Is Postpartum Depression a Public Health Crisis?

In the Minds of Mothers: How Mental Health Impacts Mothers Worldwide

A Q + A between Christy Turlington Burns and Dr. Jessica Zucker

Ever since I (Christy Turlington Burns) experienced a childbirth complication after delivering my daughter in 2003, I have been a global maternal health advocate. The focus of No Woman, No Cry, the documentary film I made in 2010 and Every Mother Counts, the organization I founded that same year have both been on maternal mortality reduction, but as a women and health advocate I am concerned with every aspect of maternal health and well-being.

It’s essentially our reproductive systems that differentiate us from the opposite sex. That’s what makes us unique and powerful, but also vulnerable to a number of potential dangers. On the list of health risks women are subjected to, mental health seldom reaches the top. And while there are a lot of stigmas around many diseases, there may not be a close rival to the stigma those with diseases of the mind face each day. Mental illness pushes those who are already marginalized in developed and developing societies, even further into the margins.

When I began to travel across the U.S. with No Woman, No Cry, I was asked many thought-provoking questions about what I saw and was able to capture on film. One question that comes up consistently is about perinatal mood disorders, and more specifically about postpartum depression (PPD). Did Janet, Lightness, Monica or Orfa suffer from postpartum depression? My answer is, I honestly don’t know. Clinically that is. I knew enough about the lives of each of these women, however, after spending several days documenting the final days of their pregnancies, their harrowing labors and deliveries, to suspect they all suffered from some degree of difficulties related to postpartum mood disorders.

I met Dr. Jessica Zucker in the spring of 2011. She is a clinical psychologist whose practice specializes in women’s reproductive and maternal mental health in Los Angeles. Dr. Zucker has a background in international public health and is passionate about reproductive issues facing women globally. In her practice she weaves together her global health experience with her clinical skills as she assesses and treats perinatal mood disorders and other mental health challenges women face during the process of pregnancy and beyond. Jessica writes and lectures extensively on these issues. She has worked in developing countries (i.e. Africa, Nepal, India) and so I asked her about PPD in those regions where she worked.

Christy Turlington Burns: Jessica, while there has been some progress around the de-stigmatization of PPD here in the U.S. it seems to not even be on the radar in many developing countries I have visited. It can’t be that we think it doesn’t exist, but why are we not addressing maternal mental health like the pandemic it clearly is?

Dr. Jessica Zucker: Perinatal mood disorders have been named the most common complication associated with childbirth. Postpartum depression is indeed a public health crisis. What we know is that in the United States, 15–20 percent of new mothers, or approximately 1 million women each year, experience perinatal mood and anxiety disorders. What we don’t know is how widespread postpartum depression is in the developing world.

Unfortunately, data has not been collected in a consistent way on maternal mental health related issues in developing countries. After doing extensive research and talking with colleagues in the public health arena as well as within the psychology community, my hunch is that mental health issues are not addressed given the various other challenges being juggled that are more immediate — basic needs such as food, shelter, and maternal and infant mortality.

When basic survival is threatened, psychological processes are not a priority.

My longtime concern, however, is that we have not widened the global health conversation to include the mental wellbeing of mothers and her offspring. If a mother isn’t thriving psychologically, her baby experiences the ramifications. Consequently, the child may not have the opportunity to form a solid foundation of relational attachment, trust, or emotional connectivity. The mental health of the mother invariably impacts the family, the community, and culture at large.

Clearly the indicators for and the assessment of postpartum depression may vary across the globe taking into account other public health dilemmas that take place in various countries as well as culturally determined rituals. It is safe to assume that women worldwide are experiencing postpartum mental health challenges. The need to fortify women in every culture is an obvious benefit to the family and future generations globally. Given the glaring U.S. statistic, it seems imperative that this public health crisis be addressed systematically across the world.

Christy Turlington Burns: We often talk about the upside of the global maternal mortality tragedy as being the fact that pregnancy and childbirth are not diseases. We are not waiting for a cure and there is no single silver bullet. But mental health is a disease and there are effective treatments out there. Do we really understand the relationship between pregnancy and mental health?

Dr. Jessica Zucker: Culture’s impact on how women talk about their mental health in new motherhood is noteworthy. Though postpartum depression is discussed, reported, assessed, and treated, the stigma and confusion around embracing one’s difficult feelings as a nascent mother is of grave concern. Coming to terms with feelings of ambivalence, anger, anxiety, grief, or outright misery — a sampling of some of the feelings that can accompany postpartum depression — at the exact moment you are attempting to navigate a new identity, a relationship with your newborn, and a shifting experience with your partner can feel earth shattering.

Women are ashamed and shocked by feeling the antithesis of what they thought they might feel upon becoming a mother.

