Transformed by Postpartum Depression: A book review

“We need both medicine and mothers to create the future of maternal mental health.” – Walker Karrraa, PhD

 

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It’s no secret that I’m a survivor of postpartum depression. It’s something I talk about a lot, and it informs everything I do with FFF.  There is an obvious correlation between breastfeeding and postpartum mental health; whether this connection is positive or negative is a highly subjective, personal, individual matter. I see so many blanket statements, based on problematic data collection, and leaps of logic when it comes to this topic. No one ever stops to listen to the mothers who don’t fit their particular thesis. And while the topic of maternal mental health has slowly been gaining proper attention in both the media and research communities, as usual, the most important voices have been ignored: the voices of the mothers who have lived through PPD, and lived to tell the tale.

Thanks to Walker Karraa, PhD, these voices are now being heard. In her new book, Transformed by Postpartum Depression (Praeclarus Press, 2014) she reports on her own analysis and research as well as that of other pioneers/thought leaders in the maternal mental health field. But throughout, she allows the words of her subjects tell the story. And it’s an important story – one that not only highlights Karraa’s thesis, that PPD can be both traumatic and transformative, but also details how we are failing mothers at every turn. This is something that’s been discussed, even here on this blog, but Karraa’s delivery of the information is profoundly moving and startling because it is so specific, personal, and honest.

Using her interviews with 20 different women, all of whom survived moderate to severe PPD, Karraa examines the experience of postpartum depression. But this isn’t some clinical, cold volume that treats its subjects like research – the care and admiration Karraa has for her subjects is clear throughout the text. It’s a unique book; one that I believe will be just as helpful to moms as it is to mental health professionals and academics.

I think the FFF Friday series is powerful for many reasons, but the one that feels most vital to me is this: for every specific, personal story I share, there are hundreds of moms out there who see themselves in the words. These experiences are individual, but also collective, and sharing them helps both the writer (catharsis) and the reader (relief/camaradarie/normalization). Karraa’s book serves this purpose for the postpartum depression community. That would be enough – but she goes a step farther, pondering complex questions about how we approach the pathology of depression, and even analyzing her own reactions to her research. The result is something entirely unique, engaging, and important.

One section that deserves national attention – like, yesterday – is Karraa’s chapter on the failure of care providers to help these women. Her interviewees report harrowing tales of begging for help, only to be cruelly dismissed, ignored, or ridiculed. Nearly all reported a complete lack of forewarning that PPD was even a possibility, in prenatal classes and OB/GYN appointments – even when they had past histories of mental illness. Lactation consultants failed to see what breastfeeding was doing to a mother’s mental health; pediatricians told mothers their suicidal thoughts were “normal”; therapists refused to help or refer to others who could. These mothers were forced to take matters into their own hands, as Karraa describes:

As I analyzed this data, images of the walking wounded came to mind – as if these women were hemorrhaging – in public – and no one noticed… To walk through daily life dying and being ignored by care providers, and invisible to support systems was crazy-making and cruel. There was almost a punitive sense of the experience of care-provider failure – an additional layer of humiliation, indignity, and negligence…women got pragmatic; if their providers were not going to fix the problem, they would do it themselves.”

Of course, this could be viewed as a silver lining, in the American, pull-yourself-up-by-the-bootstraps sort of way. But that is not what Karraa is advocating. It’s inspiring to see how these women overcame adversity, but infuriating that they had to do it alone. I hope that this book will act as the missing link – a close-up on the face of postpartum depression, a healing volume for those who have been through this particular battle, and a call to action for our society to make immediate changes in how we approach postpartum mental health.

“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.

Good versus “Evil”: How ignorance can bring out the best in the breastfeeding/formula debate

Question: If a misguided, extremist tree falls in the forest, does it make a sound?


Answer: Yes, if the tree is talking about the breastfeeding and/or formula feeding debate.




For those of you who don’t live in the forest, the tree in question – a sprawling, giant redwood of ignorance – was planted by one Darcia Narvaez, PhD. Narvaez wrote a series of articles for her blog on Psychology Today, so aptly titled “Moral Landscapes”, on the importance of breastfeeding; each one was more offensive and misleading than the last, culminating in her piece de resistance, Is Pushing Formula Evil?” (Spoiler alert: she thinks it is.)


This most recent article included such oldies but goodies as:


Formula is a starvation diet. It gives kids the equivalent of bread and water right when they are growing the most…”


and


Formula is the first junk food. Do we want our kids to be healthy? Then we know they should not have foods that are out of balance with nature. So we don’t want to give them formula. We don’t want them to get used to the same flavor day after day (unlike breastmilk). We would be setting them up for eating disorders…”


Plus, if you order now, you’ll receive hits like:


99% of moms with full-term infants can breastfeed successfully. It is ignorant doctors, nurses, family members and the push of pharmaceutical companies that make it seem untrue…”


and


“This is a moral issue because of how much damage is being done to children, society and our future by not breastfeeding…”


And those greatest hits were from the edited version of the article, altered after Narvaez received numerous comments from therapists, lactation consultants, and mothers, some harmed, and all offended, by her words.


