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Join Emily Little, a perinatal health researcher and founder of Nurturely, about the evolving definition of “postpartum” and its predominant association with postpartum depression. We’ll explore societal influences on this shift, disparities in accessing support for marginalized communities, and effective preventive measures such as cognitive behavioral therapy and nutritional interventions. Together, we’ll unpack the importance of reframing the conversation around postpartum mental health and advocating for comprehensive support systems.

Emily Little is a perinatal health researcher and founder of Nurturely.

She discusses the KevinMD article, “Postpartum does not equal depression.”

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Transcript

Kevin Pho: Hi, welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Emily Little. She’s a perinatal health researcher and the founder of Nurturely. Today’s KevinMD article is “Postpartum does not equal depression.” Emily, welcome to the show.

Emily Little: Thanks so much for having me. Happy to be here.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Emily Little: Yes. So I’ve always been fascinated by prevention. And at the most obvious level, prevention kind of leads you to babies, the earliest starting point of life. So this led me to pursue research training in developmental psychology, which was not clinical psychology, but experimental psychology.

So I did my PhD at UCSD in San Diego, in a very basic science-heavy department rather than applied science. So I was really trained in rigorous methodologies to understand how infants develop and how parents and infants communicate and navigate the social world.

But I was always passionate about connecting my research to the community, even being in a very basic science-heavy department that emphasized in-lab studies and in-lab research. So I pursued research experience alongside community members, kind of out in the wild, out in the world. So this was not only embedding myself in communities in San Diego and in the US, but also around the world. So I worked alongside midwives in community health centers in Cochabamba, Bolivia, in Huehuetenango, Guatemala, in Bihar, India, just to name a few. I also pursued a specialization in anthropogeny, which is the study of human origins.

And these research experiences really deeply shaped how I think about perinatal health and how I show up professionally today in the field. And one component that stood out from this research background is really the biases in our knowledge.

So we know that the vast majority of research literature that we have, for our knowledge around human development, around pregnancy health, around postpartum health, around health in general, is really based on these biased samples of often white, often upper-middle-class patients or participants, people who have the time and ability to participate in research studies. So this has led to really biased understanding about how infants develop in the world, but also how perinatal health shows up in different environments.

And then another bias on top of that is really our bias of not including pregnant and postpartum people in research in general.

So these biases in research also really led to an interest in the gap that we have. So we have this massive gap between research knowledge and clinical practice, which is really based in how research and academic institutions are structured, and then how our clinical settings are structured.

So all of these shared experiences led me to starting Nurturely, which is a social change organization focused on building thriving collective communities and societies by focusing on this pivotal period of pregnancy and postpartum and infant health, but really on this approach of bridging the worlds of research, clinical practice, and community knowledge, community wisdom, and cultural practices. So that’s kind of how I landed where I am today.

Kevin Pho: So you talk about the biases when it comes to perinatal research. So what are some of the biggest topics in perinatal health that these biases in research would impact?

Emily Little: Yeah, so lots of different layers to this. So I mentioned my start was kind of in infant development and infant health. And at kind of the most basic level, our understanding of what it means to be a quote unquote good parent to your baby, the literature on infant development, on social development and cognitive development, and how that relates to parent communication and parent interaction with baby, is based on this very Western-centric model of how we communicate.

So as an example, we have a tendency in our communication in Western cultures like the United States, and I say that very broadly, of just kind of conventional American culture, it’s very highly based in visual, vocal, face-to-face interaction. We’re very didactic and academic, and so that shapes our interactions with babies and how parents interact with infants.

And that has manifested in the research world as researchers being very interested and invested in things like how much parents read to babies, how much parents are reading books, how parents are sharing attention with babies. So if parents are pointing and naming objects, we’re calling that parental responsiveness, and we’re measuring that as researchers and looking at how that is predictive of language development. And it is, it is very important, we know that from the data.

But what this doesn’t tell us is all the many other ways that parents do interact with babies around the world, and how infants can also learn about the world, develop healthily in terms of social and cognitive development, learning through other mechanisms.

So for example, and I’ll tie this back to the postpartum depression piece, but for an example, in my research in my PhD program, focused on parent-infant physical contact really as a communication method between parents and babies, where direct talking or direct teaching from the parent is not even really necessary when we’re looking in communities like Cochabamba, Bolivia, or like Huehuetenango, Guatemala, where the model of parent-infant interaction and communication is such that mom is not on the floor reading books to baby, but baby is strapped to the mother’s back or another caregiver’s back all day long.

