Editing Postpartum depression (section)

== History ==

=== Prior to the 19th century ===
Western medical science's understanding and construction of postpartum depression have evolved over the centuries. Ideas surrounding women's moods and states have been around for a long time,<ref name="Tasca_2012">{{cite journal |date=2012-10-19 |title=Women and hysteria in the history of mental health |journal=Clinical Practice and Epidemiology in Mental Health}}</ref> typically recorded by men. In 460 B.C., Hippocrates wrote about puerperal fever, agitation, delirium, and mania experienced by women after childbirth.<ref>{{Cite web|title=Shedding More Light on Postpartum Depression – PR News|url=https://www.pennmedicine.org/news/news-blog/2016/january/shedding-more-light-on-postpar|website=www.pennmedicine.org|language=en-US|access-date=2020-03-25}}</ref> Hippocrates' ideas still linger in how postpartum depression is seen today.<ref name="Brockington_2005"/>

A woman who lived in the 14th century, [[Margery Kempe]], was a Christian mystic.<ref name="Kempe_2015">{{Cite book| vauthors = Kempe M |title=The Book of Margery Kempe|date=2015|publisher=Oxford University Press|isbn=978-0-19-968664-3|oclc=931662216}}</ref> She was a pilgrim known as "Madwoman" after having a tough labor and delivery.<ref name="Kempe_2015" /> There was a long physical recovery period during which she started descending into "madness" and became suicidal.<ref name="Kempe_2015" /> Based on her descriptions of visions of demons and conversations she wrote about that she had with religious figures like God and the Virgin Mary, historians have identified what Margery Kempe was experiencing as "postnatal psychosis" and not postpartum depression.<ref>{{cite journal | vauthors = Jefferies D, Horsfall D | title = Forged by fire: Margery Kempe's account of postnatal psychosis | journal = Literature and Medicine | volume = 32 | issue = 2 | pages = 348–364 | date = 2014 | pmid = 25693316 | doi = 10.1353/lm.2014.0017 | s2cid = 45847065 }}</ref><ref>{{cite journal | vauthors = Jefferies D, Horsfall D, Schmied V | title = Blurring reality with fiction: Exploring the stories of women, madness, and infanticide | journal = Women and Birth | volume = 30 | issue = 1 | pages = e24–e31 | date = February 2017 | pmid = 27444643 | doi = 10.1016/j.wombi.2016.07.001 }}</ref> This distinction became important to emphasize the difference between postpartum depression and [[postpartum psychosis]]. A 16th-century physician, Castello Branco, documented a case of postpartum depression without the formal title as a relatively healthy woman with melancholy after childbirth, remained insane for a month, and recovered with treatment.<ref name="Brockington_2005">{{cite book | vauthors = Brockington I |chapter=A Historical Perspective on the Psychiatry of Motherhood|date=2005|title=Perinatal Stress, Mood and Anxiety Disorders|series=Bibliotheca Psychiatrica|pages=1–5|publisher=KARGER|doi=10.1159/000087441|isbn=3-8055-7865-2}}</ref> Although this treatment was not described, experimental treatments began to be implemented for postpartum depression for the centuries that followed.<ref name="Brockington_2005" /> Connections between female reproductive function and mental illness would continue to center around reproductive organs from this time through to the modern age, with a slowly evolving discussion around "female madness".<ref name="Tasca_2012"/>

=== 19th century and after ===
With the 19th century came a new attitude about the relationship between female mental illness and pregnancy, childbirth, or menstruation.<ref>{{Cite journal| vauthors = Carlson ET |date=1967|title=Franz G. Alexander and Sheldon T. Selesnick. The History of Psychiatry: An Evaluation of Psychiatric Thought and Practice from Prehistoric Times to the Present, New York: Harper & Row, 1966, p. xvi + 471. $11.95|journal=Journal of the History of the Behavioral Sciences|language=en|volume=3|issue=1|pages=99–100|doi=10.1002/1520-6696(196701)3:1<99::AID-JHBS2300030129>3.0.CO;2-2|issn=1520-6696}}</ref> The famous short story, "[[The Yellow Wallpaper]]", was published by [[Charlotte Perkins Gilman]] in this period. In the story, an unnamed woman journals her life when she is treated by her physician husband, John, for [[Hysteria|hysterical]] and depressive tendencies after the birth of their baby.<ref>{{Cite web|title=The Project Gutenberg eBook of The Yellow Wallpaper, by Charlotte Perkins Gilman|url=https://www.gutenberg.org/files/1952/1952-h/1952-h.htm|website=www.gutenberg.org|access-date=2020-04-27}}</ref> Gilman wrote the story to protest the societal oppression of women as the result of her own experience as a patient.<ref>{{Cite journal| vauthors = Quawas R |s2cid=191660461|date=May 2006|title=A New Woman's Journey into Insanity: Descent and Return in The Yellow Wallpaper|journal=Journal of the Australasian Universities Language and Literature Association|volume=2006|issue=105|pages=35–53|doi=10.1179/000127906805260310|issn=0001-2793}}</ref>

