by Emily Oster
☐ Yes, quite often
☐ Not very often
☐ No, not at all
9. I have been so unhappy that I have been crying.
☐ Yes, most of the time
☐ Yes, quite often
☐ Only occasionally
☐ No, never
10. The thought of harming myself has occurred to me.
☐ Yes, quite often
☐ Sometimes
☐ Hardly ever
☐ Never
The scaling of this is simple: Each answer is scored from 0 to 3, with the worst category (the first one for most questions, the last for 1, 2, and 4) getting a 3. Doctors will typically use a cutoff of 10 or 12 as a signal of mild depression, and a value of 20 or more as signaling a more serious depression.
Some of the questions here seem so obvious that it can be hard to imagine you’d actually need a questionnaire—can’t you just ask people if they feel sad and disengaged? But the evidence suggests that using this screening tool can be extremely effective. Researchers have shown improvements in detection (and therefore treatment) of postpartum depression across a large number of women by using this questionnaire—as much as a 60 percent reduction in depression a few months later.6 Your doctor will certainly give you this at your postpartum visit, but it isn’t a bad idea to do some self-screening also, which could capture your prevailing mood better.
Treatment for postpartum depression proceeds in stages. For mild depression, the first line of treatment is to try to treat without drugs. There is some evidence that exercise or massage can be helpful. Or, perhaps most important, sleep. For new parents, in particular, lack of sleep can be a huge contributor to mild depression. This shouldn’t be that surprising. Even when you don’t have an infant, if you have a few nights of poor sleep, it can be hard to enjoy things. Now add together many, many nights of interrupted sleep—it’s not surprising this could contribute to emotional exhaustion and depression.
Obviously, it is hard to treat lack of sleep when you have a newborn, although when I discuss sleep training later in the book, one of the strong arguments in favor of it is that it alleviates maternal depression. If you haven’t sleep trained your baby, or don’t plan to, or your baby is too young, there are still ways to improve your sleep. Get help for a night or two—or more—from a grandparent or friend. Hire a nighttime doula if possible. Divide the night duties with your partner so you can each get at least one uninterrupted stretch of sleep. It may be helpful to remind yourself that addressing your depression is valuable for your baby, too, not just some kind of selfish personal indulgence.
Beyond sleep, some type of cognitive behavioral therapy, or other talk therapy, is a usual first-line treatment for many people. This focuses on reframing negative thoughts and focusing on positive actions.
For more severe depression—sometimes defined as a score above 20 on the standard depression screen—antidepressants are more widely used. Although antidepressants are passed through breast milk, there is no evidence of adverse consequences (more on this in chapter 5). This means there is no need to choose between getting the help you need and nursing your baby.
Much of the literature and popular discourse focus on postpartum depression. But not all postpartum mental health issues take the form of depression. Postpartum anxiety is also common. Many of the symptoms are similar to postpartum depression, and indeed, it is common to diagnose postpartum anxiety using the same screening tool. But women with postpartum anxiety also tend to find themselves fixated on terrible things that could happen to the baby, unable to sleep even if the opportunity is there, and engaging in obsessive-compulsive behaviors around infant safety. This can be treated with therapy or, in more severe cases, with medication.
With anxiety, it can be hard to know where the line is between normal parental worry and obsessive worry. If anxiety is interfering with your ability to enjoy spending time with your baby, if it is occupying all your thoughts and preventing you from sleeping—that is over the line.
Less common but much more severe is postpartum psychosis.7 This affects an estimated 1 to 2 in 1,000 women (versus 1 in 10 for postpartum depression) and is much more likely to develop in women with a history of bipolar disorder. Postpartum psychosis usually manifests in hallucinations, delusions, and manic episodes. It will very likely need inpatient treatment, and should be taken extremely seriously.
Although women who give birth are at greater risk of these mental health complications due to some combination of hormones and often being the primary caregiver, postpartum depression can crop up in non-birth parents, too. Dads, other moms, adoptive parents—all can experience these symptoms. And because screening is so often focused only on women who have given birth and not on others in the household, these diagnoses are missed much more frequently.
It wouldn’t be a bad idea to have every adult in the household do a depression screen a few weeks after the baby is born, and then periodically after that. But if you are worried, call your doctor. Don’t wait to see them at six weeks; the sooner you can get on top of these issues, the sooner you’ll be able to enjoy your time with your baby, and the better things will be for everyone.
There are many issues in the pre-pregnancy, pregnancy, and post-pregnancy world that we do not talk about enough. When I was writing about pregnancy, the thing that struck me in this category was miscarriage. So many women have had miscarriages, yet they are rarely talked about—until you have one and then it turns out many women you know have also miscarried.
