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Kirtly: Welcome to the "7 Domains of Women's Health." We are continuing our 7 Domains of the Fourth Trimester, the three months after a baby is born. Today is the spiritual domain.

If you haven't listened to any of the other parts of this series on the transformative three months after a baby is born, check in with our other conversations in the physical, emotional, social, intellectual, environmental, and the financial aspects of these three months postpartum.

I'm Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah. I'm a reproductive endocrinologist and I have an interest in all the parts of pregnancy from a hormonal perspective and from all of the seven domains.

My cohost, Katie Ward, is off adventuring, so I'll be flying solo for this podcast. Well, not quite solo as I will soon introduce to you our guest for this conversation.

So the spiritual domain. Almost every culture has a ritual of welcoming a baby to the spiritual or religious or cultural family into which it's born. In Islam and the Hindu tradition, the heads of the newborns are shaved. Although the timing may vary, in Islam, it's to signify that the child is a servant of Allah. In Hinduism, it's to rid the baby of the negativism of the past life.

Now, in my own Nordic Scottish family, that would hardly be possible as we were all bald as cue balls and couldn't have a hair anywhere and didn't even grow hair for the first year, so we had nothing to offer the gods. No glorious dark hair, just peach fuzz.

So another common practice around the world for newborn males is circumcision. It's been widely practiced in Islam. And in Judaism, it's part of the covenant with God from the Old Testament. For many families, it's more a tradition than a spiritual practice, and 58% of newborn boys in America are circumcised.

In my own training at the Boston Lying-In, which was Harvard's obstetrical teaching hospital, the interns were introduced to the circumcision room. It was the duty of the junior residents to do the daily circumcisions for the newborn boys after the first several days of birth. We were taught the techniques by our senior residents and observed doing our first several circumcisions.

Although by the time I was doing infant circumcisions, I had participated in open heart surgeries, huge abdominal surgeries, orthopedic procedures, and cesarean section, this tiny little procedure terrorized me. I didn't think of it as a religious one. It was just something that a family wanted and I was nervous.

Even after I had done hundreds, these circumcisions were overseen by a tiny ancient African American woman who had ruled over the circ room for decades. She would bring the baby in, soothe him with her gentle voice, and prepare him, and give me the eagle eye watching every tiny step.

I would practice the procedures in my head over and over and never drink coffee. I didn't want shaky hands before my circumcision days in fear that I would disappoint her in some way.

So although this is in some faiths, a religious relationship with this boy and his God, for me, it was this, "Please, please, God, I want to do a really good job for this little boy. And don't let this woman be mad at me."

Now the bris, the Jewish tradition of circumcision, is performed usually on the eighth day of life. It's called the bris and is performed by a person called a mohel, who is not a physician but is trained to do the procedure.

It's a lovely ceremony in which parents and grandparents present and usually . . . They're there, but it's usually not in the hospital. The baby may be soothed with a couple of tiny drops of wine or something sweet. The mohels that I observed were graceful and gracious, and it was a privilege for me to observe the families welcoming their baby into their religious covenant.

In Christian faiths, there are christenings and baptisms performed by Christian religious leaders in the presence of families and often in the presence of a few drops or more of water, much to the distress of the baby. Of course, babies scream and shout when they get water dripped on them or their heads get wet. But everybody laughs at it and realizes the baby is being presented to God by the family and the religious leader, and it's a fun spiritual event.

Many cultures have naming ceremonies. In some, the infant is given a family name, but it's also given a religious name. This is common in Jewish traditions and in many Native American traditions.

All these traditions are joyful welcomings and ceremonies for the families and the community. But for some families, a birth is met with grief, such as a stillbirth, and may need its own spiritual and family healing.

With us in the virtual scope studio is Dr. Rana Jawish, assistant professor in the Department of Psychiatry and the Huntsman Mental Health Institute at the University of Utah. Dr. Jawish serves as Medical Director of the . Dr. Jawish's research focuses on advancing innovative neuromodulation interventions in perinatal mental health, and she also works in substance use disorders.

Thank you for joining us, Dr. Jawish, and thank you for letting me drag you into the spiritual domain.