Also during the 19th century, gynecologists embraced the idea that female reproductive organs, and the natural processes they were involved in, were at fault for "female insanity."<ref name="Taylor_1996">{{Cite book| vauthors = Taylor V |author-link= Verta Taylor |title=Rock-a-by baby: Feminism, Self-help, and Postpartum Depression|publisher=Routledge|year=1996|isbn=978-0-415-91292-1|location=New York, NY|pages=2–6}}</ref> Approximately 10% of asylum admissions during this period are connected to "puerperal insanity," the named intersection between pregnancy or childbirth and female mental illness.<ref>{{cite journal | vauthors = Rehman AU, St Clair D, Platz C | title = Puerperal insanity in the 19th and 20th centuries | journal = The British Journal of Psychiatry | volume = 156 | issue = 6 | pages = 861–865 | date = June 1990 | pmid = 2207517 | doi = 10.1192/bjp.156.6.861 | s2cid = 33439247 | doi-access = free }}</ref> It wasn't until the onset of the twentieth century that the attitude of the scientific community shifted once again: the consensus amongst gynecologists and other medical experts was to turn away from the idea of diseased reproductive organs and instead towards more "scientific theories" that encompassed a broadening medical perspective on mental illness.<ref name="Taylor_1996" />

=== 20th century and beyond ===
The inseparability of the structural and the biological, the medical and the political, the exaltations and challenges of motherhood, all point to not just a history of suffering and treatment, but one of advocacy. The history of groundbreaking women health's activism between the 1970s and 2020s, in addition to the story of upholding the idealization of motherhood, is a poignant story of pushing against the status quo and also pragmatically embracing the legitimizing power of medicalization and political neutrality.<ref name="Moran_2024">{{Cite book| vauthors = Moran R |title=Blue: A History of Postpartum Depression in America|publisher=The University of Chicago Press|year=2024|isbn=978-0-226-83579-2|location=Chicago, IL|pages=3–14}}</ref> The phenomenon of baby blues was first named amid the surge of births following World War II. Baby blues or [[postpartum blues]] during the time following World War II hold an evolved understanding in the 21st century, and is understood as emotional distress of fluctuations that begin a couple days postpartum and can last up to two weeks. Baby blues is considered to affect perhaps 80% of new moms. While women experiences baby blues in the 1940s, 1950s and 1960s were often counseled to treat themselves with a new hat from the milliner or some other pick-me-up, in the 2020s, women are reminded about the role of hormones and are often encouraged to prioritize self care, and to rest as they adjust. Between the 1970s and 1990s, psychological professionals more frequently distinguished between subclinical baby blues, and the more serious medical issues of postpartum depression. The 1980s was a decade of depression in America, with huge increases in general depression diagnoses and in antidepressant availability.

