Why The World is So Screwed Up About Breastfeeding Research, In Several Paragraphs & A Few Headlines

The headlines:

“Study: Breastfeeding can ward off postpartum depression” (Press TV)

“Breastfeeding mothers less likely to get postnatal depression” (The Independent)

“Breastfeeding ‘helps prevent postnatal depression’” (ITV)

“Breastfeeding could help prevent postnatal depression, says Cambridge researchers” (Cambridge News

“Breastfeeding ‘cuts depression risk’, according to study” (BBC

“Failing to breastfeed may double risk of depression in mothers: study” (Telegraph)

“Mothers who breastfeed are 50% less likely to suffer postnatal depression” (The Independent)

“Mothers who choose not to breastfeed are ‘twice as likely to get postnatal depression because they miss out on mood-boosting hormones released by the process’” (Daily Mail, UK)

“Breastfeeding Keep Mothers Happy and Reduces Postnatal Depression” (International Business Times)

“Breastfeeding moms have lower depression risk” (Health Care Professionals Network)

“Breastfeeding protects mothers from postnatal depression, study finds” (The Australian)

 

And the reality:

New Evidence on Breastfeeding and Postpartum Depression: The Importance of Understanding Women’s Intentions.

Borra C, Iacovou M, Sevilla A.

Abstract

This study aimed to identify the causal effect of breastfeeding on postpartum depression (PPD), using data on mothers from a British survey, the Avon Longitudinal Study of Parents and Children. Multivariate linear and logistic regressions were performed to investigate the effects of breastfeeding on mothers’ mental health measured at 8 weeks, 8, 21 and 32 months postpartum. The estimated effect of breastfeeding on PPD differed according to whether women had planned to breastfeed their babies, and by whether they had shown signs of depression during pregnancy. For mothers who were not depressed during pregnancy, the lowest risk of PPD was found among women who had planned to breastfeed, and who had actually breastfed their babies, while the highest risk was found among women who had planned to breastfeed and had not gone on to breastfeed. We conclude that the effect of breastfeeding on maternal depression is extremely heterogeneous, being mediated both by breastfeeding intentions during pregnancy and by mothers’ mental health during pregnancy. Our results underline the importance of providing expert breastfeeding support to women who want to breastfeed; but also, of providing compassionate support for women who had intended to breastfeed, but who find themselves unable to.

In other words, women who wanted to breastfeed and did = low risk of PPD. Women who wanted to breastfeed and couldn’t = high risk of PPD. The researchers stress “providing compassionate support for women who had intended to breastfeed but…found themselves unable to”.

This does not prove that breastfeeding cuts depression risk. It proves that women who had a goal and met it tend to have lower rates of depression. It does not prove that there is a biological reason that breastfeeding may be protective against depression. That may indeed be the case, but then the depression risk would have been similarly high in women who never intended to breastfeed.

Our societal confirmation bias is so damn strong, that we blatantly overlook the finding that suggests something potentially negative about breastfeeding promotion. But here’s something to ponder: while we can’t force insufficient glandular tissue to produce adequate milk, or force women to breastfeed who don’t want to, we CAN ensure that every mother gets support in her feeding journey. We CAN listen to research that suggests the pressure to breastfeed is contributing to feelings of guilt, shame, and judgment – a potent trifecta of emotions for those prone to depression – and do something about it. If we are going to take this one study as “truth”, as so many parenting-related studies are mistakenly interpreted, something good might as well come out of it.

At this point, there is a pretty clear correlation between not breastfeeding and PPD. Instead of using this as ammunition against formula use, we could be asking the tougher questions: Why are women who don’t breastfeed more depressed? If it is something biological, wouldn’t the rates of PPD have been skyrocketing in past generation where breastfeeding was rare? If we stop making breastfeeding seem like the only-best-right choice to raise a happy, healthy child, would it mitigate this risk?

Source: http://en.wikipedia.org/wiki/Albert_Szent-Gy%C3%B6rgyi#Medical_research

Source: http://en.wikipedia.org/wiki/Albert_Szent-Gy%C3%B6rgyi#Medical_research

One of my favorite quotes about research comes from the Nobel-prize winning scientist who discovered the importance of vitamin C, Albert Szent-Gyorgyi: “Research is to see what everybody else has seen, and to think what nobody else has thought.” These days, the reverse seems to be true – research is to confirm what everybody else has seen, and everybody has already thought. This needs to change, and it won’t, as long as our society and media turns even the most interesting findings into self-confirming soundbytes.