With a newborn reliant on the mother for care, consistency, and nurturance, the pressure for women to feel fortified and present in their newfound role as mother is that much more pressing. Knowing this and feeling able to do this are two very different things, especially when suffering from postpartum depression. Women report blaming themselves, feeling like “failures”, worrying they are “bad” mothers, sequestering the depth and range of labile feelings, all the while gritting their teeth, getting from one day to the next hoping sunrise will yield a metamorphosis of their maternal landscape.

Unfortunately, hope and time do not squash the hardship that is postpartum depression.

In fact, left untreated perinatal mood disorders can be insidious and intractable. The stigma remains steadfast in this country and many others, even though there are resources available to women suffering.

Mood disorders during and after pregnancy can affect any woman, regardless of age, income, culture, or education. We understand that there are risk factors for postpartum depression that can be addressed during pregnancy and in the postpartum period. We know that postpartum depression is a temporary illness that is fully treatable with professional help. Frequently in the context of my clinical work I hear the question, “Why didn’t anyone tell me motherhood was going to be this hard?” Our culture is wedded to upholding the “glowing” new mother as an idyllic icon. This Super Woman image leaves millions of women feeling that much more isolated and stymied by the reality of parenthood, particularly when she is deluged by the symptoms that pervade postpartum depression.

Christy Turlington Burns: There has been a lot of media attention around the dangers of drugs used to treat mental illness on the fetus. Where do you think this information puts women?

Dr. Jessica Zucker: In an article I wrote for your vital organization Every Mother Counts titled “Considerations of Antidepressant Use in Pregnancy and the Postpartum Period” I explored the complexities involved in this media discussion. The issue is not black or white. From a clinical perspective, I witness countless women struggling with this very quandary — to be or not to be on medication during pregnancy and/or while breastfeeding. I’m less inclined to choose a side in this debate, but rather support women in making informed choices that are the most advantageous for them and their burgeoning families. Given all that we know from the attachment literature, it is quite clear that the mental state of the mother directly shapes the evolving worldview of the infant. A child comes to understand the building blocks of connection — trust, love, and relationships — through the caregivers’ responsiveness and attunement.

When a mothers’ mental welfare is compromised she is less likely to have the wherewithal to meet the everyday challenges and nuanced needs that parenthood requires. The informational debate all too often leaves women who are suffering with a perinatal mood disorder feeling unsupported, under-resourced, misunderstood, terrified, or self-blaming. Medication during pregnancy needs to be gracefully thought through on a case-by-case basis, weighing the costs and benefits for the mother and developing fetus/baby.

Christy Turlington Burns: What should all women considering becoming mothers know about maternal mental health?

Dr. Jessica Zucker: The experience of motherhood is not one-size-fits-all. The emotional spectrum is wide and varied — ranging from immensely gratifying, deeply challenging, and everything in between. What all women considering becoming mothers should know about maternal mental health is that anything you might feel during your journey throughout motherhood, others have felt. You are not alone. Speaking up and asking for help reveals strength of character and courage — two core ingredients that we should all aspire to model for our children. I often ask my patients the following question, “If your young daughter came to you and shared that she was struggling emotionally with something, how might you respond?” Unequivocally the pregnant or parenting mother sighs with relief and says something like, “I would probably embrace her and let her know that I will help her navigate through the difficulties she is facing. I would praise her for identifying the issue and talking about it openly with me.” The next layer of inquiry is inevitably about how important it is that we explore the layered answers to why it can feel nearly impossible to advocate for ourselves the way we are certain we would do for our children.

Being the role model we hoped we had or were fortunate enough to have had is always possible. Striving for perfection is an impossible conundrum that results in feelings of deflation, ineptitude, and isolation. Our children do not need perfect mothers. They need a “good enough” mother who is wise enough to know when something is emotionally astray and takes action on her own behalf. Women need to be tender with themselves as they enter into uncharted territory — learning about and getting accustomed to their new identity in motherhood.

Christy Turlington Burns: I like that as bottom-line advice — Women need to be tender with themselves. Imagine a world where mothers take as good care of themselves as they do their children and a world where mothers are so supported they’re able to do that. That’s the world we all need to create because our children, families and communities are depending on us.

This article was originally featured on The Huffington Post.
Follow Christy Turlington Burns on Twitter: @CTurlington
Follow Dr. Jessica Zucker on Twitter: @DrZucker

Jessica Zucker, Ph.D. is a Los Angeles based psychologist specializing in women’s reproductive and maternal mental health. Her writing has appeared in The New York Times, The Washington Post, BuzzFeed, and elsewhere. She is the creator of the viral #IHadAMiscarriage hashtag campaign that she kicked off with her first New York Times piece in 2014 and launched a line of pregnancy loss cards in October 2015 in honor of Pregnancy/Baby Loss Awareness Month: Find her online:

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