Though there have been attempts at defining postpartum depression, doctors now consider it amongst a host of different illnesses, and refer to call the issues postpartum, Postpartum Mood and Anxiety Disorders (PMAD) rather than postpartum depression.<ref name="Moran R_2024">{{Cite book| vauthors = Moran RL |title=Blue: A History of Postpartum Depression in America|publisher=The University of Chicago Press|year=2024|isbn=978-0-226-83579-2|location=Chicago, IL|pages=3–14}}</ref> There is still no standalone diagnosis in the American Psychological Associations Bible, Diagnostic and Statistical Manual. Rather there is an umbrella of conditions. Advocates and clinicians mention PMADs as including mental distress during pregnancy in addition to the postpartum and around lactation, as well as an array of disorders beyond just depression. PMADs include postpartum obsessive-compulsive disorder, often with moms counting ounces of pumped milk, and obsessing over if it was enough and how to heal aching breast and chapped and blistered nipples, and postpartum anxiety, such as an excess of worries, like dropping the baby. A very rare percentage will show signs of postpartum psychosis that has led to issues such as infanticide. PMADs help to create an overarching recognition of many issues new parents, especially new mothers worry about, beyond the extent of exhaustion and sleep deprivation, the overwhelm of physical pain after birth, the vast changes in hormones and body conformation, the need to keep watch on the size of blood clots, the possibility of birth trauma, the social stresses and pressures, massive changes in relationship status with your husband, partner, and family, if you have one, and a constraint and limitation on familial and community resources for support, and lessons and guidance, leaving a new mother alone and vulnerable. On top of that, for wage-earning mothers, there is additional stress navigating working or not working, how much leave you have and how you will atone for taking that leave if you are lucky enough to have it, how to survive you do not take leave, if your leave is unpaid, or you have social opinions and naysayers to you taking leave. Then there is the stress of feeding an infant, including balancing feeding needs with paid work. Some of the difficulties of defining postpartum mood disorders comes from the long list of some of these examples, but also include an incomplete list of other challenges and contributing factors. Doctors are wary to clinically diagnosis, but there exists a fine line between, for instance mild obsession with counting ounces of milk, and postpartum obsessive-compulsive disorder. There is a fine line between worrying occasionally that you might drop your baby, or hold your baby incorrectly, and the feelings of some parents that veers into intrusive thoughts, or all-consuming panic attacks, and chronic anxiety. There is a fine line between an exhausted lethargic parent simply needing a very long nap or many long naps, and there also being the presence of clinical depression, testable with the [[Edinburgh Postnatal Depression Scale]] (EPDS).<ref name="Hoffman_2020">{{Cite book| vauthors = Hoffman BL, Schorge JO, Halvorsin LM, Hamid CA, Corton MM, Schaffer JI|chapter=Psychosexual Issues and Female Sexuality |title=William's Gynecology |edition=4th |publisher=McGraw-Hill Education |year=2020 |isbn=978-1-260-45686-8|location=San Francisco|pages=302–473}}</ref>

In the 1990s, the largest advocacy organization of postpartum advocates, Postpartum Support International, began addressed postpartum politics arguing that postpartum depression is not just an illness, but the most common complication of pregnancy.

There are other health measures monitored for in pregnancy as more screenings and health concerns have been introduced with advanced research in obstetrics and gynecology, perinatal, maternal-fetal medicine, neonatology, and pediatrics. A long list of these monitored complications follows.

There are the additional screenings that pregnant women have to worry, such as general screenings with a Pap smear, complete blood count, HIV screening, urine culture, rubella titer, ABO, Rh typing, hepatitis B screening, testing for all sexually transmitted diseases, gestational diabetes, and group B streptococcus.<ref name="Ladewig Davidson & London_2017">{{Cite book| vauthors = Ladewig PA, London ML, Davidson MR |title=Contemporary Maternal-Newborn Nursing Care, 9th Edition|publisher=Pearson Education|year=2017|isbn=978-0-134-25702-0|location=Hoboken, NJ|pages=166–174}}</ref>

Then there is other monitoring, include regular blood pressure to monitor for preeclampsia, ultrasounds to help monitor the position of the placenta and for placenta previa, monitoring and screening chorionic villus sampling (CVS), preeclampsia, eclampsia, and sampling of amniotic fluid via amniocentesis for health and maturity of the fetus, monitoring the change in the pelvic organs especially for intrauterine growth restriction (IUGR) in,<ref name="Butler, Amin, Kim, & Fitzmaurice_2019">{{Cite book| vauthors = Hatfield, T, Butler JR, Amin AN, Fitzmaurice LE, Kim CM|title=Chapter 36Intrauterine Growth Restriction, In OB/GYN Hospital Medicine: Principles and Practice. |publisher=McGraw-Hill Education |year=2019 |isbn=978-1-259-86170-3|location=San Francisco|pages=46–529}}</ref> and general monitoring of changes in a mother's pelvic organs via various testing including Goodell sign, Chadwick sign, Hegar sign, McDonald sign, uterine enlargement, Braun von Fernwald sign, uterine souffle, chloasma or melasma, linea nigra, changes in nipples, abdominal striae, ballottement, monitoring hormone levels and changes.<ref name="Ladewig London & Davidson_2017">{{Cite book| vauthors = Ladewig PA, London ML, Davidson MR |title=Contemporary Maternal-Newborn Nursing Care, 9th Edition|publisher=Pearson Education|year=2017|isbn=978-0-134-25702-0|location=Hoboken, NJ|pages=143–144}}</ref>