 

Vital Signs: Ignoring postpartum depression and psychosis won’t make them go away

Another horror story. Another mom. Three beautiful girls who will never have another birthday, whose last memory will be terror at the hands of the person they trusted the most.

I don’t know the details. I don’t really want to know the details. I do know that this mother reached out, told her own mom she was “feeling crazy”. I do know that she had three babies in a row, and that the youngest was 2 months. I do know that there’s a strong chance that this was the result of postpartum psychosis.

And I know that this has got to stop.

Can we protect every family, prevent every case? Of course not. But postpartum mental health is taking a backseat when it should be sitting shotgun to every maternal and child health program. That’s a start, at least. We spend so much time worrying about a woman’s breasts, while we dismiss her mind. We worry about how hormones and birth practices affect lactation, while we disregard how they affect our emotions.

After we give birth, we are whisked off to the maternity ward. Our vital signs are monitored, but other vital signs are ignored. A mom who can’t seem to connect with her baby. Who is scared, and asking for help. Who is alone and voiceless. Her pulse may be steady, but her hands shake. Her breasts may leak colostrum, but her eyes may leak silent tears. And we ignore this.

GE-Healthcare-Dash-2500-v4-Vital-Signs-Monitor

OB/GYNs don’t see mothers until 4-6 weeks postpartum. In some cases, that will be too late.

Pediatricians see moms with their newborns several days postpartum, but they are focused on the infant. As they should be. We don’t expect a heart surgeon to be concerned with the diabetic foot of his cardiac patient’s wife.

When I see the role of lactation consultants and breastfeeding counselors growing, gaining more attention, more insurance coverage, I also see an opportunity. What if these professionals could be trained to screen for postpartum mental health issues, if they could recognize red flags and know how to refer families to the proper resources? What if they were trained to support families in their feeding journeys, with the goal being a happy, healthy family and not just a breastfeeding statistic?

With the state of our health care system, I don’t expect that an entirely new support staff can be instilled at every hospital, for the sole purpose of protecting maternal mental health. But when 1 in 7 mothers suffer from postpartum depression or anxiety, I think that constitutes just as much of a public health concern as the supposed risks of “sub-optimal breastfeeding practices” in developed countries. If we are going to focus so heavily on breastfeeding, could we at least give a little simultaneous attention to a mom’s mood while we inspect her breasts?

What happened to the Coronado family is sub-optimal. What passes as “support” for postpartum women is sub-optimal. There is no reason we can’t support breastfeeding while prioritizing maternal mental health. Both are important, but one has been systematically ignored, shoved under piles of paperwork, given lip service. We only seem to worry about postpartum depression in terms of how it affects breastfeeding “success”. There are so many things wrong with that sentence, with that mentality. It’s like worrying about prostate cancer only in terms of how it will affect sex and procreation. Biological norms are important, but support also means protecting those whose biology turns on them.

If we can only speak of maternal needs under the umbrella of lactation support, I can live with that. As long as those needs are met, I can live with that. As long as those needs are being met, maybe we can all live with that.

Survive with that.

Thrive with that.

 

 

An open letter to Chris Bingley: Your wife deserved better.

This is an open letter to Chris Bingley in honor of his wife, Joe Bingley, whom he lost to severe postpartum depression. 

Dear Chris,

I read about your beautiful wife Joe’s battle with postpartum depression, and I wanted to say… oh hell, I don’t know what to say. Because I’m afraid my anger about what happened to your wife will just feed your grief, and that is the last thing I’d ever want to do.

I write about the pressure to breastfeed, and what it is doing to women, and I hear stories every day that mirror what Joe went through. Women who suffer from a growing desperation, an inner knowledge that something isn’t right, even when everyone around them is willing it to be so; even when everyone around them is telling them it will all be okay if they just get some sleep, get some help around the house, or get over the “hump” of the baby blues.

