The pill is not the only answer

by Dr. Perle Feldman

Often when I ask women about contraception they will say “Oh I don’t use any birth control”. This surprises me because I know that these women are not planning pregnancies. What they mean is that they are not taking the pill, they are using other methods, such as condoms, withdrawal and rhythm, or breastfeeding as contraception. When I went to medical school we were taught that these methods were unreliable and undesirable. Women were encouraged to use what I now call “Doctor Centered” methods such as pills, Intrauterine devices and injections. While these methods have lower failure rates they are often unacceptable to women for a variety of reasons. The other more “free access” methods may have an inherently higher risk of pregnancy but for many they are the method, which suits the couple best, under the circumstances. What the alternative methods of contraception have in common is the need for a certain amount of skill and commitment in their use; thus they are often best for people in committed relationships for whom an unplanned pregnancy could be tolerated. In terms of risk to the life and health of the woman the best methods of birth control are conscientious use of a barrier method such as condom or diaphragm backed up with emergency contraception or early abortion. The average woman using these methods for her whole reproductive lifetime will have 2 unplanned pregnancies. The risk of pregnancy with any method of contraception decreases with the length of use, most unplanned pregnancies occurring in the first year.

To have reasonable success with alternative methods you have to use them properly. Let’s take breastfeeding. This is probably the most common method used by women around the world to space their pregnancies. Women who are not breastfeeding will have their first ovulation and be fertile as early as 3 weeks after giving birth. Several studies have demonstrated that if three criteria are fulfilled breastfeeding can be 98% effective: You must have the baby be completely or almost completely breastfed, on demand. The baby must be less than 6 months old and the mother should not yet have had a menstrual period. If any of these conditions are not met the risk of pregnancy increases.

The only male methods of contraception are included in the high skill, high motivation list. The most common male method, used around the world, is withdrawal. This is a method that is often quite ineffective with failure rates of up to 40% in the first year of use. However, skilled practitioners of this art, the “Servitore del Donna” as they used to be called in 17th Century Italy, can achieve rates close to that of the barrier methods, 4-5% failures. The problem with this method is that the man must be able to anticipate his ejaculation and withdraw far away from the woman’s vagina just at the moment when millions of years of evolution are urging him forward.

Condoms, which were completely out of favor in the late 60’s and early 70’s, are now of course, the method of choice for everyone who is not in a long-term committed relationship. Even people who are using other methods of contraception should probably continue to use condoms as well, until they are ready to commit to monogamy and perhaps until they are ready to have a first child. To be really safe the condom must be on during all genital contact, not just for that final moment of glory. It must be completely unrolled, and a little pinch must be pulled up at the end. After ejaculation the man must remove himself from danger immediately, holding on to prevent slippage. Latex condoms, used properly have a 3-5% failure rate. For those among you who are latex allergic there are natural membrane condoms such as “Fourex” and Naturalamb, which some people find more pleasant to use. These condoms are not proven protective, however, against the HIV virus.

If the condom is too small it causes a peculiar and unpleasant feeling during ejaculation; if it is too big it may slip during intercourse. Look around and experiment. Condoms come in a variety of shapes thickness and sizes, except small. Never in the history of mankind has a condom been marketed as being small; look for “slim”. Remember not to use oil based creams as lubricants with condoms, such as Vaseline or hand creams as they will melt the barrier.

Vaginal barrier methods, such as the female condom, the sponge, the cervical cap and the diaphragm are also useful methods of contraception for the right woman. Only the diaphragm is widely available in Montreal at this time. The diaphragm is basically a device for holding spermacide in place during intercourse. It must be fitted by a physician; proper use must be taught to the woman. The diaphragm must be refitted if the woman gains or loses more than 15 pounds or after pregnancy.

The main problem with barrier methods is that they never work when they are in the drawer. Since they must be used during every act of intercourse the temptation is always to use them next time, or later. This is the most common reason why these methods often slip up. There are of course method failures where the diaphragm slips or the condom breaks. The failure rate also increases with the number of acts of intercourse and these methods may not be appropriate as the only protection for people having sex more than 3 times a week.

