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• The Risk of Untreated PMADs
• Give Yourself Permission Not to Suffer
• But Dr. Aviva, Are Antidepressants During Pregnancy Safe?
• The Safest Use of Antidepressants in Pregnancy
• What if I’m Already Taking Medication?
• Do I Need Medication? 
• Are There Safe, Effective Non-Drug Options?
• Taking Care of You Is Taking Care of Your Baby

Updated 8.18.25

I get it. None of us wants to take a medication while we’re pregnant unless we feel we absolutely must – and only if we know it’s been proven completely safe for use in pregnancy. We’re all about trying to protect our babies from potential ‘toxins’. We go organic to avoid unnecessary chemicals in our foods, we switch to glass water bottles to avoid BPA, we stop drinking wine and cut way back on – or stop – drinking coffee. So the last thing we want is to expose our babies to possibly unsafe medications!

But the reality is that about one in five pregnant and postpartum women in the United States experience a perinatal mood and anxiety disorder (PMAD), an umbrella term that includes depression, anxiety, bipolar disorder, post-traumatic stress disorder, obsessive-compulsive disorder, and postpartum psychosis. And a stunning 75% of women of women dealing with mental health issues during and after pregnancy go untreated. 

And perhaps I should say one in five pregnant and postpartum women that we know of, since the actual number is much higher. For so many women this remains a hidden motherhood struggle.  Many don’t seek care at all because few women want to admit that they are less than happy when they are pregnant. After all, we’re supposed to be bathing in that joyous pregnancy glow, while basking in knowing we’re becoming mothers. And perhaps that is true for many women. But for many women, experiencing depression or other tough feelings during pregnancy leads to feelings of shame – so stigmatized are these matters.

Also, too many of  us are accustomed to dismiss our moods and suffering, to power through, and even when we eager to do something about our suffering – we’d largely sacrifice everything for the sake of our children—including our own health and safety i it means avoiding an possibly risks for our babies – no matter how small those are. No pregnant woman wants to put her baby at risk—and who can blame us? Further, most doctors – and even many midwives –  don’t consistently screen for PMADs during pregnancy (or postpartum), 

Add to this the confusion around the safety of antidepressants in pregnancy – and we end up with far too many mothers – and the families struggling, too, in limbo, not getting the help they need. 

The Risk of Untreated PMADs

Lack of care for maternal mental illness is no small matter. Maternal mental health challenges are a  leading cause of pregnancy-related death in the United States. Untreated PMADs can contribute to real risks for mothers—including worsening symptoms, complications like preeclampsia or preterm labor, and, in severe cases, safety concerns. Babies can also be affected when a parent’s suffering goes unaddressed.

Here’s what we know about the potential impact:

On Mothers

• Untreated, mental health problems in pregnancy can worsen, leading to more severe depression, anxiety, panic, or obsessive thoughts – and is also a predisposing factor for postpartum mental health challenges.
• Physical health may also suffer, with increased risks of pregnancy complications like preeclampsia, preterm labor, and difficult deliveries.
• Daily functioning and relationships are often strained. Women may feel isolated, disconnected from their partners, or unable to fully engage in work and life.
• In severe cases, untreated PMADs increase the risk of self-harm or suicide.

On Babies

• Untreated PMADs are linked with preterm birth, low birth weight, and growth restriction.
• Babies may show altered stress responses and can face developmental and behavioral challenges later in life.
• Bonding may be harder when mothers are overwhelmed, impacting infant attachment and security—though with support, healing is always possible.

When you’re struggling with depression or anxiety in pregnancy, white-knuckling it isn’t a virtue; it’s a load you don’t have to carry – and certainly not alone! Treatment—whether therapy, social support, or medication—can help you sleep, eat, keep up with prenatal care, and stay connected to the people who love you. Those are not luxuries; they’re the foundations of healthy pregnancy and early bonding. Here’s a gentle reframe: getting help is part of caring for your baby. 

Give Yourself Permission Not to Suffer

When you’re struggling with depression or anxiety in pregnancy, white-knuckling it isn’t a virtue; it’s a load you don’t have to carry. Treatment—whether therapy, lifestyle supports, or medication—can help you sleep, eat, keep up with prenatal care, and stay connected to the people who love you. Those are not luxuries; they’re the foundations of healthy pregnancy and early bonding. Here’s a gentle reframe: getting help is part of caring for your baby. 

Choosing care is an act of protection, not only for you, but for your baby and your family. You’re not failing—you’re doing what good parents do: seeking what’s best for your child by taking care of yourself. So perhaps  we need to let ourselves off the hook for sometimes needing help — even if that help comes from a prescription. 

If you are one of the many moms facing mental health challenges, please know that you’re not alone, and I understand how gutting the choice to take a medication can be. I’m here to guide you through it by sharing what we know (and what we don’t) about antidepressant use during pregnancy. 

But Dr. Aviva, Are Antidepressants During Pregnancy Safe?

The long answer is that there is still a lot we need to learn about the safety of antidepressants in pregnancy, but this doesn’t mean they cannot be used, despite concerns raised by a recent FDA panel which was biased and inaccurate. 

In fact, there’s a lot we don’t know about most medications used in pregnancy. About while about 90% of women report taking some type of medicine during pregnancy, and 70% take at least one prescription medicine, including in the first trimester, fewer than 10% of medicines approved since 1980 have enough information to determine their safety during pregnancy. This is because pregnant women are often not included in studies that determine the safety of new medicines.

But the short answer is, yes, if you are using antidepressants in pregnancy according to the most current recommendations, then they can be a game-changer – and even a lifesaver for you- and can be quite safe for your baby. 

Here’s what we know. 

The most commonly recommended medications for depression and anxiety in pregnancy are SSRIs (Selective Serotonin Reuptake Inhibitors) and SNRIs (Selective Norepinephrine Reuptake Inhibitors). These are considered the primary options in pregnancy. Most other categories—like mood stabilizers and tricyclics—are generally avoided due to higher concerns for congenital malformations.

Large studies including hundreds of thousands of pregnant women have not shown harm to mothers from using SSRIs during pregnancy, and the consensus among experts and organizations like the American College of Obstetricians and Gynecologists (ACOG) and and the National Curriculum in Reproductive Psychiatry Society for Maternal-Fetal Medicine is that untreated maternal mental health disorders put women and their babies at greater risk of adverse outcomes than antidepressants prescribed and used appropriately. In other words, when symptoms are significant, treatment—including medication—can be the safer choice overall.

Still, like any medication, there are potential risks: a moderately increased risk of preterm birth and low birth weight and a slightly increased risk of preeclampsia and postpartum hemorrhage. So using them safely and wisely, with skilled guidance, is key. 

The Safest Use of Antidepressants in Pregnancy

If you have decided you need to use an antidepressant, this may not have been an easy choice for you.  Trust that if you have do need one, you are making the best choice for you and your baby. 

To rmaximize your benefits while reducing risks linked to antidepressant exposure in pregnancy:

• Choose time-tested options.  Choose a medication that is known to result in the lowest fetal/neonatal exposure whenever possible. Zoloft (sertraline) has typically been the first line medication recommended during pregnancy. However, in a large 2020 study, Lexapro (escitalopram) was associated with the lowest number of birth defects so may be a better choice. Your doctor can help you determine which of these is best for you. Venlafaxine was associated with the highest number of defects and there is limited literature on venlafaxine use during pregnancy, so I recommend avoiding it at this time.
• Dose thoughtfully: Use the most effective dose: One significant problem is not dosing adequately in hopes of mitigating exposure. In reality, this could lead to undertreatment and persistent symptoms while one is still being exposed to the medication! So the more effective approach is to increase dosing to effectiveness.
• Avoid newly released antidepressants while pregnant Choose only from those that have been time-tested in pregnant women.
• If tapering is appropriate, work with your healthcare provider to reduce gradually—about 10% per week—and stop at the lowest dose that keeps you well. Note that lowering or switching can sometimes trigger rebound symptoms that are harder to control. Adjust gradually, and don’t try to do this alone.
• Combine supports: Add in non-supplement, non-pharmacologic treatments such as light therapy, yoga, and CBT, all of which have been found to be effective for supporting mental health during pregnancy. These non-supplement treatments won’t interfere with your medication and may allow you to effectively lower your dose.

This is not about “being on a drug” versus “being natural.” It’s about stability. A steady mood, regular sleep, consistent nutrition, and engagement with prenatal care are all part of a healthy pregnancy. If medication helps you have more of that, it can be a profoundly supportive choice.

What if I’m Already Taking Medication?

If you became pregnant while on an antidepressant, set up time with your midwife or OB to review risks and benefits of your medication. But if you’re already on a medication generally preferred for pregnancy and are past the first trimester, the evidence is clear that it is the wisest choice to stay at the dose that’s keeping you well. Lowering or switching can sometimes trigger rebound symptoms that are harder to control. If a change is needed, make a plan with your clinician and adjust gradually.

Do I Need Medication? 

If you’re experiencing PMAD symptoms, the most important thing you can do is seek help from a care-provider skilled in working with pregnant women facing these symptoms. This could be your obsetrician, family physician, midwife, or a perinatal therapist or psychiatrist. Ideally, they will assess your symptoms using a validated questionnaire. If medication is indicated, they can help you get the prescription and support you need. 

If you’re on the fence or prefer not to use medication, I get it. But do this: Consider if any of the following feel true for you:

• Your depression is moderate and interfering with experiencing joy, sleeping, eating, or other important aspects of self care or quality of life. 
• Your depression is severe, you’ve had frequent relapses, or you don’t feel able to wait to see whether natural approaches work.
• You’ve tried non-drug strategies and they haven’t helped enough.
• You feel more confident in medication than in natural therapies.
• You understand there can be risks to medication in pregnancy, but  you also understand that untreated maternal mental health issues can carry even greater risks.

