and even heart disease. If you’re pregnant, not getting an adequate amount of sleep can put you at risk for some serious conditions. Lack of sleep can also complicate your delivery.
In one research study, pregnant women who slept less than six hours at night late in pregnancy had longer labors and were more likely to have cesarean deliveries.
Another study reports that the sleep you get in your first trimester can affect your health in the third trimester. Women who don’t get enough sleep (less than five hours per night) in the first trimester are nearly 10 times more likely to develop preeclampsia late in pregnancy. Preeclampsia is a condition associated with pregnancy-related high blood pressure, swelling of hands and feet, and protein in urine.
If you’ve ever had a sleep disorder, it could be made worse by pregnancy. If you’ve had sleep apnea in the past, your snoring may get worse during pregnancy. This is especially true if you were already overweight when you became pregnant. Expect that RLS will worsen during this time. Heartburn will intensify, too."
Medically reviewed by Julie Lay — Written by Jessica Timmons on January 9, 2018
"For a new mom-to-be, experiencing sleep deprivation after the baby is born is a given. But you probably didn’t realize that it could also occur during the first trimester of pregnancy.
Most women experience sleep problems during pregnancy. Pregnant women tend to get more sleep during their first trimesters (hello, early bedtime) but experience a big drop in the quality of their sleep. It turns out that pregnancy can make you feel exhausted all day long. It can also cause insomnia at night.
Here are some of the most common culprits for insomnia during early pregnancy, plus a few tips to help you get a better night’s sleep.
What is insomnia?
Insomnia means you have difficulty falling asleep, staying asleep, or both. Women can experience insomnia during all stages of pregnancy, but it tends to be more common in the first and third trimesters. Between midnight bathroom breaks, out-of-control hormones, and pregnancy woes such as congestion and heartburn, you might be spending more time out of your bed than in it. The good news: While insomnia might be miserable, it’s not harmful to your baby.
Sheer logistics play a role as well. By the end of a pregnancy, many women have a hard time just getting comfortable enough to sleep well. During the first trimester, you might not have much of a baby belly to accommodate, but there are other issues that can prevent a good night’s sleep.
What causes insomnia during pregnancy?
Expecting? There are many reasons you might be wide awake in the wee hours. These can include:
It can be difficult to distract yourself from these thoughts, but try to remember that worrying isn’t productive. Instead, try writing down all of your concerns on paper. This will give you a chance to consider possible solutions. If there are no solutions, or there is nothing you can do, turn the page in your journal and focus on another worry. This can help empty your mind so you can rest.
Being up front with your partner about your feelings and worries can also help you feel better.
Develop a bedtime routine
One of the best things you can do to manage insomnia while you’re pregnant is to set up good sleep habits.
Begin by trying to go to bed at the same time every night. Start your routine with something relaxing to help you unwind.
Avoid screen time at least an hour before bed. Blue light from the TV, your mobile phone, or tablet can have an impact on your body’s circadian rhythm. Try reading a book instead.
Taking a soothing bath might also make you sleepy. Just be careful that the temperature isn’t too hot — that can be dangerous for your developing baby. This is especially true during early pregnancy.
To be safe, avoid hot tubs.
Diet and exercise
Diet and exercise can have an impact on your sleep.
Drink plenty of water throughout the day, but minimize drinking after 7 p.m. Try to avoid caffeine starting in the late afternoon.
Eat to sleep
Eat a healthy dinner, but try to enjoy it slowly to reduce your chances of heartburn. Eating an early dinner can also help, but don’t go to bed hungry. Eat a light snack if you need to eat something late in the evening. Something high in protein can keep your blood sugar levels steady through the night. A warm glass of milk can help you feel sleepy, too."
"Seaneen Molloy was excited to discover she was expecting her second baby during lockdown. With a history of mental illness, she carefully planned the pregnancy, but when her baby arrived she experienced the "terrifyingly rapid" onset of a crisis which left her unable to hold baby Jack."
"Having a baby is supposed to be a joyful experience, and for lots of women it is. However, up to 20% experience mental ill health during pregnancy and the year after birth. Tragically, suicide is the leading cause of death in new mothers.
Women who already have a mental illness are at a high risk of relapse during pregnancy - that's women like me.
