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Should Domperidone Be Reconsidered as a Treatment For Low Breastmilk Supply?

Author: Janet C. Currie, MSW, PhD, Research Collaborator at the UBC School of Nursing. Editors: Suzanne Hetzel Campbell PhD, RN, FCNEI, IBCLC, CCSNE, Negin Nia and Arrthy Thayaparan (Blog Coordinators)

Published: March 11th, 2022

Domperidone is a dopamine blocker that is being increasingly prescribed off-label in British Columbia and other provinces to treat low milk supply (LMS). Domperidone increases prolactin, which can stimulate milk production, an unintended side effect.

There is a global consensus on the importance of at least six months of exclusive breastfeeding because of its overwhelming health benefits. An average of 90 per cent of Canadian mothers intend to breastfeed and go on to initiate it. However, by three months the rate of mothers exclusively breastfeeding their newborns has decreased to 51.7 per cent and by six months to 14.4 per cent. One of the most common reasons mothers give for stopping breastfeeding early is because of LMS.

Low milk supply

Physiological factors can contribute to LMS. These include conditions such as mammary hypoplasia, which is limited breast glandular tissue. The prevalence of physical barriers to breastfeeding is thought to be low – from 1 to 15 per cent.

In most cases, LMS appears to be caused by other factors that affect milk supply. These include a mother’s confidence in her milk supply and/or a lack of information about lactation, infant nutritional needs, sleep patterns and hunger cues.

LMS can also be related to the degree a mother receives sustained help with breastfeeding and the medicalization of breastfeeding which can result in a premature diagnosis of LMS and the early introduction of formula.

Increasing use of domperidone in Canada

Two Canadian studies have documented the rise in domperidone use to treat LMS. In BC, between 2002 and 2011, Smolina et al. found that domperidone use increased from 8 to 19 per cent for term births and from 17 to 32 per cent for preterm births. This research showed an increase in the median daily dose from 60 to 80 mg/day and a longer duration of use.

A recent study in BC, Alberta, Saskatchewan, Manitoba and Ontario found domperidone use increased between 2004 and 2017 with some reduction in use after Health Canada’s 2012 domperidone advisor.

Off-label use of domperidone

Health Canada has only approved domperidone to treat digestive problems. When it is prescribed for LMS this is an-off-label, unapproved use. Off-label prescribing occurs when a drug that has been approved for specific use by Health Canada is prescribed for another use for which the drug has not been approved. Off-label prescribing can be beneficial especially when few treatments exist for a condition, but without data derived from the drug approval process it can be difficult to assess a drug’s benefits and harms. In addition, ADRs from off-label uses are not systematically collected or analyzed to identify safety problems.

Domperidone has not been approved for any use in the United States and the distribution or importation of domperidone-containing products into the US violates the law. Domperidone has not been used to treat LMS anywhere in the world.

Safety concerns of domperidone

Domperidone is a QT-prolonging drug which means that it can trigger ventricular arrhythmias. In the most serious cases, this can lead to Torsades de Pointes, an abnormal heart rhythm that can result in cardiac death.

The cardiac risks of domperidone are dose-related. In a 2015 advisory, Health Canada recommended that domperidone be used at a maximum daily dose of 30 mg/day for a short duration. However, Canadian research indicates that domperidone is being prescribed above recommended guidelines, sometimes over 80 mg/day.

Taking other QT-prolonging drugs with domperidone increases cardiac risks. Many common prescription drugs are QT-prolonging. They include fluoroquinolone antibiotics (e.g., Cipro), antidepressants (e.g., escitalopram and citalopram, antifungals (e.g., miconazole), and some antipsychotics.

Using a QT-prolonging drug along with CYP3A4 Inhibitors, a type of enzyme, can trigger risks. Substances with CYP3A4 inhibitors include drugs like erythromycin and foods like grapefruit/ grapefruit juice. Other factors that increase the potential risks of domperidone include having a personal or family history of cardiac problems, liver disease, electrolyte problems, and low blood levels of potassium and magnesium. Female sex is an independent risk factor.

Domperidone is an antipsychotic (neuroleptic). Antipsychotics are psychiatric drugs usually approved to treat conditions like psychoses and schizophrenia. Even if someone is taking domperidone for LMS and not for a mental health condition, the potential for adverse drug reactions (ADRs) can be the same. ADRs may intensify if the drug is reduced or stopped rapidly, especially from high doses.

Recent case studies and reports to the Infant Risk Information Centre at Texas Technical University indicate that some people using domperidone for LMS are experiencing serious adverse reactions when they stop. ADRs effects from stopping domperidone could include fatigue, movement/muscle problems, weight gain, anxiety, agitation, palpitations, dry mouth/eyes, dizziness/ poor balance, gastrointestinal problems, insomnia, cognition problems, listlessness and depression and, in serious cases, psychoses or suicidal feelings.

To reduce antipsychotic withdrawal symptoms, domperidone should be tapered consistently and slowly in small increments with a period of 2-4 weeks between reductions or at a pace that is tolerable. A tapering plan should be discussed with a healthcare provider knowledgeable about antipsychotic withdrawal.

The safety of domperidone absorbed by babies through breastmilk has not yet been clearly established.

Effectiveness of domperidone

Evidence of domperidone’s effectiveness from randomized control trials is of low quality with small study enrollment, short-term tracking, (1-2 weeks), a focus on low doses, a lack of meaningful outcome measures such as duration of breastfeeding and limited reporting of ADRs. In most cases, where domperidone resulted in an increase in milk volume, the increase was not significant. Higher dose levels were not associated with significant increases in milk volume.

Why Should We Pay More Attention to the Placenta?

Author: Jasmin Wächter, Master’s student, Department of Obstetrics and Gynecology, UBC | Editors: Negin Nia, Arrthy Thayaparan (Blog Coordinators) & Shreya Sharma

Published: December 10th, 2021

The placenta is, arguably, the most important yet continuously under-appreciated organ in the body. The placenta not only determines the outcomes for pregnancy and later life for the mother, it also impacts the life of the child. A healthy placenta is a bonus to the child’s health across mental, metabolic, and cardiovascular functions. Unfortunately, very little is known about this crucial organ. This is changing with new initiatives focusing on understanding placental health and its outcomes.

Before we dive deeper into the importance of this organ, let’s get to know it better.

During pregnancy, the placenta grows and develops alongside the baby. This disk-shaped organ forms the barrier between the maternal and fetal blood circulation.

Throughout pregnancy, the placenta releases important chemical messengers called hormones. Hormones signal to the mother’s body that there is an ongoing pregnancy and instruct it to make nutrients available for the growing fetus. As internet science and pop culture continuously remind us, hormones are essential to an optimally functioning body.

Its tree-like protrusions deeply embed themselves into the mother’s womb and selectively allow the transport of nutrients, oxygen and waste products across. Moreover, the placenta can also filter compounds that may have negatively affected the pregnancy such as stress signals.