I could go through every one of Narvaez’s bullet points and explain why they are 95% horse poop, but I’m not sure that would get me anywhere; we’ve pretty much covered all of them in past posts (just check out the tags at the bottom if you want to hear what I have to say about her claim that formula is linked to lower intelligenceor that “99% of moms with full-term infants can breastfeed successfully. It is ignorant doctors, nurses, family members and the push of pharmaceutical companies that make it seem untrue”ironic, as the stress this writer is causing with her foreboding article could harm supply) Plus, it would legitimize her in a way that I’m not interested in being responsible for. She is so far from rational in her facts and presentation that I wasn’t even offended by her post.


In fact, I kind of liked it.


Here’s why: within hours of this drivel being posted, women were coming out of the woodwork to school Narvaez on the realities of infant feeding. Therapists finally spoke up about the link between postpartum depression and the pressure to breastfeed (Narvaez tried to pacify these folks by adding a warning at the beginning of her post:
NOTE TO MOMS: Don’t read this if you are feeling vulnerable, guilty or overstressed”. Yep. Really. I don’t know whether to laugh, cry, or demand a retraction from Psychology Today); lactation consultants, even if they were nowhere close to my end of the breast-bottle-right-to-choose spectrum, told her that her approach was wrong and damaging. Sure, there was the requisite “formula feeders are sociopaths” type of fare in the comments section (mostly from Narvaez herself, who- I kid you not – blamed the selfishness of the Baby Boomer generation on formula), but overall, the sisterhood was stronger than I’ve seen in a long time.


Over on the FFF Facebook page, there was discussion about how for any “hot” topic, the extremists get all the attention, and moderate voices are seldom heard. There’s a silver lining to this unfortunate truth: Sometimes, it takes deafening zealotry to provoke the quiet, moderate voices to speak up a little louder.


I truly believe that it will be these voices who can put an end to this ridiculous “battle” and start making some real strides in improving the lives and health of women and babies. Voices like the postpartum therapist who worries that the obsession with perfection will exacerbate women already rendered vulnerable by the monster of PPD, or the PPD survivor who urges that breastfeeding is a matter of personal preference. Or the feminist activist who manages to promote breastfeeding and choice simultaneously. Or the breastfeeding mom who understands the concept of correlation versus causation, and can cherish both her belief in/love for breastfeeding and her belief in/love for using evidence-based science for prescriptive claims. Or the mother who was once riddled with guilt, caught up in the whirlwind of caring for a micropreemie, and who now has the strength and confidence to stand up for her choices and show the world how breast is best is not so black and white.


So, I applaud you, Darcia Narvaez. You’ve managed to bring lactivist and formula feeding advocate together in mutual disgust for your approach to breastfeeding promotion. You’ve made us take a step back, and reaffirmed the need for a dose of common sense, for a middle ground, for sensitivity and reason.


I applaud you. But that doesn’t mean I don’t hope someone cuts your aforementioned poorly-written tree down to make toilet paper.


Breaking news: All new moms are sleep deprived!

I’m thinking the economy must be better than everything thinks, because some pretty inane studies are still managing to get funding. Like this one, reported on CNN.com, that shows how formula feeding moms and breastfeeding moms get “the same amount of sleep”. (I’m not bothering to read this one because frankly it’s too ridiculous for words, but I would venture a guess that “the same amount” = not much in either case, unless you’re one of those lucky women who gets blessed with a baby that sleeps through the night at 2 weeks. For the record, I kind of hate you, and also want to be you.)

This is not news, people. I understand it’s an old wives’ tale (and possibly a marketing ploy by the formula companies, since as we all know, everything is. They were responsible for the Kennedy Assassination and 9/11 too…although I should probably cut the sarcasm since Enfamil did put out that ridiculous “Restful” formula which set the cause of formula feeding rights back about 50 years) that formula makes babies sleep better, but as the mom of a baby who was fed both breastmilk from a bottle and later straight formula, and who never slept more than 3 hours at a time until he was 5 months old, I can attest that this is far from the truth. I know breastfed babies who slept like lambs, and formula fed babies who kept their poor parents up all night.

Now, I do think formula allows mom one luxury – the night feedings can be shared by partners, whereas breastfeeding moms have no choice but to be involved in the feeding, as the feeding apparatus is attached to their bodies. But in a completely anecdotal, uncontrolled study, performed by myself using my group of mom friends as subjects, I found that no matter how the baby was being fed, the non-primary-caregiving parent woke up far less than the primary caregiver. Sometimes it was because the significant other had to work the next day, whereas the primary caregiver was staying at home, or at least on maternity leave; in other cases, even when both parents were working, the primary caregiver was just more attuned to the baby’s needs and woke up faster and more efficiently than her partner. In my case, Fearless Husband was far more stoic when I was pumping exclusively, waking up to feed Fearless Child a bottle of my pumped milk while I pumped more of the stuff. When we switched to formula, he was suddenly way less apt to wake up; even if his intentions were good, I’d sit up straight the second FC started crying, but no amount of smacking upside the head could wake my beloved. It was just easier for me to get up and make the bottle.

