Pregnancy and Postpartum Mental Health: Safety in the Storm

By Wendy Davis, PhD

 

The proper support of new mothers, babies, and their families requires a whole chain of care that goes from the earliest prenatal care all the way through the first early years of a child’s life. We are all links in that chain — families, providers, and communities:  we work best when we are collaborating, working together, creating nurturing environments for infants and their families.  The most important message about mental health and self-care for new parents is that it is a natural need to receive support during pregnancy and postpartum, and that includes emotional as well as physical and practical support.

How can families help when a mom has postpartum depression or anxiety? How do we learn about signs and symptoms in a way that feels empowering and not shaming? Sometimes it seems that our heaviest burden is our own self-criticism and judgment, our own expectations that a “good mom” would never feel any emotional distress.  Women who are depressed or anxious during or after pregnancy tell us that friends, family, and perfect strangers directly influence how they feel, whether they reach out, and even how they communicate with their partners. How a family responds to a new mother’s emotional and mental health can affect her through pregnancy, pregnancy loss, postpartum, and her developing self-image as a mother.

Here’s a good illustration.

I am standing in line at the grocery store and overhear a conversation between the two women in front of me. One is there with two children – a baby in the cart and an older child who calls her grandma. She is taking care of the little ones and talking to the silver-haired woman behind her, comparing notes about grandchildren. I hear the woman with the children mention that she’s helping because her daughter-in-law has “Postpartum Depression.” They pause and look at the kids. I wait…I wait for the inevitable: the rolling of the eyes, the talk about how women these days just want the easy way out, how everyone and her sister seems to have “Postpartum Depression.”  I ready myself, getting ready to tell them that it is real, it is rough, and that we are lucky to have real resources, volunteers who can help her connect, find resources, not feel alone. I want them to understand, to know that they should not judge. I want to tell them that it actually is almost true that “everyone and her sister” has it, and that we need to listen to them, not judge, and help them. I’m ready. I take a breath.

They surprise me.

The woman in front of me shakes her head. “Oh, I only wish we had help back in my day. I wish… She’s a lucky girl, your daughter-in-law. If I had been able to ask for help and have someone take the kids to the store….You know, she’s lucky to have you.” They smile at each other, and look down at the children. I feel like crying, with relief. If the grandmothers at the store understand, then we might just have a chance.

Times have changed, and they will continue to change. Although another day could have brought an insensitive conversation about depressed new moms, this day in this store reminded me that our families and communities are beginning to understand. New moms do get depressed and they get anxious. Pregnant women have as much chance of becoming depressed or anxious as their postpartum moms, and teenage moms have a greater chance than any. Even adoptive moms and dads can become depressed and anxious after a new baby arrives. We have been ignoring it and as a result families have suffered. Fortunately, communities around the world (and the internet)  are working together to create a safety net that includes raising awareness, connecting families with resources, educating providers, and forging partnerships to help families.

The earliest references to depression, fears, or psychosis around childbearing were recorded in the 4th century BCE!  In modern times, we stopped talking about them. Acknowledgement of despair seems to have been replaced by pretty media pictures of mommies and babies and shallow reassurances by families and doctors who tell mom to get a haircut, buy a new dress, or wean the baby. Traditional rituals to support new mothers and fathers were replaced by baby-shower games, and built-in help for new parents gave way to expectations that one parent will go to work and the other stay home to keep up with housework, her appearance, and the bliss of new motherhood. In this modern world, where is the language to describe mornings filled with anxious fears, dinner that remains uncooked,  and nights disrupted by mommy crying as much as the baby?

Organizations like Postpartum Support International believe that we can prevent a crisis if new parents receive reliable information, resources, and adequate support before the baby arrives. If families learn that symptoms of emotional and mental distress during pregnancy and postpartum are common, treatable, and temporary, then they will not be consumed by fear or shame if it occurs. They might find ways to rest more, reach out sooner, and engage with informed providers and support services to prevent their distress and facilitate their recovery. Most importantly, by finding resources, they can make contact with real mothers, fathers, and grandparents who have gone through their own difficulties around childbearing, and they will learn that they are not alone and not to blame. Women should know that they can contact support organizations like PSI for support around any stress, adjustment, or distress related to childbearing; they don’t need a diagnosis and they won’t be pushed into any particular treatment.

Although we most often hear about “Postpartum Depression” when we talk about mental health around childbearing, there are in fact several ways that emotional distress commonly arises – not only depression, but anxiety, bipolar cycles, grief, trauma, and psychosis. The most recent research shows that more than 1 out of 8 pregnant and postpartum women develop significant depression or anxiety, and up to 1 out of 10 fathers also have depression after a new baby arrives.  Postpartum Psychosis, the most serious postpartum psychological disorder, occurs in 1 to 2 per 1000 births.

This means that one in eight women has enough disruption in her moods, sleep, appetite, confidence, and ability to function that she could be diagnosed with a clinical mood disorder. You can’t tell who it is by looking: moms will smile on the outside while they are feeling lost, scared, and emotionally numb. Our cultural taboo against maternal depression has thwarted us from talking compassionately about our emotional lives as mothers.

There are identifiable risk factors such as a history of PMS, depression, anxiety, or bipolar mood disorders, recent loss, or life stressors. Symptoms might include feeling overwhelmed, inadequate, anxious, or detached, and in some cases the difficult anxiety symptom of repetitive, intrusive thoughts that include unwanted images of harm to their babies. If the family and their caregivers do not have reliable information to help them distinguish between anxieties that are not dangerous and delusional thinking that is, anxious mothers live in fear and their symptoms increase.

If a mom is fortunate, people around her will remind her that she is worthy of care, treatment, and help. If she has emotional difficulties, they will tell her that these are symptoms of distress, not a sign of her inadequacy. Having negative feelings about becoming a mother is a symptom of depression; it is not a cause. We can be open to the truth about the difficult adjustment of becoming a parent. Can we accept that depression, fear, anger, and loss might exist side by side with love and attentive parenting? If we can become a culture of truth-tellers and fair listeners, we will make our families stronger and healthier, and change the environment into which children and their parents emerge.

So, let’s hear it for the grandmothers in line at the store. Thank you for listening, providing safety in the storm, telling the truth.

 Contact Postpartum Support International for support, information, resources, and volunteer opportunities at www.postpartum.net or 1-800-944-4PPD  (1-800-944-4773).

