Randi Hutter Epstein M.D. M.P.H.

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Preventing PostPartum Depression Should Be Considered a Public Health Issue

I gave birth to my first son, Jack, 25 years ago in London. The birth went smoothly but I was a little freaked out when I was told that once I got home, a visiting nurse/midwife was going to stop by every day for at least 10 days.

I pictured Mary Poppins minus the show tunes. What I got was more Woodstock circa 1960. My motherhood-checker (I can’t remember her official title) wore Birkenstocks and a flowing multicolored skirt. Instead of reprimanding me, as I feared, she was encouraging and answered all kinds of new-mom questions. She also weighed my son in the same kind of antiquated scale used by my local fishmonger.

Six weeks postpartum, my earthy-crunchy helper returned. This time she wasn’t asking about Jack. She asked about me. We sat crossed-legged on the carpet and she ran through a checklist of postpartum depression signs sprinkled into a seemingly casual conversation. Had I needed help, I would have been funneled to the right place.

Two years later, as I once wrote in the New York Times, I delivered twins in a New York City hospital and left before 48 hours. The doctors signed discharge forms and I guess I waved goodbye and that was that. I went home to my toddler, husband and extended family. But I missed my English caregiver who blanketed me with support. She made me feel part of a supportive community.

I was thinking about my birth experiences again when I read the news about a new drug for postpartum depression, called brexanolone. Like most people who read the reports, I was stunned by the price tag ($34,000) and curious about the delivery system: a 60-hour infusion in a certified medical center during which time women have to pump and dump breast milk to ensure brexanolone doesn’t contaminate the baby’s food supply. Who was going to access this newfangled treatment?

Even if the price drops and it’s made into a pill (apparently one is in the works), medication, alone, isn’t a solution. We need networks to spot women in need and resources to get them help.

Last fall, I met a group of dynamic, compassionate experts at a conference in Pittsburgh called: Partnering for Change: Expanding Women’s Mental Health Treatment and Reducing Health Disparities. I was there to talk about the history of women’s health. They taught me about the future.

Dr. Sarah Homitsky is the medical director of the Women’s Behavioral Health at Allegheny Health Network there. Since August, 2016 her center has been providing psychological support to new mothers diagnosed with clinical depression.

Here’s how it works: When pregnant women are seen at the obstetrician’s office, they are provided with an electronic tablet. A few times during pregnancy and once after childbirth, they fill out a questionnaire and the responses go directly to their doctor who, in turns, alerts a therapist if the score indicates clinical depression.

“We get in touch with every woman within 48 hours and schedule an intake within two weeks,” Homitsky told me. That’s a pretty remarkable turnaround.

Women are then provided with weekly hour-long sessions in cognitive behavior therapy or interpersonal therapy. They can get medication, too. The program is funded in part by the Alexis Joy Foundation, founded by Steven D’Achille in memory of his wife who died by suicide six weeks after her daughter’s birth on October 10, 2013.

So far, some 2,500 women have been offered weekly counseling. There’s also an intensive program that provides three-hour sessions three times a week. Women are encouraged to bring their babies (where they do baby massage and learn about mother-baby bonding) and also their pre-school children (childcare is provided). In addition to psychotherapy women learn stress management techniques. Best of all, they realize they are not alone. Women get help not just from experts but from each other.

Let’s face it, motherhood is an awesome yet overwhelming time. Many of us are lucky to have family and/or friends around. Sure I missed my British-Birkenstock-wearing visitor. But I had other networks. After I gave birth to the twins, I heard about a local mother-of-twins support group and attended a few meetings and wrote about it, but never bothered going back. I think because at the time, I had two big dogs, a toddler and two babies in a double-stroller so I was like a magnet for advice-givers. I may not have loved all the unsolicited information but I never felt alone.

I’m not trying to over-simplify post partum depression. A group of friends isn’t going to prevent susceptible women from clinical depression.

Studies have documented that women who have had bouts of depression before pregnancy are more likely to suffer post partum depression. Other studies show a lack of support increases the risk of post partum depression. We seem to have accrued plenty of data, now we need real outreach.

The Pittsburgh center is one of twenty such clinics in the United States. But getting access to this kind of care shouldn’t be hit or miss. It should part of routine healthcare for all pregnant women and new mothers.

As Homisky said, maybe the media focus on the new drug will shine a spotlight on this crucial public health issue. “We need to do a better job supporting our mothers. We as perinatal providers need to advocate not just for medication, but for improved home visits and affordable child care.

As she said, we have to continue to ask ourselves: How do we strengthen the social support that postpartum women need and deserve?

At least, her center is one step in the right direction.

