'Honesty is disarming. It should set the stage for dialogue.' - Jane Honikman, M.S., founder, Postpartum Support International

One of the first written accounts of postpartum mood disorders was in 1436. Margery Kempe, mother of 14, wrote:

'Wherefore after that her child was born she, not trusting her life, sent for her ghostly father, as said before, in full will to be shriven of all her lifetime as near as she could. And, when she came to the point for to say that thing which she had so long concealed, her confessor was a little too hasty... and so she would no more say for nought he might do. And anon for dread she had of damnation on that one side and his sharp reproving on that other side, this creature went out of her mind and was wonderly vexed and labored with spirits half year eight weeks and odd daysi.'

Background to Postpartum Mood and Anxiety Disorders (PPMAD)
In the quote above, from Out of her mind: Women Writing on Madness, Margery's honesty is indeed disarming, and provides historical context to set the stage for future dialogue: perinatal mood disorders have been around a long time, and based on current evidence, they aren't going away.

• Suicide is the leading cause of death for women during the first year after childbirth.1
• Depression is the second most common cause of hospitalization for women in the U.S.; the first being childbirth.2,3
• Major and minor postpartum depression/anxiety estimates range from 5% to 25% for new mothers in US.4,5,6,7,8
• There is a seven-fold increase in the risk of psychiatric hospitalization for women following childbirth.9,10,11
• Reports show that PPMAD affects up to 48% of women living in poverty.12,13,14,15

The Role Stigma Plays
Statistically, over 500 years later, Margery would still be at risk largely due to the powerful social mechanism of stigma regarding motherhood and mental illness. Just as stigma about mental health disorders silences women today, Margery was similarly silenced in 1436.16,17,18 It is the silent fear of stigma that likely causes nearly 50% of present-day, affected women to go untreated for perinatal mood disorders.19,20

In her 2010 book Within Our Reach: Ending the Mental Health Crisis21, former first lady (and life-long mental health advocate), Rosalynn Carter noted:

Stigma is the most damaging factor in the life of anyone who has a mental illness. It humiliates and embarrasses; it is painful; it generates stereotypes, fear and rejection; it leads to terrible discrimination. Perhaps the greatest tragedy is that stigma keeps people from seeking help for fear of being labeled, 'mentally ill' (p. 1).

Raising Awareness
One of the ways to end stigma is to increase awareness. In my recent interview [KMH1] with Jane Honikman, M.S., founder of Postpartum Support International (PSI), she offered:

The causes of stigma include ignorance and denial about the importance of emotional wellbeing of childbearing women. On the community, national and international levels this ignorance is being eliminated through educational awareness campaigns. There is no excuse not to be educated about the range of emotional reactions during the perinatal period. Denial is a personal issue and more difficult to confront. It is impossible to know how one's expectations of motherhood will be met. The mythology that surrounds parenthood is another huge barrier. Taboos need to be openly discussed. Often there are conflicts between the woman and her partner. These need to be discussed. It is difficult to parent alone. Family members should participate in supporting the new family. It is important to have frank and honest conversations about opinions and expectations within the extended family unit during pregnancy and following the arrival of the baby.

Increased awareness regarding prevalence, risk factors, and the need to screen has occurred at many levels. There has definitely been progress. Jane further offered:

Awareness has increased tremendously since I first got involved nearly forty years ago. The availability of accurate information, resources and referral networks is responsible for these changes. The media has been our movement's best friend. For example, there are now free materials from the federal government, healthy start programs include maternal mental health curriculums, and states have active coalitions. Insurance companies have eliminated barriers to receiving mental health coverage. All of the major medical organizations have stepped forward offering educational seminars to their members. The courts now consider mental health history when they encounter a crime. The internet has played an enormous role. Postpartum Support International's website www.postpartum.net has been a leader in this progress.

Further evidence of progress can be found in the published position papers related to maternal mental health of the following organizations:

Centers for Disease Control and Prevention (CDC)
The American Congress of Obstetricians and Gynecologists (ACOG)
The World Health Organization (WHO)
American College of Nurse-Midwives (ACNM)
Planned Parenthood
National Organization for Women (NOW)
The American Academy of Pediatrics (AAP)
National Alliance on Mental Illnesses (NAMI)
Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN)
Children's Defense Fund (CDF)
National Women's Law Center
National Partnership for Women and Families (NPWF)
The U.S. Preventive Services Task Force
American Psychological Associatio(APA)
US Dept of Health and Human Services
March of Dimes
National Institute of Mental Health(NIMH)
Healthy Mothers Healthy Babies
International Childbirth Educators Association (ICEA)

Postpartum Support International (PSI) has had a tremendous influence on raising awareness about postpartum mood and anxiety disorders. Given their successful leadership in advocating for maternal mental health using evidence-based research, it serves to look more closely at the organization's structure and become familiar with the resources they provide all childbirth professionals.

