Rates of paternal depression were highest three to six months after birth (25.6 percent) … All of these numbers are considerably higher than the annual rate for adult male depression, which is 4.8 percent …

… Extreme examples of parental depression can lead to suicide or to harm or neglect of the baby, but even mild to moderate depression in fathers has been shown to have lasting negative effects on their children for years to come.

… “there’s a general cultural myth that men don’t get depressed,” … “Because of that cultural myth, men oftentimes think they shouldn’t get depressed, and when they are depressed they try to hide it.”

… for people who have clear cases of clinical depression, there are cues beyond typical parenting troubles, such as persistent detachment, feeling hopeless or worthless, or thoughts of death.

… doctors and pediatricians usually see new fathers less often than they do new mothers … Even though screening for depression in mothers is far from perfect, it is much easier to do given their more regular contact with the health care system …

… The sleep deprivation that comes along with being a new parent can alter neurochemical balances in the brain, making some people with underlying risk factors more vulnerable to depression …

… A personal history of depression puts both mothers and fathers at a higher risk, as does a sick baby, financial strain or relationship problems. Add to that list the changing expectations pushing dads to become more involved parents … and many new fathers are left feeling overwhelmed and at greater risk for anxiety and depressive symptoms.

… Like mothers who are depressed, fathers who suffer from depression can have negative impacts on their children’s development years down the road.

“When Dad is depressed, Dad tends to interact less with the child and bonds less with the child,” …

… “depression in fathers during the postnatal period was associated with adverse emotional and behavioral outcomes in children aged 3.5 years.” …

… children whose fathers had been depressed during their early infancy were more likely to have behavioral problems by the time they were school age …

Depression in dads also seems to correlate with depression in mothers. Although the relationship is not one-to-one, having a partner with this sort of depression seems to increase an individual’s likelihood of having it, too …

… Paulson recommends investigating treatment that focuses on whole families, addressing depression “as a family problem, not an individual problem.”

Courtenay proposes ways to help prevent paternal—and maternal—depression from becoming a problem in the first place. With a growing checklist of risk factors … the best thing to do is address any of them “before the baby comes along.”

I GAVE birth to my first child last year in the … maternity ward as a public patient.

Nothing could have prepared me for my horrible birth experience – ”herding yards” does not go nearly far enough in describing the way the hospital treats new mothers and babies. The need to minimise expenditure combined with an almost zealous obsession with promoting breastfeeding created an experience so stressful that, for me, resulted in what I call post-traumatic birth disorder – a fear of ever having another child in a public hospital.

My baby was born with fairly high levels of jaundice, which results in a very sleepy baby who is unable to feed well. Bar going under the UV lights, the only means of reducing the jaundice levels is to ”flush” it out with fluid.

Now that would be fine except for the fact that mothers do not produce milk for at least two days after a natural birth and up to five days after a caesarean. Not once was I offered formula to try to provide extra fluid for my baby. Instead, I was told to breastfeed and express extra fluid in between feeds.

So, in pain after major surgery, with a baby too weak to feed well and not producing milk, I was left struggling for hours to try to provide enough fluid to help my baby.

On day four I was about to be discharged when the attending doctor told me my baby had developed ”nappy rash” and might need antibiotics. At first the doctor said it would need a cream and I would still go home that day. A few minutes later another doctor said it was a ”severe” rash and my baby might need oral antibiotics.

Then the head of pediatrics came to look at the rash. The attending [midwife] said they thought it was a hospital-borne staph infection, which was later confirmed. At this point I was about to have a breakdown from being exhausted, stressed and furious that no one had mentioned the staph to me.

Following this diagnosis, I was discharged from maternity and my four-day-old baby was admitted as a pediatrics patient to be given IV antibiotics. The pediatrics ward is for children only so despite just having the caesarean and still being on painkillers, I was not considered a patient. I had to sleep on a fold-out couch to continue three-hourly breastfeeds but was given no food or additional pain relief …

No perfect system

WHEN my wife fell pregnant, our GP referred her to an obstetrician without discussing any options, such as the public system, birthing centres, home birth etc. This referral sent us down the path of the private health industry. We were keen on more natural options for childbirth, but it became increasingly apparent that our obstetrician was not interested in these options. Through our own research we found out about birthing centres, and decided that this was the go for us.