 

Wendy Davis, PhD, provides counseling, training, and consultation for mental health related to pregnancy, birth, loss, postpartum recovery. She was the founding director of Oregon’s Baby Blues Connection and is the Executive Director of Postpartum Support International.

 

How to Screen Yourself for Postpartum Depression

May is Mental Health Month. As childbirth education advocates, Lamaze believes that mental health during and after pregnancy is critical to the health and safety of moms and their babies. If you are experiencing depression, anxiety, psychosis, or any other mental health issues, contact your care provider and seek support and resources from Postpartum Progress and Postpartum Support International. You don’t have to suffer alone — and you don’t have to suffer. There is support and treatment available for mental health disorders. Also know that you are not alone — it has been found that 1 in 7 women will experience postpartum depression, though that rate is thought to be higher for all postpartum disorders.

So how do you know if you are experiencing a postpartum disorder? Many moms downplay or dismiss their feelings, chalking them up to “hormones,” but it’s important to take notice and check in with yourself. A postpartum disorder is more than just a “bad day,” and even if you feel as though you are coping, a postpartum disorder ultimately affects your quality of life. If you feel as though something is “off” or if your partner expresses concern about your state of well-being, you can take a free, quick, confidential, online screening quiz to determine whether you may be suffering from postpartum depression.

The Edinburgh Postnatal Depression Scale (EDPS) was developed in 1987 to help doctors determine whether a mother may be suffering from postpartum depression. The scale has since been validated, and evidence from a number of research studies has confirmed the tool to be both reliable and sensitive in detecting depression. The EPDS Score is designed to assist — not replace — clinical judgment. If you feel you may be at risk or suffering from post natal depression, please share the results with your care provider.

Finding Renewed Trust & Confidence: A Birth Story

I am a childhood abuse survivor and so I didn’t have confidence or trust in my body. That lack of confidence was reinforced when my first birth, a planned natural birth, resulted in a painful and highly medicated induction. I suffered post-partum depression for over a year after the birth. But I am blessed because though I was defeated in spirit, I had great support. When I told my husband, Rob, that I was changing my care to a group of Certified Nurse Midwives who deliver at a local hospital he stood behind me. We did not know it at the time, but the choice to change my provider became one of the pivotal moments in my recovery as a survivor, and monumentally improved my joy in mothering and my marriage.

 

When I discovered I was pregnant again, I fearfully avoided my first prenatal appointment for 12 weeks. My previous doctor wasn’t nurturing. When he checked me he did it in such a way that I was left feeling violated. No “cold touch.” No “gentle pressure.” No bed-side manner. He just walked in, “I’m going to check your cervix.” Check. “Everything looks normal.” It wasn’t his intention to make me feel bad, but when you’re an abuse survivor it’s not unlike being abused again. My midwives gave me care which chipped away at my fears. They talked with me about my feelings about my past birth and my future hopes and concerns, not just my medical history. They treated my whole person. I was more than a body which happened to be wrapped around a baby. Our first appointment lasted over an hour. I felt safe in their care. But I still didn’t feel confident in my self.

 

My due date came and went– nine days, ten days, eleven, twelve– I feared I was unable to go into labor. My midwives gave me the best standard of care and monitored my baby’s health. They trusted my body to go into labor eventually and encouraged me to be patient. On the evening of my thirteenth day post-due my contractions finally started, 15 minutes apart, and I tried to prepare myself to welcome my baby to the world.

 

I called Rob from work, and I drove my daughter to my in-laws’ home and called the midwife. She told me to hang out at  home until I felt I needed more support or contractions were coming very close together. Bedtime came, and Rob put our daughter to bed. I labored quietly in the living room while my husband’s family went to sleep. Everything was normal, peaceful.

 

In the back of my head I feared things progressing, feared going to the hospital and what would happen to me once I got there. Would my body do its work? Would I have spent 7 hours in labor just to be dilated to 2 cm when we finally arrived? As night turned into early morning we decided to make the trip to the hospital. My fears escalated as we arrived. I was defensive towards the nurses and Rob, nervous my labor would stall.

 

When my midwife arrived, she brought her calming presence with her. Within thirty minutes she had the lights turned down, and every unnecessary person removed from the room. She gave Rob instructions on how to rub my back. The three of us fell into a rhythm. Rocking, massaging, humming, moaning… finally I relaxed. Finally I felt like things were the way they should be. I joked between contractions. I was actually enjoying being in labor!

 

Suddenly, I felt the urge to vomit and my contractions started bashing on top each other. I had been lying on my side in bed and I called out for help. While I lay shaking and panting in the bed, my midwife and nurse filled the labor tub with warm water. I climbed in as soon as I could. Laboring wasn’t fun anymore, it was harder work and I had to focus, but I was still calm and relaxed. My midwife leaned against the side of the tub and talked me through contractions, Rob poured warm water down my back with each one and I focused on the sensation of water going down. It was just an hour until I began feeling the urge to push.

 

I don’t know if it’s because of my past abuse, or if it’s common to become fearful during the pushing phase of labor, but I suddenly became panicked. I was thrashing around the tub crying, “Help me!” splashing everywhere. I tried to get up and leave. I was holding back against the pushes, trying to escape my own urges. I will be forever thankful for what came next. My midwife grabbed my arms and looked right into my eyes saying, “Hold it together. Your body is strong, and you can do this. You need to hold it together and your baby will be here.” I started to sob in her arms, “I need to you help me. Help me please.” My heart was breaking because I was so afraid of what I would think of myself if I couldn’t push my baby out on my own. “Moan low. And push into the pain. Push your baby through the pain.” Ten minutes later my beautiful daughter was born into the water and placed on my chest. I rested there with her, relief and joy in my heart. She barely even cried, she just nestled in to me. Rob beamed with pride. We had overcome the obstacles and done it.

 

The next morning the second midwife from the practice came to visit me to see how my birth had gone. I told her how it had been so peaceful except the end. But I had managed to keep it together and go naturally. Besides my pride in my accomplishment, her words built me up: “You are powerful. You birthed a baby. You can do anything.” That was truth.

 

I took that confidence and power home with me from the hospital. Unlike after my first birth, I suffered no post-partum depression. I started to trust my instincts more. I began to be more open-hearted to Rob and my daughters. I don’t want to pretend that one event changed my whole life, but in some ways it did. My natural birth experience was the first time someone other than my husband trusted and respected my body. I was expected to be powerful, and I was! My daughter’s birth was a foundation of confidence that I can build my strength upon. It can’t be taken from me.

