Our Bodies, Ourselves (84 page)

It can sometimes be hard to differentiate between feelings of sadness that are part of the normal range of response to challenging life experiences and serious depression that calls for more than basic support and help with problem solving. The medical definition of depression typically ignores the cause(s) of a woman's distress, and thus often fails to address specific issues such as poverty, discrimination, sexual assault, abusive relationships, or the end of a relationship that contribute to feelings of sadness, poor self-image, and despair.

Too often women experiencing reasonable responses to difficult life situations are treated by health care professionals with mood-altering medications that can have unwanted side effects. These medications—whose popularity is fueled by simplistic and unrealistically optimistic advertising—are often prescribed before women are offered more holistic approaches that have been demonstrated to be equally or more effective. However, when social support systems are not readily available or talk therapy is not helpful, some women do find that medications can provide relief, especially by helping them return to normal function in the short term.

Currently, in North America, pregnancy is treated as though it is an at-risk situation for depression, and routine prenatal care includes screening for depression. Nonetheless, evidence shows that pregnant women experience no more depression than women who are not pregnant. According to one large systematic review, about one in every thirteen pregnant women experiences some depression.
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In a survey of U.S. women of reproductive age, there was not a significant difference in rates of depression between pregnant and nonpregnant women, and the trend was actually toward pregnant women experiencing less depression.
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Why is there potential harm with screening? Screening large, generally healthy groups of people inevitably produces false positives that may result in healthy people being labeled as having a mental health disorder and exposing them to the unnecessary risks of treatment. Furthermore, although many believe that detection and treatment of depression in pregnancy have been shown to prevent depression after birth, there is little scientific evidence to support this view.

Symptoms of serious depression may develop in the context of challenging life circumstances, or they may arise with no apparent cause.

Ever since my eighteenth week of this pregnancy, I have been feeling depressed. I feel flat/unhappy all the time, I cry a lot, I can't sleep, I can't concentrate, I'm impatient with everyone, and not even playing with my toddler makes me happy anymore. This is a much-wanted pregnancy, and there is nothing going on in my life that should be making me so unhappy
.
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If you are pregnant and experiencing feelings of mild to moderate sadness, the first things to do are to try to get enough sleep and exercise, eat well, and reach out to friends, family, religious counselors, and/or specialized support groups for practical and emotional support. If these strategies do not ease the depression, seek help from a health professional, such as your primary care provider or ob-gyn, or a psychotherapist, social worker, or psychologist with experience treating depression during pregnancy. Depression is treatable, and a good therapist can provide support and guidance as well as help assess
whether additional treatment may be helpful. If you have concerns about hurting yourself or others, or an acute sense of hopelessness or inability to function, seek medical attention immediately.

Antidepressants are commonly prescribed during pregnancy. Although these medications are widely believed to be very effective, a recent review of
all
the clinical trials submitted to the FDA—including negative studies pharmaceutical companies chose not to publish—found that antidepressant medications are only slightly more effective than placebos.
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For people experiencing mild to moderate depression, they were no more effective than a placebo. Among people who were suffering from major depression, only one of ten people treated with antidepressant medication significantly improved as a result of taking the medication. Among people whose depression was categorized as “very severe,” one out of four responded to antidepressant medication.

Furthermore, antidepressants have not been shown to be more effective for mild to moderate depression than nondrug options such as psychotherapy, cognitive behavioral therapy, and exercise. The clinical trial evidence strongly supports a model of symptomatic treatment focusing on life situation, rather than a model of an imbalance in brain chemistry that is “fixed” by antidepressant medication. Most depression is episodic, generally resolving (even without treatment) in about four to six months.

Although some clinicians believe that antidepressants are more effective than shown in clinical trials, the only scientifically valid way to determine whether and by what margin medication is superior to treatment with a placebo is from the results of randomized, double-blind, controlled trials.

In addition to the question of effectiveness, there is some concern about the possible risks of taking antidepressants during pregnancy. For example, can they cause birth impairments? Do they increase the risk of miscarriage? Several studies suggest that there is an increased risk of heart defects in infants whose mothers take antidepressant medications, especially paroxetine (Paxil and generic equivalents),
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and some evidence that women taking certain antidepressant medications have an increased risk of miscarriage.

There have also been reports of some harmful effects on infants of women who took anti-depressants in the last trimester of pregnancy, including effects such as jitteriness, crying, and feeding problems that may be withdrawal effects, and very rarely, a serious disorder called persistent pulmonary hypertension.
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There has been controversy surrounding all of these risks and the medical evidence is being hotly contested in legal cases. More research is needed to answer questions about potential risks, including risks that may be due to underlying differences (unrelated to drug use) between women who do and don't take antidepressants.

