What Maternal Care Would Truly Look Like
on undiagnosed postpartum depression and the unvarnished reality of the postpartum experience
After writing my post about the challenge of the second child, I began to wonder about something that was undergirding that entire experience: the fact that I struggled with undiagnosed postpartum depression and/or anxiety. I only mentioned it twice in the essay, but it lurked behind every single experience I explored. What would that phase of my motherhood have been like if I had gotten the help I needed?
So I posted a question on Twitter, asking how many mothers think they struggled with undiagnosed PPD. The response was immediate. 120 comments swarmed in from mothers far and wide. It turns out, this is very much an unacknowledged epidemic.
It’s not like we are unaware of how unsupported mothers are in this country. The fact that we still have no federally mandated paid family leave policy means that most mothers have to choose between their health and their baby or their financial stability. Only 21% of women have employer provided paid leave. Even employer leave can come with stipulations, like you must have been employed at the company for one year before you can receive benefits. When we ignore the need for mothers to recover, as well as care for their babies, we are signaling that we as a society do not want to support them. We do not care about their problems. We do not take their needs seriously.
This is a deeply demoralizing experience.
So why, in the 2022, are things still this bad? Why are we still so unsupported? What could we do to start truly offering postpartum care in America today?
First, let’s acknowledge that childbirth can be a trauma for the mother experiencing it.
People often say that childbirth is perfectly natural; that our bodies were designed to do this. But you can say the same about death.
I know that some women experience childbirth as beautiful, natural, mammalian; they are able to get through it without drugs, and thus enjoy all the natural endorphins on the other side. However, for others, it is hours of searing pain, followed by feelings of failure when you admit you need drugs (turns out baths and bouncing on a medicine ball just aren’t cutting it), leading to the sense that you are completely out of control of your birth experience because you are now immobilized from the waist down. For many women, they are rushed into emergency C-sections after hours of unproductive labor, thus are dealing with the adrenaline that comes from things not going according to plan, and recovering from being in a state of fight-or-flight on what is supposed to be the most exciting day of their life.
No matter how your birth goes, it is physically exhausting, spiritually taxing, and emotionally depleting. We do not move on from it unchanged. We need to do more to support women through coming to terms with their birth experience, especially if it didn’t go according to plan (and it rarely does). (Check out this cool resource where you can have someone help you tell your birth story).
Let’s recognize that the recovery from childbirth is not immediate nor is it easy.
You only have to look at our lack of paid family leave to know that our society likes to pretend that recovering from childbirth is a lark.
Here is the truth: You literally cannot sit down for days without an iced sanitary napkin and lots of painkillers. You fear the moment when it comes time to release your bowels. If you had a C-section, you cannot lift anything and may struggle to walk up stairs. I had severe tearing during my first birth; my doctor was stitching me up for what felt like 30 minutes. I lost so much blood they were considering a transfusion. It took almost four weeks before I felt like I could walk normally.
“Studies show that women need six to nine months to fully recovery from labor and delivery,” reports this article on the transition to motherhood. Six to nine months! And yet, routine care for a mother is one check up at six weeks postpartum. That is it. And that checkup has notoriously been tied to receiving the okay to have sex and exercise. Let me tell you, very rare is the mother who is thinking about having sex at a time when her breasts are leaking milk and bleeding, her vagina feels like it will never be the same again, she hasn’t had more than three uninterrupted hours of sleep since her baby was born, and she is dealing with an identity crisis that makes her feel so detached from the woman she once was, she despairs that she will ever get her back.
Let’s acknowledge the transition to motherhood as a life-altering journey and celebrate matrescence in all its permutations.
Dr. Aurelie Athan is the head of the maternal psychology lab at Columbia University and she is working to bring back a term coined by Dana Raphael in the 1970’s: matrescence. This word allows us to normalize the mother’s experience and offer a non-pathological description of what a new mother goes through. “Like adolescence, matrescence is the experience of disorientation and reorientation marked by an acceleration of changes in multiple domains: physical, psychological, social and spiritual.” We focus so much on puberty and instructing our children on the changes their bodies will go through as they transition to adulthood. What if we prepared mothers in the same way?