I have a diagnosis of bipolar disorder and an anxiety disorder. This meant that pretty much from the moment I became pregnant, the perinatal mental health team were involved.
This includes specialist midwives, psychiatrists, nurses and social workers whose goal is to support women to stay well, and intervene quickly if they don't.
Normally, I manage my mental health by being careful with my sleep and leading a pretty boring life away from overwork and alcohol, but pregnancy chucks in a host of factors you have no control over.
Hormones rage through your body, wreaking havoc upon your mood, your energy levels and your ability to keep your lunch down. You either can't stay awake or are awake for hours - peeing a thousand times and being hoofed by tiny feet.
I had managed to stay well, and off medication, for years, but in the run-up to birth antipsychotic medication was introduced to prevent postpartum psychosis. This can cause women to develop delusions and lose touch with reality.
It's the one I was most at risk of developing due to my history of bipolar disorder, but in the end, I experienced postnatal anxiety.
My mental health had been largely OK during my pregnancy and my labour and after-care were carefully planned.
I had a calm elective Caesarean section due to a traumatic first birth, a room of my own and the baby was whisked away on his inaugural night so that I could get some all-important sleep (this bit was hard - it went against every natural instinct). A procession of midwives, doctors and social workers visited to see how I was doing.
Although I found it intrusive, it helped me feel safe. When I was discharged from hospital with my baby, Jack, I felt swaddled in care and confident everything would be OK.
It was a complete shock that I did get ill.
In the chaos of newborn-life I forgot a dose of my anti-clotting medication which is given to mothers after C-sections.
And this one tiny event broke my brain.
I went from mildly chiding the home treatment team for their postnatal visits, because I was fine, to a full-blown mental health crisis within about 12 hours. It was terrifyingly rapid - which is why perinatal mental illness can be so deadly.
My mild anxiety exploded into an all-consuming panic that I was going to die imminently from a blood clot in my lung. I couldn't think of anything else but the black terror of certain death that was coming for me - how I was going to leave my children, how I'd brought a new child into the world never to know me.
I called out-of-hours GPs describing symptoms I was convinced I had, sobbed, screamed and couldn't breathe. I terrified my husband and myself.
Then we hit the emergency button.
The psychiatrist came over with the home treatment team. They took my fears seriously, which I appreciated, and gave me a physical examination and the missed dose of medication. My antipsychotic medication was increased to the maximum dose and benzodiazepines - a type of sedative - prescribed, to try and calm me down.
I wasn't allowed to be left alone and the mental health team were to visit me every day where I tried to articulate my terror to their masked faces.
At first I resented their visits, but they became a 30-minute space where I could let down the exhausting facade and share how I was really feeling.
My anxiety then transformed into an obsession that Jack was going to die. I was afraid to leave the room and rested my hand on his chest all night.
If my husband took him out to the shops with his brother, I cried and paced about, imagining they had all been hit by a car. I texted him incessantly.
Everyone was saying I needed "rest", so he tried to give me space. But after the second or third breakdown, he agreed to keep his phone on loud and to answer quickly. The home treatment team also advised he give me clear timescales so I knew when to expect them home.
But the medication also caused intense restlessness. I couldn't sit still. I couldn't get comfortable enough to hold my baby for more than a minute."
By MGH Center for Women's Mental Health | May 19th, 2021
"This is a question we often hear. One of the challenges in answering this question is the interpretation of the word “best”. On one hand, the best antidepressant is the one that is the most likely to be effective. On the other hand, the best antidepressant is the one that carries the least risk when used during pregnancy. What this means is that there is no single answer. Each situation is different, and our recommendations are based on a careful assessment of the patient’s course of illness, treatment history, past medication trials, and the most up-to-date information on reproductive safety. Added to this calculation is the understanding that untreated depression also carries some risk in terms of maternal well-being and has been associated with worse pregnancy outcomes.
Stay with the Same Treatment or Switch?