Postpartum mental and physical health have the same pattern. You have a new baby—shouldn’t you be happy and feeling great? When people ask how you are, everyone wants to hear “The baby is great! We’re so thrilled!” Not “I’m depressed and anxious and I’m dealing with third-degree vaginal tears.” The fact that these things are not talked about makes many of us feel like we are the only ones dealing with them, or should just get over it.
This simply isn’t true, and I think the more we talk about this, the more we do a service to other women. I’m not suggesting we all start tweeting the details of our vaginal healing—although I have no problem with that—but it is time to have a more honest conversation about the post-childbirth physical and mental experiences.
The Bottom Line
It takes time to recover from childbirth.
You’ll bleed for several weeks.
You may have vaginal tearing, which takes a few weeks to heal.
A caesarean section is major abdominal surgery, and it will take significant time for you to be mobile again afterward.
Return to exercise depends a bit on your birth experience, but you can typically start within a week or two, and most women could be back to their pre-pregnancy routine by six weeks.
There is no set waiting time for sex, although you should wait until you’re ready (and are on birth control if you’re not ready for another child).
Postpartum depression (and related conditions) are common and treatable. Get help as soon as you need it.
PART TWO
The First Year
Breastfeeding. Sleep training. Co-sleeping. Vaccination. To work or not to work. Day care versus nanny.
These are the big decisions that will shape at least the first year of your life as a parent. They are decisions that, up until you became a parent, you probably never thought about. And the answers are not obvious.
So we turn to the internet. Which is great, since people on the internet have the answer. In fact, it’s an answer that is easy to summarize and understand. The correct decision, in all cases, is to do exactly wha
tever that particular person on the internet did. More than that, making any other choice is roughly equivalent to abandoning your child to wolves.
Welcome to the Mommy Wars. So pleased you could join us.
Why are these particular topics so fraught? Why does it feel like an all-or-nothing battle? Why are these the focal points for our parenting anxiety and judgment?
I’m not sure, but I suspect it relates to the fact that the choices you make in these areas will dramatically affect your parenting experience. Whether you choose to breastfeed, whether you choose to have your child sleep in your room (or in your bed), whether you sleep train—you’ll experience these choices every day.
And many of these choices make your life more difficult, or at least more annoying. Breastfeeding has some wonderful moments, but among the hundreds of women I have talked to about it, not one has told me, “Lugging around the pumping parts everywhere was a fulfilling experience of womanhood!” Getting up four times a night until your child is one (or two, or two and a half . . . ) is exhausting. It affects your mood, your work, your relationships.
At the same time, choosing to not breastfeed, or choosing to let your kid cry themselves to sleep a few times, is hard in a different way. People will judge you for these decisions, and, if we are being honest, you may judge yourself. Letting your kid cry themselves to sleep does work: most kids (and, thus, their parents) will sleep better afterward. Are you just being selfish and sacrificing your children’s well-being for your own?
This is a good time to reiterate what I said in the introduction: like all other things in parenting, there is no perfect set of choices for everyone. There is a right set of choices for you, taking into account your preferences and your constraints. If you have six months off from work or are not going back to work at all, it may be easier to sacrifice sleep at night in exchange for napping during the day. If you work in an office with an opaque door where you can pump and work at the same time, it might be easier to nurse longer than if you have to sign up for time in the lactation pod (or, god forbid, the bathroom) and stop working to pump.
The fact that preferences matter, however, doesn’t mean there’s no room for facts. We cannot hope to make the right choices for ourselves without seeing the data. You and I may see the same data and make different decisions, but we should both come to the data as the first step. As an economist, I try to start my decisions with the data—What does it say? How confident are we in its findings?—and then try to think about what works for my family in light of that data. It helps to be married to another economist, but I’d argue that the language of data and preferences can work for anyone. You do not have to pay the costs of the two-economist marriage to reap the benefits.
This part of the book goes through the data on these major early parenting decisions. In many cases, the work of the book is really to separate the good studies on these topics from the less-good ones. In making decisions, we want to know the causal effect of one variable on another, not just that they are associated. It is no good to tell you that a kid who was breastfed differs from one who wasn’t; you want to know whether the breastfeeding itself matters.
How can you identify a good study? This is a hard question. Some things you can see directly. Certain approaches are better than others—randomized trials, for example, are usually more compelling than other designs. Larger studies tend, on average, to be better. More studies confirming the same thing tends to increase confidence, although not always—sometimes they all have the same biases in their results.