And so there may not be that direct didactic teaching and pointing and naming and learning and all of these very kind of academic and didactic methods of communication that we think are so important here in Western culture. But baby is absolutely sharing the perspective of the caregiver as they’re in this position. They’re connected physiologically through this long-term physical contact. And so my research was really revealing how this is absolutely a healthy way for baby to develop, and a healthy way for baby to learn about the world, that is just totally outside of our model of what good parenting looks like.

And so to tie that back to the postpartum mental health piece that I wrote about in the article, we have this knowledge about what it means to be a good parent. And so it’s like, OK, you need to read 10 books to your baby every day and you need to have the appropriate toys and you need to be talking to them constantly and naming things constantly, to be a good parent.

And that even manifests in our tools that we use to measure parent-infant interaction and bonding, for example, in home visiting programs. Home visitors go into the houses and they have a checklist of, OK, is the parent on the floor pointing at this thing with this baby? Great, I’m going to give them a high mark, versus someone who maybe is just holding baby but is not responsive in the way that we would say is so important.

And so all that to say is, there are massive cultural biases in our understanding of parenting, and that kind of bleeds into the postpartum mental health picture. Because cultures are diverse, and absolutely, everyone is parenting their baby in different ways, and there’s this huge pressure in Western culture to be a good parent with all these specific things and these specific checklists. And you have to have nap time and reading time and play time and all these things in order to be a good parent, which adds all this pressure and potential risk for mental health challenges. When in fact the research is coming from such a biased place that we’re not even sure if that’s a really accurate picture of human development and human postpartum experiences in general.

Kevin Pho: All right. So let’s talk more about the KevinMD article you wrote, “Postpartum does not equal depression.” You alluded to it earlier. Tell us more about your article for those who didn’t get a chance to read it.

Emily Little: Sure. Yeah. So the issue of the word postpartum being synonymous with depression has been on my mind for a long time in the field, and it’s something that I view as a really big problem as far as how we are using language, or letting language shape what we believe to be possible for parents and babies and health in this pivotal period of the lifespan.

So for those who are unfamiliar, postpartum depression is highly prevalent in the United States. It affects one in four birthing and postpartum parents. That’s kind of the baseline. If you’re Black or from another global majority community, risk and prevalence is much higher. This also affects non-birthing parents. All of the social determinants of health, like racism and access to insurance and living rurally versus urban, all of these are factors that can compound to increase your risk of postpartum depression. So the one out of four statistic is really just kind of the low baseline.

We have this high prevalence, which is a problem that we need to solve. But something that’s come out of that is that the word postpartum is now used as shorthand for postpartum depression, which I argue is very problematic, because the word postpartum simply means the time after childbirth.

So if we as a clinical community, as a research community, really want to envision a world where postpartum depression is not a given after birth, but it’s something that we can prevent, it’s something that we can treat, it’s something that we can support as a society to make sure parents are being nurtured, and treated in the cases where they do need treatment, but access to prevention when that is an option as well.

In order for that to happen, not letting our language get the best of us, by using the word postpartum to simply mean depression, because that’s really telling ourselves and telling everyone out in the world that, hey, this is something that we’ve just accepted as true. When in fact it doesn’t need to be.

We have more and more resources and more and more research on prevention, on how we can modify both individual factors as well as structural and systemic factors, to really support parents better in the challenging phase after birth, so that mental illness does not necessarily have to be the story that everyone accepts. And in those cases where that is the story for that individual, treatment is accessible and equitable, and there is a pathway to nurtured, supported experiences in this time period.

Kevin Pho: So before we talk about some of the techniques that can prevent postpartum depression, let’s give a little bit of context. So what is the prevalence of postpartum depression today?

Emily Little: Yeah, so in the United States, again, just kind of as this baseline, postpartum depression is affecting one in four birthing people. And again, this is really just the baseline.

So I mentioned before, if you are a birthing person who is Black or from another community of color, this rate and risk increases because of structural and systemic racism across the lifespan, and that becomes very acute during the perinatal period.