We often meet with women who have switched to a different antidepressant medication in preparation for pregnancy. Other women make a switch when they discover they are pregnant. These switches are motivated by the belief that there is a “safer” medication to be used during pregnancy. The reality is that most of the antidepressants taken by women today are relatively safe and carry a very low risk to the developing fetus. What separates one antidepressant from another is that some medications have more data to support their reproductive safety than others. But even this distinction is disappearing; we have data to support the use of most SSRIs (with less data on fluvoxamine or Luvox), the SNRIs duloxetine (Cymbalta) and venlafaxine (Effexor), and bupropion (Wellbutrin). Tricyclic antidepressants, although not commonly used today, also have data to support their reproductive safety.
We have very little data on the reproductive safety of the MAO inhibitors. In addition, MAO inhibitors may have serious interactions with other medications frequency used during pregnancy and labor and delivery, specifically medications used to manage pain, such as nalbuphine (Nubain) and meperidine (Demerol). In women taking these medications, we are likely to suggest switching to another antidepressant with a better reproductive safety profile.
At this point, we have less data on the use of the newer antidepressants. There is some data on mirtazapine, with the most recent study including 334 cases of neonates with prenatal exposure to mirtazapine. While these data are reassuring and there is no indication that mirtazapine carries significant teratogenic risk, the number of mirtazapine exposures remains small. Ideally we would like to have data from 600-700 exposures to get a better estimate of risk. Making decisions regarding safety on studies with small sample sizes can lead to miscalculations of risk in either direction.
The data is even more limited with regard to the use of vortioxetine (Trintellix), vilazodone (Viibryd), levomilnacipran (Fetzima). If there are effective alternatives, we typically recommend switching to another antidepressant.
In settings where we have limited data regarding the reproductive safety of a particular antidepressant, we may consider switching to an antidepressant with a better characterized reproductive safety profile. It is important, however, to carefully consider the benefits and risks of making this switch. With any switch, there is the risk of relapse when making a change in the maintenance treatment. Thus, there are situations where we recommend continuing an antidepressant with limited reproductive safety information because there are no effective alternatives and the risk of relapse is significant.
What About Zoloft? Isn’t Zoloft the Safest?
At some point in the early 2000s, there emerged the belief that sertraline (Zoloft) was the safest antidepressant to use during pregnancy, and many women taking other antidepressants were encouraged to switch to sertraline during pregnancy. It is somewhat unclear where this opinion came from — maybe one paper suggesting lower placental passage of sertraline compared to other antidepressants; however, there is and never was any solid data to support the assertion that sertraline is safer or the safest antidepressant. Reflexively switching women to sertraline puts women at risk for recurrent illness.
While sertraline is effective for the treatment of depression and anxiety and is a reasonable choice for many women, one problem with sertraline is that it tends to be under-dosed. The typical starting dose is 50 mg; however, many individuals will need 150 mg to 200 mg to effectively manage their symptoms. Especially when sertraline treatment is initiated in the primary care setting, we often see women whose dose is too low to effectively manage their symptoms.
What About Paxil? Doesn’t It Cause Heart Defects?
The most current data regarding the use of paroxetine (Paxil) during pregnancy does not indicate an association between the use of paroxetine during pregnancy and risk for cardiovascular malformations. However, in 2006, GlaxoSmithKline (GSK) elected to change product label warnings for the antidepressant paroxetine (Paxil), advising against the use of this drug by women who are pregnant. This decision was based on two preliminary studies which suggested a small increase in the risk of cardiovascular malformations among infants exposed to paroxetine in utero. For many years, this concern regarding risk of heart defects resulted in recommendations that women taking paroxetine should either stop paroxetine or to switch to a different antidepressant during pregnancy.
However, in 2008, a study from the Motherisk Program in Toronto reported on the outcomes of over 3000 paroxetine-exposed infants and found no association between the use of paroxetine during pregnancy and increased risk of cardiovascular malformations. Nonetheless, some women and their treaters continue to feel uncomfortable with the use of paroxetine during pregnancy. Furthermore, many websites (including reputable sites like the Mayo Clinic) continue to urge women to avoid paroxetine during pregnancy because of the risk of malformations.
At this point, we typically do not recommend switching from paroxetine to another antidepressant for pregnancy. Although paroxetine is an SSRI, there are definitely situations where an individual may respond better to paroxetine than to other SSRIs. Thus, switching to a different antidepressant may increase risk for relapse.
What About Lexapro? And Pristiq?