The function that most excites me, is the placental cells’ ability to make their presence known in the womb — which is what my research is focused on. They detach themselves from the placenta’s tree-like protrusions and invade, in a cancer-like manner, deeper into the mother’s womb to adapt it for a successful pregnancy. It’s them declaring their arrival in the body!

When it comes to the mother, the placental cells communicate with the immune cells to ensure the growing fetus isn’t mislabeled as a “foreign invader” and rejected or even attacked by the resident immune system. These adaptations are crucially important to ensure the health of the baby and mother throughout pregnancy and in the future.

Now that we know what a placenta is, let’s see what can happen when things take a wrong turn. And why it is important to educate ourselves on this organ.

Inadequate placental development can lead to a range of complications.

For instance – the fetus could experience a lack of growth and small size. This can exacerbate early delivery, infections and even stillbirth. These impacts stay with the babies as they grow into adults. Conditions such as obesity, diabetes, cardiovascular disease, autoimmune disease, allergies, neurodegenerative disease and mental health challenges have all been linked to inadequate placental function.

And it’s not just about the child being born. Placental malfunctions also put pregnant mothers at risk. Preeclampsia is one such condition that occurs when the mother’s body is unable to support the needs of the growing fetus. This condition causes the body to overcompensate and exert itself leading to tiredness, pain, high blood pressure and even organ damage. If left untreated, this may lead to seizures or even death. The influence of the placenta seems to extend beyond birth; mothers who’ve had placental complications are more likely to develop diabetes or cardiovascular and metabolic diseases.

So despite the influence of placental health on life, why is effective research yet to be done?

Various barriers prevent effective placental research, primarily funding. This may be attributed to the historical underfunding of research topics categorised into “women’s issues”. Moreover, the transient nature of the placenta makes it an especially difficult organ to target. To achieve a thorough understanding of the placental process, it is imperative to examine its development throughout the first, second and third trimesters. This is not always possible due to governmental restrictions imposed on abortions and the laws surrounding embryonic and fetal research.

However, all is not doom and gloom as the scientific community continues to work on new initiatives in the field.

Recent years have brought initiatives such as the Human Placenta Project which aims to develop new tools to study the placenta, in real-time. Improved ultrasound and magnetic resonance imaging (MRI) techniques are aimed to track the structure and blood, oxygen and nutrient flow throughout the placenta. This would allow for earlier discovery and monitoring of at-risk pregnancies.

Scientists are also investigating ways to collect information about placental health, function and genetic make-up by tracking placental components such as proteins, lipids and RNA present in the mother’s bloodstream.

Other approaches include creating mini-placentas, called organoids. These three-dimensional clusters of cells recapitulate the cellular organisation and developmental trajectory of the placenta, allowing researchers to study the interactions of different cell types throughout development. Future research may even allow for the inclusion of blood vessels in the system as seen in other mini-organ structures.

Another approach to studying placental function includes so-called placentas on a chip. This model is constituted of 2 human placental cell layers surrounded by fluid channels. The setup recapitulates the placental barrier between the fetus and the mother. This allows scientists to investigate how different compounds are transported or filtered across the placenta.

Let me beat the drum, again.

The placenta is a crucial organ for a successful pregnancy and a healthy life. Historical underfunding and barriers to placental research are being met with new initiatives and technologies such as the human placenta project, mini-placentas and placentas on a chip. Any findings generated could allow us to develop improved treatments for pregnancy complications in the future and allow people to have healthier pregnancies and a better start to their life.

Experience with COVID-19 Vaccine While Pregnant

Authors: Negin Nia and Arrthy Thayaparan (Blog Coordinators) | Interviewing: Dr. Cindy Barha, PhD, Department of Physical Therapy; Dr. Chelsea Elwood, PhD, Department of Obstetrics and Gynecology

Published: October 9th, 2021

To go along with our latest blog looking at research and effects of the COVID-19 vaccine on pregnant women, the Women’s Health Blog spoke to Dr. Cindy Barha to hear her personal experience with receiving the vaccine during pregnancy.

While the information mentioned in this Q&A is the personal anecdote of Dr. Barha, everything mentioned has been verified and additional reading has been listed along with this blog.

When did you decide to get your vaccine?

I got pregnant in September of last year, a few months after COVID had hit, and the first wave was just ending. I had already decided that I was going to get it as soon as I was eligible to get the vaccine.

Why did you get vaccinated while pregnant? What was your thought process going into that?

I kept a close eye on data coming out of the United States and the UK. They were the only countries at the time that I could find that were actually keeping track of COVID infections in pregnant women. Everything I’d seen was pointing towards COVID symptoms being much more serious in pregnant women, compared to non-pregnant women of the same age.

So if you were pregnant and got COVID, you’d be at higher risk for being hospitalized and being put on a ventilator, compared to a woman that was not pregnant and the same age as you. So that just kept coming up every time I looked to see if any new data had been published.

As soon as I became eligible, and I had the opportunity in my second trimester, I jumped on it. I had no reservations about getting the vaccine. Nothing had come out in any of the studies I had seen to suggest that the vaccine was unsafe during pregnancy. I was always going to get the vaccine and I was actually really happy to receive it during my second trimester, because I was really hopeful that Baby would receive some protection. And this is exactly what is being seen in more recent studies, COVID antibodies are found in umbilical cord blood!

Other than your research, who did you go to for advice on informing your decision?

I had two excellent OBs (obstetricians) at BC Women’s hospital, Dr. Chelsea Elwood is one of them and she is an infectious disease expert. I had a couple of conversations with her, I was curious what experts thought [about getting the vaccine, while pregnant].

Around the same time, I had a family member and a friend who were also pregnant, and were both skeptical about getting the vaccine. So, I shared my experiences and the knowledge that I’ve been able to gather from the data with them. But I also asked Dr. Elwood if she had anything to share that I could pass on to them and she pretty much echoed everything I’d seen in studies looking at vaccine safety and efficacy.

Did you have any side effects after the vaccine?

I had very few side effects. In fact, I think I only had a sore arm for maybe 12 hours, and I think that was because I slept on that side. But I didn’t get a fever, or any aches or pains. It was basically like getting the flu shot at that point for me, and I don’t normally get any side effects from that either.

I mentioned this to Dr. Elwood and she told me about some data suggesting that women that are pregnant are suffering from less side effects from the COVID vaccine. My personal experience echoed what she was seeing in the data, that side effects seemed to be blunted in women that were getting their shots during pregnancy. I had the same experience from my second shot when I was breastfeeding. I had almost no side effects whatsoever.

How did you feel about any effects to your baby?

When I got my first shot during my second trimester, researchers had just started to see that the antibodies that were being produced from mRNA vaccines were crossing the placenta.

So Baby got some protection from my first shot. I got my second shot when i was about 3 months postpartum so Baby got antibodies from my second shot, as well through breastmilk.

In a way this was a good sort of vaccine schedule for me, because the baby got antibodies through the placenta and through breastmilk.

