In 1991, the Breastfeeding Friendly Hospital Initiative was created.  In 1990 the Innocenti Declaration  was developed by the WHO and UNICEF, a document that outlines the optimal feeding of babies and children.  Part of this declaration was a recommendation that all governments should develop national breastfeeding policies and implement systems to protect, promote, and support breastfeeding.  Further to this, the following year the WHO and UNICEF developed the Baby Friendly Hospital Initiative.  This initiative is based on research that determines which activities are most likely to undermine the establishment of healthy breastfeeding relationships between women and their babies, and how to minimize these detrimental activities.  It is also based on research which determines which activities are most likely to support the establishment of healthy breastfeeding relationships, and how to implement these activities into our hospitals, maternity wards, and society.  The goal of the Baby Friendly Hospital Initiative is to improve health by raising breastfeeding success rates.

Some families will choose not to breastfeed.  Some families cannot breastfeed.  This is okay!  The BFHI is not intended to exert pressure on individuals or reduce womens’ choice when it comes to bodily autonomy.  It is intended to help provide an optimal environment for establishing breastfeeding for those families who want to.  The most difficult and heartbreaking situations are those in which women want to breastfeed and try, but are not able to succeed.  Particularly for reasons which are preventable or based on a lack of accurate information.

Since the beginning of the Baby Friendly Hospital Initiative, over 15,000 hospitals worldwide have become designated “Baby Friendly.”  In order to be designated as Baby Friendly, a hospital must implement the following ten steps, and receive accreditation from an official United Nations BFHI representative:

1.  Have a written breastfeeding policy that is routinely communicated to all health care staff.

2. Train all health care staff in skills necessary to implement this policy.

3. Inform all pregnant women about the benefits and management of breastfeeding.

4.Help mothers initiate breastfeeding within a half hour of birth (one hour for cesarean birth).

5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants.

6. Give newborn infants no food or drink other than breastmilk unless medically indicated.

7. Practice rooming-in, allow mothers and infants to remain together 24 hours per day.

8. Encourage breastfeeding on demand.

9. Give no artificial teats or pacifiers to breastfeeding infants.

10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

These steps seem simple and easy to implement, and the Canadian government signed an international agreement aiming to have many or all hospitals with maternity care across Canada designated Baby Friendly.  However, the vast majority of hospitals in Canada have failed to implement the Baby Friendly Hospital Initiative in the 20 years since this agreement was signed.  In fact, outside of Quebec, only five hospitals Canada are designated “Baby Friendly.”

St Joseph’s in Hamilton, Ontario

Toronto East General Hospital in Toronto

GR Baker Memorial Hospital in Quesnel, BC

BC Women’s Hospital in Vancouver, BC

Grand River Hospital in Kitchener, Ontario

(Breastfeeding Committee of Canada),

Within Quebec there is a long list of health centres, hospitals, birth centres, and public health units which are designated Baby Friendly, which can be viewed here (I don’t speak French well enough to adequately determine which listed facilities are hospitals and which are public health units, but the list includes at least four hospitals and three birth centres, as well as numerous other facilites).

Why aren’t more Canadian hospitals Baby Friendly?  Part of the problem with becoming accredited is that the ten requirements listed above are outlined in more detail and include specific stipulations such as in step 2, which is about training staff, and ‘training’ must be a high quality, WHO accredited breastfeeding course of 18 hours or more.  It also includes training of non medical staff such as cleaning staff and clerks.  So although the BFHI ten steps are simple, implementing them on maternity wards involves considerable cost, time, and dedication.  It is money well spent, and time and dedication which will result in improved maternal and infant health, but it is costly.  Many hospitals focus on improving their maternity wards in the direction of the ten steps, but fall short of accreditation because they fail to budget for training all staff to the standard expected by the BFHI.  Other areas besides staff training are stumbling blocks, as well.

The problem with striving towards the ten steps without accreditation is that when the ten steps are sort of followed, or almost fulfilled, women do not receive optimal support for breastfeeding.  Some maternity nurses will have accurate information and adequate training, or personal experience to draw from, and some will not.  Some cleaning staff will be supportive of breastfeeding and speak or act positively when exposed to it, and some will not.  Some women will be encouraged to initiate breastfeeding within the first half hour after birth, and some will not.  Some women whose babies go to the NICU will be aided in establishing and maintaining lactation despite separation, and some will not.  If an entire hospital has a vested interest in maintaining an accreditation as Baby Friendly, everyone will work harder to ensure that the environment of the hospital is supportive of breastfeeding. 

