Conditioned by society to put a happy face on the first months of motherhood, moms and healthcare professionals now are working to share and address the challenges of the Fourth Trimester.
In October 2019, when her son Archie was a few months old, Duchess of Sussex Meghan Markle did something extraordinary after a reporter asked her how she was doing as a new mom: She told the truth.
Face awash in vulnerability and tears threatening to spill over, with the soft curve of a post-partum belly visible beneath a couture belted dress, the duchess stepped out of her royal high heels and into a brave new world when she earnestly said, no—she was definitely not OK. The clip went viral, from The New York Times to parenting blogs to being oft-shared among the many women in Delaware moms Facebook groups.
“This is a woman who is rich, privileged, literally royalty—and she is struggling,” says Nikki Stryker of Newark’s Delaware Counseling Center. “Most new moms when asked that question won’t tell the truth, but the reality is, more than 3 out of 4 moms report [to their doctor] that they’re feeling anxious and depressed, having scary thoughts and difficulty adjusting. That’s a high number. But there’s also a fine line—only about 1 in 7 will meet the diagnosis criteria for a perinatal mood and anxiety disorder [PMAD] like postpartum depression.”
How fine a line? For Milford’s Alexis Rose, it came down to a pizza.
Rose had just had her first of two children, a little girl. She was exhausted. She was anxious. And she was hungry.
“I noticed that I had a real issue and needed help when I had a nervous breakdown over the wrong kind of pizza delivered to my home. I felt completely unhinged,” Rose says. “I never had feelings of hurting myself or my child; it was just more a sense of feeling so alone, which I thought was crazy, since I had my baby 24/7.”
Both Rose and Markle were mucking through the darkness that, for many moms, clouds the Fourth Trimester, the catchall term used to describe the first three months postpartum.
Go to any local store that sells baby products and take a look at the photo on the box. You’ll see a perfect newborn, an immaculate living space and a beaming, well-rested mother with a fresh blowout and glowing skin. Do not believe this lie.
“It’s difficult for women to wrap their head around the fact that the journey isn’t over once you give birth,” Stryker says. “Society says, ‘OK, once you get to the end, the weeks after are going to be all goo-goo-gaga, where you’re just snuggling this adorable baby.’ You know what I tell new moms? Sleep when possible, drink water, eat, and feed your baby. That is literally my entire list. Going to dinner, curling your hair, vacuuming—these are incredibly unrealistic expectations.”
Also unrealistic for many new moms: happiness, which can be difficult to admit. The National Institute of Mental Health reports 80 percent of new mothers will experience the “baby blues”—feelings of depression, fatigue and worry, which can be mild and go away on their own after a few weeks. It’s when those feelings seriously impact a mother’s emotional state that one should worry. Are you not bonding with your baby? Do you not want to feed, diaper or hold your baby? These are the things Dover’s Amy Didden of Dela-Well-Moms looks for.
“Women are good at ignoring or hiding how they’re doing,” Didden says. “Just like we are encouraged to put on makeup to hide our flaws, women are good at putting on a smile and saying they are fine. I like to ask: ‘Can you sleep when your baby is sleeping? Do you have thoughts that are concerning you? Are you able to enjoy any part of your day and of being a mother?’”
But asking for help in the first place might be tough. It’s something Middletown’s Ashley Brown, mother to three daughters, grapples with.
On the day we speak at Brown’s kitchen table, which is overrun with the detritus of Brown’s 7- and 3-year-old daughters—stray purple glitter, Frozen stickers, abandoned coloring pages—Brown, in yoga pants with a burping cloth thrown over her shoulder, cradles her newest daughter, who is 3 months old.
“As a black woman, we’re not really taught to seek help. We’re told, ‘This is life. Deal with it. Pray.’ But I’ve been listening to a podcast, ‘Black Girl Therapy,’ and it’s been so helpful,” Brown says. “It’s not that I’m depressed; at least, I don’t think. When I think of depression, I think of someone who can’t get off the couch. That’s not me. [At your first postpartum obstetrician visit] they give you a piece of paper, you grade your emotional state. … Mine is typically zeros, so I’m like, I guess I’m OK? Then it’s, ‘Hey! How’s your vagina? You can have sex! You can get on the pill! You can insert this IUD! Bye!’ I wish someone just asked, ‘How do you feel?’”
This kind of dialogue is what Delaware health care providers like Dr. Malina Spirito, a clinical psychologist at Christiana Hospital’s Center for Women’s Emotional Wellness, would like to make the new standard of care.