On a more cheerful note, how’s your baby now?

He’s great. He’s protected from COVID as far as I know. He’s four months old now and just living his life.

Is there anything you would like to share to people who are or looking to get pregnant and trying to decide whether they should get the vaccine?

I think what I would say is, don’t think only about yourself, but also think about your baby. The vaccine has been given to over 6 billion people, and a portion of those people were pregnant. There’s been no negative outcomes in terms of pregnancy or fertility in any of these cases.

So think about yourself, think about your baby. The vaccine is our best chance of getting through this pandemic. Without it, pregnant people are at a higher risk for being hospitalized, and that will potentially be harmful for your baby.

The Women’s Health blog also reached out to Dr. Chelsea Elwood, a clinical assistant professor at the University of British Columbia in the department of Obstetrics and Gynecology, to hear her recommendations.

What is the recommendation right now?

So we recommend, in line with the Society of Obstetricians and Gynecologists of Canada, and a large number of other international bodies, that persons who are pregnant, persons who are breastfeeding, and anyone planning a pregnancy get the COVID-19 vaccine.

Is there a certain time period when women should receive the vaccine?

As soon as it’s available. So we recommend that at any time in pregnancy, first trimester, second trimester, third trimester, they should get the vaccine, including postpartum.

When it comes to the different vaccines, is one better than the others? Is mixing vaccines an issue?

We recommend any of the COVID-19 vaccines in pregnancy. There is currently more published data, generally on Pfizer and Moderna, although we are expecting much more data from the United Kingdom on AstraZeneca. There’s no safety signals related to pregnancy with any of those vaccines. So we actually recommend any of them.

The data around vaccine mixing is continuing to be studied and emerging. To be honest, at this point in time, we recommend any of them as long as patients are fully vaccinated and can’t make a preferential recommendation of vaccine mixing versus not in pregnancy.

With the talk about boosters, do you think pregnant women should be getting a booster shot?

At this point in time, there’s no data to suggest that pregnant women respond any differently than their non-pregnant counterparts. So a woman who is pregnant and has, for example, an autoimmune disorder and would normally qualify for a booster, then they should get their booster. Pregnancy, in and of itself, is not a reason at this point in time to get a booster.

What do you have to say to folks worried about their babies and the vaccine?

Maternal vaccination for infant protection is a very well established modality to get babies protected from infectious diseases. We have traditionally seen that in the influenza vaccine, where moms are protected, babies are provided antibodies through placental transfer, as well as through breast milk afterwards.

We actually use maternal immunization for infant protection as a very good strategy to protect babies from whooping cough in the first couple of months after they’re born. And we recommend routinely the whooping cough vaccine in pregnancy for that reason. The COVID-19 vaccine is recommended primarily for maternal benefit. Meaning the outcomes that are being prevented by our mums getting COVID-19 vaccine, are ending up in the ICU hospitalized or having preterm birth by being vaccinated.

Being vaccinated in pregnancy, and the degree of which that is going to protect the baby from COVID-19 has yet to be seen, because we simply don’t have enough data at that point in time. But we would expect it to be protective in the same way that any other vaccine in pregnancy does, in that it would confer some protection for babies after they are delivered and through breast milk.

What would you like to say to the folks deciding whether they should get vaccinated?

I’d encourage them to reach out to their maternity care provider and have that conversation. The Society of Obstetricians and Gynecologists of Canada and most of the provinces have great resources available to help patients and practitioners have the conversation.

But again, we’re very clear about the recommendation because of the potential harm of COVID-19, the clear harm of COVID-19 if you get it in pregnancy, and the safety data we have now around vaccination in pregnancy.

I would also discourage people around the social media that’s going around about the risk of infertility. There’s no data that the COVID-19 vaccine causes infertility. In fact, the studies actually oppose this. There’s no theoretical reason why the COVID-19 vaccines would cause infertility. And so we do recommend that people who are trying to get pregnant get fully vaccinated before they get pregnant, so that they’re protected during their pregnancy.

So we recommend again that persons who are pregnant, persons who are breastfeeding, and anyone planning a pregnancy get the COVID-19 vaccine.

COVID-19 Infection and Vaccination During Pregnancy

Authors: Jennifer Richard, PhD, Department of Psychology, UBC; Liisa Galea, PhD, WHRC Lead | Editors: Negin Nia and Arrthy Thayaparan (Blog Coordinators)

Published: October 8th, 2021

Pregnancy is a vulnerable time for infection due to dynamic changes to the immune system leading to reduced immunity. This also implies an increased risk of people becoming severely sick after contracting COVID-19 (SARS-CoV-2) while pregnant. In fact, COVID-19 infection during pregnancy increases the risk of intensive care (ICU) transmission for the mother, preterm birth, caesarean (c-section) delivery, and admission to neonatal care for the baby. These risks are worsened by the Delta variant, currently the most common variant in Canada, which is up to twice as contagious as previous variants. The rise in Delta variant infections has increased the proportion of pregnant people with severe infection compared to previous variants. More specifically, Delta increases the risk of pregnant people requiring respiratory support, contracting pneumonia, and being admitted to intensive care.

How can we protect pregnant people from COVID-19 infection and related complications?

The best protection, whether you’re pregnant or not, is getting vaccinated. However, the Center for Disease Control and Prevention (CDC) reported that only about 25 per cent of pregnant people in the U.S. have received at least one COVID-19 vaccine dose. Several studies have demonstrated that two doses of AstraZeneca-Oxford and Pfizer-BioNTech COVID-19 vaccines are still effective in preventing severe disease, hospitalization, and death, even against Delta.

Recent studies suggest that two doses of these vaccines provide between 88–95 per cent effectiveness in protecting against the Delta variant. Whether one dose of COVID-19 vaccine is sufficient to protect against Delta is inconclusive. One study reported barely detectable levels of neutralizing antibodies against Delta after one dose of vaccine. On the other hand, a Canadian paper, that has yet to be peer-reviewed, states that one dose of Pfizer-BioNTech, Moderna or AstraZeneca-Oxford provides “good to excellent protection against symptomatic infection and severe outcomes” against Alpha, Beta, Gamma and Delta variants. However, the study also reported reduced protection against Delta compared to the other variants.

Vaccination is also recommended for individuals who have been infected by COVID-19. The vaccination provides superior protection compared to previous infection by another COVID-19 variant. So, despite the Delta variant affecting vaccine effectiveness, vaccinations still remain our best form of protection for severe illness, hospitalizations, and death. This is along with maintaining social distancing, masks, indoor ventilation, and hand hygiene.

COVID-19 vaccine hesitancy and safety in pregnancy

Women tend to be more hesitant towards COVID-19 vaccination than men or gender diverse individuals, with pregnant people reporting an even lower intention of getting vaccinated. The greatest concerns of pregnant people regarding the vaccines are a lack of data on pregnancy safety regarding the vaccines and/or that the vaccine may be harmful for their baby. So what do we know about the safety of COVID-19 vaccines in pregnancy? Can it cause pregnancy loss, affect your chances of conceiving, or alter your genes or the genes of your baby?