One of the most common complaints of women in the postpartum period regarding nursing support is that they get inconsistent breastfeeding information from nurses.  One nurse says your latch is good if your areola is entirely covered by the baby’s mouth, and another says areola coverage doesn’t matter.  One nurse says feed for 10 minutes per breast every feed, another says feed one side until the baby is full, then offer the other side.  One nurse says, “You have a great latch!” and another nurse says that because you have blisters on your nipples, your baby’s latch is poor.  If maternity ward staff are well trained with accurate information with high quality breastfeeding education courses approved by the WHO, this problem of inconsistent information will be drastically reduced.

Another stumbling block for some hospitals is the second part of the Baby Friendly requirements, which include compliance with the WHO International Code of Marketing of Breast-milk Substitutes.  For decades, hospitals around the world were given endless supplies of free infant formula for dissemination to new parents, and infant formula producers sponsored hospital activities and resources, which is a clear conflict of interest.  Canadian hospitals who wish to be designated Baby Friendly must purchase 100% of their infant formula, receive no funding from infant formula producers, and not provide free samples of formula to parents.

The Code seeks to protect breastfeeding by ensuring the ethical marketing of breastmilk substitutes by industry. The Code includes these ten important provisions:

1. No advertising of products under the scope of the Code to the public.
2. No free samples to mothers.
3. No promotion of products in health care facilities, including the distribution of free or low-cost supplies.
4. No company representatives to advise mothers.
5. No gifts or personal samples to health workers.
6. No words or pictures idealizing artificial feeding, including pictures of infants on products.
7. Information to health workers should be scientific and factual.
8. All information on artificial feeding, including the labels should explain the benefits of breastfeeding and all costs and hazards associated with artificial feeding.
9. Unsuitable products such as sweetened condensed milk should not be promoted for babies.
10. Products should be of a high quality and take account of the climatic and storage conditions of the country where they are used.

(BC Baby Friendly Network)

Here, again, Canadian hospitals strive to be closer to fulfilling these ten steps than they were in the past, but generally have difficulty with some steps, such as providing NO free samples to new parents.  Some parents need to supplement for a variety of reasons.  Families who are supplementing will frequently leave the hospital with a day or several days’ supply of infant formula, provided free of charge by the hospital.  In a Baby Friendly hospital, this can lead to suspension of accreditation and would be less likely to happen.  Free samples are powerful marketing tools for infant formula producers, as is the doctor-patient trust relationship.   Hospitals which participate in the dissemination of free formula are aiding infant formula marketers in undermining breastfeeding, according to the WHO Code.

Mothers of Change advocates for all hospitals in Canada to be designated Baby Friendly facilities.  China has over 6,000 Baby Friendly accredited hospitals, and Canada has a dismal handful or two.  Baby Friendly accreditation works.

Success Stories

In Cuba, where 49 of the country’s 56 hospitals and maternity facilities are baby-friendly, the rate of exclusive breastfeeding at four mounths almost tripled in six years – from 25 per cent in 1990 to 72 per cent in 1996.

In the first two years of BFHI implementation at the Central Hospital of Libreville in Gabon, cases of neonatal diarrhoea fell by 15 per cent, diarrhoeal dehydration declined by 14 per cent and mortality fell by 8 per cent.

In China, which now has more than 6,000 Baby-Friendly Hospitals, exclusive breastfeeding in rural areas rose from 29 per cent in 1992 to 68 per cent in 1994; in urban areas, the increase was from 10 per cent to 48 per cent.

The Catholic University of Chile, Santiago, initiated one of the first baby-friendly hospitals. As a result, initiation of breastfeeding within the first two hours increased. With a strong Step 10, a monthly clinic, exclusive breastfeeding at 6 months increased from approximately 20% to over 60%.

(UNICEF in action)

How can you help?