Continuing, there is the monitoring of the fetus for quickening, fetal heart tones (FHT), fetal heart rate (FHR), fetal blood sampling (FBS), fetal altitude, fetal lie, fetal breathing movements (FBM), fetal movement record (FMR)/fetal movement count (FMC) fetal growth and movement, fetal position, and fetal positioning.<ref name="Carlson_2019">{{Cite book| vauthors = Carlson BM |title=Human Embryology & Developmental Biology, 6th Edition|publisher=Elsevier|year=2019|isbn=978-0-323-52375-2|location=Canada|pages=435–453}}</ref><ref name="Woodward, Kennedy, & Sohaey_2021">{{Cite book| vauthors = Woodward PJ, Kennedy A, Sohaey R |title= Diagnostic Imaging: Obstetrics 4th Edition|publisher=Elsevier|year=2021|isbn=978-0-323-79396-4|location=Manitoba, Canada|pages=4–794}}</ref>

Then mothers have to worry about screenings each trimester, including first-trimester screenings for defects of trisomies through testing such as nuchal translucency testing (NTT), and serum testing for PAPP-A and beta-hCG, and later trimester monitoring for any pre-labor ruptures of membranes (PROM) that can lead to an abortion or if a premature pre-labor rupture of membrane (PPROM) before 37 weeks can lead to a preterm birth, if it occurs when the fetus is viable.<ref name="Butler, Amin, Fitzmaurice, & Kim_2019">{{Cite book| vauthors = Cohen IJ, Pierce-Williams RM, Ehsanipoor RM, Butler JR, Amin AN, Fitzmaurice LE, Kim CM|title=Chapter 46 Preterm Premature Rupture of Membranes, In OB/GYN Hospital Medicine: Principles and Practice. |publisher=McGraw-Hill Education |year=2019 |isbn=978-1-259-86170-3|location=San Francisco|pages=46–529}}</ref><ref name="Woodward, Sohaey, & Kennedy_2021">{{Cite book| vauthors = Woodward PJ, Kennedy A, Sohaey R |title= Diagnostic Imaging: Obstetrics 4th Edition|publisher=Elsevier|year=2021|isbn=978-0-323-79396-4|location=Manitoba, Canada|pages=798–834}}</ref>

Thus, there is a lot of stress on the mother and non-credit given to what her body goes through; hence starting after the 1940s, 1950s, and 1960s, and with headway made in the 1970s and 1980s, even more activism in the 1990s, promoted greater advocacy by postpartum groups, political advocates, medical clinicians, that emphasized how necessary and important it is for emotional and mental health screening, during pregnancy and in postpartum that can run anywhere from the first two weeks to the first 18 months. Mothers goes through often inconceivable changes in their bodies to bring a life into the world, and that can be overwhelming and stressful especially to any first time mom. This is why it is critical to continue to advocate for more screenings, support services, and self-care opportunities, that help alleviate the burden of motherhood.