Is it safe to get vaccinated against COVID-19 while pregnant?

Pregnant people weren’t included in the initial COVID-19 vaccine trials. However, over 156,000 pregnant people have now been vaccinated with Pfizer-BioNTech or Moderna vaccines in the U.S. with no raised safety concerns. More specifically, the risks for adverse effects relating to pregnancy, including pregnancy loss, birth defects or effects on birth weight, were the same, or lower, than risks reported prior to the pandemic.

Importantly, while the risk of preterm birth was not increased after vaccination against COVID-19, this risk was increased in non-vaccinated pregnant people infected by the COVID-19 virus. As for the more immediate side effects after vaccination, pregnant people reported having a slightly sorer arm (around the injection site). But otherwise, pregnant people actually reported having milder side effects than non-pregnant people, for side effects such as headaches, muscle soreness and fever.

But are COVID-19 vaccines effective in pregnant people?

Although pregnancy causes changes to your immune system, COVID-19 vaccination in pregnant and lactating people provides the same level of immunity against the COVID-19 virus compared to vaccination in non-pregnant people. The level of protection is equal across all three trimesters, as vaccination during the first, second and third trimester gives rise to the same level of antibodies produced against COVID-19. In addition, the level of protection in all vaccinated individuals (non-pregnant, pregnant and lactating) was higher than levels observed in pregnant people who had previously been infected by the COVID-19 virus, indicating that even those who have previously been infected by COVID-19 should get vaccinated.

Can COVID-19 vaccines affect your risk of becoming pregnant?

There is no evidence that vaccination against COVID-19 would affect fertility. In males, COVID-19 vaccination does not result in a reduction in semen volume, sperm concentration or motility. In females, embryo implantation rates were the same as in non-vaccinated individuals. In addition, COVID-19 vaccines can not reach or cross the placenta, they act in the muscle where the vaccine is given. And even if the vaccines could reach the placenta, they can not induce antibodies against, affect or injure the placenta. However, placentas from people who tested positive against the COVID-19 virus during pregnancy showed abnormal blood flow between mother and baby. These data indicate that vaccination during pregnancy is safer than getting infected with COVID-19 during pregnancy.

Since the vaccine rollout, thousands of individuals included in the V-safe Pregnancy Registry have reported becoming pregnant after vaccination. In addition, the rate of accidental pregnancies in vaccinated and unvaccinated individuals were reported at equal levels — showing that vaccines don’t impact pregnancy.

Can the vaccines alter your DNA or the DNA of your baby?

No, vaccines cannot alter your DNA. Pfizer-BioNTech and Moderna are the two most common COVID-19 vaccines given to pregnant people. They are referred to as mRNA vaccines, which carry information (mRNA) to make a part of the COVID-19 virus (spike protein). They can only make a part of the virus, and not the complete virus. The components of the vaccine can’t cause infection in the mother or baby. Neither can they alter your DNA, or the DNA of your baby (mRNA does not alter DNA). The vaccines don’t contain DNA and human cells don’t have the ability to transform RNA to DNA, only the other way around. Therefore, these vaccines are not able to integrate into your DNA, or the DNA of your baby, or cause long-term genetic changes. As an aside – if we could change DNA with mRNA we would already have cures for genetic illnesses such as cystic fibrous or Huntington’s disease.

Can vaccination benefit your baby?

The vaccine provides protection to the baby in the womb indirectly, by lowering the risk of severe sickness in the mother. In addition, COVID-19 vaccination can directly protect your unborn and/or newborn baby, because protective antibodies against COVID-19 cross the placenta, and provide protection against COVID-19 to the baby at birth. In addition, COVID-19-specific antibodies have been found in the umbilical cord of babies, and breast milk, of mothers who were vaccinated during pregnancy.

While cases in babies and small children reported so far have been uncommon, and often cause mild to moderate symptoms, the Delta variant has proven to be more harmful to children. In the U.S., COVID-19 hospitalization rates in children and adolescents increased nearly 5-fold in late summer, a time in which Delta has been the predominant circulating variant. In a recent study from Israel, over 10 per cent of children who were diagnosed with COVID-19 reported symptoms of long COVID, such as continued illness, fatigue or breathlessness. In addition, 30 per cent of parents of affected children reported a decline in “neurological, cognitive, and mental health abilities” compared to prior to COVID-19 infection, for example disturbed sleep and concentration problems. Furthermore, we do not yet know potential long-term effects on children whose mothers were infected while pregnant. Although rare, there are a few cases of newborns born to COVID-19 positive mothers that were tested positive for the virus at birth.This indicates that transmission of COVID-19 from mother to child during pregnancy is possible. Furthermore, the fetus can still be affected by stress, restricted oxygen, reduced placental function and sickness in the mother infected by COVID-19, in addition to the increased risk of preterm birth and c-section delivery.

Taken together, the vaccines provide great protection against symptomatic infection and severe outcomes. Recent data indicates that you are almost 30 times more likely to end up in the ICU if you are unvaccinated. Furthermore, vaccination against COVID-19 during pregnancy is effective, and far safer than the risk of contracting the virus itself, which, while rare, has a 15 times greater risk of death during pregnancy. Vaccination during pregnancy can also benefit the baby by protecting them from indirect effects of disease in the mother, and by providing antibodies against COVID-19. Not to mention it will protect you after giving birth and protect your community. The data overwhelmingly support vaccination during pregnancy as safe and effective.

So, the bottom line is: if pregnant people are concerned about their safety or the safety of their unborn child, getting the shots (of COVID-19 vaccine) is their best shot.

Feature image by Dr. Jennifer Richard

Challenging Oppressive Maternity Healthcare in Canada

Authors: Stephanie Ragganandan Hon. BSc, York University & Dr. Karen Lawford midwife and PhD, Queen’s University | Editors: Alex Lukey and Arrthy Thayaparan (Blog Coordinators)

Published: August 9th, 2021

At no time in the present era have healthcare systems been subject to the same extent of research, analysis, critique, and challenge as they have been during the global COVID-19 pandemic. There is a temptation to view any failings in these systems as a matter of contemporary shortcomings. While the health outcomes facing marginalized populations are certainly exacerbated by 21st century technological, economic, and social disparities, in addition to being disproportionately impacted by COVID-19, it is crucial we remember the root cause of these disparities. It is only by understanding the past that we can make sense of the present and imagine a future that liberates us all from oppressive, ineffective, and unsustainable healthcare services.

Canada, like many other countries across the world, was founded on colonialism. Colonialism is often framed as something from the past and as having no association with current times, but this is not the truth. We are living in an ongoing colonial project that is geo-politically known as Canada.