Advocate for Baby Friendly accreditation at your local hospitals.  When you go for a maternity ward tour, ask if your hospital has Baby Friendly accreditation; if they don’t, ask why not?  Ask your midwife or physician which hospitals in your area are Baby Friendly and generate discussion about the benefits for Canadian families.  Join La Leche League, participate in the annual Quintessence Breastfeeding Challenge, or become a member of International Baby Food Action Network, or the Breastfeeding Committee of Canada.  Write letters to your local hospital administration, health minister, head of obstetrics, maternity ward, public health unit (health units can earn Baby Friendly accreditation as well), and health authority, advocating for a push to improve infant and maternal health via the Baby Friendly Hospital Initiative.  Change the world, improve health, support women!  One hospital at a time…

It came to our attention recently that birthing women in Nanaimo could use our help to advocate for change in their community.  There are three midwifery practices in Nanaimo and six registered midwives.  Currently Nanaimo Regional General Hospital has a low VBAC success rate (19.57%).  Women in Nanaimo who wish to have a VBAC (vaginal birth after cesarean) have only two options; transfer to the care of an obstetrician, or travel to another community to give birth.  Currently in BC, midwives are endorsed as attendants for women who wish to give birth via VBAC, and women who have had one previous cesarean can choose to give birth at home if they wish to.  Midwives are acting within their license to attend homebirths for VBAC women, which is then considered an HBAC (home birth after cesarean).  Complication rates are low for VBAC women, particularly those attended by midwives.

Currently in Nanaimo no woman can access a midwife attended VBAC, in hospital or at home, because the Head of Obstetrics at NRGH has decided women must be transferred to obstetrical care (losing their midwife) upon arrival at the hospital when in labour.  This is against what research shows to be safe (http://www.cmaj.ca/content/181/6-7/377.full ~this study included VBAC at home and hospital and showed no difference in outcomes, although the overall number of women in this category was small), and against the Society of Obstetricians and Gynecologists’ endorsement of midwife attended birth.  It is also counter to BC practice, since communities all over the province with similar birth rates and similar access to anaesthesiology care are providing midwife attended VBAC.  Women in Vernon, Kelowna, Prince George, Langley, and many other communities can choose a midwife to attend her VBAC.  But women in Nanaimo do not have this choice.

In addition, no midwives in Nanaimo attend HBACs at present, because it would not be possible for them to maintain a respectful working relationship with the hospital obstetricians if they did (source: Nanaimo midwife).  This needlessly restricts women’s choice of birth attendant and drastically reduces her chances of a successful VBAC

“The SOGC recognizes and stresses the importance of choice for
women and their families in the birthing process (SOGC Policy Statement on Midwifery)”

JOIN US IN ADVOCATING FOR WOMEN IN NANAIMO!!

Write a letter to the birth professionals in Nanaimo, including the Head of Obstetrics Dr Luz Arbelaez, advocating for midwife attended VBAC, and improved professional attitudes towards midwives who act within their license by attending HBACs.

Dr. Luz Arbelaez

Head of Obstetrics, NRGH

Suite 201, 1801 Bowen Rd

Nanaimo BC, V9S 1H1

Here is the letter we sent from Mothers of Change, and cc’d to all the obstetricians in Nanaimo and all the midwives in Nanaimo.  We also cc’d the letter to the local paper.  Feel free to use our letter, modify it slightly, or write one of your own.  Please join us!!

Mothers of Change
9268 212 B Street
Langley BC

(604)882-1025
www.mothersofchange.com

Dear Dr. Luz Arbelaez, Head of Obstetrics, Nanaimo Regional General Hospital:

Mothers of Change is a national consumer advocacy group whose mandate is to advocate for positive changes in maternity care in Canada. It has recently come to our attention that midwives in your region are strongly discouraged by your obstetrical department from attending home births for women who have previously given birth by cesarean section. In fact, so strongly discouraged that no midwife in the Nanaimo region would consider herself able to maintain a workable relationship with hospital staff and the obstetrical department of Nanaimo Regional General Hospital if she were to attend home birth after cesarean, or HBAC. Effectively, no midwife in the Nanaimo area currently attends HBAC births.

This is in direct contradiction of ethical practice. Canadian law stipulates that women are free to choose their place of birth, be it home or hospital, and in British Columbia we have an integrated, funded midwifery system that allows women the choice of where to deliver, and what type of practicioner she wishes to attend her delivery. Home birth is supported by the Society of Obstetricians and Gynecologists of Canada and is proven safe for low risk women in both urban and rural settings (http://www.cmaj.ca/content/181/6-7/377.full

, a large study done in BC and published in 2009 with over 12,000 participants) (http://www.ncbi.nlm.nih.gov/pubmed/19747264

similar study in Ontario, also published in 2009).

