The insidious postpartum effect: when the norm of motherhood is equated with pathology

Journal of Psychiatry Reform vol. 10 #4, April 2023

Caroline Giroux, MD, FRCPC

Author information:

Professor of Psychiatry, Psychiatrist, University of California, Davis Medical Center, Department of Psychiatry and Behavioral Sciences, Sacramento, California, USA. [email protected]

Usually, when new mothers consult or are referred for a psychiatric evaluation of emotional dysregulation in the months following giving birth, they say “I have postpartum”. Postpartum has been so often juxtaposed with depression that its connotation is saturated with negativity. By default, for many years, it has not been something desirable to have “postpartum”. We don’t hear anyone exclaim that they have “postpartum joy”, “postpartum creativity”, “postpartum growth”, “postpartum excitement”, for instance. 

And I have concerns about that. Because in our field, pathology means problem, and it means there is a need to fix. And it usually comes in the form of a medication prescription. But when we start listening to these mothers’ stories, we find out that the anxiety, the frequent monitoring of their infant to make sure the baby still breathes, the blues, the fear of inadequacy are all in fact understandable. Yet, our evidence-based, well-meaning interventions risk exacerbating that sense of inadequacy or defectiveness… As if the issue that needs treatment was inside of the mother, like retained placenta remnants. But what if we broadened our perspective a bit? What if the “womb” of the genesis of the discomfort was way wider than it seemed? 

Years ago, I wrote an article to try to make sense of a trend I had been noticing in young or new mothers. They too often suffered from that dreaded “postpartum”, I realized, in great part because of the lack of maternity leave benefits in the USA. I know for sure that if I had to go back to earning a living 6 weeks into giving birth, if I felt like I had to choose between losing my job or leaving my baby in daycare, I would have been quite depressed too. I have not encountered that level of distress in my friends and relatives in Canada who could enjoy months, if not a whole year, of bonding time at home with their new child. And I know for myself that being at home first for 4 months, and years later for 6 months and then 8 months for my sons helped me recover from all three pregnancies, the delivery, and recharge from breastfeeding and caring for an expanding family. But going back to work prematurely, seeing patients while my kids needed my care and attention would have been torture. It also takes time to examine the impact of such a significant change and complex developmental milestone: becoming a parent. We need time to engage in self-reflection in order to process that and make room for that new person we are responsible for. It is part of the meditation practice that allows us to be more present and attuned parents, seeking to not repeat patterns that have been wounding in our own childhood. Another factor often at play is history of sexual abuse: the pregnancy, with its bodily changes, frequent vaginal exams, and the delivery process and breastfeeding can all be potential triggers because of the intrusive procedures and new mission of the body that can bring back memories of objectification or exploitation. 

Recently, I saw another unfortunate consequence of our fast-paced lives and the pervasive, sexist expectations towards women and mothers. A patient came for assessment after being referred for “postpartum”. After having been through gestational diabetes and pre-eclampsia but an uncomplicated birth, she felt overwhelmed becoming a mother, even though it was planned, or desired. Her mother had died at the beginning of the pandemic, and years later, it “hit” her. She had to learn “on the fly”. Daniel Stern wrote a book called “The Motherhood Constellation”, exploring parent-infant therapies and also referring to a concept in which parents (mostly the mothers) experience a representational change during pregnancy and are viewed as having a unique form of organized mental life and in which the child is most prominent [1]. The emergence of other motherhood-related themes, representations, conflicts and emotions associated with attachment experiences with the new mother’s own mother is also worth monitoring during and after pregnancy from a psychodynamic point of view. Being pregnant makes the future mother reflect on her own relationship with her mother, her self-concept as a parent. Although denying difficulty bonding with her child and saying her baby always wants to touch her and she lets her, my patient not having her own mother to help her go through that life transition likely contributed to her challenging emotions (sadness and overwhelm). Additionally, her mother had lost three children (a girl was stillborn before the patient, then the subsequent pregnancy was the stillbirth of a son, and another girl died from drowning as a toddler). I reflected on how painful it must have been for her mother to suffer such tragedies, to lose so many children… No wonder my patient had anxiety and had expressed the narrative “I am afraid to lose my baby”, probably inherited from her mother. And my patient started her own life in this world by being born prematurely and was apparently in the NICU for 3 months, visited by her parents only once a week because they lived over one hour away… Not only there was a transgenerational legacy of losing babies, predominantly girls, in her mother’s life, but my patient had most likely suffered from preverbal trauma due to separation anxiety from being hospitalized in infancy with only infrequent contact with her parents. This creates a synergy for the development of insecure attachment, either manifested by clinging onto or avoiding others as a mechanism to avoid reactivating these unfulfilled attachment needs. 

Well aware that history often repeats itself in a strangely persistent way until the “curse” is exposed and then, broken, I also wondered out loud if her mother’s mother had lost children. Transgenerational trauma can be found up to three generations prior at times. Her maternal grandmother had apparently “many” children, but in addition to losing my patient’s mother, she had also lost three other daughters. One might imagine that maybe my patient’s unconscious narrative had something to do with girls being cursed in her family tree, hence her postpartum Angst after giving birth to a daughter. 

While medications certainly have their place and should be recommended in cases of major functional impairment or threat to someone’s safety, no SSRI or any other pill will help free my patient from her fear nor from those narratives. No pill will help her process the grief of her mother, reactivated when she became one herself. 

Instead, what I believe will help this woman is starting to mother herself, and by this, I mean making herself a priority and not compromising her self-care because everyone in her life seemed to want or need a piece of her. Since her mother, who apparently took care of everything and everyone in the household, had died, she had to replace her and she was helping her father care for her brothers, who have a disability. So, one of her main challenges will be to find the right balance and harmonize various responsibilities, delegate, or seek help. Her healing also means continuing to let her daughter touch her and cuddle with her, something she didn’t get to do as much when she was a young baby. This way, she lets herself love her child despite her fear. Love, this renewable source of energy, will triumph over fear by melting it. I wish parents in general who feel unequipped to raise children would believe in their potential to break the cycle of insecure attachment by pausing, reflecting, looking at their fear (instead of running away from it or ignoring it) and as they bravely name it, just like my patient did, letting self-compassion in so that she gives others she cares about from the overflow rather than being depleted. And ultimately, the updated diagnosis: good postpartum evolution. 

Reference: 

1. Stern DN. The motherhood constellation: A unified view of parent-infant psychotherapy. Routledge; 2020 Jun 16.