What is colonialism? It is the process by which one group takes control of another group’s lands, resources, and governance authorities and maintains that group in a state of subordination based on the beliefs of racial and cultural inferiority of the subordinated group. In Canada, the legal, education, and healthcare systems—for example—are deeply rooted in Eurocentric, Christian ideologies and practices that purposefully oppress Indigenous Peoples’ philosophies, values, ways of making knowledge, and kinship relationships.

As healthcare researchers, we strongly assert it is vital to acknowledge and recognize the existence, maintenance, and practice of the ongoing colonization project in Canada via Euro-Canadian healthcare services, programming, and education, and within medicine itself, because Indigenous Peoples’ knowledge systems are currently marginalized, made irrelevant, and tokenized. The invisibility of these areas of colonization is ethically unsound, immoral, and does not contribute to the Truth and Reconciliation Commission of Canada’s Calls to Action, specifically Calls 18-24.

We are especially committed to drawing attention to the implications of colonization on the sexual and reproductive health of Indigenous Peoples. Since contact with white Christian colonizers, Indigenous Peoples have fought to protect their customary practices, languages, and ways of health and wellness. Yet, nationally coordinated and funded assimilation efforts via various genocidal mechanisms, such as the Indian Residential School system, have resulted in the degradation and criminalization of Indigenous Peoples including their customary healing practices and practitioners.

We strongly assert that the process of improving current systems-wide healthcare must begin by recognizing the interconnected webs of colonization that are woven into all colonial healthcare systems in Canada.

Comprehensive Gender-Inclusive Sexual and Reproductive Health Care

Indigenous customary practices and practitioners that support and manage pregnancy, labour, birth, and postpartum periods have sustained Indigenous Peoples on these lands since time immemorial. In fact, their technologies, skills, and medicines were used by white Christian settlers when they first invaded these lands to ensure their own pregnancies were conducted in a safe manner. Over time, the Euro-Canadian biomedical model and its practitioners purposefully marginalized and criminalized Indigenous knowledge and practices. The ability of Indigenous Peoples to determine how to achieve their own health and wellness eventually became—and continues to be—oppressed. Consequently, the health of Indigenous Peoples from a Euro-Canadian lens shows that Indigenous people are less healthy than non-Indigenous people. But, healthcare systems in Canada continue to refuse to see, let alone acknowledge, the harm they have caused to Indigenous Peoples via neglect, refusal of care, and structurally ingrained colonial oppressions.

While the term decolonization has become a buzzword, especially following the Truth and Reconciliation Commission of Canada reports, we advocate for the recognition of colonization in health, which includes education, training, programming, funding, and practice. High-quality, comprehensive gender-inclusive sexual and reproductive health care for Indigenous Peoples can be achieved, but we must first come to terms with the extent to which colonization has purposefully obstructed the health and wellness of Indigenous Peoples.

Canada’s Evacuation Policy for Indigenous Peoples

Beginning in the late 1800s, the Government of Canada decided to introduce European-trained obstetricians to those who live on reserve. Alongside the medicalization of childbirth, the criminalization of Indigenous healthcare practices and practitioners, the immigration of British trained nurse-midwives, and the establishment of Indian hospitals, birthing for Indigenous Peoples shifted from home and community to nursing stations, then Indian hospitals, and now urban hospitals. The federal policy driving this relocation of birth is underpinned by the Government of Canada’s evacuation policy, which requires that pregnant people between 36- and 38-weeks of gestation are relocated to urban settings to await labour and birth. In addition to physically removing pregnant people from their families, communities and pregnancy customs and practices, the evacuation policy results in increased experiences of racism as well as feelings of isolation, fear, distress, sadness, and loneliness, which can lead to post-partum depression.

Canada’s evacuation policy supported “…colonial goals to civilize and assimilate [Indigenous Peoples] into a generic Canadian body.” So, colonial maternity care practices established during a time of aggressive assimilation and civilization tactics, which were implemented and funded by the Government of Canada, have resulted in the current, disjointed approach to maternity care practices for Indigenous Peoples. In fact, evacuation for birth has not resulted in comparable outcomes: the infant mortality rate for Indigenous Peoples in Canada ranges from two to four times that of non-Indigenous people. Clearly, the justification that the evacuation policy improves the maternal and infant outcomes is unfounded. It is thus clear that the Euro-Canadian biomedical model of maternity care must change so that Indigenous Peoples can realize the health and wellness they so deserve.

What’s Next?

Indigenous Peoples’ customary practices and practitioners must be reframed as necessary components of healthcare systems across Canada and globally. The exclusion and even criminalization of Indigenous People who are healthcare providers—like Indigenous Midwives—deliberately creates oppressive barriers to health and wellness for Indigenous Peoples.

It is extremely important to understand colonialism within the historical and contemporary contexts because it globally impacts Indigenous Peoples byways of land destruction, separation from family through colonial training programs (e.g. the Indian Residential School System), and the oppression of Indigenous customary philosophies, values, ways of making knowledge, and kinship relationships.

For those of us with influence in Euro-Canadian healthcare systems, we must work towards the creation of inclusive healthcare that promotes a plurality of knowledge systems, and put these systems and practitioners who provide care for Indigenous Peoples at the forefront of our agendas. We must also contemplate the nature and extent of repairs that are required to bring justice to those who have suffered at the hands of colonial systems.

It is time to acknowledge the ongoing colonial violence in healthcare and dismantle the oppressive cultures that constitute Canadian healthcare systems.

**If this is an issue you are passionate about, consider becoming a supportive member of the National Aboriginal Council of Midwives (NACM) here.**

Here is a list of benefits of a supportive membership from the NACM

Act of reconciliation and allyship
Promote the growth of Indigenous midwifery
Contribute to the improvement of reproductive and child health in Indigenous communities
Receive NACM newsletter

Responses to Anxiety and Depression During Pregnancy Require Funding Say Care Providers

Author: Julia Santana Parrilla, MSc Population & Public Health at the University of British Columbia | Editors: Alex Lukey and Arrthy Thayaparan (Blog Coordinators)

Published: April 23rd, 2021

Perinatal mental health is considered a global public health issue. [17] So, why don’t we talk about it more?

In the Global North, pregnancy care and interventions developed exponentially throughout the twentieth century. [2] The medicalization of pregnancy and childbirth has led to significant innovations in care. It has also problematized the experience in ways that privilege medical expertise and suppress pregnant people’s agency. In the early 1900s, reproduction was commodified as pregnancy supplied the labour force for industrializing societies. [2] Given how babies are produced from our bodies, it is unsurprising that pregnancy was reduced to gestation. Over a century later, these foundations persist in our social imaginations and shape healthcare priority-setting. From research to funding, education to practice, and recommendations to policy, mental health has yet to be integrated in pregnancy care.