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A New Play Shines Light on Women Long Forgotten

In the years leading up to the Civil War, about a dozen or so female slaves were part of a series of gruesome experiments that culminated in a huge advance in gynecology.

They were operated on over and over in a ramshackle shed in Dr. J. Marion Sims’ Alabama backyard. Sims was determined to figure out a way to heal vaginal tears caused by long labors.

He succeeded and became world famous. In addition to his surgical cure—a technique that would spare women worldwide some of the ravaging consequences of giving birth—Sims also invented the speculum and founded a woman’s hospital in New York. For more than a century he was hailed as one of the great humanitarian physicians.

For years, the story of J. Marion Sims focused on his achievements. But lately, his story has been revived without glossing over his journey to prominence, culminating not only in heated discussions.

Yet, however the story is told, the spotlight has always been on Dr. Sims. Harriet A. Washington wrote about him in Medical Apartheid. Her book along with subsequent articles prompted protests that resulted in the removal of a Sims statue that had been on Fifth Avenue in New York City. Deborah Kuhn McGregor wrote about him in From Midwives to Medicine. I also wrote about Sims and his legacy in Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank.

But who are these women? There are no diaries, nothing about what they had to say. We know the names of three of them. Lucy. Betsey. Anarcha. So when we write, they become two-dimensional, lumped together in one group: “The slave women.” To be sure, Washington dug deep to bring a voice to Anarcha Wescott, but so many of the women have remained anonymous because we just don’t have the information.

Now, Charly Evon Simpson, a playwright, has given voice to the voiceless. Her new play, Behind the Sheet, is inspired by the real events allowing her to shift the spotlight from Simms to the slaves.

We meet these young pregnant slaves who endured operations—some of them had up to 30 surgeries. But for the first time we are forced to imagine them in three dimensions, as yearning, bonding, compassionate, jealous, hurting women. Simpson gives these women agency.

Ben Brantley in the New York Times said the production “takes on cumulative power in its steady, clear eyed depiction of a time when it was a given that pain would be borne uncomplainingly by human beings regarded as chattel.”

While some of the dialogue is lifted right from J. Marion Sim’s autobiography, Simpson adds a plot twist.

In her play, the doctor is George Barry. We also meet Philomena, his assistant/pregnant mistress/slave. In real life, there was no Philomena. Or rather, there’s no record of Sims having a mistress or impregnating a slave. I found the injected storyline added heft to the play—we see his own mistress suffering and we see happens to her after her child with him causes her to suffer from tears. We see what happens to her after Sims finds his cure and heads north.

Harriet Washington, the Medical Apartheid author, ethicist and historian, applauded the play as a must-see—but, as she wrote in Nature,  the Philomena addition “muddies the already murky ethical waters of volition, coercion, sentiment and motivations.”

The night I went, there were audible gasps from the audience. The woman behind me sobbed. I assumed people went for the reason I did. We knew the story and were curious to know how this fictionalized version would come alive on stage. But perhaps this was news to some of them. And that’s a good thing. This is an important chapter in medical history that needs to be debated in wide circles outside of academia.

Simpson, in an interview with Science Friday, said that her goal was not to bring what has been written to the stage but to infuse life to the women, long forgotten. “I’m a black woman and have ancestors who were enslaved,” Simpson said. “I wanted to give them back the humanity that society at the time stripped way.”

Behind the Sheet had sold-out performances at the Ensemble Studio Theatre and is now extended until March 10th. Here’s more information about the show.

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The Most Amazing Body Part of All

We tend to think of the placenta as a sponge that transfers the mom’s nutrients to the growing fetus—if we think about the placenta at all. Emerging research has been showing that this oft-ignored organ is a lot more complicated than we ever imagined. As a neonatologist explained to me recently, the growing fetus’s nutrient needs change on a day-to-day basis. Somehow, the placenta knows just the right amount of this or that bit of nourishment to provide. It’s a stunning feat.

This month’s Scientific American reports on a study that shows that the body is programmed for symmetry. (The original research was published in PLOS Biology) Researchers injected a substance into a mouse fetus that restricted the growth of one leg. They found that somehow, the cells surrounding the suppressed tissue sent a signal to the placenta to slow growth in the other leg. The study focuses on the ability to maintain symmetry. I also think it’s another shout-out to the remarkable abilities of the placenta.

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Pregnancy Hormones but No Panda Pregnancy

The National Zoo in Washington D.C. announced today that Mei Xiang, a 19-year-old panda isn’t pregnant after all. It was just a “pseudo pregnancy,” or fake pregnancy. Seems she had all the signs (nesting, eating less) and even hormonal changes. But the one thing she didn’t have was a fetus in her womb.