And these women – more often than not – are seen by an array of healthcare professionals as they try to dig themselves out of this tunnel. The stories I hear have a common refrain – all they cared about was if the baby was breastfeeding. I came second. And all I heard was that breastfeeding was the most important thing a mother can do for her child and I was failing at that. This was my refrain, 5 years ago. I sang it and sang it until someone listened, until thousands of other women answered it with a song of their own. And our collective voices are rising, growing stronger by the day, shouting our song, screaming that we deserve more, that Joe deserved more, and that we will. Not. Let. This. Happen. Again.

PPD is a strange and mysterious beast; it’s not always tamed easily, and it feeds on different aspects of different people. For some, breastfeeding is a lifeline, the one thing they can do “right”. For others, it is the sandbag strapped to them as they are already sinking. But the problem is not breastfeeding. The problems is that we are so focused on breastfeeding that all of resources and energy are going to this one aspect of postnatal care – that we have forgotten that the mother’s mental and physical health should come first. I know most people will think that is a terrible thing to say – because doesn’t the baby’s physical and emotional health matter? But what they are forgetting is that a mother’s mental and physical health can afford to be a priority because there are other options to ensure the physical and emotional needs of the baby. Formula or donor milk can suffice. A father’s loving embrace, or a grandmother’s or aunt’s or uncle’s, can fulfill all needs until a mother is well. We are lucky to live in a time where moms can get well without sacrificing their babies’ well being.

But we are unlucky to live in a time where people are unwilling to see things this way.

Joe should have been helped. The professionals who she encountered should have looked at her face rather than her breasts. They should have seen she was sinking; they should have insisted that either a lifeline be thrown or a sandbag removed. There should have been protocols in place for her prenatal, delivery and postnatal care so that she was   screened for and treated for PPD. There should not have been so much pressure put on her to breastfeed; she should have been told that all that mattered was her health and happiness, and that her breastmilk or lack thereof had nothing to do with her worth as a person or as a mother.

I didn’t know Joe. I wish I’d had a chance to. I wish she could be one of the voices in our choir of healing and hope. That she could yell with us and demand better of our governments, our healthcare providers, and our society, so that no woman would be left to drown; so that no woman would ever have to sing that stupid refrain again.

Because I’m sick of the same old song. And I’m sure Joe would be, too.

Sending love from across the pond,

Suzanne Barston, aka The Fearless Formula Feeder

Carnival of Evidence-Based Parenting: What the science says (and, more importantly, doesn’t say) about breastfeeding issues, bonding, and postpartum adjustment

As I sat down to write a piece for this month’s Carnival of Evidence-Based Parenting on the connection between breastfeeding problems and postpartum depression and adjustment issues, I realized something: everything I wanted to say in the post, I already said in my book. So, the following post is actually an adapted excerpt.

Before we get into it, though, I’d like to add that I think breastfeeding difficulties can also affect women in far less dramatic ways. Nearly every mother I know says that the early postpartum period is all about nursing – learning to latch, worrying about weight gain, and soldiering on through cracked nipples and marathon cluster feeds. And nearly every mother I know also tells me that after 4-6 weeks, it got infinitely better; that she and her baby got the hang of things, and breastfeeding became the wonderful, easy, pleasant experience people promise it will be. I think we need to be honest with women about this adjustment period – 6 weeks can feel like an eternity, and to tell new moms just to “hang in there” isn’t going to cut it. Not all of us have adequate maternity leave, familial support, and the money to pay for private lactation consultants. If we are serious about raising the breastfeeding rates in this country, we need to think more critically about how to help women handle these first 6 weeks, and get them through the “learning curve”. Otherwise, I believe we will be causing two things to happen – more mothers will suffer from stress-induced depression and anxiety, and more women will quit nursing way before they had planned or desired to do so. Neither of these are outcomes are beneficial to anyone. 

