Is Postpartum Depression Really Postpartum Neglect?

Postpartum depression may be a misnomer. A more accurate term might be postpartum neglect- not by mothers, but of mothers.

The human infant is uniquely helpless in the early weeks and months of life. His arms fly up over his head at random moments in a primitive “startle reflex.” His sleep patterns have no rhyme or reason. He eats and poops round the clock. Serving an evolutionary purpose, in part to achieve an upright bipedal posture, the human brain does 70% of its growth outside of the womb.  

For a new human parent, the young infant’s absolute dependence may translate to no sleep, no showers, no ability to do anything but care for the baby. Harvey Karp has referred to this time period as the 4th trimester. His popular Happiest Baby on the Block series offer advice about what to do for a range of behavior challenges in this time period.

But as pediatrician turned psychoanalyst D.W.Winnicott identified, a mother knows what to do. He referred to this kind of care as “primary maternal preoccupation” a preoccupation that is not only healthy but also highly adaptive. The problem lies in the fact that in contemporary culture new mothers do not themselves have a "holding environment" that supports caring for the baby in the way his immature nervous system requires.

  

In an equally important evolutionary adaptation, the human newborn is available from the earliest hours of life for connection and complex communication.  In a calm, quiet setting, at just a few hours of age a baby will turn to a mother’s voice, follow her face, make imitating movements with his mouth.  He makes himself available for falling in love.

These two evolutionary adaptations come together in the concept as described by J Ronald Lally of the “social womb.” The human infant, with his highly developed capacity for social interaction even from the first hours of birth:

turns this seeming weakness into strength. During this dependent period the human brain is very active, developing more rapidly than at any subsequent period of life. It is picking up clues as to how it should grow, learning what it needs to survive, how to relate to others, and how to fit in and function in various settings and situations.

However, when the expectation exists that a new mother will function as she did before the baby was born, offering this “social womb” may be very difficult. Faced with this expectation, many mothers feel very much alone. 

As Winnicott wisely observes, "It should be noted that mothers who have it in themselves to provide good-enough care can be enabled to do better by being cared for themselves in a way that acknowledges the essential nature of their task."

 In my behavioral pediatrics practice, whether a child is 2, 5, 10 or 17, mothers frequently describe feelings of deep loneliness in those earliest weeks and months that stand in stark contrast to the cultural expectation of joy and love.

Social isolation, anxiety, sadness, and marital stress color the experience of caring for a newborn who cried all the time, never slept, couldn’t breast-feed. Fussy infants became challenging toddlers. Tantrums, separation anxiety and family conflict define the preschool years. When these children enter the structured school system, problems of emotional regulation may lead to psychiatric diagnosis as defined by the DSM (Diagnostic and Statistical Manual of Mental Disorders.)

As I describe in detail in my forthcoming book, The Silenced Child, primary prevention lies in caring for mother and infant as a unit. In the first 8-12 weeks, brain growth (the infant brain makes 700 connections per second) and with that healthy development, requires care by the mother, or mother figures, in the same way that the mother’s body held the baby in pregnancy- 24 hours a day, seven days a week.

There is an evolutionary purpose to what in this country was once termed "lying in." During a period of 3-4 weeks mothers were able to rest and connect with their baby while a group of women helped with household chores and offered emotional support.

Cultures around the world recognize the need for protecting the mother–baby pair in this way. Contemporary American society, with its unrealistic expectation of rapid return to pre-pregnancy functioning, is uniquely lacking in a culture of postpartum care.

We cannot go back in time to a period when extended family was available to provide a community of support. Nor will we be able or even want to return to a time when mothers stayed in bed for 3-4 weeks after childbirth. But some steps must be taken.

For just as we know that supporting mother-baby pairs leads to healthy development, we know that when early relationships suffer, the long-term consequences, for both mother and child, are significant and worrisome.

To optimize brain growth and development by providing a “social womb”, new families need to be held in the same way that the mother’s body holds the baby during pregnancy. Mother-baby groups, as offered by the Community Based Perinatal Support Model developed by MotherWoman, as well as increased paid parental leave and home visiting programs offer other forms of support, as does recognizing that physical recovery from childbirth does not happen overnight.

Perhaps the first and most important step in promoting healthy development lies in locating postpartum “illness” in its proper place- not in the mother, but in the way our society cares for mothers.