The BC College of Midwives’ clinical guidelines endorse registered midwife attended HBAC births for women with one prior cesarean with a low, transverse incision, so long as the risks are clearly outlined and all factors taken into consideration (http://www.cmbc.bc.ca/pdf.shtml?Registrants-Handbook-17-04-Guideline-for-Vaginal-Birth-After-One-Previous-Low-Segment-Cesarean-Section

). Uterine rupture rates for women with one prior cesarean and a low transverse incision are generally acknowledged to be approximately 0.4%. This makes women who choose to VBAC a low obstetrical risk, particularly when not artificially induced and who are closely monitored by a licensed practitioner such as a physician or a midwife. Living in close proximity to a hospital such as Nanaimo Regional General Hospital increases access to life saving surgery should a rupture occur, and as such women in your region should not be barred from access to HBAC if they choose it.
We hope you will reconsider your policy, and work to establish and maintain a positive, professional relationship with midwives in your area who operate within their license and clinical guidelines by attending home births for women who have had a previous cesarean birth.
Midwife attended hospital VBACs are also unavailable to women who choose to birth at Nanaimo Regional Hospital at this time, because of your policy of trasferring women who VBAC into obstetrical care. The Society of Obstetricians and Gynecologists of Canada endorses midwife attended hospital VBACs, as does the BC College of Midwives. We would encourage your department to look to other hospitals with similar birth rates who have successfully integrated midwifery care for women who choose to VBAC into their hospitals even in the absence of 24 hour on site anaesthesiology. Research shows that outcomes do not improve for women or babies when VBACs are restricted to hospitals staffed with anaesthesiologists 24 hours per day. We are certain that a workable solution for midwife VBAC clients can be found for NRGH.

Sincerely,
Melissa Vose, Director
on behalf of the board of directors,
Mothers of Change in Maternity Care

We switched web hosts this week! Please bear with us as we sort out the technical details, and let us know if you notice anything missing or wonky. We are excited to make this change! In particular commenting is easier and more streamlined. We would love to hear from you, so let us know what you have to say! And enjoy our new flavour, from Mothers of Change!

Thank you to those of you who participated in our Mother’s Day giveaway, and for helping us celebrate Mother’s Day!!  The winner of our CD “Whip It Out: Songs for Breastfeeding” is the Hippie Housewife.  Congratulations!  (And thank you to Random.org for helping us select a winner)

Mother’s Day is special to us on Mothers of Change.  We celebrate women who are mothers all over the world; those who gave birth to us, those who gave birth to our mothers, and those who give birth to the next generation of lovely, sweet smelling babies.  We also celebrate women who give birth through adoption, fostering, volunteer work, or by being wonderful ‘Aunties.’

This Mother’s Day we would like to make our celebration of mothers a little bit extra special, and to that end we will be having a giveaway contest that will last for ONE DAY ONLY!  Our giveaway prize is this CD entitled “Whip It Out: Songs for Breastfeeding,” by Moorea Malatt!  (Also available for purchase on Amazon or CDBaby)

Come celebrate with us!  Celebrate motherhood, birth, and all nurturing women this Mother’s Day.  Enter our contest in the comments section TODAY ONLY~contest opens at 12:01 this morning and closes at midnight tonight.  Share on Facebook, your blog, or Twitter, leave a link, and get an extra entry for each link!  Good luck!  HAPPY MOTHER’S DAY from Mothers of Change.

Mother’s Day is special to us on Mothers of Change.  We celebrate women who are mothers all over the world; those who gave birth to us, those who gave birth to our mothers, and those who give birth to the next generation of lovely, sweet smelling babies.  We also celebrate women who give birth through adoption, fostering, volunteer work, or by being wonderful ‘Aunties.’

This Mother’s Day we would like to make our celebration of mothers a little bit extra special, and to that end we will be having a giveaway contest that will last for ONE DAY ONLY!  Our giveaway prize will be this CD entitled “Whip It Out: Songs for Breastfeeding,” by Moorea Malatt!  (Also available for purchase on Amazon or CDBaby)

Come celebrate with us!  Celebrate motherhood, birth, and all nurturing women this Mother’s Day.  Enter our contest in the comments section SUNDAY ONLY~contest opens at 12:01 Sunday morning and closes at midnight Sunday night.  Share on Facebook, your blog, or Twitter, leave a link, and get an extra entry for each link!  Good luck!  And HAPPY MOTHER’S DAY from Mothers of Change.