Mood and anxiety disorders are the most common types of mental ill-being locally and globally. [6] But, anxiety and depression occur more frequently among women than in men. [6,9,16] This lifetime prevalence is seen across cultures and most often manifests during reproductive years, particularly in times of dramatic hormonal fluctuations, such as during pregnancy and after birth. [10,16] Approximately ⅓ women may experience anxiety symptoms during pregnancy. [19] In British Columbia (BC), up to ⅕ will experience significant depression associated with pregnancy and childbirth. [4]

I dedicated my thesis research to understanding how anxiety and depression are addressed with pregnant people. In BC, people can choose to be cared for throughout pregnancy by a family physician (FP), obstetrician-gynecologist (ObGyn), and/or registered midwife (RM). I interviewed five FPs, four RMs, and three ObGyns practicing in the Lower Mainland to understand their attitudes and perspectives regarding anxiety and depression during pregnancy, those who experience them, and how to address them (identification and management). I perceived providers on the frontlines of pregnancy care to have the power to shape families’ health outcomes and the initiatives and policies that impact them. [13,20] Understanding provider perspectives is the first step in improving our healthcare system’s responsiveness to families’ needs.

Participants reported seeing anxiety and/or depression regularly. Some even expressed expecting to see them given how the journey toward parenthood is a “big change” [RM,7] full of unknowns that can cause much distress and call for psychosocial adjustments. [21,22] As this FP put it:

“[..] the antenatal period is very hard to come to terms with […] there’s just so many changes going on, mentally, physically, emotionally. It’s hard for people to even A: recognize that there is an issue, and B: sort of come to terms or accept that there might be an issue.” [FP,5]

Feeling “[…] sad of the life you left behind, and being anxious of what’s going to happen, being afraid of giving birth […]” [RM,6] was considered natural by most. However, the aggravation of fears by perceived social pressures was a common frustration. As this ObGyn explained:

“[there] is a lot of pressure on women to do everything perfectly during pregnancy and the reality is it can be a lot harder than expected and that the expectation that are created are unrealistic.” [ObGyn,10]

Most participants found that messaging about how to be during pregnancy undermined the capacity for self-compassion essential to cope with unexpected emotions/moods. This requires disruption. As asserted by this FP:

“[…] when society and this culture is telling you so many things about how you have to be as a mom and like there’s so many outside pressures […] what would help? Like, changing that!” [FP,4]

The confluence of this “big life transition” [RM,8] with the stigma that befalls those who are experiencing anything other than the “ideal pregnancy” predicts and worsens anxiety and/or depression. [23] In response, providers centered the normalization of anxiety and depression in encouraging disclosures and supporting management. Often, this involved letting pregnant people know “[…] it’s common” [FP,3], and that they’ll “[…] figure it out together.” [RM,8]

Most participants favoured this approach over-relying on standardized screening tools, such as the Edinburgh Postnatal Depression Scale (EPDS) integrated into their antenatal care forms. [5] This is consistent with previous investigations. [3,7,8,13,14] Many expressed skepticism about the EPDS’ reliability. As an ObGyn with 16 years experience said:

“All of our patients were supposed to be filling it out, but it didn’t seem to be identifying things particularly well for us.” [ObGyn,10]

Some participants reported refraining from using the EPDS due to perceived harms. They expressed worry about isolating people, giving them a stigmatizing label (i.e. mentally ill), and/or triggering the very issues they are trying to identify, prevent, and manage. One RM referred to screening tools as “systems of triggers” [RM,6] adding, “I feel like it is quite isolating, and I feel like it is quite stigmatizing.”[RM,6]

Discussing mental health openly was considered less alienating than using a screening tool. Participants explained how dialogue feels innocuous (safe) whereas tools feel official (intimidating). They considered identification an important first step toward management and supporting healthy pregnancy outcomes. Unfortunately, the stigmatization and complexity of mental health presents challenges in communication. As this RM said:

“one of the things [providers] find challenging is that […] there’s different ways that you can check in with people and people respond very differently to different types of communication.” [RM,8]

Negative perceptions of mental health and reluctance to talk about it mean that there is “[a] fine line between trying to help and offending people” [RM,7]

This is cause for concern given how anxiety and depression during pregnancy often manifest in avoidance of care, poor adherence to recommendations and poor health habits relating to sleep and nutrition. [11,15,18] All exacerbate mental health conditions and risks of poor health outcomes. [4] Providers expressed concern about keeping clients engaged.

Additionally, feeling underprepared and overburdened in supporting pregnant people experiencing anxiety and/or depression was commonplace. All wished they received the systemic support to “make it easier!”[RM,8] beginning with their training. As this RM said:

“[…] perinatal depression is the number one, uh, issue in pregnancy. Not, you know, preeclampsia, and not, you know, whatever, it’s perinatal depression […] and we’re so not educated in it […]” [RM,6]

Even though some may think of mental health as within the scope of their care responsibilities, it is not perceived to be facilitated. Most reported:

“[…] I feel like I try to do my best.” [RM,8] but when “[…] people, resources, money and resources that are… scarce.” [RM,7], “[…] healthcare providers take on a lot of responsibility and a lot of worry.” [FP,1]

Generally, there is a sense of insecurity in the quality of care provided given the lack of mental health integration.

When discussing what would be advantageous to their efforts, many echoed this RM in needing a “multi-pronged approach” [RM,9] that allocates resources to provider capacity, specialist availability, and resource accessibility (affordability and relevance). They emphasized this is our systems’ responsibility and insisted that funding translates to care priority. In this RM’s words:

“[…] the government decides how they’re going to fund us and what they’re going to pay for […] if they don’t put funding into programs to support mental health and wellness, then… then just the programs don’t exist for us to refer people to.” [RM,8]

Simply, we need “[to] build a government that supports mental health care” [FP,1]

To create demand for existing structures to change in favour of integrating mental health, we need to think about who has the power to stimulate adaptations by the healthcare system. While I entered this project assuming primary care providers had this power, participants identified that the changes need to happen upstream where the money comes from. It is with sincere alignment with participants that I assert the need to fund perinatal mental health research, training, and care. When perinatal mental health is not represented in priority-setting and decision-making documents and spaces, it minimizes the urgency of the issue, trivializes avoidable adverse health outcomes, and erases the people (and families; communities) experiencing them.

The World Health Organization and the United Nations Population Fund have jointly decreed there can be “no health without mental health”. Perinatal Services British Columbia recognizes that early detection of mental health challenges before, during and after pregnancy offers opportunities to improve health outcomes for parents and families. [5] Mental health promotion, prevention and early intervention show positive investment on returns. [12] Our Ministry and health authorities are responsible for making mental health services available and accessible, from prevention to management. [24]

Far more than producers of the next generation/s, pregnant people’s care should not be exclusive to physiology and babies’ gestation. To care for populations equitably, we must recognize how the erasure of complexity in people’s experiences perpetuate health and social inequities. We must make room for the experiences that are silenced, erased, and stigmatized to be demystified and supported.

Disclaimer: To meaningfully address perinatal mental health disparities, all pregnancy experiences within our colonial, cisgender, ableist, hetero-patriarchy must be accounted for.