Unfortunately because we do not prepare mothers for this deeply disorienting experience, they feel alone in their despair, even shame that they are not enjoying every moment, thus leading to more depression and anxiety when their experience of motherhood isn’t matching up to the idealized picture presented to them.
What might postpartum care look like?
We don’t have to reinvent the wheel. Other countries have much more extensive support for mothers postpartum:
In the Netherlands: a kraamverzorgende, or home maternity nurse, is available for up to ten days after birth to help with everything from breastfeeding to laundry. This is covered by insurance.
In Switzerland: a midwife is available for home visits for 56 days - also covered by insurance.
In Malaysia: a midwife provides a massage for 3 days following birth to encourage circulation and healing.
In China, they have a practice called zuo yue zi, or “sitting the month,” a 40-day period where the mother must stay in bed; her only tasks to feed the baby and rest. Family members come to cook food that will increase her chi, or life force.
In Japan, women stay at their parents home under the care of their mothers for 8 weeks. This is called satogaeri buben.
In France, the government will pay for ten physical therapy session to help restore the muscles of the pelvic floor.
America is severely lacking in this kind of care. While midwives can definitely help close the gap, they cost between $3-6k, thus are vastly out of reach for most American mothers. If you live in an area of the country where you can hire a postpartum doula, it can be less expensive but these services still cost anywhere from $15-$50/hr.
What we need is for the medical establishment to take an interest in support of this kind, but they have displayed a severe lack of concern for female issues time and time again. A review of Vagina Obscura in the New York Times Book Review reported this: “only in 2014 did the NIH start a branch to study vulvas, vaginas, ovaries and uteruses.” It goes on to say: “In 2009 the bioengineer Linda Griffith opened America’s first and only lab (at M.I.T) to research endometriosis.” This despite the fact that 10% of women of reproductive age struggle from this debilitating condition.
This avoidance of problems that affect women leads to lack of care around menopause, a condition that impacts nearly every female bodied person in the world. This is because doctors are not prepared to care for women in this way. From the Washington Post: “According to the Mayo Clinic, only 20 percent of postgraduate residents reported their programs had a formal menopause curriculum and fewer than 1 in 10 residents in family medicine, internal medicine and gynecology told the clinic they felt ‘adequately prepared’ to manage the care of patients in the various stages of menopause.”
Ignoring the needs of mothers, and women in general, leads us to suffer unnecessarily. Moms joke about being unable to jump on trampolines or even go running because, hello, childbirth! But it doesn’t have to be this way. This is due to lack of pelvic floor care. Many mothers suffer from diastasis recti, a condition where the muscles of the abdomen, which had to separate to make room for the growing baby, never knit back together properly. This can lead to your stomach pouching out, but also back pain and constipation. These conditions are reversible, but only with proper diagnosis and treatment.
A midwife might have helped my own experience postpartum. Not only are they attuned to check in on how the mother is doing and provide support, they also acknowledge the journey the mother has gone through to bring this being into the world, and find ways to acknowledge this transition via ritual. I recently learned about a healing ritual called The Ceremony of the Bones. HealthyMother.com describes it like this:
Many women find that when they have given birth, they feel ‘broken open’ …During the pregnancy, the hips open, becoming wider and wider to accommodate the growing baby and prepare the body for birth. It is vitally important to help the hips close post birth otherwise mothers suffer from pelvic instability, as a result, and they ‘leak energy.’
Another website reported that this ritual “helps a woman to find her own self and center again and allows her to be sealed back into herself.”
I personally needed such a ceremony, instead of feeling like I was leaking all over the place; vaginally, from my breasts, and from my very soul. The experience of being a new mother is so porous; where does the baby end and you begin? But without separation, without space, you lose touch with yourself. You become a dual being, a two-headed monster, both beings raging at this injustice.