There are some newer antidepressants that are derived from older parent antidepressants. For example, citalopram (Celexa) is a racemic mixture, composed of R- and S-enantiomers (or mirror images) of citalopram. While the S-enantiomer is clinically active, the R-enantiomer is not. Escitalopram or Lexapro contains only the active S-enantiomer. Because the S-enantiomer is contained in the original citalopram formulation, we can infer that the reproductive safety of escitalopram (Lexapro) is the same as that of citalopram (Celexa).
Another example is desvenlafaxine or Pristiq. For venlafaxine to be effective as an antidepressant, it must first be metabolized by the body to desvenlafaxine. Pristiq contains only the active metabolite desvenlafaxine. Because desvenlafaxine is a metabolic byproduct of the original venlafaxine formulation, we can infer that the reproductive safety of desvenlafaxine (Pristiq) is the same as that of venlafaxine (Effexor).
The Bottom Line
No two situations are identical; thus, we must carefully consider each woman’s clinical history and preferences in order to select a treatment plan that makes sense. Ideally this discussion should occur long before a woman is pregnant, so that there is ample time to consider the various options and to make changes, if necessary.
When we meet with women to discuss the use of antidepressant medications during pregnancy, we typically consider a number of issues:
The perinatal psychiatry consultation should be viewed as a collaborative venture, where provider and patient decide together what is the best option for treatment during pregnancy."
-Ruta Nonacs, MD PhD
By: Love Amy Michelle | October 28, 2017
"Love Amy Michelle is a space for you to reconnect with yourself + to find some peace amidst the chaos."
Depression During the COVID-19 Lockdown Highlights the Importance of Social Connections for New Moms
By MGH Center for Women's Mental Health | May 18th, 2021
"Because pregnant and postpartum women face unique challenges in the context of the COVID-19 pandemic, they may be at increased risk for mental health problems in this setting. In a recent study, researchers from the University College of London surveyed 162 new mothers in London between May and June 2020 using a social network survey designed to assess the impact of the COVID-19 lockdown.
Almost half (47.5 percent) of women with babies less than six months of age had depressive symptoms suggestive of postpartum depression assessed using the Edinburgh Postnatal Depression Scale. This is a huge increase in the expected prevalence of postpartum depression; studies carried out prior to the pandemic have shown that about 10% to 15% of women report depressive symptoms during the postpartum period.
The researchers also observed that the more contact new mothers had with other people — whether remotely or face-to-face — the less likely they were to report depressive symptoms. While this finding suggests that social isolation incurred as a result of the COVID-19 lockdown may have increased risk for depression, another interpretation is that women with greater social networks are less vulnerable to depression (whether or not there is a lockdown). However you interpret the data, multiple studies have demonstrated that social isolation is a risk factor for depression, in general, and having adequate social support reduces the risk for postpartum depression.
We often encourage new mothers to bolster their support networks and often recommend new moms groups. While this is a reasonable approach to managing the social isolation of new parenthood, many new mothers struggle to get out of the house and are unable to establish new social networks. One of the silver linings of the pandemic has been increased access to support groups on virtual platforms. For example, Postpartum Support International or PSI now offers a wide array of online group meetings for women who are pregnant or postpartum. Whether or not a lockdown is in effect, these social networks are so important to a new mother’s emotional well-being and may potentially decrease risk for psotatum illness."
-Ruta Nonacs, MD PhD
By MGH Center for Women's Mental Health | May 6th, 2021
"While we have relatively limited information regarding the prevalence of obsessive-compulsive disorder (OC) during pregnancy and the postpartum period. Previous studies have indicated that women may be more vulnerable to the onset of OCD during the postpartum period. Other studies indicate that women with OCD may experience worsening of OCD symptoms during pregnancy and the postpartum period.
A recent study published in the Journal of Clinical Psychiatry looks at the prevalence of OCD symptoms during pregnancy and the postpartum period. They speculate that using standardized instruments for the diagnosis of OCD may fail to capture perinatal OCD, and their study incorporates a detailed assessment of obsessions of infant-related harm and corresponding compulsions.