 

A few years ago, a study published in the aptly titled journal Medical Hypotheses claimed that the cessation of breastfeeding simulates child loss. According to the authors, from a biological, anthropological perspective, “the decision to bottle feed unwittingly mimics conditions associated with the death of an infant.” And since “child loss is a well documented trigger for depression particularly in mothers,” the findings of the study joined the “growing evidence [that] shows that bottle feeding is a risk factor for postpartum depression.”(1) The ominous takeaway message rang out over the Internet. “Does bottle feeding cause postpartum depression?” asked one natural parenting website’s headline;(2) “Mothers who bottle feed their infants in lieu of breastfeeding put themselves at risk of developing postpartum depression,” warned another site, directed at general consumer healthcare.(3)

Two years later, a different study examining the same issues offered a less evolutionary-based (and less daunting) explanation for why not breastfeeding seems to be linked with postpartum depression. Dr. Alison Stuebe, a respected member of the Academy of Breastfeeding Medicine, found that women who reported trouble breastfeeding in the first weeks after giving birth had a 42 percent higher risk of developing postpartum depression than those who enjoyed nursing their babies. Stuebe told Time that although it was important to advocate for breastfeeding, clinicians should “look not just at baby’s mouth and the boob but to also look at mom’s brain” and urged providers to take a more personal approach to infant feeding recommendations: “If, for this mother, and this baby, extracting milk and delivering it to her infant have overshadowed all other aspects of their relationship, it may be that exclusive breast-feeding is not best for them—in fact, it may not even be good for them.” (4)

Back in the 1960s and 1970s, theories on infant “attachment” and the “maternal/infant bond” posited that there was a “critical period” when babies formed either secure or insecure attachments to a primary caregiver—in most cases, for obvious reasons, the mother. Based on the work of John Bowlby, it was thought that a securely attached infant would use his mother as a sort of “home base”; he could explore the world, depending on his mother for comfort and security when things got too intense. If a kid was insecurely attached, the mom-as-safety-net concept didn’t hold; an insecurely attached baby would actually avoid physical contact with his mom and take longer to recover from periods of distress. (5)

By the 1980s, most experts had officially dismissed this “attachment theory,” especially the idea of a critical period beyond which there is no hope of correcting problems, because the original studies that formed the basis for this theory were flawed. (6) But the ideas behind attachment theory still permeate breastfeeding literature, which is chock-full of references to the “maternal-infant bond” and “attachment.” (Ironically, Bowlby himself believed that attachment was formed through the inter- actions of the primary caregiver and the child, rather than the act of feeding in and of itself, or “individual differences in feeding, such as breast or bottle.”) (7)

Later research into attachment discovered that “sensitively and consistently” responding to our infants’ cues—cues like crying, smiling, and eye contact—creates that coveted secure attachment; being unresponsive, unpredictable, disengaged, or, on the other end of the spectrum, overly intrusive results in insecure attachment (8)… and a hefty bill from the child psychiatrist somewhere down the line.

Interestingly, the behaviors blamed for causing insecure attachment not only are related to postpartum depression but could also be attributed to breastfeeding problems. Extreme nipple pain, clogged ducts, or mastitis can cause feedings to be unbearably painful; insufficient milk can be anxiety-provoking. Is it too much of a stretch to suggest that physical pain and anxiety could cause a mom to act “overly intrusive,” “unpredictable,” or “disengaged”? Sociologist and researcher Stephanie Knaak says that despite numerous claims in parenting literature that breastfeeding leads to better bonding, “It’s not going to be the same for all women. For some women, it’s not at all about closeness and bonding, because they don’t actually enjoy breastfeeding. They don’t enjoy the physical aspect of it.” (9)

Many of the moms featured in the FFF Friday posts here on this blog talk about formula allowing them to “finally be a mom”; about how all their energy had gone into breastfeeding, a process that often took so much out of them physically and mentally that they had nothing left to give to their babies. For those of us who have had extreme physical difficulty or emotional discomfort with breastfeeding, formula may allow us to stay calm, connected, and responsive to our children in a way that breastfeeding can’t. Some women have also told me that they believed their breastfeeding struggles made them better mothers, leading them to focus more intensely on meeting their babies’ needs in other ways. Irvin Leon, of the University of Michigan, argues a similar point regarding the benefits of adoptive parenting:

Biological parents may be inclined to believe that their genetic connection with their offspring will inevitably solidify the emotional bond with their young. It may feel a bit less important to parent when one is so assured of being the parent. Adoptive parents, not having that genetic connection, must rely on the actual parent- child bond as the principal determinant of parenthood. Attachment theory . . . make[s] it clear that in the eyes of a child the sense of Mommy and Daddy is based on who takes care of that child, meeting that child’s needs, and knowing that child’s uniqueness and individuality in moment-by-moment daily interactions.(10)

Yet, we are forced to balance our desire to connect and bond with our children in a way that actually works for us with what society – and parenting research- tells us is the “proper” way to bond.  In a review of breastfeeding’s impact on the mother-infant relationship, Norwegian behavioral scientists found that out of forty-one papers discussing breastfeeding and the maternal bond, twenty-two of them made “general statements on the positive effect of breastfeeding on either facet of the mother-infant relationship without a reference to empirical studies supporting this claim.” (11) The study authors then examined the papers which did provide evidence backing these claims, and came to the conclusion that “breastfeeding may promote the maternal bond, but mothers who bond better with their infants may also be more likely to choose to breastfeed over bottle-feeding.”

