Doulas & Recognizing PMADS

In the past five years there has been a flurry of attention given to perinatal mood and anxiety disorders (PMADs) otherwise referred to as postpartum depression. Famous women like Gweneth Paltrow, Chrissy Teigen, Adele, and Adele's friend who just shared her own postpartum psychosis story, have come forward with their personal PMAD struggles. National medical associations like the AAP (American Association of Pediatrics) and ACOG (American College of Obstetricians and Gynecologists) now recommend screening for PMADs during pregnancy, postpartum and at child well visits. These are critical steps in changing the conversation and stigma that have historically surrounded PMADs. 


There is one group of providers that are growing in popularity nationwide that can also play a key role in the identification of PMADs in new and expecting mothers – DOULA’s. A Doula is a person who offers non-clinical, judgement free support to others as they transition through major life experiences. Doulas specialize in different areas of perinatal care including labor and birth, postpartum, antepartum and death. 


The doula movement arose in response to the lack of postpartum care available from traditional care providers in the U.S. Whereas the relationship between a woman and her OBGYN or her baby's pediatrician are undeniably critical to the physical health and wellbeing of both, a doula establishes a more intimate relationship with the new or expecting mom - allowing her more exposure to mom's emotional health. Often, doulas will come to the home prior to the delivery of the baby and have multiple meetings to establish a relationship and discuss the birth plan with the expecting mother, allowing a bird’s eye view to the woman's immediate environment. In doing so, Doula's are exposed to potential external stressors that may exist in the home or in the couple's relationship - both putting a woman at greater risk for the onset of a PMAD. They can also observe any obvious psychological changes in the woman over the perinatal period and in the immediate postpartum. 


Recently, Doula groups like Carriage House Birth in New York City, are working with PMAD treatment providers like TheMotherhood Center to recognize the importance of integrating PMAD awareness into their doula trainings. Doulas need the basic skills to do the following: Recognize when a woman may be experiencing a PMAD; have the conversation with a new or expecting mother that appears to be suffering; and most importantly - refer a woman for support and treatment. 


A doula doesn't need to be a professional mental health provider to recognize a PMAD. The signs can be easily detected for someone trained:

·       This woman is excessively worried about her pregnancy or the new baby - contacting the
doula or pediatrician multiple times a day.

·       She is crying frequently and saying that she is a failure, she can't do anything right, or that
she has made a huge mistake.

·       She obsessively washes bottles, does laundry, ruminates about harm coming to the baby

·       She tells you she feels helpless or hopeless - and she refrains from seeing friends and
family or leaving the house.

·       She can't sleep when the baby sleeps at night, or she sleeps all the time - she has no
appetite and is having a hard time caring for herself and/or the baby.

·       She is irritable and angry, sometimes rageful.  

·       In severe cases, she may share that she has thoughts of ending her life or the baby’s life.


With proper awareness and training, a doula can feel comfortable and confident recognizing these symptoms and having a conversation about them. She can say, "Becoming a new mother is one of the hardest things a woman can do, we don't talk enough about the hard part. It's very common for new mothers to feel anxious and overwhelmed by this new responsibility – being a new mom can feel like it's too much. What has it been like for you?" If mom says she is really struggling a doula can say: "I have heard so many women say exactly the same thing. You are not alone, and you can feel much better with the right support. I have some resources to help you get through this challenging time, and enjoy being a mother more. Should we make the call together?" Partners and other family members also play a critical role in the mental health of the pregnant or new mom and can be educated on where to go for help. 

If untreated, PMADs can have a negative impact on the baby's development and the bond between mother and child. It's imperative for all providers that come in contact with new and expecting mothers to look out for the signs and symptoms of PMADs. PMADs are the most common birth complication among women. 1 in 5 new and expecting mothers experience a PMAD, and to her - it feels like she is drowning in an endless, dark sea, just waiting for someone to throw her a life preserver.

As seen in Every Mother Counts September 2018

To learn more about PMADs or for resources for women that are struggling visit Postpartum Support International (hyperlink If you are located in the New York Tri-State area call The Motherhood Center at  call 212-335-0034.

Having Another Baby After Postpartum Depression

16 months after my son Max was born, I felt like I was finally in the clear from my diagnosis of severe postpartum depression (PPD) and anxiety. It had taken months for me to seek treatment and months to get better, but I was finally enjoying the little guy. I remember the 16 month mark because I attended a Local PPD support group, finally feeling strong enough to be around other women’s pain. The group was a cathartic experience; I was able to tell the new moms that were struggling with PPD and anxiety in real time, that they were going to be ok. That I had felt their pain, went on medication, went into therapy and finally felt like myself again–plus one. I left the group feeling so thankful that my dark journey had finally come to an end. 