Mothers of Change advocates for the midwifery model of care to become the standard model amongst all maternity care practitioners in Canada.  We support and celebrate midwives across the country and around the world, especially today on International Day of the Midwife!

Thank you to all the wonderful midwives across Canada and around the world who change the world, one birth at a time.  Thank you for supporting us as we give birth, championing our autonomy and our ability to give birth, and empowering our choices.  Thank you for advocating for peaceful, safe, beautiful births.  Thank you for the late nights, the messy work, the encouragement, the paperwork, and for the countless days and nights spent on call.  Thank you for loving our babies nearly as much as we do, and for supporting our families through the childbirthing year.  You are wonderful!

Asheya and Melissa had the opportunity to speak today at the Virtual International Day of the Midwife Conference, an online conference that ran for 24 hours and was available internationally and presented a broad range of topics.  We presented on Mothers of Change as a grassroots birth advocacy organization, presenting about who we are and the work we do, and some of the unique strengths we have, and challenges we face in advocating for change in maternity care in Canada.  All the conference presentations were recorded and are available free of charge on the conference website.

Celebrate midwives with us!  Midwives save lives, and empower families in the journey of birth.

(photos courtesy of Melissa V, used with permission)

(Photo credit)

Postpartum mood disorders affect an estimated 10-15% of women during the months after she gives birth.  Generally these mood disorders are referred to under the umbrella of ‘postpartum depression,’ or PPD.  This term is rather inaccurate but widely used.  Manifestations of postpartum mood disorders can include depression, but can also include anxiety, obsessive compulsive disorder(s), postpartum panic disorder, postpartum post traumatic stress disorder, and postpartum psychosis.  Detailed descriptions of these conditions is available on What If I Don’t Feel Depressed? by Postpartum Progress. 

Since so many women experience postpartum mood disorders, it is important to be aware of the signs and symptoms, and how to get help if they occur.  There are some known risk factors for women who develop postpartum depression or another mood disorder after the birth of their baby, and these include;

-depression during pregnancy
-anxiety during pregnancy
-experiencing stressful life events during pregnancy or the early puerperium
- low levels of social support
-previous history of depression

(General Hospital Psychiatry Journal)

Women with risk factors should take extra care to educate themselves and their families and close friends on the signs and symptoms of PMADs (postpartum mood and anxiety disorders), but all pregnant and birthing women need to know about PMADs, since we are all at some risk of developing them in the 12 months following a birth.  What are the signs and symptoms?  They vary according to the disorder and the individual, but common ones include;

-feeling overwhelmed
-sadness
-anger
-constant low levels of irritation
-difficulty concentrating
-difficulty making decisions
-withdrawal
-thoughts of self harm
-thoughts of harming others, including the baby
-deep fears, often involving the baby
-repetitive or persistent disturbing thoughts
-compulsive behaviours, sometimes repetitive
-nightmares
-difficulty sleeping
-anxiety attacks
-delusions, hallucinations, or mania

(Postpartum Progress)

What can we do if we start to recognize some of these symptoms in ourselves or someone we care about?   It is really important to get help.  Talking about these symptoms can be incredibly scary, and the fear is that talking about it will make it ‘more real.’  But in fact, talking about it can make postpartum mood and anxiety disorders more manageable~ it is scarier to recycle signs and symptoms in our heads than it is to actually have them out in the open.  The first person we choose to talk to about symptoms of PMAD will be the scariest, so it is important to choose wisely; if your mother doesn’t believe in psyciatric illness, for example, she may not be the best person to first confide in.  For many women, their partner is an understanding and supportive person, and the right person to turn to, but sometimes this is not the case.  Who can we tell?  Tell a friend.  Tell your doctor.  Tell your pastor or spiritual mentor.  Tell the public health nurse when you go to weigh your baby.  Tell someone.

