Great Expectations

Pregnancy Blues: What Every Woman Needs to Know about Depression During Pregnancy
by Shaila Kulkarni Misri, M.D.

It should be a time of joyous anticipation - the happiest time in a woman's life. But for many women, the joys of pregnancy are clouded by feelings of fear, sadness, and confusion. And unlike postpartum depression, which is widely portrayed in the media and embraced by the medical community, depression during pregnancy has been rarely discussed and often misunderstood - until now. In this groundbreaking book - the first to focus exclusively on depression in pregnancy - Dr. Shaila Kulkarni Misri, a leading reproductive psychiatrist, draws on her twenty-five years of clinical practice and research to offer hope, help, and healing - as well as a provocative, myth-shattering examination of a subject that has too long been shrouded in darkness.

The numbers are surprising: up to 70 percent of pregnant women experience some degree of depressive symptoms, and of those, 12 percent meet the diagnostic criteria for major depression. Although it is at least as common as postpartum depression, which occurs after a child's birth, pregnancy-related depression is often cloaked in silence, shame, and denial. Pregnancy Blues lifts the veil on this heartbreaking - and very treatable - illness, examining the key social and biological factors that can come together during pregnancy to create a climate in which depression and anxiety thrive, as well as offering the many effective treatments that are available. Discover:

• How to recognize the signs and symptoms of depression - and know when to seek help
• The role of female hormones: why women are more vulnerable to depression than men
• How depression can "hide" behind physical complaints, such as back, stomach, or even chest pain
• The unspoken connection between infertility and depression
• The antidepressant controversy: the facts on specific drugs, their safety - and when medication is the right choice
• Breastfeeding and medication - the risks and benefits

Plus helpful self-tests and resources, information on alternative treatment options - from therapy to acupuncture - and much more. A work of daring and compassion, Pregnancy Blues challenges the underlying traditions and beliefs surrounding pregnancy and motherhood - and explores how those misconceptions have led to the drastic underdiagnosis and undertreatment of depression during pregnancy. A must-read for women and those who love them, Pregnancy Blues is at once an extraordinary roadmap to healing and an eye-opening report on a medical issue that no woman can afford to miss.

Chapter 1

CULTURAL MYTHS, CUSTOMS, AMBIGUITIES, AND MISCONCEPTIONS OF WOMANHOOD, PREGNANCY, AND MOTHERHOOD

If some enterprising salesperson were to create a pregnant woman's coloring book aimed at the North American market, it would surely come packaged with a box containing nothing but pastel crayons with names like Blissful Blue, Perfect Pink, and Mother's Mauve. No Black Cloud, Blue Funk, or Red Rage in that crayon box! And the mothers outlined in the book for coloring would all be smiling serenely, gazing lovingly into the eyes of their partner - an equally blissed-out expectant father - and, of course, looking nothing less than beautiful.

If that sounds like the Hollywood image of pregnancy, it is certainly the one that's been sold to Western women, and that Western culture has naively bought into. For the majority of women, it is probably even a fair approximation of the truth. It is not, however, the image of pregnancy that I see every day. And if we look a little more closely at the myths and mixed messages that have historically surrounded fertility, family, and femininity not only in our society but in cultures throughout the world, we can see that - as is so often the case with the images Hollywood has for sale - this is one that may have been meant for viewing through rose-colored glasses.

To begin close to home, let's take a quick look back at the history of our own North American culture as it has grown from a mainly agrarian to a mainly technological society. In times past, when we tilled fields, worked the land, and subsisted mainly on what a single family could produce for both sale and sustenance, children were important assets. As farmers, ranchers, or even local shopkeepers, we needed those extra hands to work alongside us and help to support us. Fertility and motherhood were, therefore, valued as well, and a woman's primary role, aside from taking care of the family homestead, was to produce and nurture children. "Mother" was a prized and universally recognized job title.