If you answered yes to any of the above, an antidepressant may be the best choice for you right now. If you answered no to all, have no thoughts of self-harm, and have a solid support network, starting with non-pharmacologic strategies may be appropriate, but I still urge you to talk with your healthcare provider to make sure that’s the case. .

Are There Safe, Effective Non-Drug Options?

I want to be clear: For many women with maternal mental health conditions, medication may be absolutely necessary for managing symptoms. For some women, non-pharmacologic approaches are enough. 

These include:

• Cognitive Behavioral Therapy (CBT) and other forms of counseling
• Omega-3 fatty acids
• Light therapy
• SAM-e (S-adenosyl methionine)
• Yoga and mindfulness-based practices

If your symptoms are mild, you’re not experiencing thoughts of self-harm, and you have strong support, it’s reasonable to try these first. (See: Depression in Pregnancy: 10 Ways to Beat the Blues Without Medication.) However, most of these are not strongly evidence based, these supplements have not been tested for use in pregnancy, and they are generally not adequate for moderate depression, and rarely enough for more severe symptoms. 

Taking Care of You Is Taking Care of Your Baby

As women, we’re conditioned to put our babies first. But one of the most protective things you can do for your baby is to protect you—your mood, your sleep, your nourishment, your sense of connection. Needing help does not mean you’re weak; it means you’re wise. Whether your path includes therapy, lifestyle changes, medication, or all of the above, choosing care is an act of love.

If you’re struggling, please know you’re not alone. Reach out—to your midwife, OB, primary care clinician, or a mental health professional. With the right support, you can feel better, and your baby will benefit from a healthier, more resourced you.

I hope this article has brought you deep peace of mind and a good plan for getting the help and support that you so deserve to have.  If you’ve found it helpful, please consider sharing it with a mama who you feel needs it, and the healthcare practitioners you know, so they too, can be more educated about this issue.

The post Antidepressants During Pregnancy: What’s a Mom to Do? appeared first on Aviva Romm, MD.

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When I was applying to medical residency, the doctor interviewing me commented, upon seeing my interest in the impact of endocrine disruptors on women’s reproductive health: “Dr. Romm, you don’t believe in that BPA crap, do you?” This was years before definitive evidence proved the association between BPA and miscarriage, sometimes due simply enough to women working at checkout counters and airlines handling BPA-laden receipts and airline tickets, as  Hugh Taylor, ironically then an OB/GYN at that same institution, blew the lid wide open on this connection, among others. 

My own research already had me informing the women in my medical and miwifery practice about the potential hazards of BPA and other environmental chemicals that mimic our endogenous hormones, for ourselves and our children, before and after they are born. . 

In February, a study published in Nature Medicine generated a slew of scary headlines: “Human brain samples contain an entire spoon’s worth of nanoplastics,” as CNN reported. Researchers had found several grams of tiny plastic particles in human brain samples—roughly the weight of a takeout spoon. Perhaps even more alarmingly: The level of plastics detected was nearly 50 percent more than found in brain samples from 2016. 

While the frequently repeated estimate that the average person ingests a credit card’s worth of plastic every week is questionable, there’s no doubt that tiny shards of plastic are getting into our bodies—and even brains. How much should we worry about microplastics? What’s the current state of the science on their health risks? And what can you do—as an individual and collectively—to reduce your exposure? Let’s dive in…

What are microplastics and nanoplastics?

Synthetic plastic was first created in the late 1800s, but our reliance on it has increased in recent decades. More than half of all plastic ever made has been made since 2002. In 2019, 460 million metric tons of plastic were produced, and production is estimated to triple by 2060. More than one third of plastic produced today is for packaging, which is used only once before being thrown away. Overall, only 9 percent of plastic is recycled; the rest end up in our landfills and oceans. 

As plastics degrade over time, it never really goes away—it just breaks down into smaller and smaller tiny pieces. Plastic particles that are smaller than 5 mm are microplastics and those smaller than 1000 nanometers are nanoplastics—1,000th the average width of a human hair. 

That’s why microplastics and nanoplastics (MNPs) are literally everywhere in our environment—in the air we breath, the food we eat, and the water we drink – even in ocean depths where they get into the fish we eat, and remote mountains tops. Researchers think that they enter our bodies mainly via ingestion, but also inhalation. For example, the wear and tear on our car tires releases MNP particles that pollute the air. There’s even some evidence that we can absorb them via skin exposure, from personal care products like cosmetics—to which microplastics are sometimes intentionally added—and even our clothes —and our babies’  diapers. 

Some microplastics—especially larger particulars—are cleared out of our bodies, but the tiniest nanoparticles especially are small enough to get into our bloodstream and travel throughout our bodies. They can cross the placental and blood-brain barriers and have been detected in human hearts, blood vessels, lungs, livers, testes, gastrointestinal tracts, placenta, semen, breast milk and even a baby’s first stool. 

The most miniscule nanoplastics are so small they can end up inside individual cells, which experts find most worrisome when it comes to potential health impacts.

What do we know about the health effects of microplastics?

Research on MNPs’ health effects is still in its infancy. But a growing body of evidence suggests it’s not good. 

Microplastics have been shown to accumulate in organs and lead to biological changes, including oxidative stress and inflammation in human cell lines. According to a 2024 systematic review of the research, published in Environmental Science & Technology—mostly animal studies—microplastics are suspected to harm reproductive, digestive, and respiratory health, possibly increasing the risk of lung and colon cancer. Emerging research also suggests links to metabolic disorders and a weakened immune system.

We also have good evidence that many of the 20,000 chemicals found in plastics—and therefore in micro and nanoplastics—are harmful to health, including per- and polyfluoroalkyl substances (or PFAS chemicals), bisphenol A, and phthalates. For example, a recent study estimated that exposure to phthalates in plastics contributed to 350,000 deaths from heart disease worldwide in 2018. The potential dangers from microplastics may come from the tiny particles themselves, the carcinogenic and endocrine-disrupting chemicals they leach, or some combination. 

When it comes to human studies, we don’t yet have large epidemiological studies comparing the long-term health of those with more or less microplastic and nanoplastic exposure. Most of the human studies to date have been small ones that find a correlation between a higher burden of microplastics in certain areas of the body and disease. 

For example, a 2022 study found that livers from people with cirrhosis have more micro and nanoplastics than healthy livers. A 2024 study published in the New England Journal of Medcine, found that patients who had MNPs detectable in their carotid artery plaque were at higher risk of heart attack, stroke, or death from any cause in the following years compared to those in whom plastics were not detected. Preliminary research released this year showed that the placentas of babies who were delivered preterm contained more MNPs than full-term babies. And in the new study of brain tissue, the researchers found three to five times more nanoplastics in the brains of people with dementia compared to healthy people. 

However, it’s important to remember that correlation does not necessarily equal causation and it’s very possible that another confounding variable explains these findings—or that the causal arrow is reversed. For example, the researchers emphasize that people with dementia may have more plastics in their brain because their disease leads them to have a more porous blood-brain barrier and makes them less able to clear toxins.

We certainly need more research to definitively say that the levels of chronic exposure to microplastics that we are experiencing are actually causing health problems—after all, the dose makes the poison—but personally, I believe that the early data is alarming enough to compel us to take action to reduce our exposure. 

How can we reduce our exposure?

First, as I always tell my patients – breathe. Given how ubiquitous microplastics and nanoplastics are in our food, water, and air, it’s not possible to avoid them entirely. 

But there are some things you can do to reduce unnecessary exposures…including these steps that you can start implementing today. 

• Don’t drink from plastic water bottles—especially if they’ve been sitting out in the sun. A 2024 study found that 1 liter of bottled water—the equivalent of two standard-size bottled waters—contained an average of 240,000 plastic particles from seven types of plastics. Some 90 percent of those were nanoplastics.
• Avoid heating food or water in plastic. And consider switching to glass or steel containers for food storage more generally. A 2023 study found that within 3 minutes of microwave heating, some containers released as many as 4.22 million microplastic and 2.11 billion nanoplastic particles from only one square centimeter of plastic area. Storing food in plastic containers in the fridge or at room temperature was much better, but after six months, they also released millions to billions of microplastics and nanoplastics. 
• Eat lower on the food chain and avoid highly processed foods. There’s evidence that plants take microplastics up from the soil and incorporate them into their roots and leaves. The higher up the food chain an animal is, the more microplastics have likely accumulated within them. Highly processed foods also seem to contain more microplastics, potentially because of contamination from processing machinery. In a 2024 study, researchers compared the level of microplastics in over a dozen types of protein products—seafoods, meats, and plant-based proteins—and found that highly-processed products contained the most microplastics per gram. 
• Avoid heating plastic baby bottles—or switch to glass bottles. A 2020 study published in Nature Food found that shaking room temperature water in polypropylene baby bottles released hundreds of thousands of microplastics and when the temperature was raised to 158 F—as required to prepare powdered formula—they released anywhere from 1 million to 16 million microplastic particles per liter, as well as trillions of smaller nanoplastics. Consider switching to glass bottles. Or if using plastic bottles with powdered formula, prepare it with 158 F water in a glass container, then let it cool to room temperature before transferring it to the plastic bottle. Researchers also recommend that when sterilizing plastic bottles with hot water to let them cool completely before rinsing them out at least three times with previously boiled water that’s been allowed to cool to room temperature.
• Try to avoid plastic items for your young children more generally.  A 2021 study found that babies’ poop contained an average of 36,000 nanograms of polyethylene terephthalate (PET) per gram, 10 times the amount found in adult feces. Researchers think infants and toddlers may ingest even more microplastics than adults because, in addition to often drinking from plastic bottles, they tend to put everything in their mouths—including clothes, plastic toys, utensils, sippy cups, teethers, and pacifiers. 
• Switch to wood or bamboo cutting boards. A 2023 study suggests that plastic cutting boards can be a significant source of microplastics in your diet, contributing tens of millions of microplastics annually.
• And don’t forget about plastic tea bags! A 2019 study found that steeping a single plastic teabag releases approximately 11.6 billion microplastics and 3.1 billion nanoplastics into a single cup of the beverage.
• Regularly vacuum and damp mop, and use an air purifier with a HEPA filter to reduce the amount of microplastics in the air and dust within your home. This is especially important if you have small babies and toddlers in your home, who crawl on the floor where microplastics that have shed from clothing, furniture, and carpets can accumulate. 
• Avoid microbeads in cosmetics, a form of microplastic that often appear in scrubs, cleansers, and even toothpaste as exfoliants, as well as in foundations, sunscreens, shampoos, and deodorants as fillers, binders, or film-formers. Products with glitter or shimmer may contain plastic-based particles too. Choose natural exfoliants like sugar or oats, and look for certified microplastic-free or eco-labeled brands. Helpful tools like the Beat the Microbead app can scan products and flag hidden microplastics. 
• If you can, choose clothes made of natural fibers, like cotton or wool. Wash synthetic fibers, like acrylic or nylon, before wearing them the first time to remove microplastics. You can listen to my podcast, How Toxic Fashion is Making Women Sick & What We Can Do About It with environmental clothing activist Alden Wicker.

