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Kirtly: So you got through your pregnancy and the delivery, and now you're a brand-new person. You have moved into the fourth trimester of pregnancy, those three months after the birth of a child that are critical for the survival of the mom and the new baby. This is a period of emotional upheaval. Profound love and attention for the newborn, exhaustion, overwhelming ups and downs, baby blues, baby love, and more.

I'm Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah. And as a reproductive hormone specialist, I've always been curious about the emotional and hormonal changes to the mom and the baby after the cord is cut, and the placenta is removed, and the sea of pregnancy hormones dries up very quickly.

There are many hormones made by the pregnancy, not just estrogen and progesterone. The placenta is actually another brain, making and metabolizing many of the neurohormones that the brain makes. These hormones don't just set the pregnancy up for the physiology of mom and baby, but may prepare the mother cognitively and emotionally for the critical period of nursing and caring for the newborn.

So we are working on the 7 Domains of the Fourth Trimester, the physical, emotional, social, intellectual, financial, environmental, and spiritual worlds of this postpartum period. And today, we're exploring the emotional domain.

With me, as always, is Dr. Katie Ward. She's a professor in the School of Nursing and a women's health nurse practitioner and an anthropologist, so we're going to get her 2 cents' worth or 3 cents or $25,000 worth of anthropology.

So, Katie, we're still working on how the brain is modeled for attachment bonding. Is it the hormone oxytocin, which is made in buckets during labor and delivery? But what about women who have a cesarean without labor? Can they still bond? Of course, they can.

When women breastfeed, the suckling of the nipple of the baby releases oxytocin and prolactin, which may enhance bonding. But do women who can't breastfeed bond with their babies? Of course, they do.

Well, what about the rapid fall in progesterone and estrogen that's critical for milk development? Does that affect some women emotionally?

Well, we have a model for anxiety and depression. For a small percent of women who experience PMS that is really difficult and have a mood disorder, just before their period when hormones estrogen and progesterone fall, they have problems emotionally and anxiety.

And we've considered that some women are sensitive to falling hormones, especially progesterone. Some therapies for postpartum depression include an infusion of a metabolite of progesterone.

What we do know is that there is a profound change in emotional states of the new mom for a good reason. And this is why the biopsychosocial model is really important. It's not only your biology and your sensitivity to hormones, but it's your psychology. Do you have a history of emotional issues, ups and downs in your social stuff? Are you worried about money? Are you in a really rough and not safe environment? So it all goes together in the seven domains.

Well, by the way, our local zoo just welcomed . . . that's a new word they use for when a baby is born to a family. We welcomed this baby orangutan, a critically endangered species, and the zoo specialist carefully watched the new mom for her ability to bond and nurse this new tiny orang.

The mom had difficulty after a previous pregnancy with bonding with her newborn and helping her newborn to nurse, and the zoo was concerned it might happen to this one. So they were watching the baby and the new mom all the time, and they noted that the new mom wasn't helping the baby to nurse. So they've taken the newborn orang under human care 24 hours a day, trying to replicate the attachment and nursing that an orangutan mom might give. So there you are. We've got to watch out for our new moms, Katie.

Katie: I mean, that's it exactly. I think, especially in humans, the thing that we do as a primate that's really unique is we're designed to be in community.

We're doing this funny experiment in the world today where women go home, and they're in their house, behind their fence, and kind of are afraid to go out and not having people around us. I think COVID has magnified this, especially. But we were designed to be what we call cooperative breeders, where you would have grandmothers and sisters and close other people in your community that were there kind of to do what the zoo is doing for the baby orangutan, right?

I mean, I don't want to say that hormones totally determine your behavior, because I think there's a lot going on in the interaction between the stress of the modern world and having maybe higher hormone levels than our ancestors did for a bunch of reasons.

But I kind of wonder if maybe baby blues aren't supposed to be maybe a gentle nudge to turn inward and be in a space where you can just be in communication with this baby.

That's one of the things about human babies, is they're not going to talk for a long time. So, as a mother, you have to read their body language and their cues. They're expressing their distress, and you have to sort of figure out how to get in sync with that.