In this study, 763 English-speaking women living in the Canadian province of British Columbia were recruited into this longitudinal study following women from the third trimester of pregnancy until 9 months postpartum. The Structured Clinical Interview for DSM-5 (SCID-5) was used to confirm DSM-5 diagnoses of OCD.
The weighted prevalence of OCD during pregnancy was 7.8%, and the weighted prevalence increased to 16.9% across the postpartum period. The estimated point prevalence of OCD diagnosis was 2.6% during pregnancy (6 weeks prior to delivery) and increased to 8.7% at 8 weeks postpartum. The point prevalence of OCD remained high (6.1%) at 20 weeks postpartum.
The incidence of new OCD cases was estimated to be 4.7 new cases per 1000 women each week during the postpartum period. By six months postpartum, the cumulative incidence of new cases of OCD was 9.0%. Most cases emerged during the first 10 weeks postpartum.
In total, the researchers observed that 100 women reported symptoms consistent with a diagnosis of OCD at some point during pregnancy or the postpartum period. In this group, 60 of the women reported onset of OCD symptoms during pregnancy or the postpartum period. The remaining 40 women reported that their OCD symptoms preceded the pregnancy.
High Prevalence of OCD During Pregnancy and the Postpartum Period
The lifetime prevalence rate of obsessive-compulsive disorder (OCD) has been consistently estimated to be 2%-3% in the general adult population in the United States. The current study indicates that the weighted prevalence of OCD during pregnancy was 7.8% and increased to 16.9% across the postpartum period. Consistent with previous studies, Fairbrother and colleagues conclude that pregnancy and the postpartum period is a time of increased vulnerability to OCD. In addition, new onset of OCD is relatively common during pregnancy and the postpartum period, with 9% of women reporting postpartum onset of OCD in this study.
These estimates of prevalence are higher than those reported in previous studies, a finding that the researchers attribute to using a more comprehensive evaluation of perinatal-specific OC symptoms, including intrusive thoughts of infant-related harm. However, the authors note that some women joined the study after childbirth and may have been attracted to the study because of their experience of postpartum intrusive thoughts. Nonetheless, this is one of the largest studies we have regarding the incidence of OCD during pregnancy and the postpartum period and is noteworthy in that it used the SCID to confirm OCD diagnoses.
Current guidelines for screening perinatal women do not specifically recommend screening for OCD. This study indicates that perinatal OCD is relatively common and the authors recommend more careful screening for perinatal-specific OC symptoms. They note that standardized assessments for OCD include questions about obsessions involving dirt, germs, arranging and ordering; however, perinatal OCD is more often characterized by intrusive thoughts related to harming the infant (e.g., unwanted thoughts or images of harming the infant on purpose, harm to the infant stemming from parental distraction or neglect, being sexually inappropriate with the infant). Furthermore, given the shameful and horrifying nature of these thoughts, many women are hesitant to share these thoughts with others."
-Ruta Nonacs, MD PhD
By MGH Center for Women's Mental Health | May 5, 2021
"At this point, nine states and Washington, DC have legalized the use of recreational marijuana. Another 30 states have legalized medical marijuana. The downstream effect of these changes has been a significant uptick in the use of cannabis among women of childbearing age. According to data collected from the National Survey on Drug Use and Health, the use of cannabis in pregnant women rose from 2.37% in 2002 to 3.85% in 2014 in the United States, noting that 21.1% of pregnant women who used cannabis reported doing so on a daily basis.
While we have data to indicate that the use of cannabis during pregnancy may negatively affect fetal growth and brain development, we have less information on how the cannabis and its byproducts, which are secreted into the breast milk, may affect the nursing infant. Here are some important things we do know:
Can cannabis be found in the breast milk?
No matter how marijuana/cannabis is consumed (smoking, vaping, or ingesting), its byproducts can be found in the breast milk. Figuring out how much is passed into the breast milk is complicated because how women use cannabis varies considerably. For example, the kinetics of smoking vary considerably from ingesting. Both cannabidiol (CBD) and the psychoactive component, delta-9-tetrahydrocannabinol or THC, have been detected in breast milk.
In the largest study to date, which included eight breastfeeding women, the amount of THC detected in pumped breast milk ranged from 0.4%-8.7% of the maternal dose, with an estimated mean of 2.5%. Using these data, the average absolute infant dose was estimated to be 8 micrograms per kilogram per day.
