"My postpartum depression, like many women, didn't hit until I went back to work. I was waking up every two hours, commuting nearly 2.5 hours a day, pumping at work, all while continuing to do a very stressful job at a new practice. There were mornings that I cried my whole commute to work, felt like a failure of a mom, midwife, and co-parent and partner. I felt simultaneously numb to the world around me and my feelings while a deep pit of worry and despair swallowed me up.

I remember the first morning I had intrusive, terrifying thoughts of throwing myself on the light-rail tracks. I didn't think them, they just burst into my head. I was too scared to even tell my partner about it. All of my colleagues were brand new and I felt I couldn't confide in them either. I felt horribly alone. My thoughts wavered from intrusive, harmful ideation to an overwhelming sense that my baby and my family would be better off without me. I did exactly what I tell my patients NOT to do, and white-knuckled my way through that first year. Eventually, better sleep came, the sun came again, my commute got a lot shorter, and around a year after Gene's birth I finally really started enjoying motherhood."

September 9th - 13th is the second annual Maternal Suicide Awareness Campaign.  This awareness week was started in 2018 by 2020 Mom, in order to share that new parents are not immune from the impact of suicide, and our support systems and networks to prevent such tragedies need a lot more attention if they are going to help with this difficult but important issue that impacts families.

Here are some important facts from the 2020 Mom campaign about maternal suicide that you may not be aware of as a perinatal professional, and that are important to share with the families that you work with:

• Suicide is one of the leading causes of maternal death in the US and is THE leading cause of death in countries such as Japan, the UK, and Ireland.  

• Sleep disturbances significantly increase the likelihood of suicide attempts and suicidal thoughts in adults and increases thoughts of self-harm in depressed postpartum parents. 

• Increased symptoms of anxiety have been linked to frequent thoughts of self-harm in depressed postpartum women.  As many as 66% of postpartum women with depression have comorbid disorders, with almost 83% being anxiety disorders.  

• Maternal deaths by suicide often involve a violent method. This may reflect greater illness severity or higher suicidal intent in this group than in the general population. The use of violent suicide methods suggests severe depression, possibly with psychotic symptoms. 

• The severity and rapidly evolving nature of postpartum psychosis increases the risk of maternal suicide.  There is an approximately 5% suicide rate for women diagnosed with postpartum psychosis.  

• A bipolar disorder diagnosis puts women at increased risk for postpartum psychosis, thus also increasing their risk for maternal suicide.

• Maternal suicide risk is not just limited to the immediate postpartum period. It is important to continue providing women with mental health resources and support throughout the later postpartum period.

• Reasons contributing to maternal suicide include (but are not limited to): stigma, potential legal repercussions that may arise from admitting to and receiving help for psychiatric problems, especially among new mothers.

• The highest risk for maternal suicide occurs at 9 to 12 months postpartum.

When you read the above statements, it is clear how many families can fall through the cracks simply by the poor design of our current systems which are definitely not set up to support families during the childbearing and postpartum year.  What new parent does not deal with sleep disturbances? How many new parents are receiving care where they can be evaluated for mental health risks at 9-12 months postpartum? In the USA and many other places around the world, both society and the medical profession do a poor job supporting the transition to parenthood.

Today on Connecting the Dots, I share an interview with a colleague of mine on her personal experiences with postpartum mood disorders and suicidal thoughts after giving birth to her son in 2016.  Michelle Farber, CNM, ARNP is a Certified Nurse Midwife practicing in Seattle, WA. I truly appreciate Michelle’s candor and honesty as she shares a very personal experience with our blog readers.

Sharon Muza: Did you have a relatively uncomplicated pregnancy and delivery?  Did your birth go as you had hoped and planned?

Michelle Farber: I had, medically, a pretty normal pregnancy. I did have hyperemesis through about 20 weeks, which really impacted my mood. I was also working full time as a midwife and experienced significant secondary trauma during my pregnancy after experiencing several, unforeseen and unpredictable stillbirths and a neonatal demise in a short period of time. My birth went exactly the opposite of how I had hoped. I labored for 40 hours, pushed for close to three hours, and eventually had a cesarean birth. My baby was OP and 9 lb 6 oz and had to come out that way. Even though my birth didn’t go as I had hoped, I knew that it was all just luck of the draw and I had a wonderful surgeon who helped me have a family-centered birth in the OR. 

