Tuesday, January 10, 2006

The First Time Is Different

Anyone who has been through birth more than once will tell you that first labor, delivery and "babymoon" are special. Not always in good ways.

First labors are typically slower to start and last longer. First babies usually take longer to push out the birth canal than subsequent siblings. Mothers' milk takes longer, on average, to come in than milk after later deliveries. And how about that feeling of bringing a new baby home for the first time? "They let me walk out of the hospital with this child and no training?" Thank heavens that only happens once.

The hormonal and physiological changes of labor, birth and recovery apparently are different the first time around, too.

Researchers have recently identified "first delivery" as a risk factor for postpartum psychosis. Fortunately, psychosis is very rare. But if it's going to happen, it is most likely to occur after a woman's first birth.

The cases of postpartum psychosis we are familiar with from the media -- women who methodically drown five children in a bathtub or drive their car full of children into a lake -- involve multiple deaths and evoke an image of an overworked mother pushed to the breaking point.

Unfortunately, this study shows, the more representative candidate will be a first-time mother, possibly one who has had a difficult delivery. But because she does not fit the image we hold from the media, we may be less likely to recognize signs of illness in her, or more easily dismiss signs as non-threatening.

An example that has stuck with me from The Chronicle of Higher Education (subscription only) is the story of a promising professor who killed her first-born child, but whose behavioral warning flags were misread:

Like many couples who have just had a baby, Ms. Ener and Mr. Donagi had a lot on their plates. They moved to a house just a few miles from the campus when Raya was five months old. On the evening of July 4, the couple had a housewarming party, where friends and colleagues danced to Arab music, ate desserts, and watched fireworks overhead. Two days later the family left for a monthlong stay in California, where Mr. Donagi would attend a conference at the University of California at Santa Barbara.

Mr. Donagi says both he and his wife were looking forward to the California sun, to running, and to shopping at organic-food markets. But after they arrived, he says in an e-mail message, Ms. Ener couldn't relax and barely slept. The couple had learned that Raya might have trouble hearing.
Ms. Ener focused on that and a litany of other concerns: Was Raya eating enough? Was the tape attaching the feeding tube to her cheek irritating her? When she spit up, was that normal baby behavior, or did it mean she could not keep down enough food?

Halfway through the couple's time in California, Ms. Langohr, the professor at Holy Cross, came for a visit. Right away she noticed something was wrong. "Mine was convinced Raya was wasting away and in a lot of pain," says Ms. Langohr, who could see for herself that Raya was healthy and giggled when she played.

Ms. Langohr tried to persuade Ms. Ener to return to Philadelphia for psychological help, but Ms. Ener said she preferred to go to Minnesota to be with her family. Mr. Donagi drove his wife and baby to the airport on July 27.

In St. Paul, Ms. Ener's family insisted that she see a doctor, who gave her antidepressants and told her family not to leave her alone. "She would say things that were really off the wall," Ruth Ener recalls. At one point Ms. Ener told the doctor that she had considered jumping into the Mississippi River. But later she reassured her family that she could never commit suicide. It was then that Ms. Ener's brother, Oran, asked her if she had thoughts of hurting her baby. She answered emphatically: No.

Even while Ms. Ener seemed ill, there were times during her St. Paul visit that she appeared almost normal. "She would say, 'Boy, I really sounded wacko when I said that, didn't I?'" recalls Ruth Ener. "She wasn't constantly that desperate, pitiful person. She went in and out of it."

Perhaps that is why, although her family never left her alone at her parents' home, they didn't feel compelled to follow her every move. When Oran Ener stopped by his parents' house to visit his sister and their mother early one August morning in 2003, nothing seemed to have changed from the day before. While he was there, Ms. Ener fed Raya and collected toys for her to play with.

At about 9 a.m., after Oran had left for work, his sister took the baby into the bathroom for a few minutes, then walked empty-handed toward her mother, Marita Ener, who was cleaning the breakfast dishes. In an expressionless voice, Ms. Ener announced: "I just killed my baby."

Marita Ener didn't say a word. "Mine looked so completely out of it, I couldn't do anything but jump up and go into the bathroom," she recalls. She found the baby lying on the floor, blood seeping onto the bathmat. Ms. Ener had slit her daughter's throat with a kitchen knife.

A very accessible book on normal and abnormal postpartum adjustment is Overcoming Postpartum Depression and Anxiety by Linda Sabastian. I did not find its value in the "overcoming" aspect, but more in the labeling and describing different types of behavior.


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