… our daughter was breech. Through the birthing centre we were told of an obstetrician who manually turned babies in utero. We consulted him, and our daughter was turned. I am sure that had we stayed in the private system with our original obstetrician, we would not have been made aware of this option, and my wife would have had to endure a caesarean. This is one example of the ”over-medicalisation” of childbirth by the private health care industry.

However, the birthing centre was far from perfect. My wife gave birth at 7.10pm on a Saturday. At 9.30 the next morning we were pressured to leave. We refused, and spent our full allotment of two days in the centre. A couple of days after we left, we received one follow-up visit from a midwife. She noted that our daughter was jaundiced, and advised that we put her in the sun for 10 minutes.

Later that day I took my wife to hospital because she was experiencing pain after the birth. While we were there, a [midwife] noted that our daughter was jaundiced, and requested a blood test. The result was that she was rushed to the neonatal intensive care unit in a serious condition. An hour later the head of the unit informed us our daughter was suffering from a level of jaundice so severe that they saw it only once or twice a year, and that as a result, she could be brain-damaged and suffer hearing loss, among other issues. If I hadn’t insisted on taking my wife to hospital for her pain, I dread to think what might have been …

Happy on home front

I HAD a satisfying birth at home with the help of two lovely independent midwives. The continuity of care from our midwives has been exemplary.

When I read accounts of less-than-adequate hospital-based maternity care, I can only say that home birth is worth every cent we paid.

Improving the maternity system is simple: the Government needs to stop attempting to put independent midwives out of business.

Support midwives

MY HUSBAND and I saved our stimulus packages to pay a private home-birth midwife for the birth of our second child, due any day now. The continuity of care, with antenatal appointments in our own home, is wonderful. I feel much more comfortable ringing my own midwife with questions than I did when I was seeing a different midwife every time at the … Birth Centre …

It’s not all gloom

WHILE there is room for improvement in any hospital system, the headlines in your report unnecessarily spelt doom and gloom.

In the past 10 years I have had three babies at the public … [hospitals] Each time I have been impressed with the service and care provided …

My first baby could not attach to the breast, and … we were allowed to stay in hospital until day five after the birth. Every time I needed to feed her I buzzed for the midwife to help me, and never had to wait more than a few minutes.

With my second and third babies we went home on day two, but we were ready … Postnatally, a midwife from the hospital visited me each day for two days after the birth. The midwives were caring, knowledgeable and helpful.

Motherhood’s trauma

I GAVE birth to both my sons as a public patient … There is almost no difference between the private and public patient experience, so having private health cover was of no benefit. My doctor was away both times but the on-call obs I had both times gave good care. Of course, they’re only there for the end bit and it’s the midwives who do all the work anyway.

… my key criticism is that they sometimes forget the strangeness of becoming a mother for the first time. We are not used to being mostly naked in a room full of other people … We are flooded with hormones that leave us lost and confused. We think motherhood will be a tender and graceful time, when in fact it can often be a time, particularly the first time, when you feel frighteningly laid bare. I would have appreciated someone to facilitate a more caring and dignified transition into my new role.

A cry for help

At home, things got worse. Feeling like you’re in an evil, black hole and not wanting to look after your own baby is not a pleasant state to be in. I had enormous problems with breastfeeding, which added even more stress to my already unwell mind.

It was the visiting midwife from the hospital who was the catalyst in getting treatment for me. At first she offered me generic advice in a way that to me seemed somewhat ”hippie dippy”, so I had to persist in letting her know how bad I felt. Eventually she gave a card for the hospital’s crisis assessment team hotline. The team member I spoke to was exceptionally understanding and gave me some calming advice. The team followed up with regular phone calls to check I was OK before they were able to send out a diagnostic team, including a psychiatrist, a couple of days later. They were also responsible for my being admitted into a mother and baby unit in the hospital’s psychiatric ward soon after.

Intensive counselling, medication, individual monitoring and support finally got me back on my feet. I am now what I would consider a ”normal” happy mother.