So I'm going to push you a little bit from what you might do in your daily practice. But how did you come to do this work with our obstetrical team?

Dr. Jawish: Thank you for having me. It's a pleasure being here. I'm trained in general psychiatrist and addiction psychiatry. My focus on perinatal mental health and substance use made the existing gap in clinical and research impossible for me to ignore.

I was mainly fascinated by the existing gap that existed in the research and clinical care of this patient population. Mainly, these patients are excluded from the majority of clinical trials that we do in the medical field.

We have very limited non-medication options for pregnancy and postpartum mental health and substance use condition. I discovered the very fragmented existing handoff system that we have after a birth or a loss.

Kirtly: You mentioned that the families are isolated. After a stillbirth, often the woman doesn't make her postpartum visit. The whole business of, "How's the baby doing?" and, "How's your breastfeeding going?" and, "How's your bottom?" They often don't make this visit and no one knows how depressed they are. There's this big hole, at least from my perspective, that they fall into. How do we reach out to try to keep them from falling even farther?

Dr. Jawish: Agree. And this is something I discovered in reality when I am planning for the maternal mental health path in this stillbirth clinic. So through that passion, I partnered with Dr. Robert Silver. Our relationship initially started as a mentorship. He is the maternal fetal medicine expert on stillbirth, and he has a personal and professional long track record of caring for women and their family with a stillbirth.

Through this collaboration with him and from getting connected with families that had stillbirth, I had started thinking about how we can craft that referral path, that warm handoff.

Kirtly: I like that. A warm handoff.

Dr. Jawish: Thank you. And also culturally responsive pathways. As you very eloquently pointed out, we have a diverse population. They have a different spiritual and religious identities, and our task is to be aware of that fact and also to be culturally educated and have cultural humility, what I call the humility.

So when we have different families from different backgrounds, our response to their needs is culturally oriented. We can at least provide a guidance that is consistent and synergic with their spiritual community practices and not just simply medication or a referral.

Kirtly: I had to do some understanding when I first came to Utah and that within the LDS faith, babies born with a heartbeat who die shortly thereafter have had the soul transfer. We don't know when ensoulment happens. We don't know when a fetus becomes a person from a scientific perspective, but from their faith, that the baby's born with a heartbeat and then dies right after, it has a soul and it has all the religious overtones that come with even a funeral.

But when a baby is stillborn, born without a heartbeat, it's different. And maybe not to the mom because the mom knows the baby was alive in her tummy not that long before.

But can you tell me some examples of how you've helped people from different religious practices find their way?

Dr. Jawish: I think what I do personally is start with a very humble, open-ended questions about what is . . . If I realize they are different, they are coming from specific culture that I'm not very familiar with, I start with educating myself openly, asking them what is their spiritual background, what they would like us to know about the process. What are they going through? How can we be helpful?

I think approaching this as a doctor from a humble standpoint that, "I am in this with you. We are going through this journey together, and I would love to know how you and your family, your loved ones, are processing this. What are the steps that you want me to assist and support you through?"

Because in my personal experience, even when I came to Utah five years ago, you can imagine I'm a transplant so I was not aware of a lot of tradition specific about the LDS faith. I started learning slowly the details and how people practice their own religion.

It was very helpful for me to ask my patient what they want me to know. What is relevant to them? What's important to them? And that helped me, of course, as any healthcare provider, educate myself and provide better care and also prepare me for how to handle other situations.

I'm sure you have come through this. There are a lot of people who actually . . . their relationship with their own religion is not black and white.

Kirtly: No. It's overlaying with their own personalities and the way their own family is related. It's very rich like a tapestry of personhood and culture.

Dr. Jawish: Exactly. Agree 100%. I learned also to differentiate between religious and culture, because these are connected and they are different. So people from certain religious or spiritual backgrounds might not be practicing daily and they still belong to this culture. They still identify with it somehow.

So I ask my patients to let me know how they identify themselves. I don't make any assumption. Even if I know from the chart or from my working relationship with them, their background, I make sure I ask them every time, "How do you identify yourself, and what do you want me to know about the situation and how I can be helpful?"

