Our Bodies, Ourselves (99 page)

It is not possible to make any recommendations for antidepressant treatment in postnatal depression from this single small trial. More trials are needed, with larger sample sizes and longer follow-up periods, to compare different antidepressants in the treatment of postnatal depression, to compare antidepressant treatment with psychosocial interventions and to assess adverse effects of antidepressants. Treatment of postnatal depression is an area that has been neglected despite the large public health impact
.
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Despite the lack of good scientific evidence about such an important issue in women's health, many health care providers and the general public
believe
antidepressant therapy to be a proven treatment for postpartum depression. And drug companies have little incentive to do clinical trials that risk having a negative effect on sales of their drugs.

Especially in light of the paucity of scientific evidence supporting antidepressant therapy for postpartum depression, it is important to remember that antidepressants (like other medicines) can produce negative effects, such as sleep, digestive, and sexual problems, and, rarely, more serious effects. Unfortunately, finding unbiased information about the effectiveness and safety of antidepressants is challenging, as much of the widely available material on the Internet and elsewhere is produced or sponsored by drug companies.

Women in severe crisis sometimes find that only talk therapy combined with medication is helpful. (For more information on the potential benefits and harms of antidepressant medications, see “Depression and Other Mental Health Challenges During Pregnancy,” page 389.) If you are breastfeeding, be sure to tell your provider. Though commonly used antidepressants do pass into breast milk, their short-term negative effects on babies, if any, appear to be transient. Additional research, particularly on the long-term safety of anti-depressants for breastfed babies, is needed. To learn more about the effects of medication on breast milk, work with a provider who is knowledgeable about medications and breastfeeding and consult Thomas Hale's book
Medications and Mothers' Milk
. (For more information, see “Resources on Medications and
Breastfeeding.”
)

Depression can make bonding with your baby difficult, which can adversely affect your baby's overall development. So finding a solution that works for you is important. Therapeutic decisions should be guided by your preferences, the severity of your illness, the risks
of the medicines in question, and the known risks of depression for you and your baby.

Through digital media, books, blogs, and parenting magazines, mothers today have more access to one another's stories and ideas about mothering than our foremothers did. Thanks to the voices of those brave enough to share their experiences, we have a fuller picture of the physical changes and emotional landscape of motherhood. And thanks to changing laws and cultural attitudes, women can more easily pursue single motherhood or coparent with a female partner, and can continue a career after having kids.

But the myth of the supermom who is perpetually cheerful, all-knowing, and self-sacrificing lives on, and it's hard to resist. We—both as individuals and as a society—still have certain expectations about what it means to be a mother.

Everyone's like “This is the best time of your life, aren't you so happy?” There's no room to say no. . . . You're not allowed to have the negative emotions. You love and hate your child so much, all together, all at once
.

It's important to be able to talk about how it feels trying to live up to others' expectations. Traditionally, though, mothers have been expected to talk only about the positive; voicing frustrations with some of the more difficult moments can be tough. We expose not only our ambivalence but our vulnerability.

I was afraid I wouldn't be a good mother or would forget to feed him or change him. I was afraid he wouldn't like me. I was afraid of everything in the world and yet was so happy at the same time. It was the strangest feeling in the world. I still sometimes feel that way and think that every mother does at some point. We doubt ourselves all the time and really need to just relax and go with it, because chances are we're doing a really good job
.

I'm a single mom. My son's father has just disappeared. My main support is my family, but it comes with a cost. My mom and aunt seem to feel they can tell me how to parent, especially since they are providing me with free babysitting while I work. . . . I really wish I didn't have to work, but I have no choice. I would much rather be home with my son, because I just love being his mother
.

In addition to feeling the pressure to be a supermom, many mothers are conflicted about balancing work and family. Those of us who work outside the home often contend with the stress of arranging for full-time child care and may feel guilt and judgment about the choices we make. Those of us who stop working to care for children may be frustrated by the loss of identity and advancement opportunities that often come with leaving the workforce.

My brain is melting and coming out my ears. I feel like everything I was trained to do, all my hopes and aspirations, are frozen in time. My husband goes about his life and his job and then gets to come home and be a great daddy. [Sometimes] he says things like “You seem really touchy today,” and all of a sudden I'm like “Did you pee by yourself today? Did you go to the bathroom alone? That's how I'm rating the quality of my days right now.”

For many women, working is not optional; it is a financial necessity. For other women, the
cost of child care may make staying home a financially sensible choice. Some women make great financial sacrifices to stay home. These are complex decisions based on our values, priorities, and needs.

The media-driven talk of the mommy wars polarizes mothers into two camps: those who work outside the home and those who stay at home. In reality, many of us cycle into and out of these roles. Too often, public discourse either praises working mothers for their multitasking abilities or condemns them for neglecting their children; similarly, it often either praises stay-at-home moms for being devoted to their children or condemns them for giving up so much of their identity and career potential. No wonder all of us feel judged.