One of the nice things about condoms, as opposed to the diaphragm, is that when they fail you can usually tell. If this happens you can get emergency contraception. The “morning after pill” which is available at almost all clinics and emergency rooms should be taken as soon as possible up to 72 hours later. IUD insertion may be effective up to 5 days after the slip-up. Immediate insertion of an nonoxyl-9 containing spermicide cream may decrease the risk of HIV transmission to the woman.

No discussion of alternative contraception is complete without talking about the various ways of using fertility awareness, the venerable “rhythm methods”. In this method women map their menstrual cycles and become aware of when they are ovulating. Remember that the first half of the cycle is more variable. A woman almost always gets her period 14 days after ovulation. Thus this method is best for women whose cycles are very stable. Many methods then use other ovulation predictors, such as the quality of the cervical mucous to help define the fertile period. Intercourse during the fertile period is avoided, replaced with other sexual activities or protected with another method of birth control. This method places a lot of emphasis on good couple relations and cooperation. It involves discipline and planning. The failure rate is quite variable, ranging from 3-9% in highly motivated, trained couples to a 25% failure rate among typical sloppy users. The Catholic Church offers training in the symptothermal or Serena method; the most highly effective form of this contraceptive. One of the advantages of this method is that it can be useful when couples are ready to conceive. They just use it in reverse.

The main thing in common among these alternate methods of contraception is that they are more the responsibility of the people using them. They are not methods put in place by doctors requiring little thought and motivation. They each have advantages and disadvantages. For many, if not most people the Birth control pill, the IUD or Depo Provera are simple and effective methods. But they do not suit everyone. Alternative methods are often cheap, accessible and “natural”, but they demand motivation and commitment on the part of their users.

The 18 Month Postpartum Marital Disaster Area

by Dr. Perle Feldman

The most important determinant of child health in Canada is poverty, and one of the most important determinants of poverty is the growth of single parent families and family breakdown. Yet there has been very little emphasis in family medicine research and teaching on those factors which physicians can employ to help couples stay together. I believe there is a simple anticipatory guidance strategy, which can help couples at one important developmental stage in their marriage. This stage I call the Eighteen Month Post-Partum Marital Disaster Area.

Somewhere between 1-2 years after the birth of their first baby, patients who have been previously happy and functioning couples come into the office with a complete dissatisfaction with their marital relationship. Statistically, 2 years after the birth of the first child is a peak in marital breakups and divorce.

What is happening here? How can couples who were so in love turn to enemies or strangers after the birth of their much beloved child? There are many reasons. Firstly, having a baby is a huge change in the dynamics of a relationship. Once the child is born many of the couple’s affilative and dependency needs shift in balance.

Sexuality also changes after childbirth. When a couple has only themselves to please, opportunity for intimacy and privacy for intercourse are practically unlimited and spontaneity is the norm. Once the baby is born sleep deprivation is a huge issue. There are also postpartum physical changes making intercourse painful. Many women are shy to ask their physicians for help unless directly questioned. This sets up a situation where intimacy may be avoided

Many men, being initially rebuffed, do not want to risk rejection by approaching their wife again. Some men are turned off by the changes in their partners’ bodies after pregnancy; some men have psychological issues with the change of roles. However, far more women feel ugly and unlovable, with their birth scarred bodies. This leads to a decrease in sexual activity in the couple and a decrease in intimacy and satisfaction.

Suddenly, at around a year or eighteen months a couple looks at each other and tries to remember who they are. It takes a year of hard work, to get through the demands and stresses of a new baby. It is only once that year is over, the baby sleeping more or less through the night, the physical problems resolved that people have the leisure to re-examine their marital relationship.

It is useful for the physician to reassure couples that this is a normal developmental stage and to suggest some strategies to deal with it. I find the 12 month and 18 month baby check up an ideal time to broach the subject of marital satisfaction.

At this stage it is very helpful to devote a little time each week for marital maintenance, to give the marriage as an entity a little quality time. It is important for any couple to have some time alone with each other, to think of themselves as a couple. This is often difficult to arrange. One suggestion is to have a standing babysitter for an evening every 1-2 weeks.