So, I would imagine that these things kind of even out. Yeah, formula feeding moms can share the burden of night feedings, but breastfeeding moms – if they are sharing a room with their infants – can simply roll over and let the kiddo feed. That always sounded blissful to me, especially as I was knocking into furniture in the pitch dark, stumbling into our bathroom to mix up a bottle….

Point being – I’m 100% not surprised about this finding. I’m just surprised someone would bother to conduct a study looking into this issue, when there are so many more important things to be researching. I should have learned my lesson by now, though, because the end of the CNN article made it all perfectly clear:

So what should new moms take from this study?  Researchers hope it will encourage moms-to-be who are thinking about exclusively formula feeding their babies to consider nursing as well.  When it comes to breast milk, says Hawley E. Montgomery-Downs, the study’s lead researcher and assistant professor of psychology at West Virginia University, “the benefits for mom and baby are unequivocal.  Yes, they are exhausted, but getting better sleep can’t be used as a reason not to breastfeed.”

Oh, right. That’s why Montgomery-Downs conducted this study, as an “assistant professor of psychology” – not a sleep expert, or a lactation consultant, but someone who should arguably be more concerned with the effect of lack of sleep on a person’s psychological makeup than worrying about some stupid petty argument between new moms, or giving prescriptive advice about the “unequivocal” benefits of breastfeeding – to ensure that no woman can use “I’m tired” as a reason not to breastfeed. I’ve also yet to meet a mom who seriously factored the rumor about formula helping babies sleep into their decision. It may have been an after-the-fact silver lining, but a reason to go directly to formula? Not so much. And I’d testify in court that I’ve talked to at least 80 formula feeding moms at length, which is the same sample size as this study.

Maybe we need to start a new feature on FFF… Studies That Make You Want to Bang Your Head Repeatedly Against a Brick Wall? STMYWBYHRABW for short? You like?

Guest Post Week: Formula feeding and maternal happiness

For our last Guest Post Week feature (well, not counting FFF Friday tomorrow), I chose a submission from Joy Paley, a blogger and writer.
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Study reports (surprise) no difference in psychological health or infant attachment between breast and formula feeding moms
I know you frequent readers of FFF might initially roll your eyes at this study about maternal happiness, since its conclusions may seem obvious. The research, which looked at psychological health of new moms and their attachment levels to their infants, showed no significant difference in these arenas between women who were breastfeeding and those who had weaned their babies.
The research, out of the School of Psychology at Australian National University, isn’t terribly new; it was published in The Journal of Reproductive and Infant Psychology in 2006, but there are so many gems in it that when I found it I knew I had to share. It directly challenges many popular notions about breastfeeding and maternal health and is refreshingly unlike the scientific rhetoric in other studies that FFF has helpfully picked apart before.
For one, the authors directly recognize that maternal happiness has not even been mentioned in the large amounts of literature that have come out in support of breastfeeding. In their focus on physiological and immunological benefits of breastfeeding, these studies have completely left out the experience of the mother. “Possible negative maternal experiences of breast feeding and those experiences of formula feeding mothers have largely been ignored in research to date,” says this paper.
Another remarkable part of this study is that it recognizes and discusses the methodological shortfalls of previous studies about breastfeeding moms and happiness. These studies had some serious issues in how they evaluated the psychological health of new mothers; they didn’t differentiate between current or past breast feeders, or women who had used formula from the birth of the child. Some had very small sample sizes, and others measured the women’s psychological health at varying times throughout the pregnancy.
Wait, there’s more: these studies also used psychological distress scales that are inappropriate for a woman who has just given birth; i.e., they count sleep disturbances and tiredness, normal parts of becoming a new mom, as probable signs of depression.
With these previous issues in mind, the researchers in this Australian study stated that the empirical evidence claiming that breastfeeding mothers were happier was mixed at best, even though that is the popularly held assumption. They set out in their study to challenge these commonly held notions and correct the methodological problems found in previous research.
To do the study, the researchers collected data on 60 new breast and formula feeding mothers using a 30 minute interview and a questionnaire. Standardized methods of quantifying psychological states such as life satisfaction, happiness, anxiety, depression, and maternal attachment were used to assess the well-being and attachment levels in the two groups.
And, drum roll please: no significant difference was found between the breast- and bottle-feeding mothers in psychological well-being, anxiety, or feelings of attachment to their infant.
“No evidence was found to support assumptions that breast feeding mothers have greater psychological health or have greater perceptions of attachment with their baby than mothers who are formula feeding their infant after weaning,” said the researchers.
I found the posture of these social scientists and the way they framed their research question to be quite encouraging—here are academics who were not simply looking at data on infant immunity and ending their papers with curt statements like “breast is best.” I’d probably attribute this to the fact that the researchers here are psychologists rather than, say medical doctors. There is an effort made to look at the potential social impact of the dominant opinion that breastfeeding leads to more happy, caring moms, and to thoroughly put to question that popular assumption.
Their final statement of the paper reflects this, and I have to agree with them: “Until more research is undertaken on maternal experience of feeding a baby, widely help assumptions may continue to place excessive and unnecessary pressure on new mothers.”
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