“Every mother you know is in this fight with herself. The sword that hangs over her is a sword of exhaustion, of frustration, of patience run dry, a sword of indignation at how little she feels like a human when she so often has to look and behave like an animal. Mostly it is the sword of rage: the rage and shock of how completely she must annihilate herself to keep her child alive.”
I’ll Show Myself Out: Essays on Midlife and Motherhood, Jessi Klein (read an excerpt in The Cut)
Annihilation of self warrants an experience of depression.
So back to the ubiquity of undiagnosed postpartum mood disorders. What I saw over and over throughout the discussion fostered on Twitter was that it is hard to distinguish between the annihilation of self required in early motherhood and true feelings of PPD. Because wouldn’t annihilation of self make most people feel depressed or anxious? How do we separate the lack of support we receive as new moms from the true chemical and hormonal changes going on in our brains? It seems like, given what is asked of you in early motherhood, how could you not get depressed? I think back to Miranda Rake’s heartbreaking yet necessary article in Romper: “It Feels Like Every Mom I Know Is Medicated.”
We must stop the practice of self-assessments for PPD and do away with the term “Baby Blues.”
I am not a medical or psychological professional, so all of these musings are my own, and probably flawed and imperfect. However, I have to wonder at the wisdom of having most PPD/PPA diagnosed via self-assessments administered at the six-week check up and subsequent well-baby visits.
As new mothers we are often completely detached from our feelings and emotions due to the triage of every day. In the early days of motherhood, I could not have told you what I was feeling even if you’d asked. These self-screenings often happen at the six-week check up, when you can still excuse your instability away due to the lack of sleep. You are assured that it will get better soon, she’ll start sleeping longer chunks, and then you will feel more like yourself. But unfortunately, that “soon” can be delayed for up to a year (or even longer as this quote from Nightbitch reveals).
“Please go to sleep, she pleaded, and then cried quietly in bed because she was so tired, wanted just an hour without the child by her side, an hour of television, an hour of sitting on the couch and staring at the wall, just an hour. Anything. Instead, she lay there and lay there and lay there, and then it was ten o’clock….
Who would she be with a full night of sleep? Someone else entirely.”
Nightbitch, Rachel Yoder
I’ll point back to the incredible quote from Angela Garbes that I opened my last Substack with. “Nearly a year after our daughter was born, my husband and I went out to dinner to celebrate our anniversary. As we sat there, martini glasses between our fingers, he asked me how I was feeling. “Honestly,” I told him, “that feels like an irrelevant question. I’m just doing stuff.””
I don’t think Garbes is alone in feeling like her feelings were irrelevant. To admit to how hard early motherhood is is to admit that we don’t like it. It is to admit that we feel erased. It is to admit that we are shells of the women we once were. So we disassociate from our feelings. It is a coping mechanism due to lack of support. It is a tool to help us get through each day.
Plus, we are not dumb. We know how to answer the questions and get things right, no matter whether it is the truth or not. Julia Fine wrote an astonishingly honest account of postpartum psychosis in her novel The Upstairs House. This passage is particularly apt:
“At Clara’s checkups I filled out questionnaires about how I was doing: had I blamed myself unnecessarily, been anxious or worried, had I looked forward with enjoyment? Did I have trouble sleeping? Yes, I did, because I was still nursing every four to six hours. Did I feel like things were ‘getting on top of me’? Yes, an eight-pound baby. It was ludicrously easy to know the right answers, the answers that would have the pediatric nurse nodding and smiling and praising me.”
The Upstairs House, Julia Fine
Later she writes this heartbreaking scene:
“What could I say to a man who was willing to leave what should have been a larger conversation – why had I left Clara, why had I locked the door, why had I told him nothing – at it’s over? How could I tell him now that what he thought was just a footprint was a cavern a thousand feet deep? Ben wanted things to be easy, and because of this he had convinced himself that they were….
I could never ever tell him….
“Should we be worried?”