Bibliography

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Photo by Janko Ferlič on Unsplash

Behind the Science with Bonnie Lee

Authors: Arrthy Thayaparan and Alex Lukey (Blog Coordinators) Interviewing: Bonnie Lee, PhD Student, UBC

Published: December 25th, 2020

At the Women’s Health Research Cluster, we strive to close the gaps in communication and knowledge between the public and scientific community. As such, our newest blog series, Behind the Science, will take a sneak peek into the world of science through a series of interviews with some amazing women’s health researchers. We hope that this series will spark interest in the general public and young students by understanding the journeys of these researchers

So we’re starting off with a BANG and introducing our very first interviewee! She is a future leader in the study of women’s health and a beloved colleague of the WHRC team. As a graduate neuroscience researcher at UBC, her work primarily looks at the impacts of motherhood and Alzheimer’s on cognition and the ageing brain.

If that didn’t make any sense to you, then not to worry! The following interview will simplify the research, whilst also breaking down misconceptions of the research field. Without furtherado, it is our pleasure to introduce Bonnie Lee…

How did you become interested in women’s health research?

So I guess I first became interested in women’s health research when, in my undergrad, I realized that none of my courses really talked about sex differences. Like how different phenomena that we’re studying may be different, or even the same in males or females. It’s kind of been ignored or glossed over.

During undergrad, I was working on a research project that looked at sex differences in the relationship between stress and neurogenesis. That’s kind of how I stumbled into the world of sex differences. Then in my fourth year, I took a course with Dr. Liisa Galea on neuroplasticity. She brought up a lot of interesting ideas about sex differences and women’s health, which really opened my mind and got me fascinated about women’s health research.

Then, of course, later on, being part of Liisa’s lab as a grad student even furthered my interest as I learned more about the intricacies and nuances of women’s health research.

Why do you think we need to focus on women’s health?

Well, I think just the woman’s lifespan is so interesting. From the menstrual cycle to pregnancy and motherhood to menopause — there is so much we have yet to learn about these life events. Even besides that, so many diseases are more prevalent or more severe in females. There’s so much we don’t know about those topics.

We all know someone who gave birth — like your mom, for example. So the fact that we don’t know much about [women’s health], it’s just crazy. Speaking of diseases that are more prevalent in females, my research is focused on Alzheimer’s disease. It is known that females have a greater lifetime risk of Alzheimer’s disease, but more intriguing to me is the fact that pregnancy and motherhood play an interesting role in the manifestation of the disease — with earlier onset, more severe pathology in the brain, and so on, in women with previous reproductive experience. It makes me wonder, why is that? And I think it’s not just about women’s health, right? The fact that we are able to learn something about why it’s more prevalent in females will tell us more about the disease in general. We’ll know more about different treatment options. So it’s not just going to benefit women, it’s going to benefit everyone, including men.

How did you decide to research Alzheimer’s, like in the scope of all possible diseases?

I was always interested in Alzheimer’s disease. A little personal background, I used to volunteer in a senior home where I played piano for them every weekend. I became really close to a senior who had Alzheimer’s disease. I guess that kind of put a seed in my brain and made me want to learn more about the disease.

I think a lot of people can relate because it is a really prevalent disease — many have family members or friends who might have been diagnosed with Alzheimer’s or experienced taking care of someone with Alzheimer’s disease. When I realized all the sex differences and long-term effects of pregnancy and motherhood in relation to Alzheimer’s disease, I think that’s when I really felt like this is something I want to dive deeper into and try to figure out why.

So, what drew you to neuroscience and to study the impacts on motherhood, especially?

So this goes all the way back to first year. In my first year, we had something called Imagine Day at UBC. My leader was actually a neuroscience major. I never knew that you could major in neuroscience at UBC! When I first got in, I thought “Okay, I’m going to be in science, I’m going to learn either chemistry or biology or physics.” I was actually interested in psychology, too, though, in high school. I always wanted to learn more about the brain so after finding out there’s a major for that, it was no brainer for me [pun intended]. So I did my undergrad in neuroscience, and then the rest is history.

How would you explain your research if you were explaining it to a second-grader?

So Alzheimer’s disease is a brain disorder that impairs cognition and your brain. I am interested in looking at females who were either pregnant or not pregnant, and then how Alzheimer’s disease affects their brain and their cognition in middle age.

Do you have any early findings? Or any interesting leads yet?

Yeah, we do. But it’s a bit more complicated, so it’s not going to be for the second-grader. We found some differences that have to do with the APOE epsilon 4 (APOEe4) allele, which is a genetic risk factor for late-onset sporadic Alzheimer’s disease.

The rats that had the genetic risk for Alzheimer’s disease made more errors in the spatial working memory task compared to healthy wildtype rats – which is what we expected to find. What’s interesting is that there were differences in search strategies in the memory task between groups of rats that had been pregnant vs never pregnant. Basically, the rats that had been pregnant before were less efficient than rats that had never been pregnant before. This shows the long-term effects that pregnancy can have on the brain, which is always exciting to see. We also found differences in neurogenesis and neuroinflammation measures between the groups. APOEe4 rats (the rats that had the genetic risk) had more neural stem cells but fewer new neurons in the brain compared to wildtypes — suggesting that perhaps their neural stem cells weren’t very active in the sense that they didn’t become new neurons, or maybe they became something else, like astrocytes or other neural stem cells. On the other hand, rats that had been pregnant saw the opposite effect: they had fewer neural stem cells but more new neurons compared to rats that had never been pregnant. This could mean that rats that had been pregnant had neural stem cells that were really active and were able to become new neurons. I won’t go into any more detail here, but if anyone has any follow-up questions or anything, they can email me anytime [bonnie_lee@psych.ubc.ca].

So, what stage of research are you in right now?

So my first chapter, I guess, my first big experiment has been done. I am dealing with brain samples now and processing the tissue to finish up analyses of different measures. Specifically, I have been looking at measures of neurogenesis, neuroinflammation, and a little bit of tryptophan metabolomics as well. So just finishing up those analyses. I am hoping to start my next chapter in January, where we will be looking closer at sex differences this time and differences between rats with either APOEe3 or APOEe4.

What makes you excited about the future in women’s health research?

I think things like the Woman’s Health Research Cluster. The WHRC is helping diverse and multidisciplinary trainees and researchers find each other and collaborate on new projects, which is really exciting. I am looking forward to seeing what kind of research comes out of those collaborations.

I am also really hopeful about the fact that the cluster is targeting a wide audience. We don’t just involve trainees and researchers, but also policymakers, patient partners, health practitioners … getting the public involved and making them aware that women’s health is important. I think that is a huge step and an important one.

Practicing knowledge translation in science is still new to me. But I think it’s so important because you could be doing all this work, but we need people to be aware of the work so it can be applied appropriately. And that way, your research becomes more meaningful, I think.

After talking about your journey, do you have any advice for people just starting or interested in research?

