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By Ananda Lowe
In 2010, while pregnant with my only child, I lined up a postpartum doula before I even chose the hospital where I would give birth.
I had worked with new families throughout the Boston area for fifteen years, mainly as a professional birthing coach (another type of doula), and occasionally as the postpartum type myself. So I knew getting help for myself after childbirth was the first thing I had to have in place.
I'd seen up close how much help vulnerable new mothers need and how rarely they get it. And I was well aware of the more-common-than-you think risk of postpartum depression. I also knew that this kind of depression or related mood disorders could take hold well after what most people understand to be the "postpartum" period.
I'd asked my therapist if they ever "put mothers away" should we become too overwrought or depressed or gripped by intense, irrational anxiety about our new babies? She immediately responded: "There would be no place to put them all."
So why a doula, you may ask? To put it plainly, a doula can help assure that a vulnerable new mother is not alone in the world. Which is to say, any new mother.
The person I contacted for help was Brenda Morris, the wife of one of my best friends. I’d previously encouraged Brenda to become a doula, and now I called to say “I found your first client. It’s me.” Brenda was a private aide to the elderly, the middle child of thirteen, a good cook, and the mother of twins whom she breastfed for three years. Though not formally trained as a doula, she had all the qualifications I needed, and my partner and I hired her to take care of me for ten hours per week after the baby came.
According to the doula certifying organization DONA International, a postpartum doula:
·Offers education, companionship and nonjudgmental support
·Assists with newborn care, family adjustment, meal preparation and light household tidying
·Offers evidence-based information on infant feeding, emotional and physical recovery from birth, infant soothing and coping skills for new parents and makes appropriate referrals when necessary
Another national organization, CAPPA, says the doula’s role “is not to take over complete care of the newborn, but to educate and support the family so that they will feel empowered to care for their newborn themselves.”
While I was pregnant, I knew I was not planning to be my own birth doula, postpartum doula or lactation counselor, even though I am trained in those roles; people who spoke to me casually at parties assumed I wouldn’t need the guidance. However, beyond the technical definition of a doula, she does something more than educate clients and make sure the chores get done.
Social support is consistently identified as an important factor in the prevention of postpartum depression and mood disorders, whether the support is provided by family and friends, professionals, or trained volunteers (DONA does a good job of compiling the research here). Much of the rest of the world still knows this, but as Hillary Brenhouse put it in The Daily Beast:
It is true that hiring a postpartum helper is far less expensive in, say, Hong Kong than in the U.S. But the problem is not one of money. The problem is that no one recognizes the new mother as a recuperating person, and she does not see herself as one.
After my daughter was born, it became harder for me to continue with my profession which required me to leave home in the middle of the night to attend other women’s births. So I shifted into leading support groups for new mothers at places like the former Isis Parenting in Boston and Diaper Lab in Cambridge. And I have to agree with Brenhouse; the refrain that I hear from new mothers has become heartbreakingly predictable.
For example, I recently gave a group of mothers the Positive Postpartum Plan created by Belmont therapist Mara Acel-Green, who specializes in the prevention and treatment of postpartum mood disorders. Acel-Green created a worksheet for new mothers to fill in the names of friends and family who can help with things like meals, emotional support and watching the baby so the mother can take a shower. The women in my group looked uncomfortable when I asked them to participate in this activity, and they hesitated to pick up the pens I gave them to fill out their worksheets. Finally, one six-week postpartum mother looked at me ruefully and said “I feel like my window for this has already closed.”
To be honest, I hear that all the time.
Reflecting on my own experience, we had hired Brenda as our doula for a full five months. I breastfed up to fifteen times a day, but during those months I did not grocery shop, cook, do laundry, or take out the trash or recycling. Once at a staff meeting at Isis Parenting, a supervisor recommended that I not share that part of my story with mothers in the support groups I led. I figured she thought it would sound unseemly of me, and needlessly inspire jealously in other moms.
It’s true, my perspective may have been naïve, as I assumed other women would simply be inspired by my family’s example and run out to get the help they deserved. But various factors probably preclude this: at the top of the list is our society’s badly mistaken assumption that going on maternity leave is akin to going on vacation. Right after that is the issue of paying for support that most people don’t realize they may desperately need, and therefore have not budgeted for.
Postpartum doulas charge an average of $25-$35 hourly in the Boston area. To an extent, my family was able to afford the expense. But I admit that my partner and I were not prepared to have the necessary discussions about the impact on our family finances that having a baby would bring. We just spent the money without much of a plan, which I do not necessarily recommend regardless of financial circumstances.
