What little we know about postpartum depression

You know it's bad when Tom Cruise, Brooke Shields and Phil Donahue really did a lot

Not long ago I saw a blurb for Rachel Louise Moran’s new book Blue: A History of Postpartum Depression in America, which piqued my interest since, like many of us, hearing the term “baby blues” and then experiencing shock, desolation, grief exhaustion, confusion and trauma (just to name a few symptoms) after having a baby are two very different scenarios. One sounds almost sweet and kinda cozy; the other makes you wonder if you’re broken with no fixing in sight.

After reading Moran’s book, I came away feeling re-enraged over how little-understood, downplayed, and under-supported PPD is in the States; how marginalized BIPOC maternal health is; and over some conservative politicians’ attempts to fold anti-abortion views into postpartum policy.

I newly appreciated how complicated an issue postpartum depression is in terms of coming to agreement over how long the postpartum period is (some friends with teenagers semi-joked to me that they’re still in it), to what extent hormones play a part vs. identity shift vs. birth trauma vs. exhaustion vs. loneliness, and what type of treatment and support is appropriate —you’d be surprised by how often the Rx is: buy yourself something nice.

And in a witchy way, I felt vindicated getting a fresh reminder that the notion that mothers ought to feel happy and content with this new role and task is patriarchal bullshit made to make you think your feelings and needs are wrong and that your own preferences are selfish: don’t fall for it!!

I spoke with Moran, an associate professor of history at the University of North Texas, to discuss what she covers in her book, which covers a timeframe that is upsettingly recent given how long postpartum depression went without getting a name or serious research. This interview has been edited and condensed.

Tell me a little about how the project changed since you first developed the concept.

I had started with this much more medicalized idea of how postpartum distress become a disease. How has it been categorized? I found that there was a real disconnect between what women’s lives were like, what women’s investment was, and those questions. Many of my questions about what symptoms should qualify as a disease and how they have historically been determined are not the questions that advocates and activists have been focused on. It matters when you’re arguing with the American Psychiatric Association, but it doesn’t necessarily matter when you’re trying to figure out how to get women’s support. I started doing interviews, which challenged me deeply about what questions were important and how I would do justice to people who told me their stories.

Can you talk a little bit about the questions and discussion over whether postpartum depression qualifies as a “disease” and why that’s important?

It’s been a complicated conversation over the centuries about what exactly defines a postpartum mental illness and what the benefit is of it getting official language.

Historically, in the 19th century, there was this discussion of puerperal mania, which is closer to what we’d call psychosis today, and sometimes melancholia, which is closer to severe depression; these kinds of feelings are going to be specifically tied to either lactation or the postpartum experience. There was a recognition among Europeans and some medical professionals in the US that this was a possible outcome of severely dangerous but possible outcome of childbearing. This is the “Yellow Wallpaper,” moment, which is a political story but also a story of personal suffering.

Then, in the early 20th century, there’s this sense that you have to be more scientific about psychiatry, which has always been like, “Oh, you’re not a real medicine.” There’s the introduction of a lot more rules about the idea of diagnosing based on symptoms because you can describe symptoms. You can’t describe or prove causes. There was a real push in the early 20th century to move away from that. You see that in American psychiatry: there’s this sense that it doesn’t matter if this woman is depressed postpartum or depressed — it’s all the same.

In the ’70s and ’80s, you see this mix of folks who are real advocates saying, “We need this language.” Sometimes, they say it’s for insurance purposes. You want to say a woman is temporarily ill and not that she forever has a preexisting condition. Sometimes, it’s for stigma. “This thing is not her fault. It was caused by the act of childbearing, and she will recover and then be totally normal and restored, not like those other mental illnesses.” Then, sometimes, it’s because of a medical or scientific argument that this simply is categorically different, that women respond differently to different medications in the postpartum and so on. People made different arguments, but there was a real push starting in the ’80s to say this is a different disease.

Talk a little bit about what you found in stories about postpartum women feeling wrong, like, “I should be happy,” or the cultural message that the state of motherhood should bring you joy.

That has been interestingly contentious in the ’60s, ’70s and then beyond. There are all these essentialist debates about motherhood; the act of giving birth should bring joy. In the section on 1970s feminism, you see these different debates over what that means. Is it that women should have their expectations adjusted a little bit? Maybe it’ll bring you joy, but it’ll bring joy when you interact more with your children. Or maybe it’s not an inherent joy, maybe it’s a learned joy. Not a complete dismissal of the idea, but a modification.

Then some radical feminists were at the time arguing, like, “You can tell by women screaming in the birthing ward that motherhood is a mess. Or, “You can tell there are examples of infanticide therefore, motherhood is wholly unnatural.” They weren’t interested in helping women with postpartum depression. They were using it to make a point to denaturalize motherhood. Then, at the same time, you have folks in the hippie counterculture in those years who are embracing midwifery and embracing natural birth and rejecting hospital birth.

I don’t think the intention was to be mother-blaming for any of those groups. It ends up being that to support their argument, they have to talk about how natural motherhood is joyful. If you give birth on the farm and are surrounded by other women, then you’ll get back to that natural point. Instead of rejecting the idea, they’re like, “You have to do it differently, and you’ll still get back to joyful motherhood.”

Tell me how other countries address postpartum in a more compassionate, organized, clinical way than the States does.

Western Europe, Canada, and Australia are usually examples of folks who are notably ahead of where the US is. Most writing about this has been in Great Britain and has dealt with the fact that because the National Health Service has a history of baby visitors and home visitors to women postpartum, and as a result, has had more surveillance, but then also more intervention points with women.