Practically speaking, I would say, do your research. Look into different topics that you might be interested in, but also different researchers and their body of work. Try talking to graduate students and early-career professors. For me, at least, talking to different people and getting their perspective has been very insightful.

Before I started, I used to think, “[research] is so boring, I would never want to do this.” But, as I started to talk to more principal investigators and graduate students, and as I started to become involved in labs as a volunteer, I began to realize what it’s really to be in research, and I began to really like it! So I would suggest talking to people, keeping an open mind, and find ways to get involved in research early on.

Is there something that people can look forward to coming from you in the future?

I do have a chapter that should be published soon. It is a chapter on the sex differences in neurogenesis and the implications for Alzheimer’s disease, and I wrote it with another member of my lab and the research cluster, Tanvi Puri as well as Dr. Liisa Galea. Yeah, I guess other than that, just more experiments and hoping to publish more papers soon!

Alex and Arrthy (Women’s Health Blog Coordinators) would like to thank Bonnie for taking the time for this interview. To our readers: keep an eye out for more blogs and interviews! If you would like to be featured, please don’t hesitate to reach out to us at womenshealth.blog@ubc.ca!

Pregnancy and Mental Health: New Research Paves the Way for Better Treatment

Authors: Wansu Qiu (Ph.D. candidate), Liisa A.M. Galea (PhD, Graduate Program in Neuroscience, Department of Psychology. Djavad Mowafaghian Centre for Brain Health, University of British Columbia) & Katherine Moore (Adv. Dip., BA)

Pregnancy and postpartum are two periods in a person’s lifetime that cause major changes to the body and brain. Anyone who has been pregnant will no doubt be fully aware of the dramatic changes to their bodies. But what is perhaps less well known is that there are also changes that occur in the brain. Indeed, you may be familiar with the term “baby brain” or “maternal amnesia”. These terms are often used in a derogatory way towards new parents, but people need to be aware that changes to the brain do occur and can have a significant impact on mental health.

Unfortunately, many of the natural brain changes that occur during pregnancy and the postpartum period are similar to what we see in people with major depression. These changes include, but are not limited to, reductions in brain volume, increased inflammation, hormonal profile changes, and metabolism changes. So, it is natural to wonder whether and how these natural changes contribute to greater susceptibility to depression during pregnancy or the postpartum.

It turns out that the perinatal period (pregnancy and the postpartum) is a particular time of risk to develop depression. Perinatal depression is defined as depression that occurs during pregnancy or in the first few months following childbirth and affects approximately 15% of new parents. However, not all people that experience perinatal depression develop symptoms at the same time or have the same symptoms. For example, the majority of people with perinatal depression experienced depression at least once before their pregnancy. However, 40% of people with perinatal depression experienced depression for the first time in their lives in the early postpartum period. Unfortunately, research has typically not separated findings according to when depression starts. This is problematic because knowing when depressive symptoms begin can help us determine the cause of depression (etiology), as well as how to properly treat it. In fact, studies that separate findings by depression onset (e.g. during pregnancy versus postpartum) and include whether there was a previous history of depression, show that the success of antidepressants vary depending on these factors. Thus, the distinct biological changes between pregnancy and postpartum may be the reason why drug effectiveness changes during these periods.

Yet, very little research exists on the connection between these biological mechanisms, depression that starts during the perinatal period and treatment efficacy. Our lack of understanding is partially due to the misidentification of perinatal depression as just another form of major depression. This issue stems from the fact that current diagnostic manuals, such as the DSM-V, do not distinguish between depression onset during pregnancy versus depression onset during postpartum. Furthermore, they only consider depression occurring in the first four weeks after birth as the postpartum period, when in fact many distinct physiological changes occur well into the first year of motherhood that may impact depression susceptibility. Considering the large number of people that live with postpartum depression, but whom have never experienced depression before, it is pertinent to determine why this period has such a high risk for depression onset. Even more troubling, antidepressant treatments may be less effective when treating perinatal depression compared to treating depression at other times. Indeed, the effectiveness of antidepressants is even worse in the postpartum period compared to other periods of pregnancy such as preconception.

Sadly, pregnant and postpartum people are not often studied and are left out of clinical trials. The lack of females in research is troubling enough given the greater number of pharmaceutical side effects they experience and misdiagnosis they receive compared to men. This is compounded by the lack of data on the safety and efficacy of drugs during the perinatal period. Interestingly, there has been a surge in preclinical animal models of perinatal depression over the last 20 years. These studies have also shown that antidepressants are less effective when depression onset is during the postpartum. Specifically, using a preclinical model of first-time postpartum depression onset, researchers found that high stress hormone levels cause depressive-like symptoms including passive coping, reduced maternal care (e.g. more time spent away from the nest) and decreased plasticity in the hippocampus. Interestingly, the hippocampus is an area of the brain that is affected by depression in human populations too. In a series of studies, researchers also found that a common antidepressant, fluoxetine (Prozac), shows limited effectiveness in treating these symptoms in the postpartum. This mirrors previous findings in humans on antidepressant use during postpartum. Astonishingly, they found that fluoxetine reversed the decrease in maternal care behaviour in the early postpartum but did not reverse depressive symptoms (e.g. brain changes, passive coping) in the later postpartum, suggesting that fluoxetine may lose its effectiveness over time.

In a recent article, cluster member (Wansu Qiu: @WQiuPhoenix) wanted to understand what mechanisms or biomarkers may be limiting the efficacy of fluoxetine in the postpartum. Using this same preclinical model, Qiu and colleagues discovered that inflammation and metabolism may play a role in the lack of antidepressant efficacy during the postpartum in females. Inflammation is important to examine because depression has been linked to increase inflammatory signalling and antidepressant effectiveness has been linked to decreased inflammatory signalling. Fluoxetine treatment in the postpartum increased a proinflammatory signal, IL-1β (a cytokine), in the hippocampus and decreased tryptophan concentrations. This is notable as fluoxetine usually decreases cytokines when it reverses symptoms, and decreased tryptophan is often found in depression in females. More alarmingly, they found that the effects of fluoxetine were still present when rat moms were given a high dose. Thus, the authors suggest that the lack of treatment efficacy is not due to how antidepressants are metabolized in the maternal body, but due to changes in drug action on inflammation and metabolism. Overall, these new findings suggest that the lack of effectiveness of fluoxetine to reverse symptoms in the postpartum may be related to tryptophan metabolism, possibly acting via inflammation in rodent moms. This new research can lead to a better understanding of postpartum depression and antidepressant efficacy, possibly paving new ways for better treatment options.

The bottom line: scientists need more research funding to study the distinct presentations of perinatal depression (pregnancy onset versus postpartum onset) and we need more researchers to take on these kinds of projects. Clinicians need to be on the lookout for perinatal mood disorders, and we need governments to develop a national strategy for perinatal mental health. As a society, we all need to support people not just during pregnancy but also in the postpartum—as they say, it takes a village.