SM: As someone who had suffered from depression and anxiety prior to becoming a parent, were you told during your pregnancy of the increased risks that you might face postpartum? Could anyone be “prepared” for such a postpartum complication?

MF: I had wonderful care providers through my pregnancy, but honestly, we didn’t talk about it much. There wasn’t a plan in place for me to be seen more often postpartum. In retrospect, I was also definitely suffering from antenatal depression as well, which also mostly went untreated. The other really difficult thing about my depression, in particular, was that when I was seen at my six-week visit I was feeling fine. My depression didn’t hit until I returned to work, which is when postpartum mood disorders often present, but we don’t talk about that often. We know that postpartum depression and anxiety can crop up at any point in that first year, but when people are feeling ok at that six-week mark,  we all breathe a big sigh of relief and assume everything will continue to be fine. 

SM: How long did you have off from work after you gave birth?

MF: I was off for four months, but only eight weeks of it was paid. My partner decided to be a stay at home parent, so part of my anxiety and depression was definitely tied to the stress of being the sole financial provider for my family. It is still mind-boggling to me that the US is the only industrialized nation in the world without any paid parental leave and that we make new parents go back to work so quickly after their children are born. It’s inhumane. 

SM: Despite being an informed, knowledgeable CNM and well aware of the signs, symptoms and appropriate treatments available, why do you think you did not or were unable to reach out for help during this very difficult time? 

MF: Even though I knew that I was clearly suffering from postpartum depression, I think I still had some internalized shame about reaching out. I felt like I “should” just be able to pull myself out of it or force myself to feel better. It also really reinforced in me that depression can be all-encompassing and my inability to reach out tied in with my depression. I would walk myself in circles of feeling horrible for resenting motherhood and knowing I needed help, but not believing I was deserving of help. 

SM: How were you able to hide this from those who loved you and those who worked with you and were also trained to spot the signs and symptoms?

MF: I’ve always been pretty good at slapping on a happy face and “faking it until I make it” when I’m not feeling well. I was pretty open about my baby’s sleep struggles and I was exhausted and a bit withdrawn, but I think everyone just chalked that up to new motherhood. My family and my partner’s family live far away, and we were some of the first people in our social group to have children, so I think my friends didn’t quite know that how I was acting wasn’t normal. 

SM: Why did you choose not to ask for help?  Was that even a choice? Were you even able to ask for help?

MF: I don’t think I could have asked for help where I was. I think it’s important not to blame people for not reaching out earlier or taking the steps to help them feel better because its so much work. At one point I reached out to my midwife and asked her to prescribe me some meds, but I wasn’t in therapy and I was worried that without supervision I might act on some of my suicidal ideation so I never picked up the prescription. 

SM: How did the experience of postpartum mood disorders and thoughts of suicide impact your partner/co-parent?

MF; It was immensely hard on my partner. We were both adjusting to this whole new role, and my partner was adjusting to being a stay at home parent, which is truly the hardest job in the world. I felt like I couldn’t burden him with needing to take care of another person, so I really tried to keep it mostly to myself. Also, I was scared that if I told him he’d (at that point, probably rightly) suggest that I maybe even consider hospitalization. It took me until after most of my intense feelings of wanting to kill myself had subsided that I was even able to tell him. 

SM: What do you think was the reason you did not attempt suicide? What stopped you?

MF: If I’m being completely honest, it’s that I knew that my family relied on me financially. I felt so worthless and useless, but at least I had a skill that could support my family so I felt obligated to keep living so that they could be taken care of. The really difficult thing about postpartum depression is that even though I felt like my family would be better off without me, I just loved my baby so much and couldn’t bear to try to leave him. Also, the guilt of knowing that I would be leaving my partner to parent alone was more than I could bear. That’s what kept me going until I finally started to feel better. 