A few weeks later, I was at a conference for work and realized I hadn’t had my period in a while. I wasn’t super worried because the last time I had sex with my husband barely counted, but I had a pregnancy test in my bag from an earlier scare (I had convinced myself that sex = baby = PPD), and so I decide to take it just to be sure. 

I remember listening to Vampire Weekend in the background (to this day I can’t listen to them because it brings these moments back), and I laid the stick on the counter and started responding to work emails. I forgot about the test for a good 20 minutes, then returned to the bathroom to see the results.

PANIC. Sheer and utter panic as I picked up the stick. I shook it, I turned it around and around trying to make the positive line disappear. This can’t be happening; it must be an expired test. Surely it's wrong because I had it in my bag for some time. This. Isn’t. Happening. 

You see, after postpartum depression with my son, I had no intention whatsoever of having another child. I did not ever want to go back to that place, ever. I couldn’t do this again–so soon –I had just started feeling like myself again.

That night I spent hours curled up in a ball on the bathroom floor holding the stick. I kept looking at it over and over again to see if the line had gone away. It was still there. In the morning, the line was still there and it was beginning to set in that I may actually be pregnant. I decided to call my husband. My postpartum depression with my son had really done a number on us as a couple. While I silently (and not so silently) struggled with becoming a mother, he made it a point to be out as much as possible. He didn’t know what to do to help me, so he self admittedly ran–literally. He began training for triathlons. I worried this news would destroy us as a couple. What should be one of the most exciting phone calls to make felt like the heaviest and darkest call ever. 

I told him I had taken a pregnancy test and it was positive. I told him it was all going to be ok, and we could talk about it in person when I got back from my trip. He was with a friend when I told him the news so his response was infused with his typical dry sense of humor. He said, “Well this is going to be exciting.” 

For the next two days at the conference, I made the mistake of confiding in a colleague who was immediately overjoyed with my news. When I explained to her that I didn’t think I could do it again after the first time, she told me that having two kids was the best thing she ever did, and I should just be thankful for this gift. I ran into the bathroom and cried.

The darkness was coming back. The feelings of hopelessness and helplessness that I had fought so hard to get rid of were creeping back in around the corners.

When I got home, I was happy to see my son, but was also hit with a wave of memories of how hard it had been when he was an infant. I told my husband that I didn’t know what I was going to do yet with this news, and I didn’t want to talk about it until I had a chance to process it. I shut him out and collapsed inside of myself to find the answer.

I called in sick to work for a few days and hid under my covers thinking about what to do. I didn't want this baby, and I didn’t want to have to go through what I went through with my son ever again. I called planned parenthood and made an appointment for the following week. I didn’t tell anyone.

But then, one night, my husband asked me to sit down on his lap. He told me that he knew I was struggling with this decision, and he would support me whatever I decided to do. He just didn’t want to lose me. We cried in each other’s arms, and I knew in that moment that we were going to figure it out–together.

Another baby. Wow. I began to slowly wrap my head around this reality. The more I did, the more I felt determined to have a different experience

I took better emotional care of myself during my second pregnancy. I continued individual therapy and began couples therapy with my husband with a focus on becoming a stronger unit. Many times, on that couch he cried and told me how sorry he was that he didn’t know how to take care of me after Max was born and that he would do a better job the second time. 

I went to acupuncture once a week and exercised and rested as much as I could. I thought a lot about what contributed to my PPD the first time: The isolation day after day alone with my son, feeling completely disconnected from achievements in my professional life, not having a community of like-minded new moms who were not afraid to talk about the dark side of having a baby, and most importantly, an overwhelming sense of shame at having to ask for help.

So I took control. I was going to be in charge of this experience–it wasn’t just going to happen to me. I created a postpartum plan, including all the things I needed the first time, but didn’t know. I had my mother-in-law agree to stay for the first month after the baby came (a mixed bag but she didn’t speak any English so I saw that as a plus) and my mom agreed to stay the month after that. I negotiated a part-time work schedule with my job, allowing me to work as many or as few hours a week as I could to stay connected. I lined up a group of second time expecting moms all due around the same time. I welcomed an epidural as my delivery with my son was physically and emotionally traumatic, all-natural 20 hours of labor that left me a shell of myself. 

Most importantly, I made sure that everyone around me knew how to recognize the warning signs of PMADs with a treatment team at the ready. Karen Kleiman writes in her book, “What Am I Thinking? Having A Baby After Postpartum Depression”: 

“The good news is that with proper preparation and planning and a healthcare team that is mobilized on your behalf, we can intervene in ways that will minimize the likelihood that you will experience a depression to the same degree that you did previously”. 

And you know what? I had a totally different experience the second time around. All of the safety measures I put in place for myself paid off. All the support I lined up, the community I built, and the perspective I had the second time around made it completely different. And most importantly, I asked for help–every day, all the time. 

