Feministe friend Jessica Grose has an important series up at Slate on prenatal depression, its pervasiveness, and the stigma still attached to it (Part 1 is here; you can click through at the bottom of the piece to read parts two and three). After detailing her own experiences with depression during her pregnancy, Grose looks at the utter dearth of conversation (and certainly empathy) for women who are pregnant and clinically depressed. She writes:
When I began looking into prenatal depression, it appeared to be an underdiscussed yet potentially devastating part of pregnancy for millions of women. This hunch was hammered home by the results of the survey that I posted along with the first and second parts of this series. At the time of this writing, more than 1,200 of you were gracious and brave enough to answer the survey. The survey was for women who had experienced prenatal depression and their partners, and the vast majority of respondents—more than 85 percent—said they felt guilty about their prenatal blues, and less than a third of survey-takers said they were comfortable talking about their depression with family and friends. Over and over again women used the same words to describe why they kept their feelings to themselves: They were embarrassed, they felt no one could relate, they feared being judged or misunderstood.
Many women, like Grose, experienced bouts of depression prior to their pregnancies and were on SSRIs or other medications to manage their conditions, only to go off of them while pregnant. Why? Because, as Grose herself reported feeling, there’s a cultural emphasis in certain parts of the U.S. for pregnancy to be natural and chemical-free. That doesn’t necessarily mean no painkillers and a bathtub homebirth, but for many women it does mean a concerted effort to avoid things that may be bad for a developing fetus — cigarette smoke, toxins in cosmetics, and certainly many prescription drugs. While studies have generally shown that some mental health medications don’t pose large risks to a fetus, the desire to do pregnancy right — to sacrifice to make sure your baby is ok — is often enormous, and something that many women bow to. Grose writes:
But even though I knew lots of women who had healthy babies while on Prozac and Zoloft, and I knew that many, many studies showed only a minuscule chance of those drugs affecting my fetus, I didn’t want to go back on. I suppose on some primal level I wanted to be pure while pregnant. If anything went wrong with the baby, I would always wonder if my being on antidepressants was to blame. This was not a science-based decision. But when it comes to pregnancy, particularly your first pregnancy, it’s tough to ignore your emotional brain.
Grose eventually realizes that her depression is wreaking havoc on her life. She also points out the value in taking holistic health into account — while there is a very tiny chance that a medication like Prozac can cause problems in a developing fetus, depression can also physically stress a woman’s body and lead to fetal damage or even miscarriage. Depression can also mean the loss of a job (and the attendant loss of health care), a disintegrating or destroyed marriage, and a new mother who is unable or barely-able to cope with an infant. Those are health care issues as well, and they need to be taken into account when making decisions about pregnancy and mental health.
But what Grose realized as she and her health care providers gradually came to the decision that going back on antidepressants was the right course for her was just how little information is out there about prenatal depression. Doctors, she found, didn’t even believe prenatal depression existed until very recently — the consensus was that pregnancy released enough estrogen to protect women from mental distress. And even when doctors do recognize that prenatal depression exists, pregnancy is such a delicate and complicated time that they’re hesitant to prescribe medication, for fear that any issues with the fetus or child will be pinned on them.
Numerous studies have pegged the rates of prenatal depression at more than 10 percent of women, and yet the myth persists that pregnancy protects you from melancholy. And it’s a dangerous one. The lack of public conversation about prenatal depression and the fallacy of the happy, glowing mother-to-be can block women from recognizing the problem and seeking help. This is particularly true for poorer women who have less access to regular prenatal care, much less sympathetic, enlightened doctors.
“Part of [the myth] is a wish that pregnancy would be protective,” says Dr. Elizabeth Fitelson, director of the Women’s Program at Columbia University. Fitelson thinks that the continued taboo of prenatal depression in part stems from our increasing devotion to all things natural in pregnancy. From the constantly growing list of foods to avoid to the overwhelming pressure to breastfeed, there’s an unavoidable cultural push toward being natural and pure in the prenatal and postnatal periods, and that includes a fear of antidepressants. “No one wants to take medications during pregnancy of any kind,” Fitelson says. “And no one wants to prescribe medication.”