SM: How can we do better? As clinicians?  As perinatal professionals? As a community? As a country? As a world? As someone who has gone through this trial by fire and come out alive and healthy on the other side (many do not), how might you answer this?

MF: That’s a big question! I think so so so many things. First, as perinatal professionals, demanding better training and resources from our midwifery and OB/GYN programs. Telling someone who is already depressed that they need to navigate our (USA) very complicated, very expensive counseling system seems like a slap in the face, and only being able to prescribe meds and send folks out the door feels like putting a band-aid on a gaping wound. We need to be able to provide more than just medication management because getting into therapy just isn’t an option for everyone, especially those working full-time, or on Medicaid (almost no private practice therapy groups take Medicaid).

 I also wish that we made a routine of seeing people so much more frequently postpartum. In the United Kingdom, a midwife travels to a new parent’s house several times before the six-week mark. In the USA, we typically see people for one 30-minute postpartum visit at six weeks and then not ever again, or not until they’re due for other health screening. Our pediatricians also have to be routinely not only screening for postpartum depression, but willing and able to intervene. 

I’ll never forget, at baby’s three-month check up, I was asked to fill out an Edinburgh Postpartum Depression Screen and I marked down that I was having suicidal thoughts. It was about as close as I could get to asking for help at that point, and I don’t think our pediatric provider ever read the sheet. I was devastated and felt even more like I didn’t matter. 

As a community, I think we need a program similar to the local PEPS in my area, but that is free and available to everyone. My PEPS group was (and continues to be) an amazing support. As a society, we have to completely restructure new parenthood and demand incredibly reasonable changes like paid parental leave, medicare for all (universal health care), equal pay for women, (and righting the fact that Black, Latino, and Native women make far less than white women), and free universal childcare. If we truly lived in a society that actually valued families we would give parents the time they need to recover physically and emotionally from birth or welcoming a child into their lives through adoption. I don’t think it’s a coincidence that the US has some of the highest rates of parental depression, and so much of that is tied to the need to return to work while our bodies are literally still bleeding and our hearts aren’t ready to be separated from our babies. 

SM:  What would you tell someone who is considering going on antidepressant medications in pregnancy or postpartum?

MF: I wish someone had spent more time talking with me during my pregnancy about starting meds. We know that the combination of medication and therapy is the most effective treatment for perinatal and postpartum depression but there’s so much fear about using medications and even providers are not well informed on how to talk to pregnant people about meds. Every medication comes with risk, and medications are, as a whole, not well studied for pregnancy. There are a couple of really rare risks like heart defects and breathing issues that come along with SSRIs, but these things are mostly hypothetical risks, and easily righted. We know that a fetus faces far more harm from untreated and undertreated depression, which also carries risks like low birth weight and preterm labor. Most people think about the risk of the medication, rather than the risk of not treating. We also need to talk to pregnant people as whole humans and remind providers that women and pregnant folks are not just incubators and that our mental health matters. That was the biggest lesson to me about motherhood--I had to put on my own oxygen mask first in order to care for my family. 

SM: A challenge is to strike a balance between preparing people for these serious challenges and potential significant situations, and not scaring people.  How can childbirth educators help?

MF: If you look at the statistics, 80% of new parents experience the baby blues and 15-20% experience a major mood disorder postpartum. We definitely shouldn’t scare people, but I think talking about it as a normal and common experience postpartum, and even inviting in someone who has had postpartum depression or anxiety to speak in childbirth classes helps decrease the stigma. I also think educating partners on the signs of postpartum depression and anxiety and how it looks can help new parents know what to look for in their partners. 

Thank you Michelle for your frankness and your willingness to share your experience. I think it is so helpful for other parents to know that they are not alone in their experiences and that it is possible to come through suicide ideation during the postpartum period and be healthy and happy on the other side.  I think that childbirth educators can be an amazing resource for these families and absolutely need to increase awareness of these issues and provide information on where families can get help.

Resources

Postpartum Support International

2020 Mom - Maternal Suicide Awareness Campaign

Suicide Prevention Lifeline - USA

Published: September 11, 2019

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