By Tracy G. Cassels

ppdLet’s first be clear – we know post-partum depression is a worldwide phenomenon, it exists in developing nations, sometimes at higher rates than in Western ones[1][2].  This shouldn’t be too surprising, though, given that it is more common amongst low-income families even within Western societies[3].  However, what I question is whether or not we can consider the high rates of post-partum depression seen around the world a product of our industrial evolution, which is certainly influencing families globally.  There is certainly evidence that while PPD is global, there are areas with much lower rates than others, and these seem to be in more rural areas around the world[4][5].  For this theory to hold, we must look at our modern day practices, what we know about their relationships to PPD, and then look at the risk factors found in other cultures.  So let’s begin…

Birth Experience

I have covered this in depth elsewhere (see here) but as a reminder, a “negative” birth experience (defined in terms of the mother’s belief about it) and separation from a newborn infant are major predictors of PPD[6][7][8][9].  Add to that that caesarean sections, which now make up a third of births in the United States and Canada, is an independent factor in predicting negative birth experiences and negative psychosocial outcomes after birth[10].  In short, despite people saying that a birth is a birth is a birth, not all births are equal.

[If you feel that you suffered a traumatic birth experience there are groups you can go to for help in addition to private therapy, if you are able to afford and obtain it.  Mothers of Change is an amazing organization here in Canada, but they are online and thus worldwide, providing support and assurance to mothers who have undergone a traumatic birth experience.]

Breastfeeding

The correlational relationship between breastfeeding and PPD is well-established with many studies finding both that problems with breastfeeding predict PPD[11] and that PPD affects breastfeeding duration and type (exclusive versus mixed versus none)[12][13].  The bidirectionality of the research is not too surprising.  For those who struggle with breastfeeding at the start, the struggle itself to do something many women feel should come naturally can trigger depressive symptoms, but also the lack of hormonal influence that breastfeeding has.  Given that breastfeeding leads to greater ease of bonding with one’s infant[14] via the release of oxytocin[15], the lack of this effect can cause problems.  But even once breastfeeding has been established, if PPD comes on after this, then breastfeeding seems to be negatively affected, despite its ability to produce hormones that help counter PPD.

This is why breastfeeding support is essential.  Support for moms who are struggling – because to struggle at first is normal – and then further support for moms who experience PPD.  The cessation of breastfeeding should not be something that mother’s feel they have to do because of depression or are pushed into doing.

[Currently if you are struggling with breastfeeding, please visit your local La Leche League chapter for help and assistance.  They are an invaluable source in giving support and helping you find the assistance you need to have a healthy and happy breastfeeding experience.]

Post-Partum Rituals

In many cultures (and in many more historically), there’s a post-partum period in which mom and baby are truly catered to and allowed to bond.  This period – typically lasted around six weeks – provides the mother time to rest from birth, master the art of breastfeeding, all the while having others around to help with duties that would normally fall on her shoulders.  In a great review of the anthropological literature, it was found that having this post-partum period for a mother was associated with virtually no PPD[16].  In her book on Attachment Parenting, Mayim Bialik recommended a modified three-week post-partum ritual in which the mother and infant don’t leave the bed for 1 week, don’t leave the bedroom for another week, and then don’t leave the house for the final week[17].  This period should allow mom enough time to rest while not concerning herself with the myriad other things that go on in the home while slowly adjusting to life with her new child.

Support

Central to being able to do a post-partum ritual, breastfeeding, birth, etc. is support.  Both emotional and practical.  While emotional support can often be obtained over the phone or from friends, it’s the practical support that many families miss and which put undo strain on new parents and lead to higher rates of PPD[18].  I wrote a piece on the importance of partner support (see here), but even outside of the family unit, instrumental help is key to a family’s well-being.  And for single parents, the availability of instrumental support is linked to better maternal psychosocial functioning and better outcomes for kids[19].  In developing countries, the lack of support has been found to be one of the largest predictors of PPD[4][5].  Interestingly, a cost-effectiveness study out of Ontario, Canada found that while a peer support prevention program for PPD cost more than the usual avenues (which have not been as successful), the savings compared to the costs of PPD itself were quite large ($4497 per woman for the peer support group versus $20,196 per case of PPD)[20].