I can’t imagine what life would be like without Ella. She is a strong-willed, confident, outspoken little terror and I love her madly

I am in no way urging moms who have experienced a PMAD with their first baby to try it again. I just want to plant the seed that for those of us who had a PMAD the first time around, there is hope.  

As seen in the 9/4/2018 Article on

Paige Bellenbaum, LMSW is the Program Director at The Motherhood Center of New York, which provides clinical treatment and support to new and expecting mothers experiencing perinatal mood and anxiety disorders. If you live in the New York City Tri-State area, call The Motherhood Center at 212-335-0034. For resources in other states visit Postpartum Support International.

Trauma Informed Care (TIC) in the Perinatal Period

Traumatic Experiences and PTSD

Approximately 70% of people will be exposed to at least one traumatic event during the course of their life and from that 8% will develop Post Traumatic Stress Disorder (PTSD). PTSD is marked by unwanted, intrusive memories of a traumatic event(s), increased emotional or physical distress and reactivity, feelings of being on high alert, difficulty sleeping and concentrating, as well as avoidance of reminders of the event(s). While most people who experience traumatic events don’t develop PTSD, women are two times more likely than men to experience a traumatic stress response, and approximately 1 in 10 women will be diagnosed with PTSD in their lifetime.

Trauma and PMADs

One quarter of women will experience physical or sexual abuse or neglect over the course of their life. A history of trauma or a traumatic childbirth increases the risk that a woman will develop complications during pregnancy or postpartum, including developing a Perinatal Mood or Anxiety Disorder. Three percent of pregnant women and 4% of postpartum women are diagnosed with PTSD, though many more experience the emotional, psychological, and behavioral impact of traumatic events. The effects of trauma can “flare” at times of transition and change, and the perinatal period is a time of profound emotional, physical, social and interpersonal transformation for a woman. While it is difficult to differentiate whether previous experiences or a traumatic birth contributes to the development of PTSD in the postpartum period, it nevertheless requires attention because of the vulnerability of mom and baby during this time.

Trauma Informed Care in the Perinatal Period

Trauma Informed Care (TIC) is a framework and set a of practices and principles that address the ways in which traumatic events shape, color and influence a person’s experience in the world and over the course of their life. TIC care shifts the question from “What is wrong with you?” to “What happened to you?” as a way to remove stigma and blame from survivors of trauma.

As both an individual practice and organizational model, Trauma Informed Care (TIC) addresses the following:

  • Acknowledges that traumatic events have the potential to create a ripple effect across social/relational, emotional, behavioral, and physical domains.

  • Provides screening for trauma as standard clinical practice.

  • Educates survivors and all providers (even non-clinical staff) about the ways in which trauma negatively impacts individuals, families, and systems.

  • Seeks to minimize power dynamics and the potential for re-traumatization by providers and systems by promoting trust, safety, collaboration, and choice helps individuals cultivate a sense of resilience, empowerment, and control uses evidence-based treatment interventions to address the impact of trauma.

  • Engages other providers and organizations to holistically approach each individual.

In addition to the above, Trauma Informed Care in the perinatal period draws specific attention to the potential intersection of previous adverse life experiences and the transition into motherhood - physically, emotionally, psychologically, and interpersonally. The TIC model is at best vital and worst helpful - not just in the field of maternal mental health, but perhaps even more so for providers attending to the physical health of pregnant and new mothers, and their children.

For all mothers, pregnancy and the postpartum period can be a destabilizing, emotional time that involves the feeling of loss of control and a sense of being more “tuned in” to threats of danger, while feeling unskilled in attending to the developmental needs of their baby. In the perinatal period these feelings can be amplified by experiences of trauma, which can impact the ongoing experience of both mother and baby. Being a survivor of trauma is not a determinate and with the elements of TIC, moms can access new experiences that help shift unhelpful narratives they have around themselves, their relationships, and the transition to motherhood, so that they make more conscious choices in coping and healing.

If you or someone you know is suffering from PPD, we encourage you to contact a member of our team at The Motherhood Center. We can help provide support in the form of counseling, consultations, group meeting, seminars, and an extended network of resources. Additional info about our support programs can also be found here.

About the Author

Meredith Carlisle is a therapist in The Motherhood Center’s Day Program, and a Licensed Clinical Social Worker with a Master’s Degree from Columbia University School of Social Work. Meredith trained in trauma informed cognitive behavioral therapy and dialectical behavioral therapy, and has practiced in residential, day treatment and out-patient settings. In the aftermath of the Sandy Hook tragedy, Meredith provided volunteer mental health services at Newtown Youth and Family Services, Inc. in Connecticut. Meredith earned her Bachelor of Arts from Ithaca College. She is a member of the National Association of Social Workers, Postpartum Support International, and ZERO TO THREE.