Forgotten option

YOU seem to have left out the home birth option in your report. Provided the woman is healthy, well-informed and well-supported, there is no reason she cannot give birth at home, with the aid of a trusted midwife. My wife did so three times …

If necessary, a doctor can be called to render extra assistance, and in the rare case of complications, which usually become apparent slowly, the woman can be taken to a hospital.

… Breast-feeding for longer than nine months dropped the risk of metabolic syndrome by 86 percent in women with gestational diabetes. Women without gestational diabetes saw a 56 percent reduction in their risk of metabolic syndrome …

… The benefits of breast-feeding for infants … include lower risk of ear infections, stomach problems, respiratory illnesses, asthma, skin allergies, diabetes and SIDS. For women, breast-feeding appears to lower the risk of type 2 diabetes, breast cancer, ovarian cancer and postpartum depression …

… The Motherhood Study, which includes over 4,000 mothers from Australia and New Zealand … explores the hypothesis that mums today suffer from a lack of “organismic psychological needs” – autonomy, competence and relatedness – due to tension between innate love for their child and misleading external pressures.

To gauge the levels of these needs, Huntsman and Hedley-Ward have drafted a 112-point survey asking questions like, “How close are your relatives?” and “Are there older women in your life helping you?”

A lack of support is proving a common thread in the early analysis of data, with 70 percent of mums saying they do not get enough support from those close to them. Combine this with over 50 percent of mums saying they do not have any close family nearby, and 68 percent of them living away from their hometown, and it’s easy to see potential danger.

With only 13 percent of mums reporting that they spend regular, quality ‘couple time’ with their husband/partner, intimate relationships are another key focus within the study.

A baby girl is born. She grows and begins menstruating. She becomes sexually active and becomes pregnant. She births her baby. She breastfeeds her baby. This is life—normal and natural, yet exciting and important. In the continuum of life, pregnancy, birth and the postpartum period are milestone events. These experiences profoundly affect women, babies, fathers and families …

When a woman gives birth, she has to reach down inside herself and give more than she thought she had … There is a moment when every woman thinks, “I can‘t do this.” If she is lucky, she has a midwife … to whisper in her ear, “You are doing it.” As she does it, she becomes someone new: a mother. If the birthing process is skipped or occurs in a hostile situation, or if the interventions become overwhelming, she becomes a different mother than she would have been if she had only had a supportive, midwifery model of care.

… A woman‘s confidence and ability to give birth and to care for her baby are enhanced or diminished by every person who gives her care and by the environment in which she gives birth.

To control and actively manage a woman‘s labor and delivery, modern obstetrical practice relies on conformity. A woman is “subject” to rules, restrictions and protocols … Physicians and the hospital staff have authority—there is an unbalance of power … I say: You can only consent to that which you are capable of refusing. If you can‘t refuse the test, the drug, the procedure or the surgery, then you did not consent to it. This is coercion and it leads to disempowerment of women …

Many women who have cesareans suffer in silence because society expects them to “just be happy about their baby.” …

… Research has shown that when we stray from evidence-based maternity care, we have a high degree of obstetric intervention that is associated with acute trauma symptoms … how a woman perceives the event, not the event itself, plays a vitally important role in whether she has trauma symptoms.

Women report experiences that fall into the following categories:

* A sense of loss: birth didn‘t turn out like expected, loss of the experience of participating in the birth experience, not being there when the baby enters the world
* Interrupted relationship with baby: feelings of detachment from her baby
* Altered identity: sense of failure, feminine identity altered; lowered confidence in her body
* Intimations of mortality: surgery gives “rise to fears about mortality”
* Feelings of violation: from surgery where the body boundaries are violated, feeling “mutilated” or “butchered”
* Anger at caregivers: particularly regarding “what was perceived to be an unnecessary cesarean, lack of involvement in medical decisions, feeling unsupported by hospital staff before, during and after the cesarean”
* Dissociation: feeling that the surgery was taking place on someone else or from a distance
* Humiliation: being scolded
* Helplessness: not being able to take care of herself or her baby
* Posttraumatic Stress Disorder symptoms: anxiety, trouble sleeping, panic attacks

Let‘s consider that a moment. What if we went to a wedding today and while waving the couple off in the limo, we see it get hit by a truck before it turns the corner. If the bride were to spend her honeymoon in the hospital, no one would tell her, “Well, at least you have a healthy husband.” …

… Some women have such a traumatic experience, they close themselves off to the possibility of more children. They never consider the idea that it doesn‘t have to happen that way …

… Women who have had cesareans have higher rates of voluntary … infertility … This is often due to their determination that the trauma, whether physical or emotional, was too much to repeat.