Kirtly: And the other thing is every stillbirth is unique. Not only is it born uniquely into a family/cultural/religious tradition, but in some babies who . . . For many stillbirths, we don't know, so what you have is a perfectly normal-looking baby born without a heartbeat. I'll say to you that the only time I have wept in the delivery room is over the delivery of a term stillborn, because here's this perfect infant and it brings me to tears just thinking about it.

Every time I would start to cry, it's not very professional, but it was just so sad. And for people who don't have an answer, they wonder if they're being punished or something.

And then there are babies that have life-ending congenital malformations, birth defects. So the babies might be born with a birth defect, but they die very shortly after. For those families, it's a sadness, but it may be a relief because this is a baby that would never live a life. Whatever it might have been, maybe no brain, maybe a heart that was never going to pump.

So we have this whole array of responses. For some, it's just pure grief and not understanding how any tolerant loving God could do it, to a birth defect where we say, "Thank you, God, for taking my child." For you, you have to be humble and agile.

Dr. Jawish: Absolutely. I think also when families have no formal faith, it could be a simple ritual like reading a letter, or a moment of silence, a footprint, a candle also can be just grounding to them.

I think I see my role at that moment is to ask, not assume. Simple question, "Are there spiritual or cultural practices we can help you honor?"

My experience is that once we offer a choice . . . It's very important for human beings to have choice. Families tell us that they don't feel different. It's less isolating. Once we approach them that, "There are many choices, let me know how you want me to proceed."

Kirtly: I like the way you said honor. "How would you like us to honor this child? How would you like us to honor your faith?" You've had several lovely words, Rana. One was a warm handoff and the other is "How do we honor this child and your grief?" That's lovely words. Sorry, I interrupted, but I just wanted to let you know I really love your words, Rana.

Dr. Jawish: Oh, thank you. I think something that I noticed from my clinical interaction with mothers who had stillbirth in the past . . . And actually, one of the things that's very special about the stillbirth clinic that we have is some of our team members are parents who had stillbirth and they are helping with these efforts and as peer support specialists for this population.

My clinical experience has been that they feel very much better when the provider uses the baby's name, especially when there is a full-term or close to full-term stillbirth. When we talk about their experience, they still, each conversation, refer to their as stillborn child with his name or her name or their names.

Kirtly: So they've given this baby a name?

Dr. Jawish: Yes.

Kirtly: Many people pick their names, they've had ultrasounds, they've seen their baby, they know that it's a boy, they picked their names already. And some people don't have a name. They just don't want to until they see the baby. I think if it were me, and I can't imagine this loss, but I would want to give this baby a name so it could live in my heart.

Dr. Jawish: Absolutely.

Kirtly: How many years has it been since I've been practicing OB? To lose a baby like that, oh my gosh.

Dr. Jawish: Absolutely. And for the provider to acknowledge that and using the baby's name, it means without saying it that, "I am on the same page with you." So that's important to note if there is a given name, you use that name. You acknowledge the baby by name.

Kirtly: I think, actually, I could have used some of this training 40 years ago when I was training in Boston. And I did, I just would weep. If I had a little bit more training, I could have gathered myself and been more professionally helpful in the delivery room with family. Rather than me handing off the baby to wherever, I could have said, "Help me with this baby's name. Do you have a name for him or for her so I can address him and let you hold him?"

I could have done a better job, so I'm hoping that you have a chance to spend some time with our residents so they're not in the corner weeping all by themselves.

Dr. Jawish: The lack of training, and specific training, is an indication for the gap in research and clinical practice. You know that research and clinical practice are synergic, so clinical practice informs research questions, and research work improves and advances and shapes clinical practice.

While we don't do much in this patient population, we will continue to be behind on doing the most evidence-based effective approaches, which is unfortunate.

Kirtly: Yeah, we're so lucky to have the Center of Excellence in Stillbirth that tries to pick all the seven domains, essentially, of stillbirth. What are the emotional and the physical and the social and spiritual parts of stillbirth? So that we can both do research and inform clinical practice so we can offer the best that we can to help these families on their way, this woman, this couple, this family, and this baby on their way.

So if you had a few things, if you had three things that you think you would like both listeners who are maybe family members or friends or women who have experienced this or professionals, what would you like them to know?