Think about it—a mother who is already nervous, depressed, or stressed may have a tougher time bonding with a newborn. This mother may ultimately turn to bottle-feeding to control at least one aspect of her new, overwhelming life. Or consider how a baby having trouble feeding may act on a daily basis. A hungry, frustrated baby does not a happy baby make (or a happy mother, for that matter). In both cases, the maternal bond may be affected and bottles may replace breastfeeding. So although it is true that the mothers of these bottle-feeding babies may exhibit less positive, “bonded” behavior toward their children, is it the fault of the bottle? Or was it the situation that led the mom to the bottle that also caused difficulty bonding?

The same question holds for the connection between breastfeeding and postpartum depression. Some researchers have found a correlation between lack of breastfeeding and higher incidence of depression; however, the majority of these studies don’t factor in why the mother isn’t breastfeeding in the first place. A 2009 study found that women who exhibited pregnancy-related anxiety or prenatal depressive symptoms were roughly two times more likely than women without these mood disorders to plan to formula feed. (12) “Prenatal mood disorders may affect a woman’s plans to breastfeed and may be early risk factors for failure to breastfeed,” the researchers point out. And even if the intention to breastfeed is there, multiple factors inform infant-feeding choices once a woman leaves the hospital.

Feeling like a failure, dealing with pain, frustration, and exhaustion, and having a baby who screams at the sight of her, could make any mother feel overwhelmed, let alone one who’s already on the brink of actual PPD. Maybe for those of us more prone to anxiety or depression, the stress of breastfeeding struggles is just the camel’s dreaded straw.

(Excerpted from “Of Human Bonding” in Bottled Up: How the Way We Feed Babies Has Come to Define Motherhood, and Why It Shouldn’t. University of California Press, 2012.) 

Want to read more on the topic of new parenthood from people far smarter than I am? Check out this post from Jessica at School of Smock, who is hosting this months’s carnival – she will link you to the contributions from the rest of the Carnival of Evidence-Based Parenting bloggers:

Introduction to this month’s carnival: http://www.schoolofsmock.com/2013/05/13/evidencebasedparenting

The Transition to New Motherhood (Momma, PhD)

Bonding in Early Motherhood:  When Angels Don’t Sing and the Earth Doesn’t Stand Still (Red Wine and Applesauce)

The Connection Between Poor Labour, Analgesia, and PTSD (The Adequate Mother)

For Love or Money:  What Makes Men Ready for New Fatherhood (Matt Shipman)

No, Swaddling  Will Not Kill Your Baby (Melinda Wenner Moyer,  Slate)

Sleep Deprivation:  The Dark Side of Parenting (Science of Mom)

The Parenting Media and You (Momma Data)

Reassessing Happiness Research:  Are New Parents Really That Miserable?(Jessica Smock)

40 Long Days and Nights (Six Forty Nine)

Also, “like” us on Facebook – we’re trying to bring fresh perspective and research-based insight to the parenting blogosphere. Plus we’re all really nice. It’s really a no-brainer.

 

Sources

(1) Gallup, Gordon G., Jr., R. Nathan Pipitone, Kelly J. Carrone, and Kevin L. Leadholm. 2010. Bottle feeding simulates child loss: Postpartum depression and evolutionary medicine. Medical Hypotheses 74 (1): 174–176.