So, what was going on with her hormones? In short, some animals after sex or artificial insemination, have a rise in certain pregnancy hormones can rise for a few weeks.   Then without a fetus gestating, the levels eventually go back to the non-pregnant state. That seems to have been Mei Xiang’s  story. She had a progesterone surge but an ultrasound didn’t find a fetus

In an article aptly called, “Pseudopregnancy in the Bitch,” and published in the Journal of Small Animal Practice in 1986, the authors explain that the condition has to do with the way post-coital hormones are released from the pituitary gland, a gland that dangles off the brain.  It’s not uncommon in mammals that go through estrus, which is different from humans that menstruate. (Estrus means that the lining of the womb is absorbed back into the body after the egg is released but there is no conception. For many species, the females are only sexually active during estrus. Humans menstruate—that means they bleed and sometimes have sex  when they aren’t fertile.) In humans (but not pandas) “pseudopregnancy” also called pseudocyesis and is listed in the DSM-5, the psychiatrists bible of mental disorders.

At 20, the Mei Xiang is considered on the older end for giving birth, but the National Zoo veterinarians aren’t giving up hope yet.

For further reading on pregnancy hormones and a pioneering researcher, check out Chapter Six in my latest book: Aroused: The History of Hormones and How They Control Just About Everything 

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Payoffs of Snooping

The Birth of Forceps Offers Insight to Birth Today

There’s an upside to being a snooping guest—you could find a long-lost treasure as this nosey 19th century mother-in-law did.

In 1813, Dr. William Codd’s mother-in-law was poking around he and his wife’s home in Essex, England. She noticed a crack in the floorboard, pried it open, and hoisted a box of metal trinkets. She must have thought the stuff looked scientific because she ran the box over to her friend, a retired surgeon who lived nearby. He knew immediately that she found a medical treasure. One that had been missing for a hundred years.

Inside the box were the world’s first usable forceps. They were created in the 1500s by the Chamberlens, passed down from generation to generation until Peter Chamberlen retired and hid them in the floor of his estate.

The story of forceps is one of a huge medical advance. Before forceps, babies stuck in the birth canal died, and sometimes so did the expectant mother. But it’s so much more. It’s a story of fierce competition and bitter debates.

The Chamberlen men developed this lifesaving device and then refused to share the secret because they figured (rightly so) it would give them an edge in the childbirth business. They became the male-midwives to aristocrats and royalty. And to make sure no one stole their idea, they stored the forceps in box the size of a coffin (so there were no clues about its size or shape) and then blindfolded the laboring women so she couldn’t sneak a peak, either. (As if a woman about to deliver a baby is going to grab a pen and paper—or quill and parchment—and jot down notes).

Eventually in the mid 1700s, Peter Chamberlen, a great-great nephew of the inventor, realized he could make money selling the design. So he did so to Dutch and then British doctors. When he retired, he buried the original forceps in the floor of his house. And there they remained until the nosey mother-in-law of the next home’s owner happened upon them.

I was telling the tale of the eccentric Chamberlens this week when I was interviewed on KWMR radio by Christina Lucas, a nurse in Point Reyes, California about the history of childbirth. I thought I knew the story pretty well until she said, “Where are the forceps now?”

I was stumped during the show, but promised I’d do some searching afterwards. Like most things in life, the answer was one Google click away. The forceps are now on display at the museum of the Royal College of Obstetricians & Gynaecologists.

Since the Chamberlen days—or really starting with the Chamberlen’s, forceps have instigated some of the most contentious childbirth debates. Women worried about the safety of high-tech birth (forceps) versus natural birth (sans forceps). The concerns are reminiscent of the cesarean section versus no-cesarean section debates today.

Today forceps fit into the natural category and many obstetricians believe that the art of using them (it takes a bit of skill) needs to be re-introduced to minimize the high rates of c-sections. There are also initiatives to teach forceps skills to women in developing countries, where surgical births may not be an option.

In any event, if you’re as curious about childbirth history as I am—and if you happen to be in London—it’s worth a stop at the Royal College of Obstetricians and Gynaecologist’s museum. You have to make an appointment. The College is near Regent’s Park, a lovely part of town.

And if you’re really curious, you can hop on a train from Liverpool street to Hatfield Peverel in Essex and see the Chamberlen’s former home. It’s called Woodham Mortimer Hall. There’s a blue plaque on the door that rehashes the history in a few sentences. The Hall is now private, but you can see if from the outside and visit the cemetery nearby. (It’s also a lovely area of the English countryside…where I got my first puppy, a Golden Retriever.)

I’m glad that Christina pushed me to get to the end of the mystery. But the one thing we’ll never know is what Dr. Codd said when he got home that afternoon and found his mother-in-law dismantling his flooring.