And we actually know more and more about both individual and kind of structural and systemic risk factors. So, individual risk factors, which again can be used for early preventative treatment if we have that mindset shift. One individual level factor that can be a marker for postpartum depression risk is intense premenstrual syndrome. So if we’re able to have these conversations in clinical context with patients who have not yet conceived, and help them understand and treat this intense premenstrual syndrome, that can even in itself be a preventative measure for supporting postpartum mental health down the road. So that’s one example of an individual marker.

But of course, we know on a structural and systemic level, things like racism in health care, things like discrimination across the board in the lifespan, can be risk factors for depression. And of course, all of that is much more vulnerable during the pregnancy and postpartum periods.

Kevin Pho: So what are some of the techniques that have been shown to be effective in preventing postpartum depression?

Emily Little: Yeah, so cognitive behavioral therapy, or CBT, is widely used as a treatment for postpartum depression, but we now know even more about how it can actually be a preventative treatment as well.

So I mentioned individual level risk factors for developing postpartum depression. Really, the biggest risk factor for developing postpartum depression is prenatal depression. So the more that we can ensure that people are getting adequate and early prenatal care, and really holistic prenatal care that includes mental health diagnoses and support, then we can identify people, OK, you’re already experiencing symptoms of depression in pregnancy, let’s make sure you’re getting prioritized for cognitive behavioral therapy and other treatments during pregnancy for that depression, so that it’s not this almost guarantee of getting postpartum depression as hormones surge in the postpartum period.

Kevin Pho: And what is the role of clinicians in promoting some of these preventative postpartum depression measures? Is it better recognizing, better treatment, all of the above, testing with some markers? What is the approach that you recommend clinicians take to better prevent postpartum depression?

Emily Little: Yeah, there’s so many factors involved. And as a researcher, I’m very interested in implementation science, so, what predicts adoption of an intervention in a clinical setting.

And really, I think, to go back to kind of the main point of the article, I really think it comes back to a mindset shift of first viewing prevention as a possibility. And so, rather than just kind of assuming that, OK, postpartum depression is a thing that everyone gets, so we’re not going to worry too much about it, let’s really shift that and say, OK, prevention is possible.

Let’s make sure we’re having these conversations early and often. We’re using screening tools like the Edinburgh Postnatal Depression Scale, which is a great, quick and easy screener that any clinician can use. And again, always recommending that people are using this in the prenatal period, in the preconception period, as soon as possible. There’s a huge movement to add these screeners earlier in the hours and days after birth, and that’s so important, but we can start a lot earlier. We can start in pregnancy, we can start in preconception, we can have these conversations.

And then also just thinking holistically about prevention. So, some of my own research, again, to go back to the parent-infant physical contact as this really important mechanism for communication, we’ve also shown in randomized controlled trials that this simple act of being in physical contact with your baby actually reduces symptoms of postpartum depression.

So this is a super simple, very easy, cost-effective intervention, of a parent carrying or wearing their baby with a baby carrier so that they’re maintaining this parent-infant physical contact, and that is decreasing symptoms of postpartum depression.

So such a simple, easy thing, that it shouldn’t add too much to the clinician workload to just have those quick conversations of, hey, have you thought about using a carrier with your baby? Did you know that using a carrier with your baby can prevent or decrease symptoms of postpartum depression? It’s an accessible way for any clinic, again, early in pregnancy is always the best time, but really at any point in the perinatal journey, to be able to share these prevention mechanisms that anyone can use.

Kevin Pho: We’re talking to Emily Little. She’s a perinatal health researcher and the founder of Nurturely. Today’s KevinMD article is “Postpartum does not equal depression.” Emily, we’ll end with some of your take-home messages to the KevinMD audience.

Emily Little: Sure. Yes. So for take-home, I would say the words we use matter. So again, the word postpartum just means the time after birth. It does not mean depression.

So if we’re thinking about how the words we use matter, let’s envision the word postpartum signifying a time of nurturing, a time of support. And that goes into our attitudes about prevention, and whether prevention is possible.

I believe prevention is possible. And we have the data now to back it up, with these randomized controlled trials, for everything from nutrition interventions to parent-infant physical contact and baby carrying to cognitive behavioral therapy. So there’s a wealth of preventative resources.

So it’s shifting that mindset to ensure that we are all believing that prevention is possible. So let’s approach this postpartum period with a proactive lens, so that we can prevent the mental health challenges that can be prevented, and proactively support and treat the depression and other perinatal mood and anxiety disorders that cannot be prevented.

Kevin Pho: Emily, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Emily Little: Thanks so much for having me.