Beyond “Baby Blues”

The first documented case of postpartum mental illness occurred in 400 BCE, when a woman who had recently given birth presented to Hippocrates as delusional and confused before ultimately dying. Later, a medieval gynecologist reportedly proffered “too much moisture in the womb, causing the brain to fill with water” as an explanation for this condition. By the nineteenth century, what was then called “puerperal insanity” had morphed into a legitimate psychiatric problem, according to doctors at the time, with debated causes ranging from anemia to a “peculiar irritation of the uterus.” It was only relatively recently, during the postwar era, that “baby blues” became an umbrella term for all postpartum mental health issues, deviating from the focus on psychosis in earlier recorded history. During the “baby blues” era, it wasn’t uncommon for psychiatrists to posit that a new mother’s despair was the result of a flawed personality or repressed lesbianism.

In the 1980s and 1990s, activists were determined to ditch the dismissive and demeaning “baby blues” lingo. They eventually settled on the term postpartum depression to encompass the various debilitating changes in mood that can occur after giving birth. The label incorporated multiple forms of mental illness: not just depression but also anxiety, OCD, and in rarer cases, psychosis. In Blue: A History of Postpartum Depression in America Rachel Louise Moran, an associate professor of history at the University of North Texas, explores how this catchall language came to be. Her book tells the story of the activists who fought for the suffering of those experiencing postpartum mental illness to be recognized and made legible to legal and medical authorities. Moran and I spoke about Blue over Zoom earlier this month. Our conversation has been condensed and edited for clarity.

—Jess McAllen

Jess McAllen: At the start of Blue, you write that you initially thought you’d be compelled to go deeper into the advocacy around the pathology and medicalization of pregnancy. How did your thesis change as you researched the book?

RLM: A major conversation within the history and sociology of medicine is this idea of medicalization. How did we get to this point, especially around issues of depression and anxiety, where we considered them medical problems, clinical problems, instead of social problems? I just assumed that would be the conversation. There is some literature that talks about how postpartum depression is this moment where we’ve medicalized distress, and it should all be political, right?

It’s an obvious sign of a lack of social support, a lack of parental leave, a lack of extended village communities. But we have, at some point, decided this is an emotional problem to be medicated with Prozac. So, there’s that discourse. And I assumed I’d challenge it a little because I find that actually pretty dismissive and condescending to women’s actual experience of postpartum distress. But I assumed, yeah, there’s gotta be a grain of truth to that too. 

So, I did the march toward medicalization story, but it had no humans in it. I was like, “How can I write a book about women’s suffering and women’s resistance to their suffering and not have it be about real women?” I eventually got some grant money and learned how to do oral history. 

JM: I see a lot of parallels between the problem you’re describing and the discussions going on in 2024 in the general mental health advocacy world, where it’s very popular to be anti-medication, but some of the people promoting this idea don’t necessarily talk to people with lived experience of mental illness. Talking about your own experience of being medicated while pregnant was an interesting way to start the book.

RLM: Yeah, I start it with the story of me saying, “I do not want to be on medication, I’m going to be an A+ pregnant person,” and my psychiatrist at the time, who could have been from central casting for an old man psychiatrist, was like “no.” I just thought that was so condescending, but that’s not actually where he was coming from. He was coming from this place of, “It will help you, not that you are sick or you will be sick, but with a lack of other resources, medication can be a very real option.” I think it’s appropriate for us to ask lots of questions about how we got to this stage. When new medications come out, we should ask questions about how they’re framed and what comes with a prescription. But it doesn’t mean there’s no value in medication, or that people shouldn’t take it seriously.

JM: You noted that you had sort of pushed yourself aside in a way, when you were having that conversation with your psychiatrist.

RLM: Right, it was that idea that is very common in pregnancy: I will be selfless, everything is about the fetus now, everything is about the baby now. Which is wild. I have a PhD in women’s studies! Just about every pregnancy book, even the ones that are critical, are still books entirely about what you should do now that you’re a pregnant person. There’s just this assumption that you’re going to change everything in your life to have a new focus. Figuring out what it means to have balance is really important in the larger conversation about mental health. 

JM: The historical research seems to show that societal concern about postpartum distress initially was focused on psychosis many centuries ago, which in the mid-twentieth century morphed into the dismissive concept of “baby blues.” Then, in the 1980s, advocates made a very concrete decision to focus specifically on postpartum depression.

RLM: This is what is so interesting about history, so many things we take as natural are very contingent. It was never a foregone conclusion that postpartum psychosis and postpartum depression would have the same advocacy groups, treatment centers, or the same plans. Some folks absolutely have experienced both, but also many of the symptoms are not overlapping; they are quite different.

It’s more complicated now that we have this whole constellation of perinatal illnesses, which often do have overlapping symptoms. It wasn’t a foregone conclusion that things would fit together, but it ended up making sense. [Postpartum psychosis activists] have made a lot of progress, I should say. I think they are very close to getting postpartum psychosis in the next revision of the DSM. I’m not sure if they’ll have it or not, but the postpartum psychosis people have been fighting a very long time, especially for legal reasons. 

Postpartum psychosis was often attention-getting, in the way that advocates could use it strategically when they had to. At the same time, you’re not going to make a mass movement, or reach a mass audience of women with postpartum psychosis, because the numbers are still quite small, and it’s quite rare. Very serious, but very rare. But the numbers of women with postpartum depression, anxiety, and different versions of OCD and PTSD: that’s a lot. So, there’s this tension between the two, but also they end up needing each other in this political context. 