 

Devona Brazier is a wife and mother of three lovely daughters living in Akron, OH. She works to support pregnant and breastfeeding women through La Leche League membership and studying to her Lamaze Educator Certification. She enjoys kickboxing, running, hiking and sewing. She blogs at tobravebirth.com

Pregnancy, Birth & Postpartum Resolutions

New Year’s resolutions may take on more meaning if you’re preparing for the birth of a child in 2013. This year, perhaps for the first time, “join the gym and lose 10 pounds” isn’t on the list. At the same time, many of the resolutions you make for a healthy pregnancy look a lot like those you would make for a healthy lifestyle, pregnant or not. For example:

  • eat fruit and vegetables daily
  • get 8 hours of sleep
  • exercise 30 minutes a day
  • carve out time for yourself
  • ask for help when you need it

For a healthy pregnancy, birth, and postpartum period, we’ve compiled a few significant resolutions for you to consider adding to your list this year.

 

Pregnancy

Listen to your body. If it’s telling you to slow down, do all that you can to make it happen. Cereal for dinner? Why not. Nap at 6 p.m.? Yep. On the other hand, if you’re feeling great, don’t let pregnancy slow you down — continue your exercise regimen, meet up with friends for dinner, enjoy life!

Learn about evidence-based maternity care. You can’t always count on your care provider to give you the best, most up-t0-date care. How will you know if you’re not receiving the best care? Learn how to navigate the maternity care system and how you can get the best care.

 

Labor & Birth

Plan for the best support. Who will attend your birth? Do they support your wishes? Will they provide positive energy? Think carefully about your birth support team. Look into hiring a doula. Share your birth plan with everyone well before labor begins.

Take labor one step at a time. Humans seem to be hardwired to think about what’s going to happen next. With labor, it helps to only think about what’s happening now. If you can take each contraction, each stage, each moment as it’s happening, you’ll be better able to put complete focus on the task at hand instead of worrying about what’s to come.

 

Postpartum

Speak up. It’s wonderful to have friends and family ooo and ahh at your new little joy. But a house full of visitors can be overwhelming during a time when you’re trying to understand a brand new world. Feel free to ask for some time and space alone with your baby. Post visiting hours on your front door or update your Facebook status to let friends know when you’re accepting visitors.

Know the signs of postpartum depression/disorders. Postpartum mood disorders (anxiety, depression, OCD, psychosis) affect hundreds of thousands of women every year. With knowledge of the warning signs and access to resources, women who suffer from postpartum mood disorders can and do recover.

Maternal Mental Health: Pre-Existing Risk Factors for PTSD and Childbirth

In light of the horrific and tragic events that took place at Sandy Hook Elementary School last Friday, Giving Birth with Confidence will be dedicating our posts this week to providing resources relating to mental health and wellness. Approximately 1.3 million women annually suffer from mental health disorders that occur during pregnancy and in the postpartum period. Perinatal and postpartum anxiety and mood disorders far outweigh the annual occurrence of several other major diseases combined. The key to finding help and treating mental health disorders is awareness; the more people who know how to spot warning signs and what to do to find help, the greater our possibility for better health.

 

 

This article is part of the Traumatic Birth Prevention & Resource Guide by PATTCh. Access the complete guide to learn more about traumatic birth and find resources for women and families.

By Heidi Koss, MA, LMHC

Health care providers aren’t exactly sure why some people get post-traumatic stress disorder (PTSD) when exposed to a traumatic event while others do not. Post-traumatic stress disorder can develop when you go through, see or learn about an event that causes intense fear, helplessness or horror. Any trauma, including birth trauma, lies in the eye of the beholder. What one may perceive as traumatic might not be traumatic to others.

As with most mental health problems, PTSD is probably caused by a complex mix of:

  • Your inherited mental health risks, such as an increased risk of anxiety and depression
  • Your life experiences, including the amount and severity of trauma you’ve gone through since early childhood. PTSD can result from a cumulative effect of multiple traumas over a lifetime.
  • The inherited aspects of your personality — often called your temperament
  • The way your brain regulates the chemicals and hormones your body releases in response to stress

General Risk factors for Post-Traumatic Stress Disorder
People of all ages can have post-traumatic stress disorder. However, some factors increase risk of developing PTSD after a traumatic event, including:

  • Being female — women may be at increased risk of PTSD because they are more likely to experience the kinds of trauma that can trigger the condition.
  • Experiencing intense or long-lasting trauma
  • Having experienced other trauma earlier in life
  • Having other mental health problems, such as anxiety or depression
  • Lacking a good support system of family and friends
  • Having first-degree relatives with mental health problems, including PTSD and depression
  • History of abuse (such as childhood abuse, sexual abuse, rape)
  • Combat exposure
  • Physical attack
  • Being threatened with a weapon
  • Car accident, plane or train crash
  • Life threatening experience (such as natural disaster, critical injury, medical crisis, attack, mugging)

These symptoms should alert you to possible PTSD:

  • Flashbacks of the event — vivid and sudden memories
  • Nightmares
  • Insomnia
  • Fears of recurrence
  • Emotional numbing
  • Panic attacks
  • Inability to recall important aspects of the event — psychogenic amnesia
  • Exaggerated startle response, hyper-arousal, always on guard
  • Hyper-vigilance, constantly looking around for trouble or stressors
  • Avoidance of reminders of the traumatic event
  • Intense psychological stress at exposure to events that resemble the traumatic event

How is PTSD different than other Pregnancy and Postpartum Mood Disorders?
Sometimes perinatal mood disorders overlap and it’s hard to tell where one ends and the other begins. PTSD is caused by an event in which you feel threatened, violated, and feel as if you could die. By the way our brain has processed the memory of the event, is causes heightened anxiety, hypervigilance, flashbacks, nightmares, etc. Therefore PTSD is an anxiety or stress reaction and it is different from other postpartum mood disorders such as depression and anxiety. However, other postpartum mood disorders can occur at the same time PTSD.