(2) Nelson, Cate. 2009. Does bottle-feeding cause postpartum depression? August17.http://ecochildsplay.com/2009/08/17/does-bottle-feeding- cause-postpartum-depression/

(3) Harutyunyan, Ruzanna. 2009. Bottle-feeding mimics child loss. Emax Health. August 15. www.emaxhealth.com/2/84/32867/bottle- feeding-mimics-child-loss.html

(4)Rochman, Bonnie. 2011. Time Healthland: Is breast always best? Examining the link between breastfeeding and postpartum depression. August 5. http://healthland.time.com/2011/08/05/do-depression-and-difficulty-breast-feeding-go-hand-in-hand/

(5) Sonkin, Daniel. 2005. Attachment theory and psychotherapy. California Therapist 17 (1): 69–77.

(6) (8) (11) Jansen, J., C. D. Weerth, and J. M. Riksen-Walraven. 2008. Breastfeeding and the mother-infant relationship—A review. Developmental Review 28 (4): 503–521.

(7) Britton, Cathryn. 2003. Breastfeeding: A natural phenomenon or a cul- tural construct? In The Social Context of Birth, edited by Catherine Squire, 305–317. Milton Keynes, United Kingdom: Radcliffe Publishing.

(9) Knaak, Stephanie J. Telephone interview – September 10, 2010.

(10) Leon, Irving. 1998. Nature in adoptive parenting. Parenting in America. 1998. http://parenthood.library.wisc.edu/Leon/Leon.html

(12) Fairlie, Tarayn G., Matthew W. Gillman, and Janet Rich-Edwards. 2009. High pregnancy-related anxiety and prenatal depressive symptoms as predictors of intention to breastfeed and breastfeeding initation. Journal of Women’s Health (Larchmont) 18 (7): 945–953.

 

 

 

 

 

 

 

 

“Where is the mother in the discussion?” An interview with Walker Karraa on maternal mental health and infant feeding

Some of you may know Walker Karraa from her comments on our Facebook community page, or from her fantastic posts on Science & Sensibility. But I doubt you’re aware of the full magnitude of her bravery and dedication to issues surrounding maternal mental health. I recently interviewed Walker for a short piece on formula feeding and postpartum adjustment, and was so blown away by her answers – I was only able to use a few of her wise words due to word count constraints, so I’m thrilled she’s agreed to let me post the interview in full here on FFF.

Walker is a doctoral candidate at Sofia University, where she is conducting a study on the transformational dimensions of postpartum depression. She was also the founding President of PATTCh, an organization founded by Penny Simkin dedicated to the prevention and treatment of traumatic childbirth, and is a perinatal mental health contributor for Lamaze International’s Science and Sensibility, Giving Birth With Confidence, and the American College of Nurse-Midwives (ACNM) Midwives Connection. Like that wasn’t enough on her plate, Walker also served as social media manager for the Integral Leadership Review, and has her own social media consulting business, On My High Horse, and is currently working toward co-authoring a book regarding PTSD following childbirth with Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA. 

I’m exhausted just reporting all of that. And did I mention she has two kids and is a breast cancer survivor? Yeah, she’s all that and a bag of reduced fat potato chips.

I hope you guys will appreciate the revolutionary nature of Walker’s discussion here – her opinions, while brilliant, probably seem uncontroversial to those who follow this blog, but they are quite “rogue” in the birth/maternal-child health community. I can’t thank her enough for being a dissenting voice and speaking up for the benefit of all women. 

FFF: Here on FFF, we see stories almost weekly which discuss how a perceived “failure” to breastfeed can lead to depression, anxiety, and self-esteem issues. Do you think the maternal mental health community has recognized how breastfeeding (or lack thereof) can affect the emotional state of new moms?

Walker Karraa

WK: I think that overall breastfeeding is very well addressed in the health psychology, and developmental psychology fields. What’s lacking is the reframe of the research to integrate more qualitative data, and methods, into the consideration of the full range of implications of breastfeeding from multiple perspectives—including the woman’s perspective.

In a 1985 Lancet article on maternal mortality, Allen Rosenfield asked the famous question, “Where is the ‘M’ in MCH (Maternal Child Health)? In the discussions of MCH, it is commonly assumed that what is good for the child is good for the mother.” (Rosenfield & Maine, 1985, p. 83). In many ways this is relevant in the discussion of breastfeeding and maternal mental health. Where is the mother in the discussion? And in what ways do we still assume what is good for the child is good for the mother? For me, this is all about reproductive rights and a deeper issue about our discomfort with women’s sovereignty over their reproductive, physical, and mental health.