I read a lot of studies—for this book, but also for my job—so some of my conclusions come from experience. Sometimes you poke into a study and it doesn’t smell quite right—the groups they are comparing are really different, or the way they measure variables is skewed. Sometimes there will be a really big study, but it will be deeply flawed, and I’ll end up relying more on a smaller study that has a better design.
And, sadly, for those of us who love data, the data will never be perfect.
In confronting the questions here, we also have to confront the limits of the data and the limits of all data. There are no perfect studies, so there will always be some uncertainty about conclusions. Beyond that, in many cases the only data we have is problematic—there will be a single, not-very-good study, and all we can say is that one study really doesn’t support a relationship.
This means we can’t ever say for sure that we’re certain something is good or not good for a baby. Of course, sometimes we are more sure than others, and I’ll try to let you know when the data really helps us see a relationship as true, and when there just isn’t much for us to go on.
I hope you’ll leave this section armed with some facts. Facts about what we know, but also facts about what we still don’t know—places where the data is just uncertain, or hasn’t provided a compelling answer. Armed with these facts, you can go forward to make your choices. Not the same choices, mind you. But the right ones for you.
4
Breast Is Best? Breast Is Better? Breast Is About the Same?
The hospital at which I delivered Penelope had a lot of pre-delivery classes, one of which was about breastfeeding. I asked a friend with a slightly older baby if I should take it; she scrunched up her face and said, “You know, it’s really not the same with a doll.”
Boy, was that right. I am going to tell you the truth. For many women, including myself, breastfeeding was hard. (This doesn’t mean the classes aren’t useful, just that they aren’t a panacea.)
When Penelope lost weight in the hospital, we had to supplement with formula. This might have been unnecessary. But what seemed even crazier was the very elaborate setup the nurse suggested for avoiding the dreaded “nipple confusion.”
Rather than just handing me a bottle and suggesting I try that, I found myself hooked up to a system in which a tube was taped to my breast and the formula bottle was held above my head. We tried to nurse that way, with the formula being delivered through the tube, but neither Penelope nor I had any idea what we were doing.
They offered to send this system home with us, but I declined; if we needed to feed Penelope formula, it was going to come from a bottle.
My milk did eventually come in, but that wasn’t the end of it. Much of the time, it still seemed like I didn’t have enough. Before going to sleep at night, Penelope would eat and eat and eat, mostly from the bottle. I felt terrible. Everyone said, “Oh, if she still seems hungry, just let her keep trying to nurse. Your supply will catch up!” But she was clearly starving (at least, that’s what it seemed like).
At the same time, I was trying to pump, to increase my supply and to have some backup for when I went back to work. But when to do this? Should I pump right after feeding her? What if she needed to eat again? Should I pump an hour after feeding her while she was napping? What if she woke up right after I finished and needed to eat again?
And worst, Penelope seemed to hate breastfeeding, and getting her to latch on was a struggle every time. When she was seven weeks old, we went to my brother’s wedding, and I remember sitting in a back closet at the restaurant, where it was approximately one billion degrees, trying desperately to get her to latch on as she screamed and screamed. Eventually, we left the closet and I fed her a bottle in the air conditioning.
Why did I continue? With hindsight, I have no idea. Eventually, around three months, she finally just seemed to accept that I was not giving up and just started nursing one day without a lot of objections.
Breastfeeding isn’t always like this, even from one baby to the next. With Finn, nursing was a breeze (other things were complicated). My milk came in faster, there was more of it, and he never had trouble figuring it out. And for some people, it’s like this the first time.
But any struggle we experience is made worse by the emphasis—societal, familial, personal—on the many benefits of breastfeeding.
Here, for exam
ple, is a list of the claimed benefits of breastfeeding, which I pulled from a couple of websites.1 (I should note that this chapter is focused on the benefits of breastfeeding in the US or other developed countries, where the formula alternative is safe and can be made with clean water. In developing countries, breastfeeding benefits are larger and different, since the alternative is often formula made with contaminated water.)
The list is very long, so I’ve divided it into sections.
Short-Term Baby Benefits
Fewer colds, infections
Fewer allergic rashes
Fewer gastrointestinal disorders
Lower risk of NEC
Lower risk of SIDS
Long-Term Child Benefits: Health
Less diabetes
Less juvenile arthritis
Lower risk of childhood cancer
Lower risk of meningitis
Lower risk of pneumonia
Lower risk of urinary tract infections
Lower risk of Crohn’s disease
Lower risk of obesity
Lower risk of allergies, asthma
Long-Term Child Benefits: Cognitive
Higher IQ