Resources
Recommended Books:

  • Postpartum Mood and Anxiety Disorders, A Clinician’s Guide, by Cheryl Tatano Beck and Jeanne Watson Driscoll
  • Beyond the Birth, A Family’s Guide to Postpartum Mood Disorders, by Juliana Nason, Patricia Spach and Anna Gruen. Published by Postpartum Support International of WA
  • When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women, by Penny Simkin and Phyllis Klaus

Useful Organizations & Websites:

Heidi Koss, MA, LMHCA is a psychotherapist in private practice in Redmond, WA specializing in pregnancy and postpartum mood disorders (PPMD), birth trauma, and parent adjustment issues. She has been the Executive Director of Postpartum Support International of Washington (PSI of WA), WA State Coordinator for Postpartum Support International as well as co-founder of the Northwest Association for Postpartum Support (NAPS). She offers consultant services and PPMD trainings. Heidi has also been a postpartum doula and certified lactation educator. Heidi is the proud mother of two beautiful daughters.

 

 

 

PATTCh is a not-for-profit, multidisciplinary organization dedicated to the prevention and treatment of traumatic childbirth. Our mission is to develop cross-disciplinary relationships, research, and programs that:

  • prevent PTSD following childbirth through education, interdisciplinary collaboration, and multidisciplinary research;
  • educate perinatal care providers and paraprofessionals in the prevention and treatment of birth and reproduction related trauma;
  • encourage the development of culturally appropriate therapeutic approaches to post-traumatic stress symptoms following childbirth;
  • promote healthy birth practices for all women and families;
  • promote evidence-based research regarding PTSD secondary to childbirth;
  • increase global awareness of the prevalence, risk factors, and effects of PTSD secondary to childbirth; and
  • support collaboration and understanding among all stake-holders, including: researchers, policy makers, medical and mental health care providers, educators, community members, volunteers, women, and families.

 

A Voice of Strength I Didn’t Know I Possessed: Part II of An Interview with Ivy Shih Leung

A Voice of Strength I Didn’t Know I Possessed: An Interview with Ivy Shih Leung, author of “One Mom’s Journey to Motherhood: Infertility, Childbirth Complications, and Postpartum Depression, Oh My!”

 

In this second part of my interview with Ivy, she shares insight into her Chinese culture and pregnancy and postpartum. Secondly, she delves into her experience with infertility and complications during pregnancy. Finally, Ivy shares wonderful thoughts as to how writing, blogging, and communication can help to end stigma about PPD and create the causes for healing. You can read the first part of our interview here.

 

How has culture affected your writing about your experience?

I don’t feel that my culture really affected my writing about my PPD experience.  Though, I have to say that I am one of the few Asian bloggers I’m aware of.  Unlike most of my Asian friends and acquaintances, I am very outspoken and opinionated.  The Chinese tend to keep their emotions bottled up and thoughts and experiences to themselves.  In general, they are a very proud people.  Everything is pretty much about “saving face,” which means not putting oneself out there when it comes to personal experiences, especially if there is anything in the least bit negative.  As we know from the Western culture, pregnancy and motherhood are supposed to be blissful experiences.  I, on the other hand, have a book that shares ALL my thoughts and experiences while suffering from PPD.  It’s a fairly big deal for any woman to share her PPD story, let alone publish a book about it.  It’s an even bigger deal for a Chinese woman to do either.  

 

What would you like mainstream culture to know about your culture regarding pregnancy and postpartum?

Although I am Chinese and even speak Mandarin fluently, I was born and raised here in the U.S.  As a result, I am very Westernized and do not observe many of the traditions my parents and the generations before them may have observed.  Actually, my mother gave birth here and was not privy to the custom of Zou Yue.  She gave birth in a foreign country with no loved ones around her.  She received less help with taking care of me when I was a newborn than I had when I had my own daughter.  At least when I had my daughter, my husband helped, and my mother and mother-in-law each stayed a week to help. 

Zou Yue is like some of the other mother-nurturing customs observed by other cultures (la cuarentena in Mexico, sarantisma in Greece, Jaappa in India) in terms of observing a 30 or 40 day period of taking care of the mother, so she can take care of her baby and get adequate sleep to recover from childbirth.  Forty seems to be a magical number, a number that has survived through the centuries and therefore has special significance….no doubt it has something to do with the fact that 40 days is the average length of time for a new mother’s body to recover from childbirth and return to a pre-pregnant state.  It’s also why an OB/GYN will tell the new mother, once she’s given birth, that he will see her in 6 weeks.  Each of these traditions involves female family members and friends of the new mother providing her and her baby with care, so that the new mother’s only focus is on getting rest and bonding with/feeding her baby.  They also help around the house and prepare meals.  Certain rituals are observed in which food is prepared a certain way to help keep her body/system warm. She is protected from feeling overwhelmed; hence, visitors are kept away (or kept at a very minimum) during this time. She is told to avoid bathing for fear of catching cold.  All these rituals have the mother’s well-being in mind.  In terms of breastfeeding, female family members are on hand to teach her how to do it. In these other cultures, there is no expectation that the new mother know how to breastfeed instinctively and easily.  There is a reason behind the phrase “it takes a village.”

I have blogged about the importance of social support and how, through the years, we seem to have lost perspective on things when it comes to the community coming together to help a new mother who has just had a baby.   Getting adequate social support—comprised of both emotional support (e.g., shoulder to cry on, listening non-judgmentally) and practical support (e.g., help with breastfeeding, cleaning, errands, laundry, taking care of the baby for a few hours so mom can take a nap or shower) is critical for new moms. Having enough support during the first 4-6 weeks—until a new mom’s body recovers from childbirth and her hormone levels return to their pre-pregnancy state—can help keep anxiety levels down, help her get the rest she needs from all the changes her body has gone through with childbirth.

 

When you were pregnant, how was your culture addressed by care providers in ways that were helpful? And what about during your recovery from PPD?

I don’t remember if my OB/GYN and hospital staff asked me any questions, either orally or via a written questionnaire, as to whether I had any cultural preferences that needed to be taken into consideration during or after childbirth.  There definitely was no attempt on the part of my OB/GYN to ask me if I had any preferences for the duration of my pregnancy.  Fortunately, I didn’t have any preferences, anyway.  I just wanted to be treated with respect and care, both of which my doctor ended up failing at. Now, in terms of the GP who treated me during my PPD, he was the ultimate example of a doctor with extremely poor bedside manner.  The way I was treated by him and my OB/GYN angered me so much that I wrote them both letters during my recovery from PPD, telling them that their treatment of me aggravated my already extremely painful experience, they should get with the program when it comes to PPD, and I was dropping them and moving on to doctors who didn’t lack bedside manner the way they did.