So in its most gentle form, I think that postpartum period is a little bit of a nudge to slow down and pay attention to yourself and cue into your baby, and maybe moms are also kind of cuing that help around them to solicit help. But we're supposed to have help.

Kirtly: Yeah, we're supposed to have help.

Katie: Whether it's the zoo or your therapist, it's a period of time when it's important to reach out and mobilize support.

We're the only species that cries tears. We did the 7 Domains of Crying, and no other animals cry tears. The babies cry out, or even the grown-up animals cry out, but they don't cry tears. And tears are a visual clue to others around us that we need some help.

Well, sometimes this important shift in hormones that leads to bonding and vigilance for the newborn doesn't happen in a way that's healthy for the mom and the baby. And recognizing postpartum depression is really important, looking at those tears in the new mom and stepping right into her space to help.

With us in the virtual studio is Dr. Lauren Gimbel to help us think about this problem. Dr. Lauren Gimbel is an Assistant Professor at the Department of OB-GYN at the University of Utah, and she's the Medical Director of the Outpatient Perinatal Mental Health Program in the OB-GYN department, and currently also serving as the Medical Lead of the Perinatal Mental Health AIM Patient Safety Bundle with the state of Utah.

Kirtly: Welcome, Lauren. But what is the AIM Patient Safety Bundle for Perinatal Mental Health?

Dr. Gimbel: Thanks so much for having me on. I'm really excited to talk with you guys about these aspects. It's such an important topic.

So AIM is the Alliance for Innovation on Maternal Health, and the organization has different safety bundles to allow for safer birthing experiences. As a state, the state of Utah selects a different patient safety bundle to work on each one to two years to help hospital systems to improve the care that we provide pregnant and postpartum individuals.

Kirtly: Oh, I got it. I remember when we did the postpartum hemorrhage bundle, and we do some other. Okay, I got it.

I think of some countries that take a different tack, which I wish we would, and I know in England, every woman who delivers gets a midwife that comes to visit them. Once or twice, they visit them in the home, and they knock on the door, and you've got to let them in. They assess how the mom and the baby are doing.

And I think there have also been some patient-centered group therapy that's been tried in this country where women who are postpartum meet with other women for some other postpartum visits and work on that.

That feeling alone . . . Now, you don't want your mother-in-law hanging on every little thing that you do and the baby does, but there is something about being with other women that people do in early cultures all over the world. You are with the other moms, and somebody who's smarter, been there before can help you out. And I think having increased access is great.

Dr. Gimbel: That part of social component is really important. So, as an OB-GYN, I work with one of my colleagues, Dr. Zakama, who's a high-risk pregnancy doctor, and so we are able to see individuals during pregnancy and postpartum, as well as preconception, and we do consultations on medications. We talk about depression and anxiety treatment during these time periods.

And often, the response that we've gotten is a little bit more of that isolation that you're talking about, too, outside of the social components, where their psychiatrist or behavioral health provider is telling them to ask their OB about it, and their OB is telling them to ask their behavioral health or psychiatrist about what to do with medications or treatment options.

And so we really try and fill that gap by providing evidence-based information that's the most up-to-date with the data that's going on in this realm so that we can really create kind of an individual holistic treatment plan for the child-bearing individual.

Katie: That's so valuable. As a provider, I think there's anxiety about prescribing things in pregnancy. People get really specialized, and you end up feeling like, "I don't know what's the best thing to do or if this is safe." So a couple of layers of isolation here. There's isolation for the mother and isolation for specialties, where we're all worried about staying in our lanes.

Kirtly: You mentioned team, and I think the team approach is important. I think one of my least favorite phrases is, "Well, you have to take care of yourself," which is true. Are you getting your exercise? Are you getting your sleep? And as a care provider for a newborn, what do you say? "Oh, yeah, I'm just going to give up nursing," or, "I'm going to give it over to my husband who sleeps through the whole thing," or, "What happens? Do I take my baby out when I go for a walk?"