I know that for many modern women, reading about the difficult and often isolated lives of those pioneer and farm wives will immediately bring to mind the now-classic advertising slogan "You've come a long way, baby!" And indeed we have. But that also begs the question "Where have we arrived?" In many ways, of course, the lives of twenty-first-century women are dramatically better. And it's certainly true that, from a medical perspective, obstetrical care is better and more universally available than ever before. But what about the lives of mothers, and even the value we put on motherhood itself?

For the majority of Western women today, motherhood, rather than being a primary function, has become no more than an add-on. Even those of us who truly yearn for children, who unwaveringly wish for the chance to be mothers, are unlikely either to perceive motherhood as our only goal or to have the luxury of enjoying it as our only job title.

In a technologically driven society, pregnancy is too often perceived as an interruption of or an addition to other, more valued activities. At best, we are ambivalent about where pregnancy and motherhood belong on our list of priorities. "Stay-at-home mom" and "mommy track" are terms that have entered our vocabulary with a kind of stigma attached. Women who choose (and have the luxury of choosing) to opt out of the job market or limit their career path in order to spend more time with their children are often marginalized by and isolated from their working peers. Those who choose to pursue both career and motherhood, on the other hand, are often made to explain or justify their choice to those who believe they "should" stay at home. And for the majority of women who simply do not have a choice, pregnancy and motherhood present financial as well as logistical burdens that can be overwhelming.

In fact, throughout history and across cultural boundaries, woman's unique ability to bear children has put her in the position of being both worshiped and feared; it has been her source of power and her burden, a blessing and a curse. Religion and mythology, which brim not only with female fertility figures such as the Buddhist Kwan Yin, the Hindu Lakshmi, and the Egyptian Isis but also with seductresses such as Lilith and Diana, reflect this dichotomy. Even the Virgin Mary, the most universally recognized mother figure of them all, is not only blessed to be the mother of the Christ, worshiped as the intermediary between the human and the divine, but also born to bear the burden of becoming the Mater Dolorosa, the mother who weeps for the loss of her only child and the sins of humanity.

This ambiguity or dual nature inherent in the concept of "womanhood" is also reflected in religious and cultural issues related to women's bodily functions. The Orthodox Jewish community, for example, considers a menstruating woman unclean. She is forbidden to have sexual relations with her husband and required, when her period is over, to immerse herself in a ritual bath not once but three times to ensure that any lingering impurities are washed away. Here we can see the duality that exists between woman as the bearer of children and woman as temptress: if she is menstruating, she cannot become pregnant, her potential for motherhood is temporarily negated, and so for her husband to have sexual relations with her during this time would be to give in to her powers of seduction - to be, in a sense, defiled by her.

Similarly, in traditional Hindu culture, women were considered both inferior to men and, at the same time, capable of seducing them away from ascetic contemplation and spiritual purity. Only through motherhood did they cement and ensure their power base through their almost total influence over their children and the household.

In these and other traditional cultures, motherhood not only endows women with a kind of retrofitted purity but also initiates them into a special company of women. In many communities throughout Asia, Africa, and South America women generally give birth surrounded by other women, and following the delivery there is a traditional period of confinement during which both mother and child are tended and nurtured by women.

In many cultures, there is a special birthing place set aside, which only women can enter, and very often - such as among the women of Yemen, the Gbaya of Congo, or the Seri Indians of Mexico - that can mean as many as fifteen female friends, neighbors, and family mem- bers in addition to the midwife present to witness the birth. Even in Elizabethan England, men were banned from the birthing chamber while female friends, relatives, and neighbors, known as "gossips," were invited to attend. Some, in fact, might spend days or even weeks after the birth attending the mother in her room.

Copyright © 2005 by Shaila Kulkarni Misri, M.D.

About the Author

Shaila Kulkarni Misri, MD, Frcpc, is one of the leading reproductive psychiatrists in North America and is internationally recognized as a pioneer in women's mental health and reproductive issues. She is the founder and director of Reproductive Mental Health at both St. Paul's Hospital and BC Women's Hospital & Health Centre in Vancouver, and Clinical Professor of Psychiatry and Obstetrics and Gynecology at the University of British Columbia, Canada.