 

Infertility and Complications

Can you share a little about your experiences with both?

Without getting into the details as covered in my book about my infertility experience and childbirth complications, I’ll just say that, like more and more women these days, I got married late (at age 36 ), had a dermoid cyst removed a year later to increase the likelihood of getting pregnant and not having it get in the way of a developing fetus, tried to conceive naturally for over a year before being referred to an IVF center where we failed our first cycle (it was such less than optimal experience mostly because the staff and environmental overall were cold and disorganized), and got pregnant successfully via my 2nd IVF cycle at a different center.  What started off as 2 fetuses became only one after a car accident I had about 2 months into the pregnancy.  Other than nausea that lasted my entire pregnancy, some spotting, and overall anxiety that I would carry to term, my pregnancy went well.  I delivered vaginally (with an epidural and episiotomy), but ended up having my uterus removed 3 days afterwards due to placenta accreta.  During my entire 7-day stay, I was constantly woken up for blood work and extremely exhausted as a result.  On top of that, I was starved for nearly the whole time I was there.  Due to my surgical procedure, I was kept in an entirely different wing from my daughter for over a day, and whenever I called for a nurse, no one came.  Some nurses were not nice to me at all.  It was like a living hell for me most of the time I was in the hospital.  To get the full details of my infertility, childbirth complications, and PPD experiences, you can read my book. 

 

How can your experience help the readers of Giving Birth with Confidence?

My hope is that those who read about my experience in my book—which covers a lot, including key statistics and information on the biopsychosocial factors behind PPD (infertility and childbirth complications are risk factors)—will become more knowledgeable about perinatal mood disorders.  I hope that they will also read the growing numbers of blogs of mothers who are speaking up about their struggles with perinatal mood disorders.  Why?  Well, knowledge is power.  With more knowledge, there would be less ignorance and stigma, and motherhood myths will have less of a negative impact on mothers than they do today. I want to see fewer mothers being caught off guard and not knowing what is happening to them, should PPD strike.  Being ignorant and unprepared for it causes unnecessary fear, anxiety, guilt, and inability to appreciate one’s baby. For example, insomnia after the third week postpartum is a common first symptom of PPD. 

My blog is hit numerous times each day via Google and other search engines using words like “postpartum insomnia,” “new mom insomnia,” “insomnia four weeks after childbirth,” “can’t sleep when the baby sleeps,” “can’t sleep six weeks postpartum,” and so on, which means that there are many moms out there who are going through what I went through, in terms of insomnia as a symptom of PPD, beginning at around 40 days.  That’s right, there’s that magical number again!  Had I known about PPD before my daughter was born, I would not have been as scared as I was as to why I had insomnia and couldn’t sleep even though I was exhausted beyond words and even during the times she slept. My fear would not have escalated to full-blown anxiety attacks. I would’ve recognized other symptoms like loss of appetite (I lost so much weight so fast that within a couple of weeks I weighed less than I did before I got pregnant!). As soon as I started to have insomnia, instead of merely taking the Ambien prescribed to me by my OB/GYN, I would’ve immediately known to question it as a sign of PPD and gotten the right treatment then.  As they say, hindsight is 20/20….

 

I would like to thank Ivy for her wonderful work and sharing her experiences and knowledge with Giving Birth with Confidence. To learn more about Ivy, visit her blog at http://ivysppdblog.wordpress.com/.

Treatment Options for Trauma Survivors with PTSD

 

This article is part of the Traumatic Birth Prevention & Resource Guide by PATTCh. Access the complete guide to learn more about traumatic birth and find resources for women and families.

By Kathleen Kendall-Tackett, PhD, IBCLC, FAPA

Traumatic events can have a long-term impact on both your mental health and the overall quality of your life. Fortunately, you have a wide range of possible treatment options available to you. Comprehensive trauma treatment involves patient education, peer support, trauma-focused psychotherapy, and medications.

Education and Peer Counseling

The role of both patient education and peer counseling is to help you understand your experiences and reactions after trauma. Education and support lets you know that your reactions are both normal and predictable, and your symptoms are not your fault (Friedman, 2001; Kendall-Tackett, 2010).

Trauma-focused Psychotherapy

The two most effective therapies for PTSD and trauma symptoms are cognitive behavioral therapy and EMDR.

  • Cognitive-Behavioral Therapy (CBT) – CBT includes several modalities, including cognitive therapy, exposure therapy, and stress-inoculation therapy. All types of therapy address beliefs caused by trauma (e.g., that you are helpless) and also helps counter conditioned-fear responses. If treatment has been successful, you will be able to confront your traumatic past without triggering PTSD symptoms (Friedman, Cohen, Foa, & Keane, 2009).
  • Eye Movement Desensitization and Reprocessing (EMDR) – EMDR is highly effective and considered a frontline treatment for PTSD. In EMDR, you are instructed to think about your traumatic experience while moving your eyes back and forth following the therapist’s fingers as they briefly move across your field of vision (Friedman, 2001; Friedman, et al., 2009; van der Kolk, 2002). It is based on the hypothesis that saccadic eye movements can reprogram the brain, and therefore can be used to help alleviate the emotional impact of trauma (Friedman, et al., 2009). EMDR reduces symptoms after just a few sessions. Certified practitioners of EMDR can be found at the EMDR Institute or the EMDR International Association .

Medications

There are several classes of medications that can be used to treat PTSD.

  • Antidepressants – Antidepressants are a key part of treatment for PTSD. The Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin/Norepinephrine Reuptake Inhibitors (SNRIs) are frontline medication choices in that they treat all types of PTSD symptoms, and include medications like Zoloft, Paxil, Lexapro, Prozac, and Effexor (International Society for Traumatic Stress Studies, 2009).
  • Adrenergic Agents and Atypical Antipsychotics – Other medications that may be added if the SSRIs/SNRIs and/or psychotherapy are not bringing you sufficient relief of symptoms. These include adrenergic agents and atypical antipsychotics.  These can be helpful for symptoms such as nightmares and intrusive thoughts (International Society for Traumatic Stress Studies, 2009).
  • Benzodiazepines – In the past, trauma survivors were often been prescribed benzodiazepines, such as Valium, to help them cope their trauma symptoms. These medications are no longer considered appropriate for patients with trauma because they can make depression worse, and are also addictive (International Society for Traumatic Stress Studies, 2009).