JM: I think that tension is part of the wider mental health situation, generally. I wonder if, following that train of thought, it’s now more accepted to have postpartum depression than general depression? Because of the historical advocacy, you might argue that society now sort of sees postpartum depression as this thing that is very important—people are sacrificing themselves and then get depression from this beautiful thing where they’ve created a baby.

RLM: It’s so complicated because context matters so much. There’s lots of conflation around postpartum depression and postpartum psychosis. Postpartum depression, which I continue to use for research, is really the vernacular term we use. It’s the word we all use for each other, but it is also very much the language of the 1980s, 1990s, early 2000s. Sometimes the conflation [of depression] with psychosis means that there’s only certain times that we hear about postpartum mental illness. And one of those times is infanticide, occasionally it’s suicide.

When those moments come up, it feeds into these killer mom tropes, and true crime sensationalism, I think tainting all of it, for everyone. I hear this a lot with the Andrea Yates case from the early 2000s, this idea that every time postpartum depression was in the news, it was tied immediately back to this woman who had killed all her children. The fear that you might kill your children is very common, but the chances you will act on that is extremely, extremely rare. But because of that, people are afraid to admit their intrusive thoughts. Because how are they not just one step away from being the killer mom? 

JM: And potentially having their kids taken away.

RLM: It’s very hard. On that hand, I think there can still be incredible stigma. On the other hand, I do think some of the framing of postpartum depression has been incredibly successful. [Advocates] did a lot of work to navigate the political climate they were in during the 1980s and 1990s, where politics around motherhood, working motherhood, and abortion were all very, very toxic. And these advocates wanted their [issue] to be seen as separate. So, they did a lot of work for that. And some of the payoff has been in having an incredible medical framework, and lots of medical partnerships from the very start with thoughtful medical professionals. 

I think there is some of the language of sacrifice you’re talking about, but then there’s also the real language of temporariness too. It’s not like being a depressed person, where you might be battling it forever. There’s this idea of postpartum illness as a thing that will happen within a year postpartum, or in the official language, six weeks postpartum. And then you will be restored to good motherhood, you’ll be okay again.

JM: It’s like, we’re not like them.

RLM: Yeah, and in some ways that is incredibly important to some women who can come forward because it’s less stigmatized than it would have been forty years ago. There’s this sense of, this is a biological thing, there is a medication, it will treat me, I will be okay. But it does open larger social questions. So, okay, it helps individual women, but it doesn’t necessarily make us question the social structure of motherhood, and what kind of resources are there really. What does [life] look like in the years postpartum? 

JM: It’s a question which is probably going to be asked more and more given the current political climate. Certain states have passed regressive abortion laws in the past couple of years, all while there has been this rise of “tradwife” content on social media. Do you think we might be entering another wave for postpartum advocacy, particularly when people are essentially being forced to have a baby in some cases?

RLM: I’m not sure how it’s all going to play out. Advocates in the 1980s and 1990s, and beyond that, worked really hard to say that this is not a partisan issue: our legislation will be bipartisan, and conservative women and liberal women experience postpartum mental illness. One of the biggest moments in the early 2000s for postpartum mental illness was Marie Osmond’s memoir. She was a popular singer but also a Mormon figure, and so she framed her postpartum illness within this very traditional mother context. There’s an interesting space for considering what this means. What ends up happening is that very nimble advocates work within the context they have. So when we’re in a more conservative conversation about women’s health, or a more conservative moment about what motherhood should look like, then postpartum illness is going to continue, but our approaches to it are going to be really constrained by what is possible. 

Unfortunately, some of the things I personally think we really need—like parental leave, childcare subsidies, national screening for postpartum illness—several things that seem baseline, the more conservative the moment is, the harder it is to get those on the table. 

JM: In a chapter on “The Problem of Diagnosis,” you quote Dr. Michael O’Hara on the conflicting idea of whether the problem is postpartum depression or depression in the postpartum period. I thought this was interesting in how it goes back to the postwar treatment of postpartum mental health issues, which had sort of Freudian ideas around it like, “Is this because you are secretly a lesbian?” Professionals were openly considering if this was really a postpartum thing or simply some internal, dormant, personal issue. I was wondering whether you think that conflict still plays out today?

RLM: Right, it probably doesn’t have as much of that role-adjustment stuff from the Freudian days, but I do think there’s that tension. In the diagnosis chapter, I’m really talking about the 1980s and then into the early 1990s, when advocates, especially Dr. James Hamilton, are focused on how we change the Diagnostic and Statistical Manual of Mental Disorders. Getting postpartum illness in the DSM seemed both practically important for women who might have an infanticide case—or who might be at risk of losing their children—and it needs to be explained that [their condition] is temporary and explicable, women who need that language, for legal reasons or insurance reasons. It’s also legitimizing in a much broader way: if we can get this official language on the most official book, then we can stop having to listen to people saying, “This isn’t real, this is ‘baby blues,’ you’re going to get over it.” We’ll stop that.

Which is interesting in the larger context of feminist anxiety at the same time about pathologizing women with something like Post Menstrual Dysphoric Disorder (PMDD) and its place in the DSM. Is that pathologizing women? Is postpartum depression pathologizing women? Or is it legitimizing their suffering? Big old tension there.

It just comes down to this question of what it means to take women’s pain and suffering seriously, and the answer at the time was, we need it in writing, in this official book, to make people take it seriously.