The Precautionary Principle

It's important to acknowledge that it’s not at all clear how much taking these kinds of steps to reduce plastics in your homes and routines will actually reduce your overall body burden of microplastics and nanoplastics. We don’t yet know how much our exposure from things like cutting boards or water bottles or food storage containers compares to our exposure from drinking water, eating food, and breathing the air. 

In fact, some researchers on MNPs think we should be most concerned about the extremely small nanoparticles from plastics that have degraded in the environment long ago, rather than so-called “fresh” microplastics released from things like cutting boards and water bottles since those particles are much larger, and research suggests that the body clears out some larger microplastics.

But given the growing body of evidence on microplastics, I believe in embracing the precautionary principle, which says that when an activity poses a threat to human health or the environment, precautionary measures should be taken even if some cause-and-effect relationships are not fully established scientifically. This means taking proactive measures—both individual and collective—even in the face of scientific uncertainty. 

While I think individual efforts to reduce your exposure are worth doing, ultimately, we need to collectively advocate for systemic changes to the way we manufacture and safely dispose of plastic and for the use of safer chemicals in plastics. As Dr. Philip Landrigan, director of the Program for Global Public Health and the Common Good at Boston College, and the man responsible for discovering that lead in paint and gasoline was affecting childrens’ cognitive development, whom I interviewed for the podcast says, “Just because we don’t know everything there is to know about every chemical in plastics does not mean we should not take action against the plastic chemicals we know are bad actors.”

Given the life cycle of plastic, taking action is important not just for us—but for future generations. The plastics discarded today will continue to degrade into microplastics for centuries, impacting not only ourselves but also our children and grandchildren. Reducing our personal exposure, supporting our body's resilience, leveraging our economic power as consumers, and advocating for systemic change are not just about avoiding potential harm to ourselves; they are acts of responsibility towards a healthier future for all.

More articles:

https://www.nytimes.com/2025/05/20/well/microplastics-health-risks.html

https://www.nytimes.com/2025/04/08/well/microplastics-health.html

The post Microplastics and Nanoplastics: How Alarmed Should We Be? appeared first on Aviva Romm, MD.

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Most women don’t look like they’re falling apart on the outside—even when they’re struggling just to stay afloat on the inside. We keep the calendar moving, remember the birthdays, show up for work, hold it down for everyone… all while, too often, carrying silent stress, depression, anxiety, grief, and trauma. 

In this deeply open and personal episode, I’m joined by UK-based integrative psychotherapist Helen Marie to talk about something that touches so many of us: what happens when our nervous system can no longer carry the weight of “I’m fine.”

We explore how burnout, people-pleasing, perfectionism, and high-functioning anxiety are often signs of a deeper story—one our nervous systems are telling, even when we’re doing our best to hold it all together. Through the lens of Polyvagal Theory and trauma-informed care, Helen shares the language, tools, and gentle wisdom to help us come back to ourselves.

This episode is a balm for anyone who’s ever felt exhausted but unable to rest, disconnected but still showing up, or overwhelmed by emotions they can’t name. It’s a reminder that you’re not alone, and that healing begins when we give ourselves permission to be human.

In This Episode We Cover:

• The quiet ways anxiety and depression show up in high-functioning women
• Why we often feel the need to appear “fine” even when we’re not
• An introduction to Polyvagal Theory and nervous system mapping
• Somatic practices to bring you back into your body and into safety
• How to meet your nervous system where it’s at—without judgment
• What it really means to choose yourself, one breath at a time
  

About Helen Marie

Helen is a UK-based integrative psychotherapist, author of Choose Again, and host of the podcast I Don’t Think We Talk About This Enough. With a background in public health, Helen returned to train in psychotherapy in her forties after supporting a loved one through a mental health crisis. She is now a certified clinical trauma practitioner who helps women reconnect with their worth and find safety in their own skin.

Resources + Links

• Helen’s website
• Helen’s Instagram: @h.e.l.e.n.m.a.r.i.e
• Deb Dana’s Befriending Your Nervous System
• Dr. Aviva’s Tapping Solution Menopause Series

The High Cost of ‘I’m Fine’: The Truth About High-Functioning Anxiety and Invisible Depression

I often ask my patients about Perfectionism, burnout, people-pleasing, and subtle trauma responses like fawning and freezing—not because they’re trendy psychological terms, but because these patterns shape our health in profound ways. When we’re operating in overdrive—trying to hold it all together—we’re not just emotionally exhausted, we’re physiologically altered. Our immunity, hormones, metabolism, heart, sleep, and mood all feel the impact.

And most women? We don’t “look” like we’re falling apart. We’re showing up to Zoom calls with a smile. We're making the meals, remembering the birthdays, meeting the deadlines. But under the surface, so many of us are carrying anxiety, overwhelm – even silent grief, and trauma. The dissonance between what we feel and what we present to the world can be profoundly isolating.

This is what I sat down to talk about with Helen Marie, a UK-based integrative psychotherapist who brings an extraordinary gentleness to how she speaks about emotional healing. Her words, both in her new book *Choose Again* and in our conversation, felt like a balm. A reminder to soften. To choose ourselves. To stop performing and start listening—to our stories, our bodies, and what we truly need.

Why High-Functioning Anxiety and Depression Don’t Have a “Look”

One of the most powerful moments in our conversation was this: anxiety doesn’t have a look. Depression doesn’t have a look.

Helen described it as the “swan effect.” So many women are like swans—appearing graceful on the surface while paddling furiously beneath the water, trying not to sink. And while the world sees us gliding, our nervous systems are in full-blown stress mode. Cortisol and adrenaline flood our systems. We’re inflamed, exhausted, and disconnected—but still smiling.

We feel ashamed to admit we’re struggling. Worry about being judged. Don’t want to burden others. So we stay silent. And the silence hurts.

I’ve seen this firsthand in my practice: women who show up polished and high-achieving, but beneath the surface, they're managing panic attacks, insomnia, racing thoughts, and disconnection. They’re not just tired—they’re burned out at a soul level. Yet they keep going. Because somewhere along the way, we internalized the message that it’s better to be productive than to be present, better to appear strong than to admit vulnerability.

What It Means to “Meet Your Nervous System Where It’s At

Helen and I spoke deeply about the nervous system—not in clinical terms, but in the real, lived experience of what it feels like to be in fight, flight, freeze, or that rare but beautiful state: calm, safe, grounded.

She teaches women to map their nervous systems using polyvagal theory, describing three key states like rungs on a ladder:

• Ventral vagal (safe, connected): Rest and digest. Deep breaths. Emotional regulation. This is where we feel like ourselves.
• Sympathetic (fight/flight): Anxiety, anger, urgency. The stress response on full blast.
• Dorsal vagal (freeze/shutdown): Exhaustion, disconnection, numbness. The “I can’t do it anymore” feeling.

The invitation is to “notice” where we are on that ladder and ask, “What would support me right now?”

This framework is powerful because it gives us language and agency. Instead of feeling like we’re broken, we begin to understand—we're having a “nervous system response.” And that response can shift. With a gentle breath, with a grounding touch, with the smallest act of self-kindness, we can begin to climb back up the ladder to safety.

The Stories We Tell Ourselves—and How to Unravel Them

One moment from our conversation that hit home for me was when I shared how, in moments of anxiety, my mind creates stories. “You’re behind on your book. You’ve lost your mojo. The movement will move on without you.”

But when I step back, I can see the truth: these are *sensations*, not facts. And when I move my body, step outside, dance, or simply take a breath, the sensations shift—and so do the stories.

Helen offered a simple but profound reminder: ask yourself, “What’s true here?” That one question can separate the inner spiral from reality.

We all have narratives—crafted by past wounds, cultural expectations, and the constant mental chatter that anxiety brings. But awareness is the first step to healing. I often encourage my patients to write their anxious thoughts down and then question them like a detective. Is this absolutely true? What else might be true? It’s a gentle way of loosening anxiety’s grip.

Creating Capacity—Not Just Coping

We talked about the metaphor of the water glass. Imagine your glass is already filled to the brim—maybe even overflowing—and then life adds a few more drops: a sick child, a deadline, an emotional conversation. Suddenly, everything spills over.

That’s when we break down. The work isn’t about making sure no drops come in. Life *will* keep adding. The work is about keeping the water level lower. Making space. Creating capacity.

For Helen—and for me—that means routines, sleep, boundaries, support, journaling, and rest. It means showing up for ourselves every day *before* the breakdown.