=== The 21st century ===

The first quarter of the 21st century has brought about regression in many women's health gains of the 20th century. As 21st-century legislation has led to deep divides and debate in regard to abortion politics and who makes decisions over a woman's body and in regard to a woman's health.<ref name="Hoffman_2018">{{cite web |last=Hoffman |first=Charity M |date=2018 |title=21st Century Motherhood: Navigating Work, Family, and the Struggle to Have it All  |url=https://deepblue.lib.umich.edu/bitstream/handle/2027.42/145984/charityh_1.pdf |website=University of Michigan Library |location=Ann Arbor, Michigan |publisher=Department of Social Work and Sociology, University of Michigan |access-date=April 8, 2025}}</ref> There needs to be more advocacy for universal parental paid leave, more equality and increases in women's pay where discrimination continues to persist, and additional opportunities for paid time off for family needs, medical needs, and mental health needs. For new parents, better health insurance plans and leeway and lenience for parents need to be tolerated and respected, especially during the first five years, until a child enters school systems. With this, there also need to be better options for childcare—a program that often ends mid-day—and more flexibility from employers on employees to decrease the stress of working obligations and the need to pick up a child from childcare, which can exacerbate postpartum mental health conditions (PMHCs). Additional after-school care programs that do not leave parents feeling like they are neglecting their children simply in financially supporting the family would also help alleviate PMHCs, especially for working women who are the primary financial provider and/or go from previously one full-time job to two full-time jobs, with only one being paid and financially compensated.<ref name="Scholar_2016">{{cite web |last=Sholar |first=Megan A. |date=2016 |title=The Politics of Motherhood: The History of Family Leave Policies in the United States |url=https://www.oah.org/tah/november-3/the-history-of-family-leave-policies-in-the-united-states/ |url-status=live |archive-url=https://web.archive.org/web/20250513092939/https://www.oah.org/tah/november-3/the-history-of-family-leave-policies-in-the-united-states/ |archive-date=May 13, 2025 |access-date=April 8, 2025 |website=OAH.org |publisher=Organization of American Historians |location=Bloomington, Indiana}}</ref><ref name="Coombs_2021">{{cite web |last=Coombs |first=Sarah |date=2021 |title=Paid Leave is Essential for Healthy Moms and Babies |url=https://nationalpartnership.org/report/paid-leave-is-essential-for/ |access-date=April 8, 2025 |website=NationalPartnership.org |publisher=National Partnership for Women and Families |location=Washington, DC}}</ref><ref name="Lojek_2024">{{cite web |last=Lojek |first=Christina |date=July 31, 2024 |title=Majorities of U.S. women agree - there isn't enough focus on postpartum healthcare for mothers, they are often forgotten once baby arrives |url=https://www.prnewswire.com/news-releases/majorities-of-us-women-agree---there-isnt-enough-focus-on-postpartum-healthcare-for-mothers-they-are-often-forgotten-once-baby-arrives-302210520.html |website=PRNewswire|location=Washington, DC |publisher=The Harris Poll |access-date=April 8, 2025}}</ref><ref name="WHOPostnatalPostpartumCare_2008">{{cite web |last=Matthews |first=Matthias |date=2010 |title=WHO Technical Consultation on Postpartum and Postnatal Care based on the Conference held in October 2008 |url=https://www.ncbi.nlm.nih.gov/books/NBK310591/pdf/Bookshelf_NBK310591.pdf |website=NIH|location=Geneva, Switzerland |publisher=World Health Organization Department of Making Pregnancy Safer |access-date=April 8, 2025}}</ref>