What’s next?  Come up with a treatment plan.  This can feel incredibly daunting but is key because the longer PPD lasts and the more severe it is, the longer it takes to recover.  This is where your doctor or naturopath can really help you determine which approach is best, and what fits your beliefs, your body, and your situation the most.  Treatment can include medication, naturopathic supplements, cognitive behavioural therapy (CBT), support groups, exercise, books, self care, and building a community of supportive people to help you cope.  This link is a PDF pamphlet outlining a breastfeeding friendly approach to depression in new mothers~it is very comprehensive and provides an excellent tool for learning about the various approaches and their effectiveness.  It is worth the time it takes to download, and I have recommended it even for women who are not mothers, because the research based information  it contains on treatment for depression is so solid.  Treatment plans need to be flexible to change, and weekly evaluations as to effectiveness and manageability. Get help devising a treatment plan, too, so that the task of planning isn’t so daunting.

What now?  Self care.  What does this mean?  It means, in essence, being kind to yourself.  The road back to health and wellness is curvy and often long.  It will include easy days and difficult ones.  Some days you will not be able to get dressed or brush your teeth, and others you will need to use the television as a babysitter: be kind to yourself.  You are doing the best you can, and it is enough.  The support group I went to for PPD after the birth of my third child broke self care down into four categories:

-Nutrition: eating well is important for mental health but can be incredibly challenging with a new baby.  Nutritious and easy to prepare are key.  Keep goals attainable, steer clear of elaborate dinner plans or food that involves a lot of preparation time.  Just make sure you eat.  Try to eat healthy.  Keep your eye out for easy sources of protein; nuts, seeds, nut butters, eggs, and healthy meat options, and try and include some of these each time you eat.  Eat when you can, and don’t get down on yourself if you can’t manage to ‘eat well’ one day.  Just do the best you can!

-Exercise: exercise is very effective in mitigating symptoms of depression and can be an integral part of overcoming PPD.  We’re not talking running marathons, here!  A walk around the block with your baby in the sling or stroller is enough.  If you can manage more, great!  If not, that’s just fine, too.  Walking is good exercise and cheap and easy to do.  Again, be kind to yourself!  Just do what you can manage.

-Sleep: this is a big challenge for all new parents.  Babies are biologically programmed to feed often and wake several times at night.  Sleeping for eight uninterrupted hours with a baby in the house is not realistic.  But lack of sleep can significantly worsen PPD (and anxiety disorders in particular), so it is an important part of self care.  The key here is simply to try and increase the total number of hours you sleep in a 24 hour period.  Nap when your baby naps.  If someone offers to take care of your older children, take them up on it, and sleep.  Some partners will be willing to get up for part of the night with a new baby so that new mothers can sleep a bit more~pumping breast milk beforehand for the partner to feed the baby with can be a feeding solution for nighttime parenting.  Also, partners can help increase overall sleep time for postpartum women by doing all of the other nighttime parenting tasks; diaper changes, pyjama changes for inevitable diaper leaks, soothing, rocking, burping, etc, so that all the mother needs to do is breastfeed and then go back to sleep. 

Another option for improving sleep is to cosleep with your baby.  There are two ways to do this; one is to sleep with your baby in your bedroom with you, but in a separate bed such as a cot or crib.  Health Canada recommends that all infants aged 6 months or younger sleep in the parents’ bedroom, in a separate cot or crib.  Research indicates this is the safest sleeping environment for babies.  The other way to cosleep is to bedshare.  This creates a familiy bed which often has the overall effect of more sleep for postpartum mothers because they don’t have to rouse quite as much out of a sleep state to feed their babies, and their babies don’t need to rouse quite as much to communicate their need to breastfeed.  Safe bedsharing tips are available on Dr Sears’ website, and more information on cosleeping here. 

-Time for yourself: wouldn’t it be lovely if MSP covered daily, in home massages for all postpartum women?  Until that day, we have to be creative in coming up with ways for us to make time for ourselves.  Again, nothing elaborate, but a few minutes alone to have a bath or to walk around the block without the baby, or to visit with a friend, can be a key ingredient to healing from postpartum depression or other mood disorders.

There is a distinct lack of effective resources for postpartum depression in Canada, and a lack of awareness of what PMADs are, how they impact families and overall health, and that it is not possible to simply snap out of it.  PMADs are real, and they are complex, physiological disorders which have emotional and social components.  Sometimes it takes several tries to get a doctor to recognize your symptoms, or to convince your partner that you need help, or to find a therapist who is a good fit for you and knows how to do CBT effectively.  Sometimes in small communites, support groups and other resources are only available online.  But healing from PMADs is possible even in less than ideal circumstances.  It takes time, help, and treatment, but it is so very important!