And it's not about adding more to your to-do list. It's about subtraction. Where can you say no? Where can you delegate or delay? What can you let go of, not just physically but emotionally? Can you create a rhythm that nurtures your nervous system instead of depleting it? This is how we build resilience—not by pushing harder, but by making space.

Letting Go of Perfection and Choosing You

Our conversation meandered through so many beautiful paths: journaling rituals, drawing in the margins, non-dominant hand writing, breathing into the body. But it all came back to one central truth: you matter.

Choosing yourself isn’t selfish. It’s revolutionary. And it’s often as simple as asking: “What’s the next kindest thing I can do for myself right now?”

It might be making a cup of tea. Saying no. Crying. Dancing. Journaling. Asking for help. You don’t have to figure it all out—you just have to take the next kindest step.

I love Helen’s question: “How have you cared for yourself this week?” Not in an idealistic or Instagram-perfect way, but in the real, messy, grounded way. Choosing you might look like a warm bath or it might look like letting go of toxic relationships. It’s both soft and fierce; it’s boundaries and gentleness. It’s a reclamation of your nervous system—and your life.

The Nervous System Isn’t Just a Concept—It’s Your Compass

When I first learned about polyvagal theory and the mapping of nervous system states, it changed how I understood myself—and my patients. Suddenly, it wasn’t just “I feel off today.” It was, “My body is speaking to me.” The science gave structure to what so many women feel but can’t name.

We’re taught to override. To hustle, to toughen up, to perform. But polyvagal theory invites us to pause and ask: “What does safety feel like in my body?” And the answers are incredibly individual. For some, it’s lying down in a dark room. For others, it’s a walk, a phone call with a trusted friend, or a familiar song played on repeat.

Helen and I talked about how this understanding gives us back our agency. We're not at the mercy of moods or dysfunction—we're in a relationship with our bodies. And like all relationships, it takes time, curiosity, and kindness to build trust.

Rituals, Tools, and Tiny Shifts That Matter

The practices Helen shared were deeply somatic and profoundly simple. One of my favorites? Tapping the side of the hand gently with your fingers while breathing. It’s not flashy. It’s not complicated. But it brings your awareness into the body. It slows the mind.

Another beautiful technique: cupping the body with your hands—gently patting your arms, chest, thighs, and legs. You don’t have to fix everything to shift something. Just one breath. One point of reconnection.

These micro-practices aren’t substitutes for therapy or structural change—but they’re like breadcrumbs leading us home. When I’m overwhelmed, it’s often the smallest shift—lighting a candle, placing a hand on my chest, standing barefoot on the earth—that reminds me I’m still here, I’m still me.

The Myth of Doing It All—and the Power of Saying No

We touched on something crucial in our conversation: the belief that we’re supposed to do it all. Be the caregiver, the professional, the supportive partner, the competent friend. But the truth is, the system is designed to benefit when we self-sacrifice. And the cost? It’s our health, our vitality, and our joy.

Helen reminded me—and I’ll remind you—that it’s okay to disappoint others if it means not abandoning yourself. Boundaries are not walls; they are the architecture of a sustainable life. And when we start choosing rest over performance, authenticity over approval, something begins to shift not just inside us—but in the culture around us.

Redefining Success Through Nervous System Awareness

One thing that came through in our discussion was how often success is defined by output—our titles, our income, our schedules. But what if success was about regulation? About spaciousness? About waking up and not feeling like you want to hide under the covers?

Imagine if success meant being able to notice your anxiety before it hijacks your day. Or knowing how to come back to calm when life inevitably throws curveballs. That’s the kind of success that builds a foundation. It’s slow, steady, and often invisible to others—but it changes everything.

So much of what Helen and I discussed points to a collective hunger for a slower, truer pace. Especially post-pandemic, many of us are craving lives with less rush, more meaning, and a deeper attunement to what our bodies are asking for. This isn’t laziness—it’s evolution.

Journaling as a Mirror and a Map

We ended our conversation with a delightful shared discovery: we both journal with the same orange Leuchtturm 1917 notebook. There’s something deeply comforting in having a sacred space where your thoughts, feelings, and fears are held.

Journaling isn’t just about recording events—it’s a form of listening. Sometimes I write what’s going on. Other times I draw. Sometimes I write “as if,” imagining the life or book I want as if it already exists. Visualization, as Helen shared, can regulate the nervous system, too. It gives your brain a new template, a hopeful pattern to follow.

Whether you write three free-flowing pages like Julia Cameron’s “Morning Pages” or respond to a simple prompt like “What do I need right now?”—the point is presence. You become your own witness, your own companion. You begin to build that muscle of self-reflection that turns into resilience over time.

It’s Okay to Start Small

If all of this feels overwhelming—please hear me: you don’t have to overhaul your life to begin healing. You don’t have to quit your job, move to a forest, or suddenly adopt a perfect morning routine.

Start with a breath. With a hand on your heart. Notice how your body feels right now. Ask yourself Helen’s beautiful question: “What’s the next kindest thing I can do for myself?”

It might be drinking a glass of water. Stepping outside. Turning your phone off an hour earlier. It might be journaling for five minutes or lighting a candle with your tea. The nervous system responds to “consistency”, not intensity. These small acts, done over time, rebuild the safety we’ve been taught to abandon.

I hope this conversation with Helen, and the reflections I’ve shared here, remind you that you’re not alone—and that there’s nothing wrong with you if you’re struggling.

Your nervous system is speaking. Your body is wise. And you are worthy of rest, of softness, of choosing yourself again and again.

The post The High Cost of ‘I’m Fine’: The Truth About High-Functioning Anxiety and Invisible Depression appeared first on Aviva Romm, MD.

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What if the way we care for new mothers is all wrong?

Not just lacking. Not just outdated. But built on a model that misses the heart and soul of what postpartum truly is — and what it could be.

When I was a home birth midwife, postpartum care was the care. I'd visit mamas and babies at home five or six times in the first few weeks. We’d talk about everything — from latch to lochia, sleep deprivation to soul shifts. It wasn’t “extra.” It was essential.

It’s part of why I went into medicine, because as a midwife I saw too often, how in this precious, vulnerable, formative window for mothers and babies –  care just disappeared for the mother after the baby was born. A first visit may have been 6 or 8 weeks after the birth, by which time mothers were struggling alone with overwhelm, breastfeeding challenges, or worse, anxiety, depression, isolation, and sometimes they’d given up breastfeeding because they had no support. And when they did get care, all too often they had to sit in waiting rooms, a baby and toddler often in tow, waiting for an appointment only to get 15 minutes with a doctor whose had no idea to support mothers postpartum. 

This week on On Health, I’m joined by my long-time colleague and kindred spirit Dr. Eva Zasloff — a fellow family physician, artist, mother, and fellow revolutionary in postpartum care — to talk about the radical simplicity and profound necessity of caring for mothers in their homes, in their own rhythm, and on their own terms.

 Inside the Episode We Talk About

• The surprising (and heartbreaking) truth about conventional postpartum visits
• Why 20-minute clinic appointments can do more harm than good
• Eva’s bold leap from family doctor to founder of Tova Health — a home-based, whole-person care model serving over 600 families
• The “twilight zone” of early motherhood — and how we can hold space for it
• What home visits offer that clinic visits never can
• Why postpartum depression and anxiety are often symptoms of a broken system
• The healing power of birth stories, coconut oil massages, and Zoom mama circles that make a difference

What Eva is doing with Tova Health, and what I’m doing with The Mama Pathway, are  not just beautiful experiences for mothers— they’re necessary for maternal health. It’s a return to wisdom we’ve always known. And it’s a model I dream of seeing in communities everywhere.

If you’re a doula, a midwife, a family doc, or a mama (or someone who loves one), this episode will touch you deeply — and perhaps inspire you to bring this care into your own community or at least raise your awareness about the importance of listening to, being with, and supporting new mothers. 

Resources + Links

• Learn more about Eva and  Tova Health
• Explore the Mama Pathway postpartum program
• Read Aviva’s book Natural Health After Birth — one of the earliest guides on the fourth trimester

Loved this episode?

Share it with a friend, sister, or doula. Leave a review. Join us on Instagram @DrAvivaRomm and let us know what postpartum care has meant for you. And if you’re dreaming of a better way — whether you’re a practitioner or a mama — I see you. And this episode is for you.

What if we treated postpartum as sacred?

Not as an afterthought. Not as a single rushed appointment six weeks out. But as a vital season — tender, transformative, and deserving of the deepest care.

For over two decades, I practiced as a home birth midwife before becoming a family physician. My postpartum visits weren’t “optional” — they were the heart of what I did. I’d show up for mama and baby on day one, then again on day three, day seven, day ten. I’d sit with them in their homes, often barefoot, sometimes sipping tea, always listening.

We’d talk about breastfeeding. About bleeding. About sleep (or the lack of it). We’d go over their birth story. I’d hold space for the messy middle — the tears, the doubts, the awe, the ache. Because in those first weeks, everything is raw. The milk is coming in. The uterus is still cramping. The baby is learning how to latch. And the mama? She’s learning how to mother this baby — not just any baby.

Then I entered medical training. And everything changed.

A System That Doesn’t See Mothers

As a family medicine resident, I quickly realized how fragmented our system is. We expect new parents — sometimes just days postpartum — to schlep into clinics, sit in germy waiting rooms, and squeeze their story into a 15- or 20-minute slot. Most pediatric visits don’t include meaningful postpartum check-ins. And the maternal visit? That might not happen until six or eight weeks out.

We are failing mothers.

We’re so focused on baby's weight gain that we forget the mama whose body is still bleeding, whose nipples are cracked, whose hormones are shifting like tectonic plates.