Postpartum Support International Background
PSI was founded in 1987 by Jane Honikman in Santa Barbara, California. The purpose of the organization is to increase awareness among public and professional communities about the emotional changes that women experience during pregnancy and postpartum. The non-profit organization's greater mission is to promote awareness, prevention and treatment of childbearing-related mental health issues in every country worldwide. It is the vision of PSI that every woman and family will have access to information, social support, and informed professional care when needed. PSI promotes this vision through advocacy and collaboration, and by educating and training the professional community and the public.

How PSI Works
PSI is run and maintained by volunteers. According to Wendy Davis, Ph.D., PSI Program Director, there are currently 479 active members and of that number, approximately 50 of those are childbirth professionals (birth or postpartum doulas, childbirth educators, lactation consultants). There are 145 PSI Support Coordinators in the United States, and 48 in other countries. Support coordinators provide support, information, and resources to anywhere from 2 to 20 families every month, and many of them lead free support groups. We also have specialized PSI Coordinators for military families, Dads, Spanish-speaking moms, and legal resources.

PSI maintains a warm line (1.800.944-4PPD) which is managed by 9 English speaking volunteers, and 8 Spanish speaking volunteers. On average, the English warm-line receives 90 calls a month, and the Spanish warm-line, 70 calls per month. The toll free number connects the caller with informed and caring PSI telephone support volunteers 7 days a week. What happens when an individual calls in? Dr. Davis explained:

The caller hears a greeting and then can leave a voicemail message in English or Spanish. The calls are usually returned within several hours; volunteers make every effort to connect with the caller within 24 hours at the most. The warm-line is answered live in English on Tuesdays and Wednesdays, during regular business hours, Pacific time. Warm-line volunteers offer non-judgmental support, information, and local resources. They will connect the caller with their area PSI Support Coordinator so they can find support or providers as close to home as possible.

The PSI website provides consumers and professionals with current research, and resources. According to Dr. Davis:

The hallmark of our website is our Support Map Page that lists PSI support coordinators, free support groups, and events in every U.S. state and 35 other countries. Childbirth professionals can be assured that they can find volunteers in their own area who are available to help them and the families they serve. Our Coordinators are trained to provide support, information, and local resources as well as phone or email support to families as needed. The website also includes current evidence-based information on the range of pregnancy and postpartum mood disorders, tips for coping, resources for moms, partners, and professionals, educational materials like brochures and posters in English and Spanish, new research articles, and a bookstore. There is one page that just lists information and links in non-English languages, and one section of the website has been translated to Spanish. We update the website constantly to keep it current, adding new research and resources daily.

One of the additional resources she described is the PSI Free Chat with an Expert:

PSI hosts free, live phone sessions every week facilitated by licensed professional experts in perinatal mental health. There is a session for moms and their helpers every Wednesday and for Dads on the first Monday of each month. These sessions provide a forum to share, listen to others, and talk with a PSI expert about resources, symptoms, options and general information about perinatal mood and anxiety disorders. You can learn more about the facilitators and call schedules [here].

Sensible Resource: How to use PSI in Practice
How can childbirth professionals best utilize PSI for their clients? Dr. Davis suggested:

• Find your local PSI Coordinator on the Support Map so that you can connect clients with them.
• Create links to PSI website in the resource section of your websites, provide basic facts about perinatal mental health in educational materials, include information about pregnancy and postpartum mental health in prenatal education.
• Have PSI brochures or posters available.
• Use the 13-minute PSI educational DVD with clients. You can see a preview of the DVD, and one for fathers on the PSI website here.

How could childbirth organizations best utilize PSI for their professionals? Again, Dr. Davis shared great ideas:

Come to PSI trainings, use the PSI website, join PSI and be part of our listserve for PSI members who are doulas, contact local coordinators or the PSI office with questions, provide educational materials and training for their students and members. The PSI Professional trainings, offered in several places around the country and at the PSI annual conference every year, are designed to include childbirth professionals. PSI 2011 trainings are scheduled for Los Angeles in January, Michigan and Kentucky in March, Indianapolis in May, and in Sept 2011 the 25th annual PSI conference will be held in Seattle in conjunction with PSI-Washington, which has a long history of involvement with childbirth professionals. You can keep track of trainings on the website here.http://postpartum.net/Professionals-and-Community/Trainings-Events/Trainings-and-Conferences.aspx

Conclusion
My heartfelt hope is that the information shared here will provide childbirth professionals evidence-based resources for their practice and clients.

Thank you for reading the article.

Still, I keep thinking about Margery Kempe: over 500 years later, why are depression and childbirth the two top reasons for a woman to be hospitalized2,3?

I extend an invitation to all childbirth professionals to honestly examine current positions, or lack thereof, regarding maternal mental health. What are current positions regarding perinatal mood disorders? Are we, as childbirth industry professionals, comfortable discussing mental health issues with our clients? Do we know how to screen? Do we know how to refer to local resources in our local communities?

Ask yourself this: What help do you need in becoming comfortable discussing mental health issues with your clients? Let your organizations hear from you.

Professionally, let's examine if our organizations have mental health resources on their websites, blogs, training materials, and fact sheets. Given that suicide is the leading cause of death in the first year following childbirth1, I would offer that having suicide prevention information on websites might be a place to start.