“Many of [the screening tools at OB visits] look at classical depressive symptoms: tearfulness or lack of interest, for example,” Spirito says. “But lots of these physiological symptoms may be easy to dismiss because of course these things are happening with a new baby—difficulty sleeping, changes in appetite. Let’s spend a little more time [in OB offices] asking questions like, ‘How are you feeling through this experience? Are you enjoying it? Is motherhood what you thought it was going to feel like?’ No screening tool is ever going to beat a good old-fashioned conversation.”
And the conversation must include more than just postpartum depression.
“That term doesn’t give enough credence to some of the other mental health challenges that are common, like anxiety, irritability and rage,” Spirito says. “People hear ‘depression’ and think tissues and tears, or they think of women who want to hurt their babies or themselves. That’s incredibly misleading—that’s the minority.”
Yet perhaps the most challenging of all is sitting down with our village of women and saying, “I’m not OK.”
“Society is just barely getting to a place where we can admit it’s not all rainbows and unicorns,” Spirito says. “Intrusive, ‘bad’ thoughts are very common. The more we speak the secret [#speakthesecret], a movement born of Karen Kleiman’s book Good Moms Have Scary Thoughts, the more women will know that they’re not alone.”
It was a very particular loneliness that put Kristin Bowen over the edge after the birth of her first daughter.
“I was a young single mom,” says Bowen, a Wilmington restaurant owner who has four daughters. “The first six months are hazy, but what’s vivid is finding my mom’s pain medication. I took a bunch and started chugging vodka. Then I looked at this tiny, helpless baby and got very, very scared.”
Bowen pauses, and her eyes land on the semicolon tattoo on the pale underside of her wrist, a symbol of solidarity in the fight against mental health challenges. “I ended up in inpatient mental health,” she says. “This might be the first time I’m ever talking about this.”
Bowen had a history of mental health struggles, making her the exact type of mother that Spirito hopes health care professionals will be able to identify much sooner.
“The earlier we are able to address these things, we can prevent symptoms from becoming more severe,” Spirito says. “We know that women who experience mental health challenges in pregnancy will often face challenges postpartum. The data tells us that we need women going into delivery as mentally and physically strong as possible.”
So how do we bridge the gap between pregnancy and birth? Spirito says collaborative health care is good first step, something she’s been helping cultivate at ChristianaCare.
“We should be talking about mental health issues during pregnancy and preconception, period,” she says. “At Christiana, we’ve developed ongoing collaboration between our perinatal mental health services and obstetrical services.” The same method is in place at all ChristianaCare–owned practices. “When we approach maternal health this way, as proactively as we can, a mom with a higher risk factor, like depression and anxiety, is much better equipped. She’s not just white-knuckling her way through pregnancy. She is supported from [the get-go].”
From the get-go is where Katie Madden wants to step in, too.
Madden, who many Delaware women and beyond would call a breastfeeding savant, is a board-certified lactation consultant who for years set up shop in The Birth Center in Wilmington. Earlier this year, she struck out on her own with Balanced Breastfeeding, a new business model she hopes will radicalize the standard of care.
“I have been doing so much of this one-on-one postpartum crisis cleanup for the past 15 years, and every day I looked at these mothers and was plagued with, ‘How do I solve this?’” Madden says. “We’re missing a huge opportunity during pregnancy. Let’s have these conversations earlier. So much of the mental health struggles of the Fourth Trimester are rooted in breastfeeding, and we have a whole community of professionals who rallies around to hurry up and ‘fix’ women postpartum, then we have this community of professionals trying to encourage healthy, safe birth choices—I want the communication in between.”
In Madden’s model, she’ll begin working with women early in pregnancy, and on a seasonal basis: Mothers having babies in the spring will come through Balanced Breastfeeding together, resulting in a micro village of women dealing with similar issues on a similar timeline. “Let’s bring back what women have historically done—work together to help one another raise babies,” Madden says.
“One of my biggest missions is to change the language an OB or pediatrician uses from ‘Are you planning to breastfeed’ or ‘Are you breastfeeding?’—which is specific and loaded with shame and inherent bias,” Madden says. “Instead, let’s talk as early as viability, around 24 weeks, and ask, ‘Have you thought about how you’re going to feed your baby?’ It’s open-ended, and we’ve got three months to figure this out.”
Madden applauds the lengths hospitals like ChristianaCare have gone to earn Baby Friendly Hospital accreditation, which denotes that the center is dedicated to promoting and supporting breastfeeding as a first choice.
“It’s working. Our statistics in Delaware are pretty high; almost 77 percent of new mothers are saying, ‘Yes, I am trying this,” Madden says. “But the problem is, within six months, these numbers plummet. Why? Because it’s not as easy as ‘Are you breastfeeding or not?’ Women can hybrid feed, women can exclusively pump. … The culture has become that formula is harmful and risky, yet we literally have the best formula in the history of time. There are supplemental options for breastfeeding moms, but there’s a lack of education. That’s where Delaware is falling short: We’re not creating unique care plans for real life.”