Designating $1,000 or more for postpartum help feels out of reach for many of the families I talk with. And yet the average cost of a wedding in the U.S. is nearly $30,000. Health insurance reimbursement for the cost of a doula is theoretically possible, but still rare. American families across the economic spectrum live miles or even oceans away from extended family, who would have been the assumed postpartum helpers anytime up until the last half century or so. For many in my generation, that once-obvious support system has vanished, and to quote Brenhouse again: “it certainly wasn’t replaced with anything.”
That is, unless your own mother is retired but still able-bodied and you get along well enough that you can import her for at least a few weeks.
Or, you happen to know about doulas.
According to research, doulas are credited with reducing the incidence of postpartum depression. In 2009, CommonHealth’s Rachel Zimmerman and I co-authored The Doula Guide to Birth: Secrets Every Pregnant Woman Should Know (Bantam Books). We originally
became acquainted when I had been Rachel’s postpartum doula, and she wrote this in the introduction of our book:
I don’t think it’s exaggerating to say Ananda, an experienced birth and postpartum doula, helped keep my marriage and my life intact.... With Ananda in my house, rather than postpartum insanity, I experienced something akin to postpartum elation.
I actually had moments — rare for me, a dark, cynical New Yorker — when I thought, I have it all: two healthy daughters, a job at a great newspaper, a wonderful husband — and a clean house.
That was Rachel’s tongue-in-cheek conclusion to a more serious story. It was the description of her second birth, but her first had resulted in a genuine case of postpartum depression.
As Rachel’s doula, I started the job about two days after she came home from the hospital. She handed me the baby and went outside for an hour to exercise, probably her most important depression-management tool. I filled up the kitchen with trays of food, then she came home to nurse the baby while we talked. We did this three times a week for a month. On the last day her husband asked if I would continue working with the family for half a year, and I agreed. A longer-term doula contract such as this is not typical, but when I became pregnant three years later, I knew exactly what kind of support to seek out for myself.
I was at risk for postpartum depression, and discussed it with my nurse-midwife and various other healthcare providers. Being the recipient of our doula’s support had an obvious and profound effect on the well-being of our family; perhaps even more than the medical care I received (not that I would give that up either). But I understand what Rachel Zimmerman meant about “postpartum elation,” a feeling I’ve never had with antidepressants.
Human kindness plus the arrival of a new baby equals an incredible high, or at least it has the potential to do so. Other factors known to support postpartum mental health played out in my situation too: a fairly smooth birth, success at breastfeeding, a therapist on hand, and other social supports in addition to our doula (including a meal train delivered by friends for about fifteen weeks).
Postpartum depression seemed to pass me by in the first half of the year when I had so much support. Later in my baby’s life, I remember at times having what are known as intrusive thoughts, in which my anxiety about her safety went off the charts. It was usually for just a few minutes, which was enough to leave me shaken but that I could also shake off.
That's when I questioned my therapist about whether postpartum depression could still take hold and a mother could be put away; I have since learned how primary this fear is for so many mothers.
After the first few months of my baby’s life, it’s my sense that my healthcare providers were not on the lookout for postpartum mood disorders. Massachusetts is still in the early stages of attempting to offer screening to all mothers in the early weeks and months after birth. Awareness of PPMD in the later months may not be as readily on the radar. And I know from my own work in Maternal Child Health over nearly two decades that policy and practice can take years to change.
Truthfully, new mothers can benefit from emotional and social support for more than a few days in the hospital, for more than a few weeks postpartum, and for more than the first six months of parenthood. A study released last month by Murdoch Childrens Research Institute found that “maternal depression is more common four years after the birth of a first child than at any time in the first 12 months postpartum.”
When my doula was present, I didn’t necessarily talk with her directly about postpartum depression. But it might be fair to say I’ve never had so much support in my life. I would not expect a doula to shoulder sole responsibility for preventing severe postpartum tragedies, but I do wonder how many have been averted by arranging this type of support for mothers who might have otherwise been at risk.
Every so often I gratefully remember my postpartum experience, and I think about what a difference those ten hours a week can make.
Note: Regarding fees for postpartum doula services, some facilities such as Boston Medical Center and the Cambridge Birth Center provide doula services free of charge to low-income clients.
Ananda Lowe is a parenting educator, doula and mother. She lives in Somerville, Mass.