This Isn’t What I Expected: Prologue



by Karen Kleiman and Valerie Davis Raskin


When we wrote the first comprehensive guide for postpartum depression, This Isn’t What I Expected, almost two decades ago, we surely hoped that things would be different by now: mothers wouldn’t feel so much pressure to be perfect, the link between hormones and postpartum depression would be well understood, new medications would work quickly and without side effects, and society would support young families, as is done in some parts of the world, with generous parental leaves and flexible work schedules. Maternal love wouldn’t be evaluated by whether a woman works in the home full time, not at all, or something in between.  Women with postpartum depression and anxiety wouldn’t be judged as either trying too hard or not trying hard enough.  Every obstetrician would know that postpartum emotional disorders are the most frequent medical complication of childbirth, and therefore all new parents would be screened and educated about this disorder.

We were certain that the stigma and shame of postpartum depression and anxiety (PPD) would lessen. We imagined that by the time our daughters become mothers, everyone would laugh at the quaint notion that postpartum depression was any less “real” than anemia or an infected milk duct.

Some things are better these days. Thanks to prominent celebrity moms such as Brooke Shields, Gwenyth Paltrow, and Marie Osmond, who bravely discussed their own struggles with PPD, most of us now recognize that this illness truly can happen to anyone.  There are better resources and treatment options than ever before.  There are some newer medications, none perfect, and we know more about breastfeeding and medication safety than we used to.

Public awareness has definitely improved.  As clinicians, researchers, and advocates for women’s healthcare, we both are thrilled to have witnessed and been a part of these important advancements.  Even so, it saddens us that our communities and larger society haven’t made all the progress women who are having difficulty after childbirth deserve.  It remains frustrating that postpartum depression is still perceived as a personal weakness; that a suicidal mom may still be afraid to disclose how she is feeling; and some doctors still mistake postpartum suffering for normal postpartum adjustment.

In updating the book, we were not surprised to find outdated references to portable cassette players and $3.00 an hour babysitters.  What did surprise us, though, was how relevant the majority of the book’s messages and recommendations remain to this day.  For some thirty years we have been treating women with postpartum depression and anxiety.  And though we have newer medications with fewer side effects, welcomed legislation, greater public awareness and more research to validate treatment options, one truth has proven to be constant: Women with PPD continue to wait apprehensively in the dark corners of their lives, fearful of judgment, stigma, ridicule, and misdiagnosis.  They wait, hoping this will go away by itself, hoping they will not go completely mad, hoping they do not have to let anyone know how they are really feeling.

Because of this increase in public awareness, more women have heard of PPD but continue to believe “that couldn’t happen to me.”  No one expects to get depressed after they have a baby. Yet women may be vulnerable to depression after childbirth for many reasons. They may have gone through painful, lengthy infertility treatments, certain that a baby would bring nothing but joy.  They may have expected their partners to be like Hollywood dads:  doing half the work.  They may be very accomplished women who find themselves helpless when it comes to soothing a colicky baby. They may be deeply affected by hard economic times, struggling with their own unemployment, or partners’. They may be terrified by the ongoing media fascination with the extremely rare mother with postpartum psychosis, afraid that someone will think they are a danger to their beloved children.

And so, again, we present this book to the postpartum woman and her family, to insure that accurate information is getting into the hands of the families who need it most.  It is generally accepted that approximately 1 in 7 postpartum women suffer from a serious mood disorder, referred to clinically as a major depressive disorder (MDD).  The statistics are even more striking (1 in 5 postpartum women) when referring to the entire spectrum of postpartum disorders which encompasses postpartum depression, postpartum anxiety, postpartum panic, postpartum obsessive-compulsive disorder (OCD), postpartum post-traumatic stress disorder (PTSD).  We also offer this book to women who are not experiencing full-blown postpartum depression. Another whopping 20-30% of new mothers won’t ever meet diagnostic criteria for PPD, but they feel terrible and are not sure what is wrong.  They may cry at times, feel overwhelmed on occasion and may have moments of despair or panic.  We call this phenomenon postpartum stress syndrome.  When it comes to the anticipated joy of new motherhood, the painful reality is that only one in two women find that motherhood is all that’s it’s cracked up to be.  If you take nothing else away from this book, we hope that you come to know that you are not the only one and you are not to blame.

When we initially set out to write this book, we were both young mothers ourselves, dedicated to our work with the challenges and joys that accompany this time in a woman’s life.  Since that time, our own cribs have been replaced by empty nests giving us a new perspective from which we now continue to observe and learn.  And sadly, we have come to realize that some things have not changed much.  Postpartum women continue to suffer in silence.  So much so that “suffering in silence” is paraphrased throughout countless worldwide campaigns to raise PPD awareness.  From New Zealand to Durango, from the U.S. National Library of Medicine National Institute of Health to The Tyra Show, “suffering in silence” has become a hallmark expression to depict the isolation that is so characteristic of this illness.  Women are still not talking about how they are feeling.  They are still not sure that they are safe to disclose their scary symptoms.  They are still not convinced they won’t be judged, or misunderstood, or locked away, or labeled crazy.  Similarly, healthcare providers remain locked into unproductive patterns that do little to encourage postpartum women to speak out.  Some fail to ask the right questions.  Some fail to refer appropriately after screening.  Some hand out a prescription for antidepressants without adequate probing or follow-up.  Some believe that postpartum depression doesn’t exist or is synonymous with baby blues or psychosis.  Others think their patients would feel better if they had more sex or a date night with their partner.

It is still, therefore, up to each individual woman and her family to ensure that she is getting good, accurate information and exposing herself to state-of-the-art treatment or self-help strategies that have been shown to be effective when managing symptoms of depression or anxiety during the postpartum period.  Self-help books can be extremely helpful, particularly during the postpartum time frame when women are often encumbered by time and financial constraints, schedules, exhaustion, etc.  Women have told us that our book was a “lifeline” and their “bible” when they were struggling with acute symptoms.  One woman said, “This book was the next best thing to having you right there with me at home.”   For these reasons, we believe in the value of the printed word and aim to reach the large number of postpartum women who need support, information, and hope during this difficult time.

These words from our original preface are still true: “The syndrome of depression and anxiety after childbirth is a common disorder that can strike any mother… We have yet to see a woman suffering from postpartum depression who expected it—we all have grown up expecting that this would be one of the best times of our lives… Although postpartum illness affects each individual woman in a unique way, many of the issues precipitated by this crisis are very similar among its sufferers.”

There is more information available to the consumer than ever before. With the click of a mouse you now have access to more theories, facts and opinions on postpartum depression than ever before. You can find sound advice and you can find false claims that avoiding chocolate will help PPD.  Now, more than ever, you need to trust your sources and be discriminate about the knowledge you seek to help you feel better.  Sometimes, there is so much information and so much advice, it’s hard to know which way to turn.  We want to help you with that.  We’ve done the research and we’ve read the literature. We’ve seen women get better and we are familiar with the techniques and interventions that have helped smooth their way.  We hope that this book will help you if you or someone you care about is experiencing PPD.  We also hope that this will help to continue to increase public awareness of PPD, and lessen the shame and isolation that makes this disorder so devastating.



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