Or the real birth situations women find themselves in.
On the day nurse Taylor Burges of Wilmington, mother of two, went in for her scheduled C-section, her face felt puffy. “I had full-on Bell’s palsy,” she says. “They brought neuro in and wanted to do an MRI that would involve dye that would have prohibited me from breastfeeding for 24 hours, and I’m like, ‘Well, do we have to do that?’ Isn’t that insane? My brain is going haywire, half of my face is drooping, but let’s not worry about that because I have to breastfeed.” She shakes her head. “He could have had formula!”
Kate McCracken of Smyrna, mother of one, had challenges, too. “Worse than the physical pain was the emotional pain,” she says. “I had to give up breastfeeding because the medicine they gave me dried up my milk. I feel like this is the first way I failed my son. In fact, my son is 1, and I still struggle with these feelings of failure.”
To Madden’s ears, the stories are frustratingly common.
“These women are being brought to their knees over breastfeeding,” Madden says. “Breast milk is a great, awesome thing, but everyone is fighting for breastfeeding, yet breastfeeding doesn’t have feelings. Mothers matter. Babies matter. I tell my moms to say: ‘No matter how much breast milk I’m able to give to my baby and for how long, I am enough as a mother.’”
While nothing about postpartum life could be called normal, Didden is quick to remind her patients: “You are not alone. You are not to blame. With support, you will be well.”
She advises women struggling through the Fourth Trimester to connect with support. “A spouse or partner, friends, family, mom groups, a therapist, your doctor—tell someone,” she says. “Then connect with strength: What are healthy coping strategies? New moms typically put themselves at the bottom of the priority list when it comes to self-care, but exercise, writing, prayer, meditation—try them. Last, connect with meaning: What can you look forward to in the short term or the long term as a parent? Can you look forward to your baby’s first laugh or first steps? What is meaningful to you?”
But what of the extreme cases, in which those first steps never come? When mothers face down trauma and grief that feels enormously outside of what a person can carry? What does wellness look like then?
Middletown’s Allison Kerr is still working through that.
She gave birth to her first child, Alexander, on a Tuesday. He weighed 1 pound and 15 ounces. He died that Sunday.
“For those six days, all he knew was love,” Kerr says from her home. She and her second child, Genevieve, who has just begun to walk, are both wearing blue, something they do often to honor Alexander’s life. “We sang, we told stories. We held him for hours. We read. It was around Halloween and my husband said, ‘He’ll never taste chocolate.’ His nurse said, ‘I don’t know why he can’t.’ So, we melted a little bit of chocolate for him.”
It was Ghirardelli, and the Kerr household is always stocked with it.
“On his last day, I held him for five hours,” Kerr says through tears. “After he was gone, there was an imprint on my chest, like he was still hugging me.”
Stryker, who specializes in infant loss, says the first stop to healthy grief is acknowledging life will never be the same.
“Healthy grief is acknowledging what you feel and processing it and trying to still live,” she says. “People ask, ‘How do I get better?’ The answer is time. There is no putting your life back together. You are never the same. When you lose a child, the hole never heals until the day you die. The goal is to try to function with that unfilled hole.”
Steps include prioritizing goals, asking, “What is going to make your heart happy again?” and expecting that guilt comes along with it. “The first time people feel joy or smile or food tastes good again, 100 percent of parents feel guilt,” Stryker says. “The goal here is try to process that this is OK.”
How do you help a mother through loss? Be present, be candid, sit in the grief with them, and be mindful of triggering events—like Mother’s Day.
“I’ll never forget those first few Mother’s Days after Alexander,” Kerr says. “Most people did not acknowledge that I was a mother—I was. He just wasn’t here. I mourned his death, but also the death of the dream of motherhood. My hair was falling out, I gained weight. … The physical representations of what my body went through were present, but no baby. This year, on Mother’s Day, I had Genevieve. I posted a reminder that this is not my first Mother’s Day. It was to protect myself from going to the dark place, but also a hope that everyone was cautious with their words for other loss moms.”
Stryker also says to say the names of the children that mothers have lost. “Say it often. Acknowledge this life. Remember dates, birthdays; the anniversary of the death,” she says. “Be mindful of where you take that person—surrounding someone who just lost their child with babies is catastrophic.”
There are also moms like Noreena Sondhi Lewis who have to make devastatingly difficult decisions for the sake of their own health and live with the societal consequence.
Lewis and her husband, Sam, had a difficult time getting pregnant. With the help of fertility treatments, they were elated to find out they were having twins, which was further complicated by a previous health history for Lewis that included an eating disorder. The challenge was to get pregnant but manage it in a healthy way. All was going well until a horrific and unexpected birth experience.