I knew what he wanted to hear, and because I still loved him in love’s simplest form, and still wanted to please him, I said, “No. No, you shouldn’t be worried. I have it all under control.”
“Thank you,” said Ben. “Thank you for being so honest.”
The Upstairs House, Julia Fine
To witness the folly of the self-screening firsthand, take a moment and go to this link where Mental Health America provides a 10-question self-assessment screening for postpartum depression. Before we even begin, I see a glaring error. “Please select the answer that comes closest to how you have felt in the past seven days, not just how you feel today.”
As any new mother knows, the days blur together. What day is it? What was happening seven days ago? I only know this moment, and the next, and that after that it is nap time and then it starts all over again. Already, the mother feels like she is failing and she hasn’t even begun the test.
Then scroll down to statements 4 and 5.
“I have been anxious and worried FOR NO GOOD REASON.”
“I have felt scared or panicky FOR NO GOOD REASON.”
For no good reason? Who determines what a good reason is? The entire experience of motherhood, the impossible task of keeping an infant alive, is an exercise in anxiety. What does she need? More food? A burp? A diaper change? Why is she crying? Is she sick? Should I call the doctor? Is this normal?
These are the inevitable anxieties of new motherhood and when you are in them for the first time, you have no way to discern whether they are logical or not. How are mothers supposed to answer these questions?
Now scroll to #7: “I have been so unhappy I have had difficulty sleeping.”
Who can answer that question accurately? First of all, you aren’t sleeping because your baby wakes you several times a night. Many times, you have trouble falling asleep because you are just anticipating the cry, the waking, that requires your wakefulness. I remember dreading going to bed because it was like my entire body was on high alert, just waiting to respond to the call.
“They do not realize that I have the ears of an owl now, that my aural reach can pick up the movement of my daughter’s breath across the city. This is what it means to be a mother. My claws are ready. I am always hunting.”
Burnt Sugar, Avni Doshi
Finally, #9: “I have been so unhappy that I have been crying.”
Um, isn’t crying just a constant state of new motherhood? Because you are exhausted and overwhelmed and never have a moment to yourself?
I don’t mean to disparage this tool that clearly seeks to help mothers. And yet, it is lacking, is it not? We need more than self-assessments. We need more than a belittling reference to “baby blues.” This term was coined in the 1940s by a doctor who also advised that expecting mothers have no more than 10 cigarettes per day.
Finally, we need affordable childcare.
We must acknowledge that requiring adult humans to be fully satisfied by caring for barely sentient beings for endless hours every day UNPAID is an exercise in insanity. We need time away from our babies so that we can get back in touch with who we are apart from mother, whether we choose to work outside the home or not. We need a chance to miss our children. We need a chance to breathe. The one thing I did right after having my second child was I enrolled my oldest in preschool two mornings a week at the JCC, dropped my infant off at the gym daycare, and went into the locker room to take a shower. I just needed a few hours a week to myself. A few hours to separate from their physical touch. A few hours to listen to the thoughts in my own head. A few hours away from the house filled with tasks I never got to.
When we lack childcare, we lack the ability to take care of ourselves. This riveting interview with the author of the award-winning Sylvia Plath biography Red Comet asks a question that underlies this entire post: “I often wonder if [Plath] would have died by suicide if she’d had a good live-in nanny during the winter of 1963.”
FUTHER RESOURCES: Anya; Maternal Mental Health Now; Katharine Stone and Postpartum Progress; The Matrescence; Chamber of Mothers
If you have further resources to offer, please leave a comment for the community.
FURTHER READING
Stop everything and read this excerpt from Jessi Klein’s new book, I’ll Show Myself Out, in The Cut. Then listen to her talk to Terri Gross on Fresh Air. You’re welcome.
I wrote about my linguistic indoctrination as a woman in Isele Magazine.
“X-Men” by Alissa Knickerbocker in Tin House, on how disorienting the postpartum experience can be.
Watch Alexandra Sacks discuss Matrescence in a 6-minute TED Talk.