**View Walker's complimentary post over at Giving Birth With Confidence where she expands further on her interview with Jane Honikman**

I would like to extend my gratitude to Jane Honikman, M.S., for her contribution to this article, and for her steadfast commitment to women everywhere. Jane... I will pass my heart to you any day. And thanks, as always, to Wendy Davis, Ph.D., for working until 3AM to help me with this article. Also, thank you to both Cara Terreri, and Kimmelin Hull for giving me the opportunity to write for their sites, and to Lamaze International for their support. The full content of my interview with Jane Honikman can be found at www.fullydilated.net

Posted by: Walker Karraa, MFA, MA, CD (DONA)

iKempe, M. (1436). The book of Margery Kempe. In Shannonhouse, R. (Ed.) (2003). Out of her mind: women writing on madness. New York: Modern Library. pp. 3-7.

1 Oates, M. (2003). Suicide: The leading cause of maternal death. The British Journal of Psychiatry, 183, 279-281.

2 Gold , K., Marcus, S., (2008). Effect of maternal mental illness on pregnancy. Expert Review of Obstetrics & Gynecology, 3 (3), 391-401.

3 Blenning, C., Paladine, H. (2005). An approach to the postpartum office visit. American Family Physician, 72(12), 2491-2496.

4 Gaynes, B., Gavin, N., Meltzer-Brody, S., Lohr, K., Swinson, T., Gartlehner, G., et al. (2005). Perinatal depression prevalence, screening accuracy, and screening outcomes: Summary, evidence report and technology assessment, No. 119. AHRQ Publication No. 05-E006-1.

5 Onunaku, N. (2005). Improving maternal and infant mental health: Focus on maternal depression. National Center for Infant and Early Childhood Health Policy at UCLA.

6 Knitzer, J., Theberge, S., Johnson, K. (2008). Reducing maternal depression and its impact on young children: Toward a responsive early childhood policy framework. National Center for Children in Poverty, Project Thrive Issue Brief 2.

7 Yonkers, K., Chantilis, S. (1995). Recognition of depression in obstetric and gynecology practices. American Journal of Obstetrics and Gynecology, 173(2), 632-638.

8 Gavin, N.I., Gaynes, B.N., Lohr, K.N., Meltzer-Brody, S., Garlehner, G., Swinson, T. (2005). Perinatal depression: A systematic review of prevalence and incidence. American Journal of Obstetrics and Gynecology, 106(5 Pt 1), 1071-1083.

9 Harlow, B.L., Vitonis, A.F., Sparen, P., Cnattingius, S., Joffe, H., Hultman, C. M. (2007). Incidence of hospitalization for postpartum psychotic and bipolar episodes in women with and without prior prepregnancy or prenatal psychiatric hospitalizations. Archives of General Psychiatry, 64(1), 42-48.

10 Manisha, S. (2005). The role of state public health in perinatal depression. Fact sheet. Association of State and Territorial State Officials.

11 Postpartum Mood Disorders. The Jennifer Mudd Houghtaling Postpartum Depression Foundation Website. Retrieved May 1, 2009 from http://www.ppdchicago.org/.

12 Onunaku, N. (2005). Improving maternal and infant mental health: Focus on maternal depression. National Center for Infant and Early Childhood Health Policy at UCLA.

13 Knitzer, J., Theberge, S., Johnson, K. (2008). Reducing maternal depression and its impact on young children: Toward a responsive early childhood policy framework. National Center for Children in Poverty, Project Thrive Issue Brief 2.

14 Position statement: Screening for prenatal and postpartum depression. (n.d.). Perinatal Foundation and Wisconsin Association for perinatal Care. Retrieved April 9, 2009 from http://www.perinatalweb.org.

15 Isaacs, M. (2004). Community care networks for depression in low-income communities and communities of color: A review of the literature. Submitted to Annie E. Casey Foundation and the Howard University School of Social Work and the National Alliance of Multiethnic Behavioral Health Associations (NAMBHA).

16 Knitzer, J., Theberge, S., Johnson, K. (2008). Reducing maternal depression and its impact on young children: Toward a responsive early childhood policy framework. National Center for Children in Poverty, Project Thrive Issue Brief 2.

17 Ibid.

18 Abrams, L.S., Dorning, K. (2007). Bridging the gap: Barriers to service use among low-income women with postpartum depression. Funded by the Center for Vulnerable Populations Research at the UCLA School of Nursing and the UCLA Faculty Senate in cooperation with the Public Health foundation Enterprises WIC program.

19 Maternal Depression Making a Difference Through Community Action: A Planning Guide (n.d.). Mental Health America, Substance Abuse and Mental Health Services Administration (SAMHSA). Retrieved March 4, 2009 from: http://www.mentalhealthamerica.net/go/maternal-depression.

20 Ramsay, R. (1993). Postnatal Depression. Lancet, 314, 1358.

21 Carter, R. (2010). Within our reach: Ending the mental health crisis. New York, NY: Rodale, Inc.

Tags