[Currently there are few programs like that in Ontario, but if you do not have family and friends who can help, there are post-partum doulas who are there to help you in this post-partum period.  While they do cost money, it may be the best money you spend if you find yourself having problems.]

Work Away From Home

Traditionally, women’s work was such that they were able to do it with baby close.  In fact, many hunter-gatherer tribes today still have infants close to or attached to their mothers for close to 100% of the day[21].  Mothers work with their children.  However, our current work structure in which the parent must leave the house and separate from their child, sometimes very early (e.g., USA), has repercussions for everyone, but notably for post-partum depression.  Research in the United States found that if economic hardship was not low (i.e., the families were not well-off), returning to work after the traditional six-week leave resulted in lower mental and physical health for women[22].  In fact, the authors of this piece argue that there needs to be a reconsideration of the current six week leave for women, proposing extended benefits and flexible work schedules upon return.  In cases where women must return to work, we must work to ensure that they can keep their infants close.  On-site daycares, flexible work schedule, working from home – all of these are ways to allow a mother to work and earn much-needed income while staying close to her infant.  Companies may want to consider this given that the cost associated with postpartum depression health for employers was 90% higher than for non-depressed women[23].

[If you are interested in letting your State or Federal representatives know that this type of extension is needed, we have a downloadable letter, filled with research, for you here.  Just fill in the needed representative information, sign it, and send it off.]

Sleep

This is one of the areas that is consistently highlighted in the research as support for sleep training infants.  As I’ve already covered elsewhere, I do not think that this is the way to go (see here).  But to the fact that sleep does influence PPD, severe sleep deprivation seems to be due to our more modern sleep habits.  We place infants in rooms away from us (contrary to every traditional, tribal culture[24]) which has the net effect that not only must we fully wake to feed our infants, but we also have to remain awake while they feed and only when they are done and resettled, can we return to sleep.  Compare this with co-sleeping in which the infant is either in bed with the mother or close by (and the mother typically feeds in bed), and mom does not truly have to wake or move much to feed her infant.  The second factor is formula.  If one is not breastfeeding, infant arousals will be less frequent, but when they do rouse, it’s not a simple matter of putting the infant to the breast, but actually having to prepare a bottle, including heating it up and sterilizing.  This type of disjointed sleep is very different to what most co-sleeping families report.  For a great review on co-sleeping, see Dr. Helen Ball’s academic review, found here.

———–

Personally I think it’s clear that our modern birth and parenting practices have led to a rise in PPD amongst women globally.  Unfortunately, the main focus of the research on PPD is in fixing the problem, with the assumption that the problem is inevitable, even when the risk factors are found to be things that could be fixed.  I know that there will be a small group for whom none of these factors matter – depression will ensue, and therefore we do need research and resources for treatment.  But for the majority of cases, I believe one or more of these factors are at play.  Thus focusing all our attention on fixing a problem instead of preventing the problem seems wrong to me.  While it’s great to “fix” problems, isn’t it better to simply not encounter them?  I have yet to meet a mother who was happy about her PPD experience, even if she did receive proper treatment (something that is also a rarity, very sadly, especially when many women encounter problems at the first stage of simply telling people they are suffering).  We need to focus research on preventative methods in addition to treatment.  Unfortunately, many of these preventative measures contradict our modern society (or the society others are striving for) which means we need a radical shift in the way we think about our priorities.

At the moment, though, it is up to each of us to help each other.  If we know someone who is having a hard time, be there.  Be it sitting there to listen, helping a mother who is struggling to breastfeed, bringing food over, doing a load of laundry, helping watch the kids while mom takes a shower or naps, or whatever it is that may help a particular mother cope.  I have said it in other words in other pieces, but we have to be the change we want to see.  We cannot rely upon the rest of society to change their views on the importance of community before we jump in.  The only way we will see this change is if we initiate it.

So let’s realize that we have failed.  Not mother.  Not families.  But our entire society.  And it’s up to each and every one of us to try and change this.  Our mothers, our children, our families all deserve better.  And it’s up to us to try and give it to them.

[Front photo credit: http://mikadokids.com]



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