For information on all of these types of medications that can be safely used while you are pregnant or breastfeeding, visit the InfantRisk Center Website.

Summary

If you have experienced trauma, you do not need to continue to suffer in silence. You have many treatment options. And in most cases, these treatments can be safely used while you are pregnant or breastfeeding. For more information, visit the National Center for PTSD, or the International Society for Traumatic Stress Studies.

References

Friedman, M. J. (2001). Posttraumatic stress disorder: The latest assessment and treatment strategies. Kansas City, MO: Compact Clinicals.

Friedman, M. J., Cohen, J. A., Foa, E. B., & Keane, T. M. (2009). Integration and summary. In E. B. Foa, T. M. Keane, M. J. Friedman & J. A. Cohen (Eds.), Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies (pp. 617-642). New York: Guilford.

International Society for Traumatic Stress Studies (Ed.). (2009). Effective Treatments for PTSD: Psychopharmacology for adults (Guideline 6). New York: Guilford.

Kendall-Tackett, K. A. (2010). Depression in new mothers: Causes, consequences and treatment options, 2nd Edition. London: Routledge.

van der Kolk, B. A. (2002). Assessment and treatment of complex PTSD. In R. Yehuda (Ed.), Treating trauma survivors with PTSD (pp. 127-156). Washington, DC: American Psychiatric Association Press.

 

Kathleen Kendall-Tackett, PhD, IBCLC, is a health psychologist and board-certified lactation consultant. Dr. Kendall-Tackett is a Fellow of the American Psychological Association in both health and trauma psychology, and is a clinical associate professor of pediatrics at Texas Tech University School of Medicine in Amarillo, Texas. She is the owner of Praeclarus Press, a small press focusing on women’s health and is editor-in-chief of the journal Clinical LactationDr. Kendall-Tackett also can be found at Uppity Science ChickBreastfeeding Made Simple, and www.facebook.com/kathleen.kendalltackett. She is a board member of PATTCh.

 

 

 

PATTCh is a not-for-profit, multidisciplinary organization dedicated to the prevention and treatment of traumatic childbirth. Our mission is to develop cross-disciplinary relationships, research, and programs that:

  • prevent PTSD following childbirth through education, interdisciplinary collaboration, and multidisciplinary research;
  • educate perinatal care providers and paraprofessionals in the prevention and treatment of birth and reproduction related trauma;
  • encourage the development of culturally appropriate therapeutic approaches to post-traumatic stress symptoms following childbirth;
  • promote healthy birth practices for all women and families;
  • promote evidence-based research regarding PTSD secondary to childbirth;
  • increase global awareness of the prevalence, risk factors, and effects of PTSD secondary to childbirth; and
  • support collaboration and understanding among all stake-holders, including: researchers, policy makers, medical and mental health care providers, educators, community members, volunteers, women, and families.

 

10 Questions for a Partner of PTSD Survivor

 

This article is part of the Traumatic Birth Prevention & Resource Guide by PATTCh. Access the complete guide to learn more about traumatic birth and find resources for women and families.

By Walker Karraa, MFA, MA, CD(DONA), President PATTCh

This is an interview I did with my husband, Tony. His perspective on the events of my traumatic birth and subsequent PTSD speak to the impact of these issues on partners, but is not a statement of suggested treatment. It is an honest snapshot of a partner’s experience of birth trauma and his partner’s PTSD, hopefully shedding light on recovery from traumatic birth and reclaiming life post trauma.

 

Were you aware of the PTSD in my birth?

I think that my first clue that something was beginning to happen was during labor. It was specifically during transition that I noticed a slow but clear change in your presence. It appeared as though you began to dissociate from not only me but the world, as if your body had been left behind to experience the rest of the experience without you. It changed after we were home with the baby but for me, that was the moment it began.

 

When did you realize something was wrong?

I knew something was wrong right away. But I didn’t realize the extent of the problem. I kept thinking it would get better. But instead it got worse. I didn’t know where mild baby blues ended and where postpartum depression began. Nor did I have any information on how to get help.

 

What was that experience like for you?

Extraordinarily frightening. I didn’t know what was happening during labor. We were so connected as a couple and it began to shift in a way that was very scary. Once the full force of the PPD began to level itself in our lives in the first few weeks of being home with the baby, I felt confused and helpless and I was experiencing extreme anxiety. When you passed out from lack of sleep and fell to the floor behind me as I was holding the baby, my anxiety changed to terror.

 

What would you do differently now that you know about postpartum depression?

I would have reached out immediately to health care professionals for help. I would have encouraged formula feeding and weaning of breastfeeding right away to facilitate more ease of movement for you to be away from the baby for treatment or even just a break. I would have encouraged proper prescribed medication under the guidance of a psychiatrist to begin to ease the terrible burdens of the disease. It is so difficult to remember how helpless I felt and how under the influence I was of all the media hype about breastfeeding and bonding. That really affected my ability to act

 

What surprised you about my PTSD and postpartum depression?

The insomnia. I was used to seeing depression and how it affected your daily life due to your chronic condition, but the affects of the insomnia were devastating.

 

What scared you the most?

The scariest thing was the constant fear that you may try to hurt yourself.

 

What advice would you give a partner?

To act quickly. To know that no matter what the level of depression, anxiety or insomnia your partner is experiencing, they should be seen by a health care professional and there are lots of options.

 

What do you think women need most if they have PTSD following birth?

They need people in their lives who are willing to acknowledge it for what it is and are willing to be there with them no matter how scary it is.  They also need good professional medical care as quickly as possible. Whether it is therapy or medication, they need to be under the care of a professional. They also need to know that they are not permanently damaging their baby and that they can take time away during the day or night, whenever possible, for a break.

 

How did you see the interaction with our son?

I was worried about him a lot at first.  Not just because of your depression but also because of my own stress and anxiety. I was very afraid that it would affect him adversely. But having watched him grow and mature over the last ten years, I am completely convinced that having the treatment that you finally did receive, starting around his third month of life was an invaluable change in the dynamic between the three of us. It was not all smooth sailing after that but it continued to improve because of it. I shudder to think of what might of happen, had you not found and accepted the treatments of the wonderful therapist and psychiatrists that first saw you.

 

How did you see the interaction with our son?