So how you actually operationalize the suggestions regarding eat, sleep, social, exercise, which are all probably good for the mom, could take a team to help a woman get through that.

Dr. Gimbel: We're doing a lot of postpartum planning, so meeting with individuals in the third trimester to talk about the postpartum time period so that, like you're saying, if mood worsens, we're kind of having things in place, or preventatively, how can we make sure to prioritize sleep? Which is such a funny thing to tell people postpartum, because sleep is one of the hardest things to get but one of the most important components for improving mental health.

So we kind of talk about some of those aspects, brainstorming some components, and we try and do it in a little bit more of a realistic way.

Kirtly: Yeah, or do it in the presence of the partner and family. I mean, you can give all these instructions to the woman herself who's there at a visit with her baby in her arms, but then she's got to go home and make this happen with her family or her friends. I think it's complicated to do it, and it was easier when we all lived in the same long house or something like that.

Dr. Gimbel: Yeah, that's exactly the component. It's really having a village kind of to take care of this aspect so that it's not just the child-birthing individual who's providing all the care.

Katie: You're talking about the third trimester, so there are some things that you're recognizing in advance that can be helpful, it sounds like. Are there people that you can identify that are more likely to have problems with postpartum depression?

Dr. Gimbel: Yeah, there are definitely risk factors. So people who have a history of anxiety or depression are at the highest risk, and then other components of less social support, having complications during pregnancy. So there are a lot of risk factors for development of it.

One of the interesting things, though, is that it occurs in about 15% to 20% of individuals. So it's the most common comorbidity of pregnancy. It's also kind of hard from the aspect that most people have at least one risk factor for developing postpartum depression or postpartum anxiety. And so, because of that, we're trying to talk a little bit more just about that prevention component, about the self-care aspect, about having conversations earlier on to kind of not have it just be the child-bearing individual who's doing all of the care.

Kirtly: Well, from an evolutionary perspective, as I think about any disease state that happens so frequently, you'd say, "What is it about this?" I mean, this is a serious issue for the welfare of a newborn and success in passing on your genes, and if it's that common, there must be something about it that you can . . . You mentioned involution, or being sad and hoping that people will gather around you when you're not doing well.

When it's so common, is it the way we live now? Do we have the same rate of postpartum depression and anxiety as people who live in villages in Africa and India and South Asia? Do you have any sense about that?

Dr. Gimbel: So when you look across the world, the rates differ a little bit based on what's used as a measurement. Sometimes some studies are looking at more positive screenings instead of an actual diagnostic component to it.

So, to your point, it seems pretty even across the world, and it seems pretty even across the U.S. When you include the pregnancy time period, it's more that 15% to 20% of depression and anxiety. When you include just the postpartum, it's a little bit more like 10% to 15% for depression, specifically. So it kind of depends on which study you're looking at.

But to your point, I think that some components also have to do with, as you were talking about earlier, how we've changed the narrative of what we're allowed to talk about and what we're not. Historically, mental health has always been stigmatized, so it's been something that we're really trying to encourage people to bring up if they are having symptoms.

Kirtly: Yeah. Well, we believe that the attachment between the baby and the mom . . . And it doesn't have to be the mom. I think dads can do that too. But it's critical for the healthy emotional development in the baby. Babies have these mirror neurons in their emotional brain that mirror the emotion that they see in front of them.

This is important in the first year of life, and it's important for us to develop an emotional state that we get. So how do we know what sadness is? How do we know what happiness is? How do we know what love is? Well, we've seen it mirrored in the people who've cared for us.

Katie: Right. I think I was alluding to that earlier, that moms were kind of built for interacting with our babies. Baby's eyes can focus at mom's face. That's about as far as they can see when they're new. And so they're intently looking at mom, and they're kind of designed . . . their features are designed to attract your attention and hold it. And so there's a lot of this nonverbal communication that's going on between the mom and the baby.

