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Postpartum Depression

Is Postpartum Depression a Misnomer?

When mothers are themselves held, they can hold babies as nature requires

The human infant is uniquely helpless in the first weeks and months of life. His arms fly up over his head at random moments in a primitive “startle reflex.” His sleep patterns have no rhyme or reason. He eats and poops round the clock. All these behaviors are the result of an immature brain that, in the service of evolutionary adaptation, does 70% of its growing outside the womb.

With bipedal and upright anatomy, the fully developed human brain could not fit through the already narrow birth canal. Anthropologist Holly Dunsworth has recently proposed alternative evolutionary explanations. At nine months gestation the metabolic demands on the mother become too great. Because we are cultural creatures, maximum brain growth within that culturally rich environment allows for optimal development.

For a new human parent, this helplessness may translate to no sleep, no showers, no ability to do anything but care for the baby. Harvey Karp has referred to this time period as the 4th trimester. His popular Happiest Baby on the Block series offer advice about what to do for a range of behavior challenges in this time period.

But as pediatrician turned psychoanalyst D.W.Winnicott identified, a mother knows what to do. He referred to this kind of care as “primary maternal preoccupation,” a preoccupation that is not only healthy but also highly adaptive. The problem lies in the fact that in contemporary culture new mothers do not themselves have a "holding environment" that supports caring for the baby in the way his immature nervous system requires.

In utero, the mother’s body was available 24-7 to support the developing fetus. The helpless newborn requires a similar amount of time and attention. If all goes well, by three months of age, the baby develops the capacity to self soothe. His movements are no longer random. He can bring his hand to his mouth. His sleep cycles become more regular. A mother can take a shower.

However, when the expectation exists that a new mother will function as she did before the baby was born, the kind of attentiveness an infant requires will not only be challenging, it may be impossible. Faced with this expectation, many mothers feel very much alone. Enormous strain on a marriage may occur when a spouse is the sole source of emotional support,

Extensive longitudinal research spanning over 40 years has shown the importance of attuned caregiving in healthy emotional development. Given the baby’s helplessness, or what Winnicott termed ’’absolute dependence,” in the early weeks and months this kind of attunement is a full time job. Not necessarily by only the mother, but also by an extended holding environment that may include family, friends and community.

There is an evolutionary purpose to what in this country was once termed "lying in." During a period of 3-4 weeks mothers were able to rest and connect with their baby while a group of women helped with household chores and offered emotional support.

Cultures around the world recognize the need for protecting the mother–baby pair in this way. Contemporary American culture is uniquely lacking in a culture of postpartum care.

Fortunately there is recently increasing attention being paid to the emotional wellbeing of mothers. However this attention often comes in the form of calls for "screening and treatment of postpartum depression." Others have reframed the issue as "perinatal emotional complications," a less stigmatizing and more descriptive term. But perhaps it should be renamed postpartum neglect. By this I mean neglect of mothers, not by mothers.

Mothers today are facing a kind of social abandonment, not an illness to be medicated away. Even cognitive behavioral therapy, shown to be effective in treating postpartum emotional struggles, places the problem squarely in the mother. The problem can only be understood in social context.

For example, ambivalent feelings about the baby, with the loss of control and other massive changes in one’s life, are normal and common, expressed in a beautifully lighthearted fashion by Winnicott.

Then, one day, they find they have become hostess to a new human being who has decided to take up lodging, and like the character played by Robert Morley in The Man Who Came to Dinner, to exercise a crescendo of demands til some date in the far-extended future when there will once again be peace and quiet; and they, these women, may return to self-expression of a more direct kind.

But when mothers do not have license to express this ambivalence, when they are alone and increasingly overwhelmed, with thinking impaired by severe sleep deprivation, normal feelings may become distorted. As mothers experience increased self-doubt and low self-esteem, a downward spiral rapidly develops.

When in the setting of my behavioral pediatrics practice I talk with mothers who struggle in these early weeks and months, I am struck by how totally alone they feel. Even for mothers who are coming to see me many years later, with older children who are now dealing with a range of behavioral and emotional problems, the memories of loneliness from those early weeks and months are vivid and striking.

Rather than focus on the mental health of the mother separate from care of the baby, we need to think of mother-infant care in the first 2-3 months of life as a unit. Just as we pamper pregnant women, we should think of those first two to three months as an extended gestation period for the infant brain. Brain growth, and with that healthy development, requires care by the mother, or mother figures, in the same way that the mother’s body held the baby in pregnancy- 24 hours a day, seven days a week. The postpartum mother requires the same, if not more, care and support.

As Winnicott wisely observes, "It should be noted that mothers who have it in themselves to provide good-enough care can be enabled to do better by being cared for themselves in a way that acknowledges the essential nature of thier task."

We cannot go back in time to a period when extended family was available to provide a community of support. Nor will we be able or even want to return to a time when mothers stayed in bed for 3-4 weeks after childbirth. But some steps must be taken.

For just as we know that supporting mother-baby pairs leads to healthy development, we know that when early relationships suffer, the long-term consequences, for both mother and child, are significant and worrisome.

A weekly mother-baby group for an 8-week period starting in the first weeks of life will run for four times the baby's lifespan. The brain makes as many as 700 connections per second during that time. The opportunity for promoting healthy development is enormous. When a mother feels held by the group, she has more energy to hold her baby, both physically and emotionally.

Such a group, as offered by the Community Based Perinatal Support Model developed by MotherWoman, should be made available to every new mother-baby pair. Increased paid parental leave and home visiting programs offer other forms of support, as does recognizing that physical recovery from childbirth does not happen overnight.

Perhaps the first and most important step in promoting healthy development lies in locating postpartum “illness” in its proper place- not in the mother, but in the way our society cares for mothers.

More from Claudia M Gold M.D.
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