In terms of medical research, much more was often happening in Europe. I talk about the founding of the Marcé Society in 1980, which became and still is the preeminent psychiatry, psychology, and professional society on perinatal mental health. It was founded in Great Britain. While there were a couple of Americans at the table, their reporting was always somebody like Dr. James Hamilton, who was there, took it back, and it’s like, “Nobody in the US psychiatric community is listening to me.”

I remember being at one of my kids’ early pediatric appointments and getting this survey basically asking, “Are you in danger of killing yourself or your baby? No? Then you’re fine.” I remember at the time being like, ‘That was so superficial.’”But from reading your book, I learned how that took a ton of work to get that in front of me.

I had the same experience with so many problems with some of these screeners, but the resistance to screeners even existing was wild. The screeners are such incomplete tools. Some measures have been taken, but essentially, a pediatrician gives a new parent a screener, but then what? They’re not even your doctor, and who are they going to refer you to in the US healthcare system where we have such a shortage of mental health providers? Will your insurance cover it? There are so many holes still.

What was most surprising in the process of researching this book?

The idea of how important some of those interventions were. Women going on Phil Donahue’s show to talk about postpartum depression was wildly important, both in the popularization of language of postpartum depression and in individual women’s lives. When they turned on this talk show and heard this was a common condition, this was a common reaction that there was help out there, even though it was so hard to get that you’d have to call the television studio to get information or whatever—but that it existed was important.

It goes into the 2000s to 2010s when you have mommy blogs, which are super condescending language about what was happening. These women are moving the needle. They’re writing about their feelings, they’re being public about them, and they’re also arguing for call your congressmen when they wanted the MOTHERS Act pass, for instance. That is something for which no credit has been given.

What has made you hopeful?

In the past five to 10 years, there’ve been a few interesting and important moments where we see, in many ways, we see the lobbying and the organizing become much more professional, which in some ways is hard for my feminist grassroots loving heart, but also it’s what works that’s been important. The women behind that have made substantial progress, especially at the state level.

I write about a program in Massachusetts where women can get a hotline for obstetricians to connect to a psychiatrist who can advise them on what to do for a postpartum patient. That’s not necessarily something an obstetrician has been heavily trained in, and psychiatrists are also hard to come by. That’s been an important move. Then, they had federal funds and exported that program to several states.

Then you also have the work done in Illinois specifically around infanticide law, which is still an Illinois-specific law, but the first law in the US that has essentially required that if a woman is postpartum and wants that as a consideration and a trial, that has to be considered. It’s a big deal.

If you were in charge of everything, what would you do differently that would make women who are about to have a baby feel a little less scared or abnormal or less of a failure or a danger of postpartum?

It’s a mix of things because what’s so complicated about postpartum illness is that it actually has a lot of different illnesses. Women with postpartum psychosis symptoms need different kinds of support. There’s overlap, but they often need different kinds of support, immediate intervention and absolutely professional intervention. It’s a small number of women percentage-wise who get postpartum psychosis, though it still ends up being a lot of women. Then within that is an absolutely tiny percentage that try to harm their children, that want to harm their children, or that ultimately do harm their children.

Women with postpartum psychosis need access to care. It needs to be easy to know who to call. It needs to be not scary. You need to not worry that your children will be taken away. That’s doubly true if you’re low-income or a racial minority, somebody who feels more targeted is more targeted for that intervention. Then, for women who are more likely to experience mild to moderate depression, there needs to be all these social supports that are so hard to come by. This is the pie-in-the-sky part. There has to be paid parental leave. There have to be accessible outlets for people. We live in a society where you likely do not have a family network nearby. That’s a modern development in many ways, but it’s a lot less likely you can leave the baby with mom or grandma for a few hours and go do something or have those boundaries. That’s a big issue because even if you’re on parental leave, that alone will not make you well.

No, some of us do not have a good time on maternity leave. I was like, “I would not want more of this.”

Both those things have to be addressed. There need to be accessible, enjoyable outlets. There need to be childcare options. People need to feel good about their childcare options. People need to feel like they have a real choice about when they return to paid work. They need different kinds of support at different levels. Some of that is peer support, and sometimes that is professional support.

What do you think has been heartening in undoing some of the whitewashing of this conversation and the research?

There are lots of incredible activists who are people of color who are setting a clear agenda and who have been working in these organizations. A lot of the work in the last few years has been to say the experience of motherhood is substantially shaped by race, social, economic class, sex, quality, and all of these things. There’s a long history of racism and white supremacy shaping what motherhood means. Acknowledging this history and understanding it is important. One of the folks I talked to talked about how, in the earlier years, you’d get to training on postpartum depression, be mostly white, and there’d be a slide on “culture.” “We need to be culturally sensitive.” There’s no conversation to be had about mental health of any kind that doesn’t center on inequalities and doesn’t think through those things from its core. We moved a lot in some ways, and then we’re also at a political moment where we might be moving away from that.

Do you have any takeaways about what we can do at the individual at the most immediate social level to support either research or simply advocate? What can we do now that will not go into the void or get rejected or co-opted by bad actors?

A thing I was fascinated about is how successful advocates for postpartum depression research and conversations were in the 1980s, which was a politically conservative moment in many other ways. I don’t think the 1980s are comparable to where we’re at right now, but I do think that many of the things they did, they were strategic in different ways, sometimes with mixed results. There was an emphasis that this was for mothers and for the safety and health of babies. Now, that’s a huge compromise. That’s a dangerous thing to say in many ways. Why can’t this be for women? Why does it have to be for babies? On the other hand, if you want resources, sometimes compromises are worth thinking through.

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