Another husband expressed … he was “ashamed that I let them hurt my wife as I stood by.”

… Birth has become extremely interventive and this includes everything from the seemingly minor … to the most invasive—the cesarean. It has become so interventive that it takes something away from what the experience should be. As a result, many women find themselves grieving.

… Partners witnessing birth trauma are also at risk of developing depression, caused by feelings of helplessness during the traumatic event. Men are more likely to express their feelings of depression through anger and abusive behavior. Truman stated, “The cesarean completely destroyed my faith in the medical community … ”

… Tim stated: “I‘m mad and bitter—disillusioned. That likely won‘t change with time. Recovery is not a term I would use. I‘m not recovering. I have learned a lesson.”

How the couple process their experience can determine whether the marriage survives. Chris said, “… It put us at the brink of divorce. I didn‘t understand fully what happened and my wife thought I didn‘t care.”

The cesarean may be difficult for the father. A husband may have seen his wife rushed to the OR. He saw her uterus taken out of her body. He was worried about her. He may not have words to describe the experience, but he needs to process it.

When I broached the subject of intimacy after cesareans to husbands, some asserted, “Everything‘s fine there, thank you.”

Others report having to work hard to restore intimacy to their marriages: “It took more than a year for intimacy to start returning. More than a year.”

One husband, when asked, snorted, “Hah, are we seriously going there? Personally, it has left ’intimacy‘ out in the dark. She is embarrassed about her scar and she thinks it makes her less sexy. I guess it‘s more of an emotional hardship for her and she just doesn‘t feel sexy anymore.”

The cesarean recovery has an impact on the couple‘s ability to resume intimate relationships. The immediate problem is healing of the incision and recovery from the surgery itself. There also is long-term impact that is rarely noted by the medical community. Some women report a loss of feeling around the scar. Others are hypersensitive to any touch or pressure in the scar area—which may be psychological as well as physical. They report pain and discomfort.

Intimacy is an emotional connection. After a cesarean a number of things may interfere with this connection. The husband may have been frightened by the sight and sounds of—or the scenario that lead to—the cesarean. He may be hesitant to resume relations, worrying that he might hurt her. What if she gets pregnant again? He certainly doesn‘t want to do that again. His wife might feel the same way. She has to focus on her own recovery, which takes away from what she can give to their relationship.

… Stephanie‘s cesarean changed her husband‘s view of the medical community. He said, “… To know that people we trust with our lives and the lives of our children are so careless and insensitive about our lives and the little ones they savagely bring into this world.”

Professor Lesley Barclay … is a leading proponent of the need to reorient maternity care around the needs of women and babies …

“When women talk about what matters to them when it comes to childbirth, the issue they repeatedly mention is safety.

But their understanding of safety around childbirth is often quite different to how health systems and many professionals define it.

For women, a safe childbirth is not only about what occurs at the time of the birth. It also refers to longer-term issues, such as their social and emotional wellbeing in the weeks and month after the birth.

When women talk about safety, they are also thinking about the increased rates of depression and anxiety that manifest after operative birth or the consequences of wound infection on general health.

The Australian health system often makes it difficult for women to make wise choices around birth …

For example, evidence shows for most women most of the time birth does not need to take place in hospital. Some women will only feel safe however, whether this is evidence-based or not, with specialist medical services and technology.

The term “maternity care” … incorporates their social and emotional needs. It puts them – rather than the professional or the service …

Evidence shows maternity care can be provided by both midwives and obstetricians in public and private sector hospitals and can be safely provided at home.

… evidence also shows that safety from morbidity is less likely for Australia’s healthiest and wealthiest women cared for by private obstetricians in private hospitals. More recent epidemiological evidence shows as volumes of operative birth increases, deaths of mothers and infants are also increased by overuse of the very operation that was developed to save lives.

So where does choice fit in this repertoire of terms, locations, professionals, services and outcomes?