I think to your point, because this postpartum depression is so prevalent, you have to think about it as maybe there's a piece of it that is adaptive. And so that adaptive piece of just being, "I'm right here paying attention to the communication that's going on between myself and my baby," whether you've given birth or you've adopted a child, or even if you're the grandmother or the other or the father. Babies are kind of designed to solicit love, and we have a little bit of a built-in feature to be focused on that.

Dr. Gimbel: Yeah.

Kirtly: Right. So you mentioned, Lauren, that this affects the whole family, because a mom that's not doing well, it brings everybody in a worry state.

Dr. Gimbel: Definitely. And kind of one of the things you guys are talking about is I think that more than just the components of the mom themselves and the quality of life, but the day-to-day functioning becomes challenging.

We know that suicide and overdose are the most common cause of mortality or death during pregnancy or in the postpartum time period. And there are a lot of things we can do for prevention of that component.

Some of my favorite data that's been coming out is when you look at untreated depression or anxiety and you look at long-term outcomes of infants, and they have a little bit of data on adolescents, but mostly infants and infant behavior and attachment and development, you actually find that there's worse attachment disorders, behavioral problems, and then, later on, more depression and mood disorders.

So it brings up this question that if we treat people for depression and anxiety not just with medications but other components too, would it decrease the intergenerational transmission of certain aspects of mental health disorders? Which I just think is so fascinating.

Katie: Yeah, those mirror neurons, again.

Kirtly: Yeah, we've done this in mice. There are moms that lick their babies a lot, and there are moms that don't. And the moms that don't, their babies grow up to be a little bit more anxious and fearful. So it's this whole mammalian thing. Those who are nursing and being there with their babies, it's important.

But when we get down to baby blues and depression, how do we recognize this? Because every mom, we're certainly overwhelmed. Katie, maybe you weren't. I was kind of overwhelmed, but I wouldn't . . .

Dr. Gimbel: Yeah, postpartum blues actually occurs in 80% of individuals. So it starts to develop the first few days after birth, and then it can last up to two weeks. People can have crying a lot. They're impatient, more irritable, restless. They have a lot of anxiety, trouble sleeping, and really sad. But it doesn't impair their function, and it's never associated with thoughts of harming themselves, and it only lasts those first two weeks.

Postpartum depression is similar, with a low mood and interest. You're really angry, irritable. You have a lot of rage. And there's disturbance in sleep, appetite, crying a lot, feeling really guilty, having low energy. And you could also have thoughts of harming your baby. These symptoms affect how the person is actually functioning and then last for longer than two weeks.

Kirtly: And then there are rarely, and I do mean rarely, people who really need emergency help and hospitalization. Can you talk about that?

Dr. Gimbel: So one aspect would be if someone has thoughts of hurting themselves and they're developing a plan to do so. That would be something I would want them to go to a crisis care center. And there are multiple different crisis care centers across Utah. Huntsman Mental Health Institute actually has the Kem and Carolyn Gardner, a new crisis care center in South Salt Lake. But there are other ones, too.

So if there are thoughts of hurting themselves or their baby and an intent to do so, or something called postpartum psychosis, which typically occurs within the first one month after delivery. That, like you said, is really rare, only 1 to 2 per 1,000 individuals. But it can be the person has delusions, they have hallucinations, they're seeing or hearing things that others are not, and their activity is a lot different than either what they're saying or than it used to be previously. They have a lot of trouble differentiating between what is real and what is not real.

Kirtly: So we talked a little bit about mobilizing support from the medical side and from the social side. What else should we know about how we treat postpartum depression?

Dr. Gimbel: So it really depends on the severity of symptoms. For mild symptoms, doing lifestyle and conservative components of . . . You kind of put them all together into this self-care, but the most important one is sleep. So really prioritizing sleep and kind of using the community to get any help with taking care of baby during those time periods.

The other aspect is healthy eating and then some form of exercise, even if the exercise is just getting outside and walking around the block once a day, taking five minutes doing some mindfulness activities, and just really paying attention to the components around you.

You often hear that people haven't left the house after delivery until their six-week postpartum visit or until that four- to six-week mark, and that can be really helpful, is kind of getting outside.