In a visual timeline by the Maternal Mental Health Leadership Alliance (MMHLA), a 501(c)(3) nonpartisan nonprofit organization leading national efforts to improve maternal mental health in the United States by advocating for policies, building partnerships, and curating information, there have been numerous advancements in services and legislation,<ref name="MMHLA_2025">{{cite web |author=<!-- not stated --> |date=2024|title=Maternal Mental Health Federal Legislative Summary |url=https://www.mmhla.org/legislative-history |website=MMHLA.org |location=Washington DC |publisher=Maternal Mental Health Leadership Alliance Inc. |access-date=April 8, 2025}}</ref> including the 21st Century Cures Act signed into law in December 2016.<ref name="Congress_2016">{{cite web |author=<!-- not stated --> |date=2016 |title=H.R.34 - 21st Century Cures Act Public Law 114-255 of the 114th Congress (2015-2016) |url=https://www.congress.gov/bill/114th-congress/house-bill/34/text |website=Congress.gov |location=Washington D.C. |publisher=Congress |access-date=April 8, 2025}}</ref><ref name="Women's Healthcare_2016">{{cite web |last=Foley |first=Susanne |date=2016 |title=Reaching postpartum women in the U.S.: Demographics and generational characteristics |url=https://www.npwomenshealthcare.com/wp-content/uploads/2016/03/0216WHNP_Postpartum-1.pdf |website=npwomenshealthcare.com|location=Philadelphia, PA |publisher=Women’s Healthcare: A Clinical Resource for NPs |access-date=April 8, 2025}}</ref><ref name="Policy Center_2025">{{cite web |author=<!-- not stated --> |date=March 2025 |title=Paid Family and Medical Leave and Maternal Mental Health [Issue Brief] |url=https://policycentermmh.org/app/uploads/2025/03/Paid-Family-and-Medical-Leave-MMH-2025.pdf |website=Policy Center for Maternal Mental Health |location=Washington, D.C. |access-date=April 8, 2025}}</ref> And, as of 2024, family and medical leave has been cleared for use of PMHCs, including postpartum depression.<ref name="Applewhaite_2024">{{cite web |last=Applewhaite | first=Helen M |date=August 21, 2024 |title=Yes, you can use FMLA for PPD and other postpartum mental health conditions |url=https://www.mother.ly/postpartum/can-you-use-fmla-for-ppd-and-pmhc/ |website=Motherly |location=Washington, D.C. |access-date=April 8, 2025}}</ref> This is a start, but there is still much progress to be made, given the consideration that of 41 countries, only the United States lacks paid parental leave, though it offers unpaid leave under the Family and Medical Leave Act (FMLA).<ref name="Livingston_2019">{{cite web |last=Livingston | first=Gretchen |date=December 16, 2019 |title=Among 41 countries, only U.S. lacks paid parental leave |url=https://www.pewresearch.org/short-reads/2019/12/16/u-s-lacks-mandated-paid-parental-leave/ |website=Pew Research |location=Washington, D.C. |publisher=Pew Research Center |access-date=April 8, 2025}}</ref><ref name="Nonacs_2023">{{cite web |last=Nonacs | first=Ruta |date=March 14, 2023 |title=Among 41 countries, only U.S. lacks paid parental leave |url=https://womensmentalhealth.org/posts/paid-parental-leave-a-novel-approach-to-improving-maternal-mental-health/ |website=MCH Center for Women's Mental Health  |location=Cambridge, Mass |publisher=Massachusetts General Hospital and Harvard Medical School |access-date=April 8, 2025}}</ref><ref name="Williamson_2024">{{cite web |last=Williamson | first=Molly W |date=January 17, 2024 |title=The State of Paid Family and Medical Leave in the U.S. in 2024 |url=https://www.americanprogress.org/article/the-state-of-paid-family-and-medical-leave-in-the-u-s-in-2024/ |website=The Center for American Progress  |location=Washington, D.C. |access-date=April 8, 2025}}</ref><ref name="Williamson_2025">{{cite web |last=Williamson | first=Molly W |date=January 15, 2025 |title=The State of Paid Family and Medical Leave in the U.S. in 2025 |url=https://www.americanprogress.org/article/the-state-of-paid-family-and-medical-leave-in-the-u-s-in-2025/ |website=The Center for American Progress  |location=Washington, D.C. |access-date=April 8, 2025}}</ref> There is currently no federal law providing or guaranteeing access to paid family and medical leave for workers in the private sector, especially during the postpartum period. However, some states have their own paid leave programs and requirements for companies to provide paid parental leave.<ref name="Women's Bureau_2025">{{cite web |author=<!-- not stated -->  |date=2025 |title=Paid Leave |url=https://www.dol.gov/agencies/wb/featured-paid-leave |website=Women's Bureau in the Department of Labor  |location=Washington, D.C. |access-date=April 8, 2025}}</ref> Paid leave advocates realize that paid leave, as opposed to unpaid leave, helps to alleviate some of the stress and overwhelming burden tacked on to the postpartum period that can exacerbate PMHCs and can inhibit or make it more difficult to return to work after maternity leave.<ref name="Franzoi_2024">{{cite journal |vauthors= Franzoi IG, Sauta MD, De Luca A, Granieri A |date=April 5, 2024 |title= Returning to work after maternity leave: a systematic literature review |url=https://link.springer.com/content/pdf/10.1007/s00737-024-01464-y.pdf |journal=Archive's of Women's Mental Health |volume=27 |issue=5 |publisher=Springer Nature |pages=737–749 |doi=10.1007/s00737-024-01464-y |pmid=38575816 |access-date=April 8, 2025}}</ref>