While our society idealizes motherhood, our government provides little concrete support for children and families. Unlike most other industrialized countries, the United States has no guaranteed paid family leave, no guaranteed health care, and little affordable high-quality child care. We need public policies that value and support families and caregivers, who are mostly women. We also need to push for a society that recognizes that fathers, like mothers, need to strike a balance between their career and their family life.

It's often said that it takes a village to raise a child. Finding
your
village, gathering support around, and allowing other nurturing adults into your circle will ultimately enrich both you and your child's world. As your child's first role model, leading the way with a sense of balance, a commitment to your priorities, and a strong network of support will provide a road map for your child as he or she navigates the road to healthy adulthood.

Whenever I feel guilty or start worrying that I'm doing it wrong, I remind myself that in the end, it usually turns out okay. Because a huge part of our kids' emotional and physical health as adults is due to what kind of parents we are. But an even huger part is because of the kids themselves: their temperaments, abilities, intelligence, etc. And their teachers and peers also play a big role. There's no One True Path to successful motherhood
.

CHAPTER 18
Miscarriage, Stillbirth, and Other Losses

D
espite their frequency, pregnancy and childbirth losses are not widely recognized or understood in our culture. Many pregnancy books barely cover the topics, and when they do, they tend to sequester the information at the back. Most health care providers are understandably reluctant to inform women of the possibility of loss or discuss medical options until a problem occurs. Yet this lack of knowledge means we learn about our options and make choices only in the midst of the crisis.

The loss of a pregnancy or the death of a baby during pregnancy or after childbirth is often an immense and shocking blow. The grief that follows can be intense.

We went home from the hospital dazed and tired. I was weak and enormously sad. I don't know that I've ever experienced such deep emotional pain. The loss was so great and so complete. . . . For the first few days I couldn't talk to anyone, but at the same time, it was painful to be alone. I would just cry and cry without stopping
.

Another woman says of her miscarriage:

I was hysterical with grief and jealous of all those pregnant moms and moms pushing strollers. I didn't know anyone who had had a miscarriage. That was a terrible thing. Even though intellectually you know miscarriage is quite common, there is still a great deal of secrecy and shame surrounding the experience
.

Women who experience the loss of a pregnancy or a baby need emotional support and sensitive care and attention from health care providers, families, and friends, both during the loss and afterward. Some hospitals now have bereavement teams and organize pregnancy-and-infant-loss support groups. Sensitive providers and in-person or online groups can help us and our partners with the isolation that often follows a loss and support us in grieving, healing, and making decisions about future childbearing.

The vast majority of women who experience loss go on to have successful pregnancies and give birth to healthy babies. Having a subsequent successful pregnancy, however, does not necessarily erase the pain of earlier losses.

Pregnancy and infant loss occurs in many different ways, including miscarriage, ectopic or molar pregnancy, loss in a multiple-gestation pregnancy, the decision not to carry to term a fetus with genetic anomalies, stillbirth, and early infant death.

Miscarriage, the loss of a pregnancy before the twentieth week, is by far the most common type of pregnancy loss.
*
An estimated 15 to 20 percent of known pregnancies end in miscarriage.
†
The risk of miscarriage increases as we age: Women under age 30 have about a 12 percent chance of miscarrying; women between ages 30 and 34 about 15 percent; women between 35 and 39 about 25 percent; women ages 40 to 44 an estimated 40 percent; and women ages 45 and older about 80 percent.
1

Most miscarriages take place within the first twelve weeks of pregnancy. The chance of miscarriage decreases significantly once a heartbeat has been detected.

The vast majority of miscarriages cannot be prevented. Early losses often occur without a detectable embryo. Between 50 and 70 percent of first-trimester miscarriages and about 30 percent of second-trimester miscarriages are caused by chromosomal anomalies in either the sperm or the egg. Other conditions that can result in miscarriage include infection; abnormalities of the uterus or cervix; smoking; substance abuse; exposure to environmental or industrial toxins; and chronic diseases, including diabetes, kidney disease, and autoimmune processes. In rare cases, women miscarry after certain tests during pregnancy, such as chorionic villus sampling (CVS) or amniocentesis.

Many women learn about an impending
miscarriage at a routine prenatal visit, before experiencing any physical symptoms of loss. Some women first notice that early signs of pregnancy—nausea, fatigue, breast tenderness—have diminished or gone away. The first symptoms that a miscarriage has begun are usually spotting or bleeding, followed by cramps in the lower back or abdomen.

Roughly two to three out of ten pregnant women experience some vaginal bleeding or spotting during the first trimester of pregnancy, and only half of those women will miscarry.
2

Bleeding in the second trimester is more likely to be a sign of miscarriage. If you have any vaginal bleeding during pregnancy, your health care provider can help determine if the bleeding is likely to result in miscarriage or if it has another cause that does not threaten the pregnancy.

If a blood test or sonogram indicates that you are going to lose the pregnancy, you and your care provider will need to decide whether to allow the miscarriage to occur and complete itself naturally or to schedule a procedure to discontinue the pregnancy.