Safe birth should be the goal of choices offered to women and decisions taken by those who provide care for them.

Unfortunately, the choices some professionals offer or accept are self or income centered and ignore evidence. As a consequence of gender-located power historically, and a rapid increase in the numbers of more technically oriented professionals in recent decades, health services and costs do not reflect women’s needs or evidence.

The most important example of this is allowing caesarean birth to be a choice rather than only using this as the lifesaving emergency procedure it is.

… caesarean birth is rapidly becoming a life threatening procedure itself because of excessive use … maternal death reviews and coroner’s reports now show the risks attached to using a major surgical procedure as a routine mode of birth.

Maternal mortality is between two and seven times higher for surgical than vaginal birth …

… The physical, social and emotional morbidity attached to women who experience this mode of birth is not recognised therefore ignored within acute care hospitals but is evident in their homes and the community.

Research has identified that physical morbidity associated with CS is five to ten times higher than for women birthing vaginally. No less importantly there are also psychosocial consequences of surgical birth with women less satisfied, more concerned about the baby’s condition and fearful. Women delivering by CS report feeling less in control than women who have birthed vaginally.

Research also shows rates of post natal depression significantly different between women who birthed vaginally and the group of women who delivered either by planned or unplanned CS … Women who birth by CS evaluate their babies less favourably, are less likely to breastfeed and/or feed for a shorter duration.

Paradoxically, the choice to have a normal, safe, confidence affirming birth that is low cost and relieves pressure on hospitals is only available to a small minority of women.

This is not possible for Australia’s most vulnerable women and families, who, the evidence suggests, would benefit most. How many rural or remote living Aboriginal women can opt for a home birth attended by a skilful midwife?

… 1 in 10 remote living Aboriginal women in one large community avoid hospital services or skilled professionals because of the unacceptable risks to them of being evacuated from their community …

Other Australian women with more options are also taking this route, fed up with what they see as biased, self-interested advice and unacceptable risks of our current system.

To have real choices, one needs options and good information on which to base decisions. Better resourced women … can chase evidence themselves, or question doctors, hospitals and midwives …

… there are some ultimate arbiters beyond opinion. One of these is the impartial review of evidence provided by such as the Cochrane data base.

I saw to my great delight a writer (male and medically qualified) who also a Member of Parliament, recently quoting this source in a newspaper. His message, while aimed at indemnifying home birth midwives, was that home birth is safe.

… home birth is indeed safer at times than hospital birth when planned and supported by good hospital care for rare emergencies.

I wish the current president of the AMA, an erstwhile obstetrician, would be similarly correct with his claims that certainly are not recognisable as fact to those familiar with the evidence.

Choices for women are difficult when all they receive is highly partial and ill-informed opinion. Choices around birth are important or women will opt out of a system that does not meet their needs.

…. Should it be a matter of choice though for women to give birth via major abdominal surgery? Should we permit choice that means their babies avoid the process of vaginal birth that prepares them to live and breathe? Should it be women’s or obstetrician’s choice that health pays or heavily subsidises the avoidable costs of unnecessary operations that prevent other necessary surgery being performed and add to waiting lists? I think not.

Researchers compared birth outcomes among babies born to 329 women who took selective serotonin reuptake inhibitors (SSRIs) during pregnancy, 4,902 women who had a history of psychiatric illness but did not take SSRIs during pregnancy and 51,770 women with no history of mental illness.

… After controlling for preconception measurements of body mass index (BMI), all metabolic syndrome components and physical activity, Lewis and her colleagues found that women who had given birth to one child or more than one child were independently associated with a higher incidence of the metabolic syndrome (33 percent and 62 percent higher, respectively) than women who had not had children. Among women with gestational diabetes, once baseline adjustments were made, the researchers found that they were nearly two-and-a-half times more likely to develop the metabolic syndrome than those women who had not had gestational diabetes-complicated pregnancies.

“Our findings suggest that childbearing can contribute to the development of the metabolic syndrome and that part of the association may be through weight gain and lack of physical activity,” Lewis said. “And, although women with gestational diabetes had the highest relative risk of developing the metabolic syndrome, those with non-gestational diabetes pregnancies made up the larger at-risk group.”…