Dr. Eva Zasloff, my guest on this week’s On Health podcast, saw the same thing. Trained as a family doc, Eva began noticing how inadequate and disjointed postpartum care was — not just for babies, but for mothers. She’d finish a visit with a newborn and find herself saying, “I think I need to see you again tomorrow.” But that meant dragging the whole exhausted family back in again, with no additional time allotted to assess mama’s healing, bleeding, or mood.

So she did something radical.

She stepped outside the clinic — and brought the care home.

Reimagining Postpartum: One Home Visit at a Time

Eight years ago, Eva founded Tova Health, a home-based fourth trimester practice now serving hundreds of families in the Boston area. She shows up at their front door, baby scale in one hand, stethoscope in the other, and begins each visit not with the baby — but with the mother.

“How are you?” she asks. Not just as a pleasantry. But as a true check-in. A lifeline.

She listens to birth stories. Assesses healing. Talks about boobs and bleeding and latch and leaking. She weighs babies, yes — but without obsessing. She screens for postpartum mood disorders. And she reminds mothers of something essential:

Your body is wise.

Your baby is wise.

You know more than you think.

In a world of parenting apps and endless advice, Eva helps parents come home to their own instincts. She calls it “demedicalizing the moment” — replacing fear-based rules with spacious, supportive care.

A Twilight Zone of Transition

There’s something else that happens in those early weeks after birth. Something we don’t talk about enough.

It’s disorienting.

You’re not sleeping. Your body’s not your own. You’re nourishing a whole human with your breasts, your touch, your everything. And yet, you may feel totally alone.

As Eva describes it: “You’re never alone, and yet you’re so lonely.”

That’s why she created virtual mama groups — weekly Zoom circles for her postpartum families. There, mamas share birth stories, cry, laugh, ask questions, and simply see each other. The fourth trimester becomes communal again — even if the connection is digital.

Returning to What We’ve Always Known

What Eva is doing isn’t new. It’s old. Ancient. It’s what midwives and wise women have done for generations. And it’s what modern medicine has nearly forgotten.

But we can remember.

Whether you're a birth worker or a pediatrician, a new mama or a grandmother, this matters. Because when we care for mothers, we care for babies. We care for families. We care for our collective future.

As Eva said to me: “This is just good design. Two people — the mother and the baby — needing care, together, in the comfort of their home.”

It’s that simple. And that's profound.

If You’re Dreaming of More…

Maybe you’re a practitioner dreaming of starting your own home-based care model. Or maybe you’re a mama longing for support. Maybe you’re somewhere in between.

Start where you are.

Find your people. Ask your doula or midwife if there’s a local postpartum group. Join the Mama Pathway. Connect with Tova Health if you’re near Boston. And if you’re a provider wanting to learn more, reach out to Eva. She’s growing this movement — one mama at a time. Or reach out to me to become a Mama Pathway Mentor – and learn the art of postpartum care.

We can’t change the whole system overnight. But we can bring the medicine home — literally and metaphorically — and it starts with remembering what really heals – and what mothers really need

The post Reclaiming Postpartum: A New (Old) Model of Mama + Baby Care appeared first on Aviva Romm, MD.

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In 2000, my book Natural Health After Birth was still an early voice in the wilderness on the  conversation on postpartum depression – a topic which was then still only whispered about, and was largely taboo – because what new mom isn’t happy? 

In reality, many. Motherhood, even on the best of days, is an enormous job and requires incredible inner landscape and life shifts. 

For many new mothers there are deep valleys and mountains to climb. 

• 1 in 5 pregnant and new mothers experiences a PMAD- Perinatal Mood and Anxiety Disorders (PMADS)
• 1 in every 10 women/birthing people endures postpartum anxiety after GIVING birth and 6% of women/birthing people experience it while still pregnant.
• More than 15% of women/birthing people experience postpartum depression, perhaps even more given that the diagnosis goes highly unreported.
• 3-5% of mothers/birthing people report feeling as though they cannot escape  intrusive, irrational and upsetting thoughts about something happening to the baby unless they engage in a repetitive act.
• While rare, postpartum psychosis is a dangerous and devastating condition that requires prompt medical care. 
• PMADS are the #1 complication associated with birth
• PMADS are the #2 cause of maternal mortality

It’s not just you. You're not crazy. You're not a bad mom. You're not alone.

These are words – and deep beliefs – that resonate through and form the backbone of the work of today’s guests, Catherine Birndorf, MD, and Paige Bellenbaum, LMSW. Catherine and Paige are dedicated to changing the perinatal mental health terrain, and they do it through The Motherhood Center, a place of radical acceptance, nurturance, and individual and group support.

On today’s episode, we pull back the curtain on motherhood and redefine what is considered “normal” and “typical”. With Perinatal Mood and Anxiety Disorders (PMADS) being the #1 complication associated with birth and the #2 cause of maternal mortality, this is a critical conversation. We unpack why it’s so important that we talk more about these conditions, how to do your best to prevent PMADs, and what to do if you or someone you love has symptoms. 

Aviva, Paige, and Catherine discuss: 

• The definition of Perinatal Mood and Anxiety Disorders (PMADS) and the different diagnoses that fall under the PMADS umbrella 
• What PMADS taboos still exist today, why this needs to change, and how Roe v. Wade affects these taboos 
• Paige and Catherine’s personal stories with perinatal mood disorders and what brought them to the point of specializing in PMADS and opening the motherhood center 
• The kinds of physical and psychological feelings and symptoms associated with PMADs and signs birthing people and their providers should watch out for 
• Why we need to move in the direction of making it mandatory for OB-GYNs, midwives, pediatricians, and any providers who come in contact with newer expecting mothers to begin educating their patients about PMADS and screening for symptoms  
• The effects of the pandemic, social isolation, and potential cultural contributors on PMADS  
• The role of medication and psychotherapy in treating conditions 

Catherine Birndorf is a reproductive psychiatrist and the co-founder, CEO, and medical director of The Motherhood Center of New York. Dr. Birndorf is the founding director of the Payne Whitney Women’s Program at Weill Cornell Medicine and a clinical associate professor of psychiatry and obstetrics & gynecology. Dr. Birndorf was a regular mental health columnist for Self Magazine and has appeared on numerous television programs, including The Today Show, Good Morning America, MSNBC, and CNN. She is the author of The Nine Rooms of Happiness and What No One Tells You: A Guide to Your Emotions from Pregnancy to Motherhood.  

Paige Bellenbaum is the founding director and chief external relations officer at The Motherhood Center of New York. For the past 20 years, she has worked in public policy, advocacy, and clinical care with various populations, including homeless families and incarcerated young adults. She drafted legislation in New York State championed by Senator Liz Krueger, mandating hospitals to provide education on PMADS and strongly encouraging screening of all new and expecting mothers, signed into law in 2014. She has appeared on the Today Show, Good Morning America, NPR, PBS Newshour, Fortune, The New York Times, and The Wall Street Journal. 

To contact The Motherhood Center:

Website: themotherhoodcenter.com

Phone: 212-335-0034

For more on prenatal and postpartum depression, check out this article – Natural Approaches to Depression in Pregnancy – and this podcast – Facing and Healing Postpartum Anxiety with Gabby Bernstein – on my website.

Please share the love by sending this to someone in your life who could benefit from the kinds of things we talk about On Health. And make sure to SUBSCRIBE wherever you listen to podcasts.

Thank you so much for taking the time to tune in to your body, yourself, and this podcast!

This conversation has been edited for length and clarity.

Aviva: These are the voices of mothers who have come through the Motherhood Center of New York. In 2000, my book “Natural Health After Birth” was still an early voice in the wilderness in the conversation of postpartum depression, a topic which was then still largely taboo. Why? The assumption is that every new mom should be happy. In reality, motherhood is an enormous job even on the best days, and requires an incredible landscape shift for many new moms – both inwardly and outwardly. 

There are deep valleys and mountains to climb for new moms. One in five pregnant and new mothers experiences a PMAD – a Perinatal Mood and Anxiety Disorder. One in every 10 women and birthing people endures postpartum anxiety after giving birth, and 6% of women and birthing people experience it while still pregnant. More than 15% of women and birthing people experience postpartum depression – perhaps even more, given that the diagnosis goes highly unreported. 3% to 5% of mothers and birthing people report feeling as though they cannot escape intrusive, irrational, and upsetting thoughts about something happening to the baby unless they engage in repetitive acts – OCD behaviors. While rare, postpartum psychosis is a dangerous and devastating condition that requires prompt medical care.

PMADs are the number one complication associated with birth, and the number two cause of maternal mortality. My guests today, Catherine Birndorf, MD and Paige Bellenbaum, LMSW, are dedicated to changing the perinatal mental health terrain through The Motherhood Center of New York, a place of radical acceptance and nurturance. The center is a place that offers individual and group support for pregnant people and new mothers. It’s a place that understands their diverse needs and helps them learn the transitional skills necessary in order to survive and thrive as mothers. It teaches them how to ease the transition into motherhood and heal from devastating conditions like pre and postpartum anxiety, depression, and OCD. I know that some of this stuff is scary to hear about, especially if you're pregnant now or plan to be down the road. My guest and I have a message for you.

Every disorder we are going to talk about is both temporary and treatable. We're going to unpack why it's so important to talk about these conditions, how to do your best to prevent PMs when possible, and what to do if you or someone you love has symptoms.

Catherine: Thank you for having us.

Aviva: I love being with you. I'm so inspired and moved by everything you do. Let's start by defining PMADs, so that everyone knows what we're talking about. I trust that you do this all the time, so tag team however you want to.

