Keep Away

I recently spoke with a doctor who founded and runs a clinic specifically for women who are or want to be pregnant who have a mental illness diagnosis, everything from mild depression to schizophrenia with active psychosis. I approached her because I heard her ask a smart question of another doctor about the effects of antipsychotic meds prenatally (the question went without a satisfying answer). For a psychiatrist, she seemed very conscientious and caring, and far more aware of the dangers of psych meds than most. She also seemed to understand that withdrawal needs to be gradual. This doctor said that she tries to maintain all of her pregnant patients off of meds, and that if she sees women prior to becoming pregnant she has them withdraw over 3 months. This sounds hideously short, but is longer than the 2 week line I have been fed personally by doctors, and have even heard presented at research talks as “gradual,” and she is also probably treating women who are antsy to start getting pregnant ASAP (I know that feeling well).

What was scary about the conversation though was that she said “The absolute hardest to treat are bipolar I women who want to breastfeed.” She went on to describe how many/most of her bipolar patients have some level of post-partum psychosis and most end up back on drugs very quickly. She also said that for almost all of her patients, she has their pregnancies treated as high risk because of the association between birth trauma and schizophrenia (of course, a “high risk” label often leads to increased medical intervention at birth which leads to greater risk of c-section, which carries a higher risk of hypoxia, which is what has been linked to schizophrenia, but I digress). She also arranges for these women not to be left alone for over a month after birth, by encouraging paternity leave and arranging state supported doula care (she doesn’t practice in the US, so things like state supported doula care exist).

When she was describing this my blood went cold and I was filled with so many conflicting thoughts. On the one hand I was thinking, crap, I’ve been doing so well, but what if I actually am bipolar and I end up getting psychotic after birth (should I manage to get pregnant and all the way to the birth, I know I’m jumping ahead here). Maybe I’m fine now, but a birth will push me over the edge, only now I’ll be labeled as someone who is non-compliant since I won’t have informed any of those reponsible for my prenatal care about my “history.”

On the other hand, I was feeling confirmed in my gut instinct to stay as far away from the hospital as possible, both in terms of trying to get pregnant and for prenatal and birth care, and to take care not to go to a hospital that has access to my medication/lab or mental health records. If my pregnancy and birth (assuming I even get pregnant) get labeled “high-risk” you’d better believe my chance of a risky c-section goes through the roof. It hadn’t occurred to me that a doctor could use my mental health history to insist on more interventions at birth, but of course it makes perfect sense. In both birth and mental health care, medicine is about power as much as it is about health care. A diagnosis always gives the doctors the upper hand. I had only thought to worry about nurses and doctors being overly solicitous after the birth, offering me meds and psych consults before my feet hit the floor since I’d be “at risk” for post-partum depression. I hadn’t even managed to worry yet about the impact on the birth itself.

But some of what this doctor was saying made wonderful sense for anyone. NO woman should be alone with in a house with a baby mere days after giving birth, but most are. Dads and partners should be supported in taking generous parental leave, both to support their spouses, and to bond with their own child. State supported doula care would have felt like a gift from heaven when our daughter was born, and certainly would have helped many families we know through some very rocky first months as parents. So much of what should constitute good “mental health” care, is just caring for people through difficult times, and it was refreshing to hear a doctor acknowledge this.

Should I be lucky enough to actually pull off getting pregnant, a lot of what I’ll be dealing with in interactions with the medical world will be dramatically colored by my past interactions with psychiatry. I’ll have trouble deciding what and how much to tell my midwife. I’ll wonder whether I’m lying or whether I’m protecting myself and our child. I may be so fearful of transferring to a hospital during the birth, that I won’t be able to get down to the business of birthing (we planned a home birth for our daughter, but did end up transferring to the hospital, which is a whole separate story. It was the right decision, both to labor at home, and to transfer when we did). Some of my fears will be founded, and some won’t.