Dr. Jawish: I think that I would like them to know that, first, the heart and core of spiritual domain is identity, and it's very important for providers to use language that affirms whatever identity the patient's population identifies with.

I think the heart and core of mental health support early is connection, and I would say connection is care.

I will emphasize my earlier comment about the role of peer support, faith community ties, and the most important thing is the warm handoff between clinician and transition from one setting to other. It's very important. And I think reaching out and asking for help is key.

I would think that my ideal goal for mental healthcare in this patient population is to have everything set up for the patient, because we know that they are already overwhelmed and dealing with a lot of things. At the time of discharge, in an effective system, a follow-up and a warm handoff should have been done automatically.

I think that the ideal situation . . . And there is the current reality. Until we reach our ideal situation, I encourage every woman, every family member who is struggling with processing or grief of a loss to reach out for support. I think connection is the word that I've heard from all my patients and their family.

Connection is care, and isolation is the thing that is actually the first step to get into adverse mental health, social, and all the other adverse outcomes following a loss or traumatic experience.

So I think my final word is to reach out. Whoever you think you can trust, reach out and ask for help.

Kirtly: Yeah. Well, that's been a theme of this entire fourth trimester "7 Domains," is that we weren't evolved, engineered, created to do this alone. We're meant to be in community. And however that looks, however you find it, we hope as healthcare specialists and a healthcare system that we provide and make those connections for people to need them. But we weren't ever meant to do this alone.

Well, thank you. I'm going to change course just a little bit, or a lot. One of my favorite memories is of a little baby who was born prematurely. This tiny person was given up for adoption in the intensive care nursery by a young woman who was probably overwhelmed. I don't know her circumstances. I only know that this child was adopted out of the intensive care nursery by a wonderful family I knew. And I was invited to the blessing in their LDS church.

It was a beautiful warm day full of sunshine and little children in their Sunday best. Several men gathered in the front of the church and put their hands on and blessed this tiny child and welcomed them into their LDS community. And this is what this particular religious faith, spiritual faith does. They give blessings to new babies.

So however this baby came into the world, it was now in the arms of a loving family and a community. And I sat in my Sunday best and wept at the loveliness of this welcome.

I cry a lot about babies. I don't have an LDS tradition, but I do have a 50-year tradition of taking care of women and their babies, so I cry a lot about babies.

Anyway, even in non-religious families, parents often designate someone or some couple to be godparents. And this is more about connection. In the Christian faith, it's the job of the godparents to make sure that these children are raised in this faith and to perform their religious duties. The godparents often hold the baby during the christening or the baptism if they're present and if they've been elected as godparents and willing to serve.

In the more secular world, the designation of godparents are those who will reach and watch out over the child and take over if something happens to the parents.

So we tried to build in connection. We tried to build in community, whether it's family who are godparents or if it's a friend.

So wrapping up this 7 Domains of the Fourth Trimester, I really want to thank Dr. Jawish for some wonderful words, warm handoff and honor. Boy, I'm going to remember those. Thank you.

Dr. Jawish: Thank you very much for having me. And I agree, I think to add to your last section, human beings look for belonging. All of us, no matter what is our background, what is our belief system, religious or not, we want to belong. We foster the sense of belonging within the system that we think is a good fit for us.

Kirtly: Perfect.

Dr. Jawish: In the time of pain, our role as a mental health provider is to understand that belonging and to understand that belief system and supportive environment and just help our patient through this journey no matter what.

Kirtly: So, the messages we've tried to give during this 7 Domains of the Fourth Trimester, all of the domains, is that it takes a village to help the baby and the mom through these early months and through the life of raising a child or children.

It's the evolutionary consequence of giving birth to these big-headed infants who mature slowly that we need help. We need belonging. We need community.

We hope that this series has been informative and maybe sparked a conversation with you and your friends and family about this transition.

And if you haven't listened to the other 7 Domains of the Fourth Trimester, check them out at womens7.com, or . And thank you so much for joining us.

I'll end with a little 7 Domains of the Fourth Trimester haiku.

Welcome to this world.
A first breath and a first smile.
We've been changed for good.