Catherine: Thank you again, Aviva, for having us. We are so privileged to be here and to be able to get this much time to talk about our favorite subject, PMADS – Perinatal Mood and Anxiety Disorders. I say it slowly and deliberately, because that is the acronym for a whole host of conditions and illnesses that we are trying to lump together. We lump them together so that if anybody feels anything that is related to becoming a new mother, they will be able to find themselves there. The reason I say it that way is because we used to just say postpartum depression. Before that, we didn't say anything – we weren't talking about it. Once we started talking about it, we would use the terms “postpartum” or “postpartum depression”, but people would say things like “Well, I'm pregnant and I'm anxious – am I included in there?” It became this big term that Paige and I don't totally love because it has the word mad in it. However, it's the best term we can find at the moment that holds everyone within it and allows them to  find themselves there if they should be struggling with any kind of mental health issue related to the perinatal period – before, during and after pregnancy. I hope that explains it.

Paige: There's a number of different diagnoses that fall under the PMAD umbrella – some that your listeners might be familiar with, and some they might not. To Dr. Burner's point, it includes not only depression, but anxiety, obsessive compulsive disorder, bipolar disorder, post traumatic stress disorder, and in rare but very serious instances, postpartum psychosis.

Aviva: Thank you – it does help to have that clarified, because I think that many people believe something along the lines of “Oh, well this isn’t postpartum depression, so it must just be something normal”, and this leads them to ignore it.

With this podcast, I am committed to breaking down taboos and shining a light on what's hidden. You all know that I've been in maternal health for a really long time now. I started my midwifery journey in 1981, and it wasn't until the late nineties or 2000 that Marie Osmond came forward about her PPD. It was almost like tabloid fodder at the time; I think that she was initially treated as a joke in some ways. However, for so many women it was like the revelation of a dirty little secret that opened the lid on a hermetically sealed jar of postpartum realities. Why was PPD originally postpartum depression? What taboos persist now, and why? Why does this need to change?

Paige: I think that it remains taboo today for the same reasons that it was taboo 20 years ago; 50 years ago; even 150 years ago. There is a very specific interpretation of what it means to be a mother. Motherhood is very romanticized and glamorized, to an extent. When we hear the word motherhood, many of us automatically go to that place of “blissful, amazing, best thing that’s ever happened to me”; unconditional love and bond with my baby; glowing; happy – all of these things that we associate with the perinatal period. What ends up happening in that kind of romanticized version of motherhood is that all the other parts get left out. When we have this very specific definition of what it is to be a mother and what it is to feel like a mother, we don't make any room for all of the other complicated, normal, and very real aspects of the transition to motherhood.

What we are left with is “If I don't feel that way, then there's something wrong with me”. “I'm failing at this. I'm doing it wrong.” “Everybody else has this figured out. I'm the only one who feels like I made a mistake – who wishes I never had this baby. The only one who is so anxious that I can't even be in the same room with the baby.” The list of symptoms goes on and on; it is a deep, dark secret. It always was. To your point, there are more and more people who are coming forward to share their stories, which helps to destigmatize. Unfortunately, the stigmas still very much exist. I think the fans are flamed in this new Instagram, social media world we live in, because that's all we see –  the blissful part.

Aviva: It's so curated – so dangerous and misleading. It isn’t that motherhood can't be all those things; I didn’t experience postpartum depression anxiety, diagnostically. I had a relatively easy transition compared to what a lot of women go through. But even within that sort of “normal” range of the experience, it was often really hard. It was helpful for me to already be studying midwifery and around other mothers with whom I could be honest about my experience.  I think that sometimes just vocalizing it, even when it's the “normal” stuff, is helpful. We have to be able to tell the truth, because it's so overwhelming. 

Catherine: Very true. I hate to bring this up so early on, but I think that in the post Roe era the idea that motherhood is something that everybody wants and should have only moves us back in terms of taboo. It’s going to keep it entrenched; it’s going to make it worse. We have a bigger problem ahead of us – not just in terms of reproductive rights and women's healthcare at large, but in terms of what motherhood is, because now we're being told what it is by the legal system. We are being pigeonholed more than ever. To your point, Aviva – you don't have to have a diagnosis to struggle or feel ambivalent about the challenges of becoming a new mother. That is the norm. 

Aviva: I'm going to call it “compulsory motherhood”. We do know from pretty well conducted studies that the inability to have an abortion, if that is what you need or want to do, statistically increases the rates of perinatal anxiety, depression, and other poor outcomes for mothers across the board. Yeah. I feel that our collective and individual work as human beings is so often a reflection of our own journey – things that shape us along our educational path, or that happen to enter our lives and put us on a path.  I would love to hear each of your stories about what brought you to the point of specializing in PMADs, and to opening The Motherhood Center. I know that you're both deeply invested in this work. Paige, you specifically had a very trying experience with perinatal mood disorder.

Paige: I did. Despite the fact that it was 16 years ago, I can still touch it and feel it like it was yesterday. I trained as a clinical social worker during the pregnancy of my first child, and I highlight this because even as a clinician, when I started to experience symptoms of anxiety and depression, I didn't know what they were. I didn't know if it was or wasn’t normal, and I didn't really talk to anyone about it. When my son was born, I rather quickly started to experience very acute symptoms, primarily of depression and anxiety. I didn't tell anyone; I kept it a secret for about 6 months. It  was very difficult for me to get out of the house, to care for myself and for the baby. I felt like I'd made the biggest mistake of my life.

I wished I'd never had my son. I wanted to buy a one way ticket to another country and never come back. I didn't want to be alive, and I felt like the biggest failure as a mother – the biggest failure of anyone on the entire planet. I was petrified to tell anybody that I was feeling that way, because what kind of a mother would feel that way about her own child? 

One day when I was taking my son for a walk on the sidewalk and everything felt gray and dark. It was the first time I'd been outside with him in a really long time. I started to approach a corner, and I saw that a bus was coming. All I wanted to do at that moment was to throw both of us in front of that bus, because I thought we'd be better off. I thought he'd be better off without me – this terrible mother who couldn’t live with such a big mistake. I don't know what held me back, but I did not do that. I remember the bus passing by; I caught a reflection of my face in the window and I thought “Who is that person? I don’t recognize her”. I knew that I undeniably needed help. As fate and luck would have it, I found myself being treated at the Payne Whitney women's clinic, which is the very clinic that Dr. Birndorf started. I started to heal and get better; I started therapy and I went on medication. I started to feel more connected to my son, and I started to enjoy motherhood as I was meant to.

When I got better – and when I can tell that so many other women at the clinic are on the road to recovery – was when I realized how common this experience was. I started speaking with so many other women who knew how I was feeling.  They said “Me too, me too”. That's when I took it to the legislative street -I started drafting legislation. Fast forward, we got our law. As you mentioned, our bill was signed into law  in 2014, and I was hooked. A few years later I joined forces with Dr. Birndorf and the original co-founder. Seven years ago we came together to create this amazing space that's been open for five years now. It’s the best thing that we ever did, and it's the hardest thing that we ever did – kind of like motherhood.

Aviva: Catherine, do you mind if I ask Paige a few questions about her experience before we jump in? Paige, during those six months, what kind of physical and psychological feelings and symptoms were you having? Did anybody around you notice or say anything?

Paige: I wasn't sleeping.  I wasn't eating.I felt anxious all the time. I always had cortisol racing through my body. I didn't feel connected or attached to my baby at all. I was going through the motions of caring for him, but I didn't feel anything towards him or for him. I had really dark thoughts of not wanting to be here anymore – not wanting to be alive. I had a hard time caring for myself, bathing, brushing my teeth, going outside. I wasn't finding any joy in anything that I used to enjoy. I felt hopeless. I couldn't make decisions. 

I know my husband knew that something was wrong; we actually did a really beautiful story together for NPR a couple of years ago, and it was amazing to hear him share his side of it in that moment. But he didn't know, either. He didn't know what was normal and what wasn't. There was one woman – a friend of ours – who came over to visit. She pulled aside and said “There's something really going on here”. That was right around the time that I decided I really needed to get care in order to stay alive. But other than that, nobody said anything – not my providers, not friends or family. I don't blame anybody, because this was 16 years ago. Well, I do blame providers a little bit –  we don't talk enough about it. This is where we see women fall through the cracks.

Aviva: I struggle with this a lot.  When I'm teaching pregnant people or even preconception people, it’s a balance between not wanting to scare them but at the same time knowing that, when we have the information, we have the knowledge and permission to get help. If we have symptoms of preeclampsia during pregnancy, somebody's looking for that, because we know it can be life threatening. Not enough people are looking for it postpartum, and that is when it's also life threatening. Even when these conditions are not life threatening, they're life disabling. They can be joy robbers of new motherhood.

With all the information we have around bonding, it’s a double whammy, right? You're experiencing all this horror, and then you're also worried that you're not bonding with your baby – that you're harming your baby in that way. When it comes to prenatal or early mom education, how much do you feel like we should be weaving this into the conversation of anticipatory care, along with nutrition and other things? 

Catherine: Can we start in grade school?

Aviva: I'm with you.

Catherine: I'm not joking, even though we're laughing. We need to be talking about this as if it’s typical. There's a word, “matrescence”, which means becoming a mother. It's not a developmental stage per se, because it doesn't apply to everybody. Not everybody goes through it. I think that in that journey, it is typical. Again, I hesitate to use the word normal, but it is normal but to feel ambivalent – to feel challenged and to know that it’s confusing. You know, all the emotions – a full spectrum of emotions. When you think back to the childhood books we read, or to the stories that we've been told and the movies we’ve watched, what we see is that it's just beautiful and easy.

Moms and women who don't like kids – don't feel bonded to their children, who struggle – are sometimes considered monsters. That's so unfair. It's so not right. There are so many different ways to feel. That is normal. That is typical. Because we only allow it to be a certain way, we don't have that opportunity. We could be teaching that at an incredibly young age, if we could just open that door. You asked the question, how much do you say in a prenatal visit? I've been up against this since I started my training in the early 90s. They didn't want us to go into the hospital. I would say, “Can I come talk to your moms about postpartum issues?” and they'd say “What do you mean? What are you going to say? You're going to scare them”. I was like, “I'm really not. I'm going to speak about the spectrum of feelings that women can have, or families can have”. They really made it hard – The establishment, even the nurses who ran this program. They were nervous to have me come in and speak about postpartum illness because of what it was going to do to the patients or to the prospective parents. It’s so unhelpful to not tell anybody the truth.