Like you guys were talking about, socialization is also helpful. It's hard in this age, but if people are willing to do in-person groups, I think that those are really nice. So mothers' groups or fathers' groups or parent groups can be really nice kind of trying to connect with the community or other people going through that time period.

For more moderate or severe illness, therapy is incredibly helpful, and then medications in some people. And we have really great data on medications during pregnancy and during breastfeeding if people are choosing to breastfeed.

Kirtly: Yeah. Well, you mentioned before postpartum anxiety, and I thought that was part of the drill. I remember thinking that I couldn't do this. I'm an OB-GYN, and my husband was a pediatrician, but I thought, "I can't do this." And then I said, "No, wait a minute, I'm not stupid, and he's not fragile. He's a great big baby, and we can get through that."

But I had many years of training to treat myself to think I could do this, and some people don't. Or just it's so overwhelming, the anxiety that you have that you're not going to do this right.

Katie: Right? And that's just sort of baked into us, because you do have to be a little anxious. You have to be vigilant all the time. And so when does that sort of worry about "Where is my baby?" and "Is the baby safe?" tip over into anxiety? Because you do need a degree of vigilance to pay attention to a baby.

Dr. Gimbel: Yeah, and some component of that is probably protective, too. If there wasn't a component of anxiety, then it probably wouldn't be parenting. But it's when some of those anxieties are starting to affect function.

There's a prior study that looked at people in the postpartum period, when they were screening for anxiety, and about 50% of them screened initially, but then as time went on, that decreased.

It really just becomes more of a disorder or problem that I'd want the person to kind of talk with someone else about when it's really pervasive and affecting their function. So they're not going to the grocery story anymore because they're worried they're going to get into a car accident, or something will happen to the baby while they're trying to get baby in and out of the store.

Or it's affecting their relationships. One of them worries so much that no one else is allowed to take care of the baby. They're not functioning if they're returning to work, or they're getting into repeated fights with their partner.

Kirtly: Well, this is on the next topic, but as an OB-GYN trained in another era, we were told that all the stress hormones of delivery, all the endorphins help block out the memories of difficulties. Otherwise, why would women ever do this again? So they must forget their birth experience, or we wouldn't have populated the planet. It's kind of like running one marathon. Why would you ever do another?

It was sort of what happens in the delivery room stays in the delivery room, but that's absolutely not true, and some women have terrible memories about their birth experience. We could talk a little bit about postpartum memories of difficult birth. The current term might be postpartum post-traumatic stress disorder.

Katie: Yeah, it's a way to learn from it. So if you have a negative experience, then it's important to remember that so that you can learn from it. But when that negative experience . . . I think some of it is the degree of things we can do to people in the birth suite or in the operating room that are intense experiences.

And sometimes it's just that you've built up an expectation for a birth, and then that doesn't happen. So there are so many things that then you can play over and over again in your head, and they get magnified.

Kirtly: So I think that's the issue, and I think it's a disconnect between providers who said, "Hey, healthy baby, healthy mom. What's the problem?" and the woman who said, "I didn't sign up for this, and I feel terrible." So, Lauren, what are your thoughts?

Dr. Gimbel: Birth trauma is a really common topic now. You don't have to have something traumatic actually occur to develop birth trauma. Post-traumatic stress disorder and birth trauma are two separate components, but people kind of lump them together during the reproductive time period. But some people have PTSD or post-traumatic stress disorder beforehand, and then some have recurrent symptoms afterwards.

Actually, up to a third of individuals rate their delivery as traumatic, but only 4% to 6% of them meet criteria for a mental health diagnosis of postpartum post-traumatic stress disorder.

Kirtly: How can you not think the birth was traumatic?

Dr. Gimbel: Yeah.

Kirtly: Especially the first one. Yeah, even though it's lovely and wonderful, oh my goodness.

Well, I think that it's an amazing thing that talking about birth experiences often happens organically in any group of women, whom I'm with anyway. They talk about pregnancy and labor. Maybe a friend or a daughter has just had a new baby and a complex labor, and the doors open for women to share their often difficult experiences.