I was worried about him a lot at first.  Not just because of your depression but also because of my own stress and anxiety. I was very afraid that it would affect him adversely. But having watched him grow and mature over the last ten years, I am completely convinced that having the treatment that you finally did receive, starting around his third month of life, was an invaluable change in the dynamic between the three of us. It was not all smooth sailing after that but it continued to improve because of it. I shudder to think of what might have happened, had you not found and accepted the treatments of the wonderful therapist and psychiatrists that first saw you.

 

How did the next pregnancy and birth of our daughter differ?

Everything was different, but for me, the most notable difference was choosing to be open to bottle feed with formula from the start. That gave you a much greater sense of freedom. You were able to be away without the constant fear that the baby would starve without you. I can’t recommend that enough to other parents. I know it goes against the conventional wisdom of the day regarding breastfeeding. But in my humble opinion (which is grounded in personal experience) they are flat out wrong. Our daughter is attached, loving, kind, deeply in touch with emotions and easily able to connect to others. Not to mention she is flipping brilliant (state test score fact…not merely a parental opinion) and she was bottle fed from infancy.  And once you were diagnosed with breast cancer when she was only 7 months old, we were able to transition her so easily. You just never know what is going to happen—and having that option saved our lives.

__________________________________________________________________________________________

Final Thoughts

Trauma impacts everyone, and the experience of trauma subjective — in the eye of the beholder, the person experiencing an event as traumatic. This is true for partners and care providers as well.  The perception of sudden, life-threatening circumstances by partners in the birth room merit deeper understanding. Neurological dynamics, and biological responses to trauma perception are on the forefront of much of the trauma research today. And champions in the field are asking the important questions about the effect of birth trauma on partners. And PATTCh will continue to promote ongoing discussions, symposia, and opportunities to share this research. We have a lot to learn.

Preventing the occurence of traumatic birth experiences, through consideration of risk factors for both parents is key. Partners in the military, law enforcement, with a history of trauma or interpersonal violence deserve to be considered with respect in the birth room, and birth process. Support in both information from qualified professional, and instrumental support during birth and at home during postpartum period are necessary for partners to understand the normal range of emotions and what to do if they or their partner experience symptoms of distress beyond that range.

More information on PTSD can be found on the PATTCh Resource Support page.

Disclaimer: Tony’s experience, and feelings regarding treatment, and bottle/formula feeding are his, and should not be misunderstood to be those of the Board of PATTCh.

 

Walker Karraa is  a doctoral student at the Institute of Transpersonal Psychology. She is a birth doula, maternal mental health advocate, and researcher. She currently writes for the Lamaze research blog, Science and Sensibility. She presents at conferences, trainings, and organizational retreats pertaining to perinatal psychology, postpartum mood disorders, childbirth education, and labor support. Walker also is the President of PATTCh, a not-for-profit dedicated to the prevention and treatment of traumatic childbirth.

 

 

PATTCh is a not-for-profit, multidisciplinary organization dedicated to the prevention and treatment of traumatic childbirth. Our mission is to develop cross-disciplinary relationships, research, and programs that:

  • prevent PTSD following childbirth through education, interdisciplinary collaboration, and multidisciplinary research;
  • educate perinatal care providers and paraprofessionals in the prevention and treatment of birth and reproduction related trauma;
  • encourage the development of culturally appropriate therapeutic approaches to post-traumatic stress symptoms following childbirth;
  • promote healthy birth practices for all women and families;
  • promote evidence-based research regarding PTSD secondary to childbirth;
  • increase global awareness of the prevalence, risk factors, and effects of PTSD secondary to childbirth; and
  • support collaboration and understanding among all stake-holders, including: researchers, policy makers, medical and mental health care providers, educators, community members, volunteers, women, and families.

 

Breastfeeding After Traumatic Birth

 

This article is part of the Traumatic Birth Prevention & Resource Guide by PATTCh. Access the complete guide to learn more about traumatic birth and find resources for women and families.

By Teri Shilling, MS, LCCE, CD(DONA), IBCLC

The image of a baby’s arrival into the world often shows a calm, romanticized picture of a beautiful baby being gently lifted into the waiting arms of the baby’s mother, followed by the mother putting the baby skin to skin, leaning triumphantly back while releasing a relieved sigh in the spirit of “I did it.” The baby is then supported in doing its dance to bop and wiggle to find the breast and latch on.

What if instead the journey has been fraught with challenges and struggles and separations or surgery? What if fears and trauma and suffering have colored the experience? What if the mother is overwhelmed or not supported or unable to deal with anything other than the basic survival of the experience? What happens then to early breastfeeding?

Cheryl Beck and Sue Watson (2008) in their research on the impact of birth trauma on breastfeeding, cited that over a third of all mothers have reported experiencing a traumatic birth. The breastfeeding research lists challenges to early and successful breastfeeding as unscheduled cesarean birth, psychosocial stress, and pain related to labor and birth. Other influences include loss of control, exceptionally long labors and dissatisfaction with care and support.

By closely looking at the impact of birth trauma on breastfeeding, there seems to be two paths — on one path women persevered and on the other path, breastfeeding is curtailed. What allows a woman to take the path toward a fulfilling breastfeeding experience? Beck and Watson (2008) identified three themes:

  • sheer determination
  • a motivation to make up for a baby’s less than optimal arrival or
  • the time spent breastfeeding was soothing

The path that led to less than the desired length of breastfeeding was influenced by:

  • a fear that breastfeeding was just one more way to fail
  • no emotional or pain-coping reserves were left to cope with possible breastfeeding pain and discomforts after the overwhelming physical pain of birth
  • a feeling that the traumatic birth created an insufficient supply of breast milk
  • flashbacks that intruded on the breastfeeding experience
  • a feeling of detachment from the baby created by the birth trauma

So what guidance is there for the women who have had a traumatic birth who want to follow their own path to a fulfilling breastfeeding experience?

  • Seek intensive one-on-one support to establish breastfeeding. Set short-term goals. Discuss options like pumping or substituting skin-to-skin time for breastfeeding or supplementing early feeding with donor milk.
  • Find respectful support. Often it’s preferable to find help from someone who can provide support and assistance while verbally guiding you and building your confidence vs. someone who grabs your breast and pushes the baby on for the sake of efficiency.
  • Locate non-judgmental help from someone who will support you in your choice to continue or stop breastfeeding without guilt or judgment.  This person should be someone who can listen to your birth experience and knows the symptoms of traumatic stress and knows to whom to refer you to for dealing with these feelings and reactions to a traumatic birth.