Another useful suggestion is to encourage couples to plan their intimacy in advance. While it seems a little cold blooded to pencil in time for intercourse for many young parents that is the only way it is going to happen. You can call the arranging, verbal foreplay.

It is important to encourage parents to believe that a good couple relationship takes work and dedication. A marital relationship saved is an important determinant of the future health of all members of the family, particularly the children.

References:

The Transition to Parenthood: How a First Child Changes a Marriage 
Jay Belsky, Ph.d. & John Kelly 
Delacorte Press, 1994

Patterns of marital change during the early childhood years: Parent personality, coparenting and division of labour correlates. 
Belsky,Jay; Hsieh, Kuang-Hua, 
Journal of Family Psychology. Vol 12(4), Dec 1998, 511-528.

Joint custody of infants and toddlers 
Fay, Robert E. 
Medical Aspects of Human Sexuality. Vol 19(8) Aug 1985, 134-39

Postpartum Depression

By Elizabeth Pantley, author of Gentle Baby Care and The No-Cry Sleep Solution

QUESTION: I know that it’s normal to have the “baby blues” right after you have a baby, but my son is six weeks old. I thought everything would be wonderful by now and I would be so in love with my baby. I thought mothering would come easily. It’s not that way at all! I can’t sleep, even when he’s sleeping. I feel hollow inside, like the real me is gone. Sometimes I cry for hours; other times, I feel angry enough to explode. Life feels like an endless amusement park ride, and sometimes I just want to get off. Why am I such a terrible mother?

Learn about it

You’re not a terrible mother! You are a mother who is suffering from a condition known as postpartum depression, a condition that is treatable. While as many as 80% of mothers experience a temporary and mild condition referred to as the baby blues, up to 15% of women have the more severe reaction you’re experiencing. Having PPD doesn’t mean that you have done something wrong, or that something is wrong with you; it is an illness and it can be cured. Once you learn more about what’s causing your despondent emotions and take some steps toward treatment, you’ll be on the road to finding yourself again and enjoying your baby.

What is postpartum depression?

PPD is a medical condition - a specific type of depression that occurs within the first few months after childbirth. It is caused by the biochemical and hormonal changes that happen in the body after pregnancy and birth ... nothing that is within your control.

What are the symptoms of postpartum depression?

While PPD affects all women differently, a few typical symptoms can help your physician make the diagnosis. You probably are not experiencing everything on the following list, and the degree of symptoms may range from mild to severe, but if a number of these apply to you, you may be suffering from PPD.

Symptoms of postpartum depression may include but are not limited to:

If you suffer from extreme degrees of any of these symptoms, particularly thoughts about hurting yourself or your baby, or if you have additional physical symptoms such as hallucinations, confusion or paranoia, then please call a doctor today. NOW. Your condition requires immediate medical care. If you can’t make the call, then please talk to your partner, your mother or father, a sibling or close friend and ask them to help you arrange for help. Do this for yourself and for your baby. If you can’t talk about it, rip this page out and hand it to someone close to you. It’s that important. You do not have to feel this way.

What can a doctor do about postpartum depression?

As with any form of depression, help is available and only as far away as your healthcare provider - contact your ob/gyn or midwife to start with, if that’s most comfortable for you. She can help you get the professional care you need from someone who has experience dealing with this condition. In the longer term, it’s important that your therapy take place with a professional who has experience in treating PPD; the malady is different from other forms of depression, and it is very specifically related to your role as a new mother.

PARENT TIP

“In the time it takes you to read this chapter, you could set up an appointment with a doctor. Remember, this is a medical problem and it can be serious; for your sake, for your baby, and for all those who love you, you must make that call. With help, you will regain your life and your perspective.”

Vanessa,
mother of Kimmy (12) Tyler (10) Rachel (5) and Zachary (3)

A visit to a doctor for the symptoms you’re feeling is nothing to fear. Your condition is something your doctor has seen before - so you need not feel at all self-conscious. As for treatment, there are a variety of options, depending on how severe your symptoms are. Your doctor will evaluate your condition and may suggest medication, such as antidepressants. (Make sure that you let him know if you are breastfeeding so that the proper medication can be prescribed.) In addition, he will tell you that therapy and support are critical for recovery.

