The current popular notion is that postpartum depression (PPD) cannot be prevented. Rather, it can only be diagnosed with an Edinburgh test once the patient has PPD. Often PPD is considered to be both surprising and mysterious. In reality, it is neither. PPD is nothing new. We’ve known about it for years. My first experience with postpartum depression goes back to 1976, when I was a third-year medical student.
I listened to a young mother with a two-year-old daughter and a four-year-old son. She spent some time talking and I spent some time listening. Her daughter seemed to follow her mother’s directions without resistance, but her four-year-old son seemed to be contrary, too often questioning his mother’s authority. Specifically, he did not want to get dressed.
“Tell me about dressing,” I asked. My patient answered, “Well, he doesn’t want to wear the clothes I choose.” Having little children, I knew about dressing kids. I said, “Maybe he wants to choose what he wears.”
My patient said, “Yes, but he might choose plaids and stripes.” I asked, “What’s the problem with plaids and stripes?” As it turns out, my patient was concerned about what other moms would think about her mothering skills if she allowed her son to run around in plaids and stripes. I recognized the problem as a power struggle. I asked, “Could you let him pick out his own clothes? “No,” was the answer. Then I asked her if she could pick out two outfits that she liked and give him a choice. That way they shared control. Her son was happy with that small amount of choice and she was happy with his outfits.
There have been many attempts to explain PPD. These include hormones and pre-existing depression. In my experience, the most common problem is a parent’s unrealistic expectations. These unrealistic expectations revolve around two issues: new parents who think nothing is going to change with the birth of a new baby and the notion on the part of the new parents that they can handle anything.
New parents need to plan for the division of labor before they leave the hospital. No new mother can get by on four hours of sleep a day and nursing their baby every two hours—at least not for very long. New parents need to be confident in their role in caring for the new baby. Visitors can make the meals and do the dishes instead of monopolizing holding the baby and expecting the parents to do the chores.
The National Library of Medicine recently posted a 2019 article on the importance of the mother-child dyad. In other words, the article emphasized that the mother-child relationship needs to be considered when dysfunction in the relationship is evident and the physician is well-situated to observe and help resolve the dysfunction. From my perspective, it’s actually much more than a problem with mother-baby dysfunction because the father of the baby needs to be included in the equation. And yes, if there are other children, they need to be included, as well as the father.
The father’s reaction and the reaction of existing children are very much a part of the postpartum experience. Some fathers are helpful. They prepare food, do the dishes, clean the bathroom, help care for the baby, feed the baby, do grocery shopping, and make the life of the new family more workable.
PPD rests upon much more than the mother and baby. If you bring a newborn home to a three-year-old child who is already there, you have to be very careful how you manage the relationship between the child at home and the new baby. You cannot displace the three-year-old or allow the three-year-old to feel displaced. I was very careful to involve everybody in my family with the care of the new baby. In other words, the three-year-old was not displaced by the newborn. We would read together, bathe the newborn together, and take care of the newborn together.
The best way to deal with PPD is not to have it. The best way to not have PPD is to prepare for the changes that will be coming into your life with a new baby. You should make plans for how to manage postpartum changes before you leave the hospital and before you take your new baby home.
Years ago, we had the time to take care of our patients. Since insurance companies have been interfering with the medical care we provide, we have lost the opportunity to get our parents ready to go home from the hospital. Physicians used to be able to decide when a new mother was ready to go home. It’s been so long since insurance has taken over mandating when a new mother is ready to go home; I often wonder if the newer generations of doctors and nurses even think about getting patients ready to go home as part of their job. Now new mothers are given some CDs to watch or are offered the ability to email someone with questions, but this hardly replaces the way we used to observe if the new mother was able to nurse adequately or whether the baby was getting enough to eat. Now, new mothers are often turned out of the hospital in less than 24 hours, whether they’re ready or not. The insurance mandate to spend less time in the hospital has not decreased the cost of the hospital stay and has contributed significantly to poorer postpartum outcomes and hospital readmissions.
We need to recognize that most of the problems surfacing at home with a new baby have to do with practical management of a schedule which is bound to be different after the birth of a baby. The importance of recognizing the need to revise the schedule to accommodate the new relationship with the new baby and the family is key to avoiding PPD.
This approach to preventing PPD is so simple, yet remains so surprising and mysterious to so many people.
Think of Occam’s Razor.
Alan Lindemann is an obstetrics-gynecology physician and can be reached at LindemannMD.com, doctales, and Pregnancy Your Way. Follow him on YouTube, Twitter @RuralDocAlan, Facebook, Pinterest, Instagram @ruraldocalan, and Substack. He is the author of Pregnancy Your Way: Choose a Safe and Happy Birth.