Aviva: My book came out in 2000, which means that I was writing it in ‘98. Now thinking back, it was ahead of its time. I had a midwifery client who came in with her second pregnancy. She had experienced six years of deep postpartum depression – it was a PTSD situation from a birth trauma. Interestingly, she had had a homebirth and had to transfer to the hospital because of a hemorrhage. Midwifery was illegal in the state that she was living in, so the midwives put her in the car and sent her to the hospital with her husband. She felt desperately abandoned. On top of it, she had a postpartum thyroid problem, so she had had heavy bleeding. 

She had so many reasons for being at risk for postpartum depression, but it was clear when she came to me that no one had noticed the symptoms in her for two years. She lived with two years of hell. That was when I started to dig in –  to actually print out articles from the medical library. There wasn't that much available, but there was some work There was Dana Raphael's work, some work on doulas and the importance of female care and birth, and some work on postpartum depression. What's crazy to me is that ‘ve been through seven years of medical education – three years of that  with a focus on obstetrics in family medicine – and many years of midwifery. There was no training in any of that on postpartum, and the prenatal anxiety and postpartum anxiety are certainly newer. Catherine, you were ahead of your time as well with setting up the clinic and getting into the work around postpartum depression and PMADs. What inspired you?

Catherine: Your story is so resonant – mine is not so different. My story begins long ago, when I was at Smith, an all women's college. I loved always having the woman's perspective incorporated into all classes – I thought they did it so brilliantly. That was just part of the culture. I became very interested in reproductive rights, and I thought I was going to go that route professionally. When I found that I wasn't qualified to get a job working in policy after college, I ended up working in a women's health center. It was  essentially an abortion clinic in a halfway house. I lived there two nights a week  and helped to provide mental health care. It was a really progressive place in Washington, DC – it was amazing. 

All of that informed where I was heading. I didn't know I was going to end up in med school, but I found myself there. I was feeling like the women that I saw around me were doing the coolest things, but were not getting the respect they deserved because they didn't have the MDs. I don't know if you’ve had that experience, Aviva.

Aviva: That’s why I went to medical school. I was happily practicing as a home birth midwife, but I was in an illegal state, which also happened to have (and still has) the highest maternal and infant mortality rates in the country. I felt really powerless to do anything, because my voice as a home birth midwife was entirely invisible. I even tried to involve the Atlanta University black family health project – got a board together to try to create a MOMobile to go into high risk communities. This was in 1986, and I was told I couldn’t do it. “You're an illegal midwife – you guys don't count here.” So for me, it was really about having the credentials and the credibility to make a change – exactly the same thing that you're talking about.

Catherine: I would've come to work for you if that was happening. That's incredible. It’s sort of the same – I thought to myself, “Well, if I'm going to go this route, I might as well go big.” I had to go back to school and do my post back – my premed. When I ended up in medical school, I really thought I was going to be an OBGYN.  I worked with midwives. I was at Brown, and all the babies I delivered in med school were with the midwives, which was so cool. I got to psychiatry and I figured out what I wanted to do – it blew my mind. I thought, “You know, I can get to women's mental health in a variety of ways, and this seems to be a better fit for me.”

I was always committed to the intersection of OBGYN and psychiatry.  I got into the field when I was in my residency. I had my first kid, got pregnant in my third year, and delivered in my fourth year. I'll never forget how incompetent I felt.  I left maternity leave early to get back to work. I got eight weeks, because I had a C-section – you get six weeks for a vaginal delivery, and eight weeks if you had a C-section. I remember at week seven thinking, “I'm losing my mind. I don't know what to do with this kid. I'm totally incompetent. I think I'm making things worse, and I better get back to work where I know how to be successful.” It wasn't going that well at home. My husband is also a physician, and he was in his research years. The two of us were looking at each other like ding dongs, and didn't know where to get help or what to do. So I think that my personal story started there – it was really hard to be a new mom.

Aviva: It  brings you to your knees, no matter what competencies you have in your life. Sometimes I think the women I work with who have a significant amount of external competencies are cognitively challenged by the transition. Suddenly they’re thinking, “I don't even know how to change a diaper or make this baby stop crying. Are they starving? What's happening here?”

Catherine: I was always pushing, always asking for more. “Hey, can I go over to observe at OBGYN and talk to the patients?” Nobody was doing it. I also ended up in Chicago during my second year of residency, because my boyfriend at the time (who is now my husband) was at University of Chicago studying surgery. I went there for my second year so that we could be in the same place, and I ended up getting myself a position in a residency program for that year. 

I worked with Laura Miller, who’s one of the foremost experts in the field. She had a unit that I wanted to work on for psychotic, pregnant, addicted women. They didn't have it in New York, so it turned out that the year I went to Chicago, I actually got the most robust trading of my residency. When I came back, I was on fire. I was like, “How do I get this? How do I find this? How do we create this? Why isn't this happening?” There were a few people doing it, but they were kind of in their own silos; there was nothing organized. When I started the women's program, I went back to Chicago with my husband to finish and apprentice there with a colleague at Northwestern. When I came back to New York, there were six or so seminal articles on the topic of meds in pregnancy.

I remember when I started the program – I was like, “Here's your little packet of what we know. Here's the definitive work in the field, and it's not particularly definitive.” I was adamant that we were going to help these women – to sit with them, trying to understand their individual positions and why they were struggling. I tapped everyone I ever knew in the field and asked them for their help. I asked them what they did, how they pushed forward.  I really stand on the shoulders of many before me who helped to create this field of reproductive psychiatry, or perinatal psychiatry. It didn't even have a name back then. 

Aviva: Now most women go to their OBs. Some women go to their midwives. In conventional medicine, we don’t start postpartum care until eight weeks postpartum. Most people don't get sent to a perinatal psychiatrist or psychologist, and most OBs – well, it's not just OBs. Pediatricians, family, doctors, midwives, postpartum doulas – all the people involved in the care either don't know what to look for, or don't know the questions to ask. Even if they do see something, they don't know what to do. Unfortunately, the onus is on the pregnant or birthing person to recognize what signs and symptoms to look out for. 

Paige: There's a couple of things that I want to say. You've made some really important points here. The truth is, I’m coming off of the coattails of a three day conference. I was with a whole bunch of perinatal mental health specialists in New Orleans, and you're right. OBGYNs, pediatricians, and other providers that come in contact with new and expecting mothers are not talking about or screening for PMADs. Where does that leave us? That leaves the onus on a new or expecting mother who's already struggling, who's drowning in a sea and paddling as fast and as hard as she can to keep her head above water. I speak from experience when I saw that the last thing she is able to do is pick up the phone and start trying to find help for herself.

We need to move in the direction of making it mandatory for OBGYNs, midwives, pediatricians, and all of the other providers who come in contact with a new or expecting mother, to start talking about PMADS. Education is prevention. We need to be screening for PMADs – not just once.  I would go so far as to say every three months. PMADs need to be a part of every visit, every conversation, because that's where we start to break down the stigma and the barriers. We give women permission to feel this way and ask for help. That is one of the only ways we're going to be able to fight the statistic of 80% of all new and expecting mothers falling through the cracks. Now I’m going to pass it over to Dr. Birndorf to talk to you a little bit more about the actual signs and symptoms.

Aviva: Amen, sister. I could totally get behind working together to make that requirement a reality.

Catherine: Yes – back to basics. I want to make the point that just because depression, anxiety, PTSD, OCD, and psychosis are happening during the perinatal period, it doesn’t mean that it’s causal.  It's just the timeframe. They're happening in the context of the hormonal storm, yes, but we don't know if that’s the cause. That is a stressor; it is part of it, but it is not the whole story. People see pregnant or postpartum women and they're like, “I don't know what to do. I can't touch that patient. We can't do research on these people because they're so fragile and different.” That's a problem.

Aviva: We're living through a mental health epidemic where one in four women is on an antidepressant or on an anti-anxiety medication. As you say, this may just be something that exacerbates an underlying condition or is part of a bigger cultural milieu.

Catherine: There's lots to say about what you just said, but first I want to get back to basics. I go back to med school asking, “What is depression?”  don't know if you remember SIG-E-CAPS: It's an acronym for depression screening that all of us medical students had to memorize.

Aviva: We have so many acronyms.

Catherine: So many acronyms! But it’s about sleep interest. G is guilt; E is energy; C is concentration; A is appetite; P is Psychomotor –  retardation or agitation. 

Aviva: For people who don't know, retardation and agitation means slow movement and irritable movement, respectively.

Catherine: Thank you for the translation. What I want to point out is that people go to their doctor, midwife,  or providor during pregnancy or afterwards, and they say, “I don't feel great. I'm not sleeping well or eating well. I can't concentrate. I don’t have my usual energy.” Those are the first four symptoms of depression. It gets confusing, because people will write you off and say, “Oh, you're fine. Everybody feels that way.” But what Paige was describing is never normal – hopelessness, guilt, feeling like you don't want to be here anymore, not enjoying things. None of that is normal. Hopelessness, helplessness, guilt, and suicidality are never normal. You don't always know to ask those things or to tell those things during your postpartum visit or your prenatal visit, so they could easily be overlooked.

Aviva: What about the anxiety symptoms?