What can I do about PPD?

The first step you can take is to understand that you have an illness that requires action on your part so you can heal. Forgive me for repeating this, but it is important: Take that first step and call a doctor. In addition, the following things can help you begin to feel better right away:

Talk to someone.

Whom do you trust? Whom do you feel comfortable talking to? This might be your spouse or partner, it might be your mother, your sister or brother or a friend. It can really help to share your feelings with someone who cares about you. Even if you feel you can’t talk specifically about PPD, just discuss your feelings and your new role as a mother and its effects on you.

Read books about baby care and parenting.

Knowledge is power. Reading may help you feel more confident, which in turn will help you feel more in control of your situation. It will also give you the knowledge you’ll need to ward off the unwanted advice or criticism that can come your way during the early months of parenting, and that can be especially hard to take when you are feeling depressed.

Join a support group.

PPD support groups allow mothers who are dealing with depression to talk with others who have similar feelings. A list at the end of this section can help you find a group in your area. You might also call your health care provider, your local hospital, or your church for information. While PPD support groups are an excellent choice, any group for new mothers in which you can share your feelings about motherhood can help you feel better about yourself. Choose your support group with care, as you’ll want to be around people who support your parenting decisions. Being with a group who criticizes or questions your mothering choices will make you feel worse, not better. Conversely, spending your time with like-minded people will boost your self-confidence and help you feel more confident as a mother. This idea shouldn’t be seen s a cure, but rather one part of the process of recovery.

Accept help from others.

If anyone offers to help you - whether it is to take your baby for a walk, cook a meal, or drive your older kids to sports practice - accept! Learn to say yes. You don’t have to do everything to be a good mother. It’s natural for human beings to lean on each other, so go ahead and do a little more leaning.

Get some extra sleep.

Put your efforts to get your baby to sleep through the night on hold right now; this will come in time. Forget about the clock. Just sleep - both of you - whenever you can. Extra sleep will help you feel better.

Relax your standards.

This is not the time to worry about a spotless house, gourmet meals, the corporate ladder, or your manicure. Try to stick to the basics and concentrate on yourself and your baby.

Get some fresh air.

When possible, put your baby in the sling or the stroller and take a walk. The exercise and open spaces will help you feel more energized. Try to work a daily stroll into your schedule. If you have older children, walk them to school. If the weather isn’t suitable for outdoor walking, then drive to a shopping mall for an indoor walk.

Feed yourself healthy foods.

You can eat properly without much effort. Focus on fresh fruits and vegetables, and simple but nutritious meals. And eat frequently. Going long stretches without food wreaks havoc on your system. Simple snacks like an apple with peanut butter, a bagel, or yogurt with cottage cheese are easy to prepare and prevent your blood sugar from dipping and adding to your feelings of depression. Continue to take vitamins, and drink plenty of water.

Love yourself.

You are going to be okay. Take it one step at a time ... but do take steps (such as those outlined in this section). With help and time, you’ll develop a refreshing and healthy outlook on your new role as a mother.

For more information

Books

This Isn’t What I Expected: Overcoming Postpartum Depression 
by Karen Kleiman and Valerie Davis Raskin (Bantam Books, 1994)

Beyond the Blues, A Guide to Understanding and Treating Prenatal and Postpartum Depression 
Beyond the Blues contains the most recent information for women who suffer with mood and dpression during and after pregnancy. 
by Shoshana Bennett and Pec Indman (Moodswings Press, 2006)

Más Allá de la Melancolía 
contiene la información más reciente para las mujeres que sufren de problemas temperamentales y depresivos durante y despúes del embarazo. 
by Shoshana Bennett and Pec Indman (Moodswings Press, 2006)

The No-Cry Sleep Solution: Gentle Ways to Help Your Baby Sleep Through the Night 
by Elizabeth Pantley (McGraw-Hill, 2002)

Web sites

Pacific Post Partum Support Society

To locate a support group

Postpartum Support International

Postpartum Education for Parents

La Leche League Support Groups

This article is a copyrighted excerpt from Gentle Baby Care by Elizabeth Pantley. (McGraw-Hill, 2003)