By Mara Acel-Green, LICSW
Listening will change worlds.
Is this just the promise of an idealistic social worker? In some ways I fit that stereotype. Shapeless dresses, check. Chunky jewelry, check. Optimist, check. But idealist? No, I shed that mantle long ago. I work with women who have perinatal emotional complications, so I no longer have the luxury of being an idealist. (Perinatal emotional complications are feelings and behaviors that cause mothers distress and interfere with their functioning, including depression and anxiety across a spectrum of severity; the spectrum includes normal pregnancy and postpartum adjustment and stress, as well as baby blues, depression, anxiety, and panic disorders.) I have to change worlds--mothers, babies, fathers, partners, grandparents, co-workers, and employers are relying on it. Before I went into social work, I was an idealist; I wanted to change the world. But as you might have noticed, the world is a big place; I quickly grew tired. However, throughout my training I was taken with the realization that changing one person's world would change the worlds of others around them, and I never looked back.
According to many sources, including the Women's Mental Health Center at Mass General Hospital, mood disorders are the most common complications of pregnancy, but they are treatable. I have heard my fair share about pregnancy, but I am pretty sure I never knew this until I started working in the perinatal field. Women are not routinely screened for mood disorders during pregnancy, despite the latest research that suggests that almost 20% of women experience depression and anxiety during pregnancy. That's one in five! We do not talk enough about the 12-20% of women who experience depression and anxiety in the postpartum period. We rarely talk about the almost 6% of women who will develop post-traumatic stress disorder as a result of their birth experiences. Unfortunately, we do often hear about the very small 0.1 - 0.2% of women with postpartum psychosis who make the headlines, scaring many other women into silence for fear that this could become them, too.
How can I be so sure that listening change lives? My certainty is rooted in my own professional life. I have had very few women walk into my office and tell me directly that they are depressed or anxious, even when it is clear to me that they are. I listen as women say things such as "my feelings come on like a mood flu," or "I think that when I push the baby out all of my organs are going to come out too and I am going to die," or "this baby is like a ship in a bottle -- I know how it got in there, but I am not sure how it is going to come out," or "every step is like walking in water." By the time women come to me they are often so uncomfortable that they fear that they are losing their minds. When mothers or expectant mothers do talk about how they are feeling, they often hear responses like "of course it's hard--you just had a baby," or "once you get some sleep it will all be better." While both of those statements have kernels of truth, in dismissing women's experiences we discourage them from sharing their feelings. If we listen, we hear exhaustion, fear, anxiety, and depression.
Given the staggering statistics for perinatal emotional complications, what can be done to tackle this issue as the serious public health issue it is? To start with, we must listen to women--not minimize, not pathologize, not ostracize, but listen. We must steer away from idealizing for women their product (the baby) and instead offer them real support through the process, which is an exhausting event, even when it is straightforward. We must not overlook that the same outcome can be experienced differently by different women, for in doing so we miss the opportunity to hear what it was like for them.
Maybe now you are persuaded that women's experiences can be changed by listening, but you may still be wondering how this changes worlds. Let me explain: for each woman who experiences perinatal emotional complications, there are ripples in her world affected by her compromised state, including babies, parents, partners, co-workers, siblings, and neighbors, to name a few. Each time we support women through their pregnancy and postpartum period, we improve their experience and improve the lives of all those they touch--most immediately their babies.
Fathers are also susceptible to postpartum depression. Studies suggest that for the 10% of men who experience depression connected with the birth of a child, one of the risk factors is that their female partner is experiencing a perinatal emotional complication. So when we listen closely to men talk about their partners, be sure to listen to hear if he is having trouble and reach out to give support. We know about underidentified and untreated male depression through the work of Terrance Real and others. Unfortunately, we do not yet have research studying same-sex partnerships, but it is reasonable to suggest that all families need people to listen closely as they journey through pregnancy and the first year postpartum. We must attend carefully to all non-birthing partners to hear if they are also struggling and are in need of support.
Health providers and other professionals who interact with pregnant and postpartum women have an especially important role to play in addressing perinatal emotional complications, but anyone can ask basic questions and then listen--really listen--to the answers! Here are just a few examples of the kinds of language you might hear from women with depression, anxiety, OCD, acute stress disorder, or PTSD associated with birth:
"I am so tired I am not sure I can keep doing this."
"The birth was nothing like I thought it was going to be."
"Sometimes I just want to leave and never come back."
"Sometimes I think my children would be better off without me given how angry I am all the time."
"I wanted to have children; I did this to myself."
"It seems like it is so much easier for everyone else."
"The other moms in the new mothers group do not seem to be having any difficulty. What's wrong with me?"
"Is it supposed to be this hard?"
If you recognize that a mother or pregnant woman is struggling, be sure to talk to her extended support network about what you see. Don't only tell her; she may feel guilty for having these feelings, and become even more overwhelmed. Tell her that an emotional complication is the most common complication of pregnancy and the postpartum period. Normalize it. If you have personal experience with pregnancy and postpartum complications (and statistically, many women do), share it; let her know that it was hard. Tell her that it is important to mention to her doctor, midwife, or pediatrician at her next visit. This allows these professionals, if they listen, to ask additional questions and do what they are trained to do in their visits. And if your friend/partner/child mentions that she needs to talk to a professional, cheer her on; for some women this step alone feels like admitting defeat. As one of the most popular blog posts on postpartumprogress.com, a popular site for discussions of postpartum depression and anxiety, stated, "Asking for help sucks!"
I recently got a call from a women who got my name from a listserv. She had requested the name of a therapist who specializes in postpartum anxiety and a former client of mine had reached out to her to share my name. The former client shared that with treatment she feels like herself again, that treatment "saved her life." We can all play a part in helping to guide women who are experiencing perinatal emotional complications to the services they need. So together let us go out and birth healthier families by listening and by encouraging women and their support people to talk to their birth team. Organizations like MotherWoman are creating perinatal support coalitions to ensure that communities can come together to help mothers who are experiencing perinatal emotional complications. For resources in your state, contact Postpartum International at 1-800-944-4PPD or postpartum.net.
Mara Acel-Green, LICSW, is a psychotherapist in Belmont, MA. In addition to her private practice and adjunct faculty position at Northeastern University, Mara is the President of the Board of Directors of Healthy Mothers, Healthy Babies of Massachusetts.
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