The mental health community has responded to the growth in published data regarding infant health and breastfeeding. This has also been the funding stream for a large part of the last 20 years. But maternal mental health has yet to directly address a woman’s infant feeding choice as a part of her reproductive choice, rather than discrete periods of time that occur with as a continuum of events that are inextricably woven through reproductive events—none of which, taken by themselves, gives either the best data on mental health.

FFF: What do you feel needs to change in order for new mothers to be better supported in terms of mental health in general?

WK: I think one of the first calls to action must be for maternal care providers to get support in knowing that perinatal mood and anxiety disorders are common and create the conditions for morbidity and mortality for mother and children. This is starting to happen, but still very slow. I think new models of medical care such as Dr. Michael C Lu’s life course model, which places the woman at the center of care, not the doctor. And, she is treated across the lifespan, not merely when she is pregnant. This facilitates better reproductive health in preconception and interconception, and uses a reproductive life plan for women and families from an early age. At puberty, to have a conversation with medical, nutritional, mental health providers as to planning one’s reproduction (girls and boys) would be ideal.

FFF: Many women struggle with the decision of whether to treat postpartum or prenatal depression/anxiety with psycho-pharmaceuticals, especially when they are breastfeeding. Why is there such mixed information and messaging about what drugs are safe, and what the relative risks are (ie, breastfeeding without meds vs breastfeeding on meds vs formula feeding and taking the meds)?

WK: Not having good information is a barrier to care for everyone involved. The OB/GYN or midwife, the social worker, the woman, her partner and family—when we don’t have good information, we cannot make informed choices. And for women in poverty, the risk is twofold. Specifically regarding breastfeeding, but also education across the board regarding psychopharmacology, pregnancy, and lactation. With organizations such as OTIS (Organization of Teratology Information Specialists) and Motherisk, there really is no excuse for not having current evidence-based data regarding risk and benefit of untreated depression and anxiety, as well as risks and benefits of medications used to treat them.

Byatt et al. (2012) did a wonderful grounded theory study regarding community mental health provider reluctance to providing psycho-pharmacotherapy. 28 obstetric care providers (nurses, OB/Gyns, etc.) shared how they perceive community mental health practitioners as obstacles to psychopharmacology for perinatal women. The participants felt community mental health providers “99% of the time” discontinued a patients’ medication, and put women at risk of relapse. Secondly, Byatt et al., (2012) reported that participants perceived a lack of collaboration and communication between community mental health care providers and OB/Gyn providers, and that pharmacists also “further impede or delay depression treatment by not filling needed psychotropic prescriptions, often exacerbating women’s mental health symptoms” (p. 3).

FFF: Why do you think so many women express grief, guilt, and feelings of failure around the subject of infant feeding?

WK: Because that is their experience! And I attribute all of it to social constructs that are completely ingrained in medical, social, and mental health systems that have been made for and by men. The intentions of those men is not necessarily nefarious, and not really the point. It is that the constructs we have to measure ourselves (abilities and weaknesses) are made by men. We tell women from the get-go that they need us to be good mothers. They need our insight, knowledge, treatment, book, video, technique, services, product to be taught how to mother. This is so ironic, because so many of the birth movements have evolved from a call to empower women. But to empower, we have just made more systems of knowledge that mimic the ones we refute. That is not very popular to say, but it is true. The messages still given to women is that if they “know” something analytically, they are devoid of femininity, and if they “know” something inter-subjectively, they are devoid of ration.

Shame is a powerful force for women. And at no time in her life is a woman more susceptible to shame than early motherhood. If they are lucky enough to find a safe space to share their feelings without judgment, such as your blog, they are given the gift of voice. They can speak their truths.

FFF: Any tips for a mom who is having a tough time reconciling her use of formula?

WK: You know, when I was a doula, I had clients ask me to go buy formula for them so they wouldn’t be seen in public. When I was diagnosed with breast cancer shortly after the birth of my second, I underwent two mastectomies before she had turned one. I learned that my body parts have nothing to do with my inherent ability to love her. My breasts were gone—off of my body, one in one hospital and another at a hospital down the road. I fed, nurtured, attached with, loved, and parented without them…and still do! So my advice is to write down on a piece of paper: My breasts have nothing to do with my love for my child. And keep it where you can see it. Memorize it, know it.

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