For women who become pregnant while taking antidepressant medication, these concerns must be weighed against the risk that stopping antidepressant medication during pregnancy will lead to worsening of depression or the symptoms
of drug withdrawal. One study showed a high rate of depression relapse when pregnant women were taken off their antidepressant medication, but the study did not gradually taper the dose of medication and failed to distinguish between symptoms of drug withdrawal and recurrence of depression.
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Depression in pregnant women is associated with low weight gain, alcohol and substance abuse, and sexually transmitted infections, all of which can harm mothers and babies. Although there is no evidence that taking medications will prevent any of these problems, women with severe depression clearly need professional help.

In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) recommends the use of older and less expensive tricyclic antidepressants rather than newer drugs such as Prozac, Paxil, and Zoloft because of the longer experience with their use and because of concerns that the newer antidepressants may be less safe overall during pregnancy.

Pregnant women who are struggling with other mental health problems, such as bipolar disorder, anxiety, or post-traumatic stress disorder may be offered medications other than antidepressants. If medication is recommended, make sure that you are fully informed about its benefits and adverse effects, as well as the full range of alternatives—both drug and non-drug. Also, check the FDA's assessment of the safety of each medication for use in pregnancy. (This information is included in the package insert of each prescription medication, which is available from your pharmacy.) You and your health care providers can also get free information on the possible risks of medication on your pregnancy from the Organization of Teratology Information Specialists
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(otispregnancy.org).

As the weeks pass and you get closer to the day your baby will make his or her long-awaited arrival, it's a good time to ask yourself, “What do I want out of my birth experience?”

Every woman hopes for a safe birth and a healthy baby. Beyond that, you may prefer strongly to have a natural childbirth, or you might know you prefer an epidural. You may have cultural or religious customs you would like to integrate into your birth. If you have other children, you may be particularly motivated to have an easy recovery. If you have had a prior traumatic birth or other past trauma, you may wish to avoid certain triggers during this birth. These are just a few examples of the many hopes and expectations we bring with us to the birth-planning process. It is important to ask yourself questions to clarify your values and preferences and, if you have a partner, to discuss these and find out about his or her hopes as well.

As you learn more about pregnancy, childbirth, and early motherhood, you may find that your values and assumptions have changed since early pregnancy. As you begin to think about your upcoming birth and transition to motherhood, ask yourself if your midwife or doctor still seems like a good fit. It is common for women to switch care providers or birth settings in mid- or late pregnancy, and most women who do switch are happy they did.

The major labor and birth choices you will need to consider ahead of time are who you want to have with you for support, strategies for coping, and which labor interventions you will agree to under which circumstances.

Having continuous, high-quality supportive care from others during labor and birth is one of the best ways you can ensure a safe and satisfying experience. Studies demonstrate that women who receive continuous labor support while giving birth need less medication, have lower cesarean section and assisted vaginal birth (vacuum extraction, forceps) rates, and are more satisfied with their birth experiences.
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Many of us count on and receive excellent support from our partners or our health care providers. Yet our partners are probably inexperienced at attending births and need their own support, especially in long labors. Midwives, doctors, and nurses in hospitals may not be able to provide continuous care because of the many different demands on their time. (Midwives who attend women at home or in a birth center typically do provide continuous support.) For these reasons, some women choose to be accompanied by a doula (a trained labor support person) or a relative or friend who is knowledgeable about and comfortable around birth and who can stay through the whole process.

Birth doulas provide continuous emotional support, comfort techniques, and encouragement throughout labor and birth. Doulas complement midwifery and medical care, offering a wide range of services, sometimes including home visits after the baby is born. To find a doula in your area, try doulamatch.net or the websites of any of the doula-certifying organizations.

Doulas usually make an initial visit during pregnancy and then arrange to be with you during labor. Some doulas specialize in certain situations, such as teen mothers, women whose native language is not English, women who have experienced a prior loss, VBAC mothers, women whose partners are deployed overseas, or women who cannot afford traditional doula services.

During pregnancy, most of us wonder how we will cope with the intensity and pain of labor and birth. You and those who will support you during labor can learn relaxation routines and other strategies from classes, books, or audio or video resources and practice them before you go into labor. These strategies range from comfort measures such as changing positions, using touch, or relaxing in water to mental strategies such as focused breathing or hypnosis to medication such as opioids (narcotics) or epidurals.

The pain relief methods you choose to use can affect your experience and memories of labor. Learning about the potential advantages and disadvantages of different methods, thinking about your preferences with regard to pain control, and talking with your provider and support people about what you want before you go into labor will help you make sound decisions.