Katie: And women remember these.

Kirtly: They do, and it gets bigger. For me, my baby was now 11.5 pounds instead of only 11.25 pounds, or the labor was 2.5 days instead of 2, whatever. But I think women do share their birth stories.

Katie: I was on a shuttle bus recently, and there was a family. And the matriarch, who was the grandmother, was talking to her grandchildren about her birth experience in a very public setting.

It just reminded me, one, that women can tell this story, it's an important story, it stays with us, and you don't forget it. And there you are, the grandmother, telling your granddaughter about your own birth experience down the road.

They can be these wonderful stories that you're very happy about, but when they are traumatic in whatever way, that means that that retelling reinforces the feelings.

Dr. Gimbel: It can also, kind of like you were saying, shape how the individual sees the child, that certain aspects of the child's story kind of begin at that time. So, "You were stubborn during labor. You're still stubborn," or certain kind of words that we choose to put onto it can kind of go on to affect that relationship and continued building of a narrative.

Kirtly: Yeah. So how do we get women and families the help they need? Can we be kind of specific about this?

Dr. Gimbel: Yeah. So the most important thing is one of the aspects that we're doing right now, which is encouraging people to talk about it, to destigmatize mental health. Really, the first thing would be to bring it up with your provider. And without talking about it, your provider won't really know kind of what's going on from that aspect.

Typically, each obstetrics provider has resources. But at the University of Utah and HMHI Perinatal Mental Health Program, we're always happy to see you as well.

If you're already a patient at the University of Utah, ask your provider how you get connected with us. Otherwise, we're working on updating our website so that individuals can directly access us to do consultations, medication management, talk about therapy options, or directly get into therapy options from that aspect.

The other thing is that the state of Utah, in doing some of these patient safety bundles and then also on their Utah Women and Newborns Quality Collaborative Maternal Mental Health Subcommittee, has developed some really great resources for individuals in Utah. They have a website, , where you can search for a provider who has specialized training within this realm by both location and insurance.

Postpartum Support International has phenomenal resources with virtual support groups for anyone across the world that you can access, and they have so many different ones that it's really specific if you're looking for a military member with mood concerns or same-sex couple. They just really have every single domain on there.

And then the Utah Chapter, which their website is , is the local chapter of Postpartum Support International. They have resources, volunteer opportunities, and then more information on perinatal mood and anxiety disorders.

And then the last part is just what we were talking about before. If you're in a crisis with thoughts of hurting yourself or hurting your baby, or you're concerned that a loved one is having a hypomanic or a manic episode or postpartum psychosis, or just in general whenever you need to talk to someone, there's a national crisis line now called 988. So all you have to remember is 988, and then they directly connect you with the Utah crisis line.

Kirtly: And you've mentioned the Kem and Carolyn Gardner Center where you can go in and be evaluated anytime, 24/7, which is really helpful.

Well, for humans, it takes a village to help a new mother, an infant, to raise a child. And we're the only great ape that will share our infants with nonrelatives. We pass our babies around with a group of trusted women. "Do you want to hold the baby?"

I used to love holding and getting eye contact with the new babies born to our patients who went through IVF to achieve their family. They come in, and they say, "Do you want to hold Joey?" and I say, "Absolutely."

So new moms who are struggling may not have the ability to reach out for help, and we need trained clinicians to be aware and friends and family to help a new mom struggling to reach out for help. And it's for the new mom and the new baby who's going to be a future citizen of our planet. So this matters.

Thanks for joining us in the Emotional Domain of the Fourth Trimester. And please share with people you know, or let this discussion set up a conversation. We welcome you to join the other episodes of the 7 Domains of the Fourth Trimester and the other hot topics in women's health at womens7.com, or at the "" wherever you get your podcasts.

Thanks again, Lauren, for your expertise and your energy.

Katie: And what you do in our community.

Kirtly: And what you're doing for all of us. Thanks, Katie, for the 30,000-foot view. Thanks to our amazing producer, Chloé. And thanks to the University of Utah, which helps make the "7 Domains of Women's Health" happen.