Part of it is also good old-fashioned “fetus first” prenatal medicine. The same biases that lead doctors to go to court to force women to have C-sections and leads hospitals to attempt to drug test pregnant patients and then report them to police are in play here: The fetus’s health and rights are primary, and the woman is simply a vessel to get that fetus into the world.
Of course during a pregnancy that is being carried to term, doctors should inform patients of any risks posed to the fetus by the patient’s medications, behaviors or other conditions. And I would even argue that doctors do have an ethical obligation to advocate for the developing fetus. But advocating for the healthiest pregnancy possible can’t come at the expense of the actual patient, and her health should be the priority, even while fetal health is taken into account.
This is also a class issue. Unsurprisingly, prenatal depression is far more common in low-income women, with one study putting prenatal depression in low-income Atlanta women as high as almost 50%. That makes sense. Having a baby is stressful and life-altering no matter who you are, but if you’re an hourly wage worker without health insurance or maternity leave or a stable source of income? If you can barely afford to care for yourself and your existing family? Not to mention that under-insured or uninsured women may be seeing an OB through their very basic insurance or a variety of governmental programs, but probably aren’t able to see anyone who specializes in mental health care. And the doctors that low-income women do tend to see are in turn over-worked and stretched thin, and may not be able to spend adequate time talking with patients. Compounding all that is the sexism and racism in our health care system. Reports of pain or medical distress are less likely to be taken seriously if the patient is a woman — this is true for everything from chronic pain to joint pain to reproductive heath problems to heart attacks. It’s no surprise that pregnant patients — who are mostly women — see their mental health concerns belittled or ignored. The same goes for people of color. Black patients (including children) are less likely to get pain medication than white patients. And when it comes to pregnant patients who receive punitive treatment from doctors — being hauled to court to force c-sections, being prosecuted for drug use while pregnant — we’re looking at women who are disproportionately black, Latino and/or poor.
So not only are low-income women (and I would guess women of color) more likely to experience prenatal depression, but I’d imagine they’re also significantly less likely to receive adequate mental health treatment.
In the third part of her series, Grose discusses the various responses from Slate readers. They’re illuminating. Some women received great care; many others were told some variant of “it’s hormones” and prescribed fish oil. Many reported feeling embarrassed and ashamed; pregnancy is supposed to be a happy glowing time, and depression doesn’t fit that narrative.
If you want confirmation of just how strong the prenatal depression stigma is, read the comments (or don’t). Jessica is repeatedly attacked for simply being a “depressed women” who happened to get pregnant, and therefore not really a woman with prenatal depression (as if the two things are severable, and as if depression is universally a condition that is ongoing and even-keeled rather than, in many people, a condition that culminates in episodes). She’s also branded “Whiny” and self-indulgent. And then there are the amateur doctors in the house who insist that no woman should ever be given antidepressants unless x, y or z reason, or that depression is REALLY caused by dehydration or a lack of Omega-3s or whatever else. Also depression is just people who are maladjusted or overly-privileged crying about anything hard in life. Also BIG PHARMA! (Also, for the record, I do think there’s something to the argument that doctors prescribe antidepressants because it’s cheaper and easier than utilizing other therapies that might be as effective and a patient might prefer, but it doesn’t follow that because the jacked-up American medical system incentives antidepressant prescriptions over other therapies that all or even most antidepressant prescriptions are suspect or lazy or bad). Point being, a well-researched and well-articulated article is immediately shouted down with the usual accusations: You’re just whiny and narcissistic. Pregnancy should be the happiest time in your life. Seeking help is a sign of weakness, not strength and self-care.
It’s a shame, but it’s also the internet. And I’d imagine there’s a much larger group of people who read the article, found it informative and relevant, and didn’t bother commenting (as is true for everything written on the internet ever). I’m heartened, at least, that women like Jessica are willing to write about their own experiences, and encourage others to discuss theirs as well. And it’s certainly an unmitigated good to have prenatal depression come out of the shadows.