“I had two major surgeries in less than two weeks [after intestinal issues], and after, had two newborn babies to take care of, but I was alive,” Lewis says. “I had to get a colostomy bag and wear it for three months. Then I had another surgery to have everything reversed. All is in working order now.”
The experience was so traumatic that a family decision was made not to have any more children, and her husband got a vasectomy.
“Eight months later, I was pregnant,” she says. “The vasectomy wasn’t done properly. I was tremendously angry and deeply sad. At the ultrasound, I didn’t even look. I couldn’t. My doctor said, ‘This is your choice. But there are a million reasons why this isn’t safe.’ We agreed and terminated the pregnancy.”
She lives with unrelenting guilt. “My daughters, Sofia and Naomi, love babies,” she says. “They ask for one all the time, and I killed their sibling. My inability to get over it is something Sam and I are trying to work through. Every time I see a family with three children, it’s a knife through my heart. I disassociate a lot. I put my grief on a shelf, take it down later. Then I start to remember and have delayed feelings, which I think is confusing for Sam. But I am where I am. And we keep moving forward.”
Stryker says that “when you lose a child, it’s awful no matter how, but for people who terminate a pregnancy for reasons like mom’s or the baby’s life at risk, there is a second degree of shame that goes along with that. These women often have lifelong guilt issues: ‘I’m a murderer.’”
Even worse, she adds, women don’t feel like they can stand in their truth.
“Women will lie and change their story to make other people more comfortable,” she explains. “We as a community need to address how we’re taking care of each other. It would be a game-changer if women talked about the things we’re feeling instead of taking society’s cues to remain unheard.”
So, what is Delaware doing to help mothers navigate this tumultuous time?
For starters, the Delaware section of the American College of Obstetricians and Gynecologists (ACOG) hosted its first Maternal Health Awareness Day in Newark in January 2019. Multiple topics were addressed, like the state’s heightened infant mortality rate, which is decreasing.
“Our rate is still one of the highest in the country, but we’ve improved a lot with the help of resources like additional funding from the CDC,” says Wilmington’s Dr. Nancy Fan, vice chair of the state’s ACOG chapter. “We’re also looking at gaps in our perinatal and neonatal care. Why are our babies being born prematurely? What is that we’re not doing well?”
Fan says the chapter has come out with a committee opinion on critical guidelines for physicians about how to optimize postpartum care. “The overarching goal for us is to optimize care, with big-picture goals of decreasing maternal morbidity and identifying high-risk factors. How is the United States the highest in the industrialized world when it comes to maternal death?”
But she acknowledges maternal wellness is not one-size-fits-all. “It’d be nice to say, ‘Let’s do X,’ and it will be beneficial for everyone—like giving all working moms six months paid leave,” Fan says. “But my patients at St. Francis are a high Medicare/uninsured population. Sometimes they don’t show up for appointments because they can’t get there. Transportation and food could be a need for some moms but not others. We have to be inclusive.”
Didden says she’s seen improvement in health resources in the past 10 years. “There are more trained mental health professionals. There is more screening going on in OB offices and hospitals, which is great news from new moms,” she says. She cites Kent County’s Bayhealth Medical Center, which has begun to use the Edinburgh Postnatal Depression Scale to screen women, and the efforts of Dedicated to Women, an OB/GYN practice that is pulling women in three weeks postpartum instead of six to keep an eye on moms’ emotional health. “I’m also proud to say that we now have a state chapter of Postpartum Support International, with initiatives to increase provider training on perinatal mood and anxiety disorders and peer support for new parents.”
Madden gives props to the state for its recent policy of 12 weeks of paid leave. “Dads are getting paid leave, too, which is huge,” she says. “Of course, three months is still a ridiculously short amount of time. We also need to work on availability of breastfeeding resources for working mothers—it’s a wasteland. Part of me going independent is that I could serve that population with evening hours. I’m a working mom, too. I get it.”
Madden and Stryker both lament an overburdened health care system that results in long waiting lists for specific providers like infant loss professionals. “I can’t see everybody,” Stryker says. “But this is not just a Delaware-specific problem, this is a national issue.”
Maybe one soon to be tackled by the next generation of health professionals.
“My birth experience taught me that there’s a lack of resources for maternal wellness everywhere, period,” says Rose, the Milford mom who sought treatment after feeling “unhinged” over a pizza delivery mistake. “I am currently getting my master’s degree in clinical health counseling, with a concentration in women’s mental health. My overall goal is to open a facility flush with female therapists who can be present before, during and after the birth of a child. I want women to have a safe space to come and speak to someone without the fear of judgment.”
Published as “Speaking the Secret” in the May 2020 issue of Delaware Today magazine.