If cannabis is consumed, how long does it persist in the breast milk?
Cannabis concentrations in the breast milk are variable and are related to maternal dose and the frequency of dosing. However, there are some things that make cannabis a little different than alcohol or other recreational drugs. Cannabis and its byproducts are very fat-soluble or lipophilic. Because in women the percentage of body fat is 25-30%, there is a large reservoir for the storage of cannabis. What this means is that it takes much longer for cannabis to leave one’s system, compared to substances like alcohol. Furthermore, there is an especially long washout period in those who have been daily users. Long after the psychoactive effects have faded, THC and its metabolites can be detected in blood, urine, and breast milk.
Studies focusing on the detection of THC in milk have yielded variable results, with duration of detection ranging from 6 days to greater than 6 weeks in various studies. The most recent study from Wymore and colleagues In a recent study, Wymore and colleagues collected data on self-reported marijuana usage and measured levels of THC in maternal plasma and breast milk samples several times a week. In all 25 participants, THC was detectable in breast milk throughout the six week duration of the study.
The researchers estimated the mean half-life of THC in breast milk to be 17 days (SD 3.3). Based on this estimate, they calculated that it would be possible to detect THC in breast milk for longer than 6 weeks. In addition, the researchers were able to calculate a milk:plasma partition coefficient for THC which was approximately 6:1 (IQR, 3.8:1 – 8.1:1). Milk:plasma ratios give us a sense of how easily a compound passes from the mother’s bloodstream into the breast milk and can be used to estimate the amount of exposure through breast milk. Most M:P ratios for drugs commonly used in breastfeeding women are around 1 or less than 1; thus, an M:P ratio for THC of 6 is high and suggests that levels of THC in the breast milk may be higher than in the mother’s bloodstream.
The findings of the Wymore study are consistent with previous studies measuring THC in breast milk which observed a duration of detection ranging from 6 days to greater than 6 weeks after using cannabis. The longevity of THC in the breast milk may be related, in part, to the extremely high fat content of breast milk and the lipophilic nature of THC, so that the breast milk “traps” the THC, in a sense acting like a reservoir for THC storage.
What are the effects of exposure to cannabis in the nursing infant?
The bioavailability of cannabis and its metabolites ingested by neonates in the breast milk has not been well-characterized. There are conflicting data regarding the outcomes of infants exposed to cannabis during breastfeeding and very few studies assessing outcomes in this population. These studies are not easy to conduct. First of all, recreational use of cannabis continues to be illegal in many states. Furthermore, it is difficult to disentangle the direct effects of cannabis delivered in the breast milk from the indirect effects of cannabis on the quality of childcare and parenting, especially in heavy, chronic users or when cannabis is combined with other substances.
In one study, 136 breastfeeding infants were assessed at one year of age. In the 68 infants exposed to cannabis during the first month of life, there was evidence of decreased motor development at one year, when compared with matched infants who were not exposed to cannabis. Specifically, there was a 1465-point decrease in the Bayley index of infant motor development. However, the authors of this study cannot conclude that these findings were entirely due to exposure via breastfeeding, as many of the women also used marijuana during pregnancy.
In another study, 27 breastfed infants exposed to cannabis were compared to 35 unexposed breastfed infants. At one year, no differences were noted for motor and mental development using the Bayley Scales of Infant Development. However, the small size of this study limited statistical analysis.
So the jury is still out regarding the effects of cannabis on the nursing infant.
All women should be screened for drug use as a component of standard prenatal care. Screening for substance use should occur during the course of pregnancy with the goal of providing information regarding the potential adverse effects of cannabis and to ensure referral to appropriate resources for treatment as needed. Because many women are able to abstain from substances during pregnancy but resume use after delivery, screening must be repeated during the postpartum period.
Both the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics recommend that women refrain from using cannabis during pregnancy and while breastfeeding. Because of the persistence of cannabis and its byproducts in the breast milk for days to weeks, using cannabis and waiting for it to clear out of the breast milk is not a viable option. For women who use cannabis for medical indications, alternative therapies with more safety data during breastfeeding should be considered."
-Ruta Nonacs, MD PhD