Find the support and resources to follow your path to feed your baby!

Reference

Beck, C.T., & Watson, S. (2008). Impact of birth trauma on breast-feeding. Nursing Research 57(4), 228-36.

 

Teri Shilling, MS, LCCE, CD(DONA), IBCLC is the director of Passion for Birth, the largest Lamaze accredited childbirth educator training program, creator of the Idea Box for Creative and Interactive Childbirth Educator, and instructor at the Simkin Center for Allied Birth Vocations at Bastyr University.  A past president of Lamaze International, she now focuses her volunteer work with PATTCh, Skagit Valley Breastfeeding Coalition and W.I.S.E. Birth (a 3 county Doula Collective.) She has a small private practice providing doula support, lactation support and birth education in her Mount Vernon, WA, community.


 

 

PATTCh is a not-for-profit, multidisciplinary organization dedicated to the prevention and treatment of traumatic childbirth. Our mission is to develop cross-disciplinary relationships, research, and programs that:

  • prevent PTSD following childbirth through education, interdisciplinary collaboration, and multidisciplinary research;
  • educate perinatal care providers and paraprofessionals in the prevention and treatment of birth and reproduction related trauma;
  • encourage the development of culturally appropriate therapeutic approaches to post-traumatic stress symptoms following childbirth;
  • promote healthy birth practices for all women and families;
  • promote evidence-based research regarding PTSD secondary to childbirth;
  • increase global awareness of the prevalence, risk factors, and effects of PTSD secondary to childbirth; and
  • support collaboration and understanding among all stake-holders, including: researchers, policy makers, medical and mental health care providers, educators, community members, volunteers, women, and families.

 

Pre-Existing Risk Factors for PTSD and Childbirth

 

This article is part of the Traumatic Birth Prevention & Resource Guide by PATTCh. Access the complete guide to learn more about traumatic birth and find resources for women and families.

By Heidi Koss, MA, LMHC

Health care providers aren’t exactly sure why some people get post-traumatic stress disorder (PTSD) when exposed to a traumatic event while others do not. Post-traumatic stress disorder can develop when you go through, see or learn about an event that causes intense fear, helplessness or horror. Any trauma, including birth trauma, lies in the eye of the beholder. What one may perceive as traumatic might not be traumatic to others.

As with most mental health problems, PTSD is probably caused by a complex mix of:

  • Your inherited mental health risks, such as an increased risk of anxiety and depression
  • Your life experiences, including the amount and severity of trauma you’ve gone through since early childhood. PTSD can result from a cumulative effect of multiple traumas over a lifetime.
  • The inherited aspects of your personality — often called your temperament
  • The way your brain regulates the chemicals and hormones your body releases in response to stress

General Risk factors for Post-Traumatic Stress Disorder
People of all ages can have post-traumatic stress disorder. However, some factors increase risk of developing PTSD after a traumatic event, including:

  • Being female — women may be at increased risk of PTSD because they are more likely to experience the kinds of trauma that can trigger the condition.
  • Experiencing intense or long-lasting trauma
  • Having experienced other trauma earlier in life
  • Having other mental health problems, such as anxiety or depression
  • Lacking a good support system of family and friends
  • Having first-degree relatives with mental health problems, including PTSD and depression
  • History of abuse (such as childhood abuse, sexual abuse, rape)
  • Combat exposure
  • Physical attack
  • Being threatened with a weapon
  • Car accident, plane or train crash
  • Life threatening experience (such as natural disaster, critical injury, medical crisis, attack, mugging)

These symptoms should alert you to possible PTSD:

  • Flashbacks of the event — vivid and sudden memories
  • Nightmares
  • Insomnia
  • Fears of recurrence
  • Emotional numbing
  • Panic attacks
  • Inability to recall important aspects of the event — psychogenic amnesia
  • Exaggerated startle response, hyper-arousal, always on guard
  • Hyper-vigilance, constantly looking around for trouble or stressors
  • Avoidance of reminders of the traumatic event
  • Intense psychological stress at exposure to events that resemble the traumatic event

How is PTSD different than other Pregnancy and Postpartum Mood Disorders?
Sometimes perinatal mood disorders overlap and it’s hard to tell where one ends and the other begins. PTSD is caused by an event in which you feel threatened, violated, and feel as if you could die. By the way our brain has processed the memory of the event, is causes heightened anxiety, hypervigilance, flashbacks, nightmares, etc. Therefore PTSD is an anxiety or stress reaction and it is different from other postpartum mood disorders such as depression and anxiety. However, other postpartum mood disorders can occur at the same time PTSD.

Resources
Recommended Books:

  • Postpartum Mood and Anxiety Disorders, A Clinician’s Guide, by Cheryl Tatano Beck and Jeanne Watson Driscoll
  • Beyond the Birth, A Family’s Guide to Postpartum Mood Disorders, by Juliana Nason, Patricia Spach and Anna Gruen. Published by Postpartum Support International of WA
  • When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women, by Penny Simkin and Phyllis Klaus

Useful Organizations & Websites:

Heidi Koss, MA, LMHCA is a psychotherapist in private practice in Redmond, WA specializing in pregnancy and postpartum mood disorders (PPMD), birth trauma, and parent adjustment issues. She has been the Executive Director of Postpartum Support International of Washington (PSI of WA), WA State Coordinator for Postpartum Support International as well as co-founder of the Northwest Association for Postpartum Support (NAPS). She offers consultant services and PPMD trainings. Heidi has also been a postpartum doula and certified lactation educator. Heidi is the proud mother of two beautiful daughters.

 

 

 

PATTCh is a not-for-profit, multidisciplinary organization dedicated to the prevention and treatment of traumatic childbirth. Our mission is to develop cross-disciplinary relationships, research, and programs that:

  • prevent PTSD following childbirth through education, interdisciplinary collaboration, and multidisciplinary research;
  • educate perinatal care providers and paraprofessionals in the prevention and treatment of birth and reproduction related trauma;
  • encourage the development of culturally appropriate therapeutic approaches to post-traumatic stress symptoms following childbirth;
  • promote healthy birth practices for all women and families;
  • promote evidence-based research regarding PTSD secondary to childbirth;
  • increase global awareness of the prevalence, risk factors, and effects of PTSD secondary to childbirth; and
  • support collaboration and understanding among all stake-holders, including: researchers, policy makers, medical and mental health care providers, educators, community members, volunteers, women, and families.