Catherine: Again, the anxiety symptoms come in the form of apprehension, dread, fear, and avoidance. With a panic disorder you have elevated heart rate, sweating, and sympathetic responses. You feel like you're going to go crazy or die. They crescendo and decrescendo quickly. You can have OCD type symptoms, which have been kicked out of the anxiety disorders category, but we still think of them that way. You have thoughts that you can't get out of your head, or compulsive actions like washing, checking, counting, cleaning, evening things up, touching specific things – sort of magical thinking that revolves around ways you can neutralize the anxiety that you feel. That can take up lots of time in the day, and to some extent can also lead towards a loss of touch with reality. We also have PTSD, which is a re-experiencing of trauma. The trauma can be from birth or from other events in the past. You experience the traumatic event or events again and again, or you have hyper arousal. Those are the basics.

Paige: I want to throw in two more, one of which I feel is important because it happens to so many women. Every time I say this to a crowd, people are like, “Oh my God. I'm so glad you said that. That happens to me, and I didn't know it was something that 80% of all women experience.” Scary, intrusive thoughts that are very distressing and disturbing. Sometimes graphic thought images will pop into a new mother's head, and she can’t get rid of them.

Catherine: Horrific thoughts about hurting the baby, throwing the baby. Terrifying stuff.

Paige: A new mom cannot get rid of these thoughts – they keep happening. Thoughts about putting the baby in the microwave, throwing the baby down the stairs, throwing the baby out of the window, pushing a stroller into traffic. You name it. These thoughts just pop into her head. and she is petrified. Oftentimes they get in the way of her actually going into the kitchen, leaving the house, getting close to windows, or even walking down the stairs. There is an OCD flavor to it, and 80% of all new mothers have these thoughts. They're so disturbing that we don’t talk about them; we keep them inside, and feel terrible. What kind of mother would think this way about her baby? Well, 80% of all new mothers would have those thoughts. 

The other thing  I want to say falls into the category of birth trauma – PTSD is birth trauma. It happens so frequently. Because birth, for all intents and purposes, can be such a beautiful experience, that’s often the only way we're conditioned to speak of it. But so many women experience a traumatic birth. As Dr. Birndorf always says, trauma is in the eye of the beholder. It doesn't matter if, as a listener, you think it's traumatic or not. It's about how that person experienced it. Birth trauma can lead to all kinds of PTSD symptoms,  and so many women experience some level of birth trauma that can be really activated in the postpartum period. It can oftentimes be seen in concert with some of those other symptoms.

Aviva: It can be triggered by breastfeeding or hearing the baby cry – by the relationship with the baby in general. The data I read most recently says that 7% to 14% of women experience birth trauma, and up to several percent could be diagnosed with PTSD based on their birth experience. That's a really high percentage.

Catherine: I thought the number was actually a little bit higher.

Aviva: It may have gone up since the pandemic, which I want to ask you about. Again, when I was writing my book many, many years ago, there was much more anthropological data than there was actual data, and anthropological data can be romanticized. We know that there's dramatic under reporting, and at that time, the conversation was primarily around postpartum depression. It does seem that in many cultures – especially ones where people live in community, or more traditional foreign cultures –  perinatal anxiety and depression, and especially postpartum depression are not much of a thing. I'm curious to hear your thoughts on that.  

Paige: We've all heard the term “it takes a village”, right? Sometimes we've heard it so often that it's lost its meaning, but we revive it all the time because it's such a powerful statement. It is so true. When we look back anthropologically at families and family systems, we see that there were much more expansive units of family members – cousins, aunts, and uncles around to help new moms. Many, many years ago, there were many family members eating at the same time, so the baby was passed around. It was really a family affair. Fast forward to contemporary society: even in the best of times, parenting is a very isolating and lonely experience. 

You take a place like New York, which is where we are, and I can speak for myself. My parents are in California. My husband’s parents are in Germany. We don't have any family members here with us – it's just us. This doesn't even begin to talk about the experience of single mothers who don't have that family network and social support system in place to help them transition to motherhood. They are alone and isolated by design. Add a pandemic to that scenario, and you’ll understand why we have never seen rates of mental illness so high across the board, and in our particular area in regards to PMADs, That lack of social support is even more sparse; the isolation is even more profound. High levels of stress and anxiety are a direct result of an international pandemic, a pandemic that is life threatening to a pregnant person or a new mother, whose sole purpose is to keep her infant baby safe and healthy. You bring all of that into the room, and it's no wonder that we've been seeing these skyrocketing rates of depression and anxiety in the perinatal period.

Aviva: What kind of rates have we seen since the pandemic? I heard a statistic that said there has been a 70% increase in perinatal mental health symptoms and conditions. Is that about right?

Catherine: Yes. I don't have the statistics off the top of my head, but a study at the Harvard school of public health showed that there was an astronomical increase. I think Paige and I usually quote around a 72% increase in rates of anxiety and depression during the pandemic. That’s the top end of the range, but what we know is that we have all been so fundamentally changed during this never ending pandemic that rates of everything seem to be having an uptick. 

I don't know where we're going to land or how it's going to go, but I would say that there is most certainly a maternal mental health crisis happening. It’s evident in the number of calls that we're getting at the center; in the rates of admission to our programs, both our outpatient program and our perinatal day program. As I sit here now, I'm getting a call about another emergency. There are emergencies happening daily in ways that we have never seen before. People are unhinged – that's a colloquial word that everyone can understand. What we're seeing with pregnant and postpartum women is profound. We're dancing as fast as we can to keep up with the need, but there is so much more that we could be doing. Everyone in our field is trying to meet the needs, to be ahead of it. To have the places for people  to go, knowing that crises are on the horizon. I don't mean to be so negative, but on the other hand, I feel like there is so much that we know, and there is so much we can do. You can medicate pregnant women and those who are breastfeeding. We have tons of data on that, and it's relative safety, yet people are still wondering, “Do I have to go off my medications because I'm pregnant?” Well, if you're bipolar and you go off your meds, you're likely going to end up in the hospital. Does that seem like the better way?

Aviva: Back to this issue of being negative – I think that our culture has such a toxic positivity that if we talk about the truth, then we're somehow seen as negative. I apologize for it too. There's a liberation in knowing that we're not alone.

I've told this story before, because sometimes people look at someone like me, or other people who are out there in the public, and think that we have it all together. I remember being pregnant with my third kid and trying to get my oldest two off to a playdate at the park. It was like a cartoon strip of a mom escalating and escalating just to try to get the kids to put their shoes on, trying to go do something fun with the kids. I was emotional.I had this empty plastic Tupperware in my hands, and I took it and threw it on the ground. It bounced up to the ceiling and the kids were like, “Oh shoot – Mom's really upset.” They got their shoes on and we got to the park. I was a midwife at this time, and the other moms in the mom group looked up to me. I sat down, and the moms were sharing all their happy stories. Someone said, “How's it going, Aviva?” I was like, “Well, you know, I did throw the Tupperware at the ground this morning in lieu of throwing it at  someone.” There was this moment of time standing still, and then it was like time fast forwarded. All the moms started talking about what was really going on. 

When we say 72%, is that negative? No, it's, it's real. If you're a mom out there listening and you're hearing that number, I hope you're going, “It's not just me.” This is almost three quarters of all mamas. It doesn't make it better, but maybe it makes it feel a little less shameful. I want to keep emphasizing that it's a cultural phenomenon; it's how we live. There are known biochemical shifts and hormonal things happening. There are also unknown biochemical shifts happening. You're not alone. It's not you. Stop apologizing.

Paige: What you’re talking about is permission, right? We are normalizing it by sharing our truth and telling our stories, and giving other women permission to do the same.

Aviva: Catherine, I know you have some emergencies coming in, so I want to be respectful of time and what's going on for you. If you have a few more minutes, I'd really like to talk about medications. Paige, you mentioned medications being transformative for you, and Gabby Bernstein has been public about her work with you. I've spoken with her. I was there for her postpartum support, and I know how liberating medications can be, but they're incredibly stigmatized. In my online community, there's often a leaning into natural medicine, so there may be an even higher level of stigma around medications. I'm very supportive of their use prenatally and postpartum. We know from substantial data, at least in non-pregnant people, that combining medications with therapies like CBT can actually improve their efficacy and outcome. Can you talk about the role of medications, and the importance of giving women permission to explore them?

Catherine: This is my favorite topic, because we used to think that it was the mother or the baby – that it was an either/or situation. But if you have some kind of mental illness, from mild depression to more severe psychosis, you are at risk. You have to accept that if there's illness, there's risk, and you're weighing that against the medication – the potential risk of the medication versus the potential risk of the symptoms or the illness. No decision is risk free. People think, “I'll just sacrifice. I'll suck it up and stay home. I’ll never leave my house and I won’t go for prenatal care. Someone will give me something natural over the counter. I'll get it at the drugstore. Maybe I'll even smoke marijuana, because that calms me down.” But won’t take the FDA approved medications that are relatively safe and have been very well studied – probably more studied than any other category of medication that we know – because they think that those will harm the baby. What they don't realize is that they're potentially harming the baby in a million and one other ways that they are not considering, because they are not taking care of themselves. If you are not okay, and you are not well, you are not helping your pregnancy or the fetus. You are not helping your baby or child.

Aviva: Yes, we don't have to suffer. In my work, I'll make sure their thyroid is normal. I'll make sure they're not anemic. I'll make sure vitamin B12 vitamin and Vitamin D levels are normal. I’ll make sure there's social support. I may try botanicals, and other things. However, if I’m trying these things for weeks and weeks, they’re losing a lot of time. We all appeal to moms to do things, because it's better for the baby, but it’s also better for your memories and experience of pregnancy and postpartum – experiences that in and of themselves can cause you ongoing trauma. I'm a big fan of giving ourselves permission to not suffer and to not be miserable.

Catherine: Amen. I’d like to add that it might not even be medication that helps. It might be psychotherapy. We try everything in addition to, or before medications. If we don't need to use them, we don’t, but obviously by the time a pregnant or prenatal woman gets to a psychiatrist like me, there’s a high chance we might be introducing medication. We don't do it against anybody's will – we always do it in conjunction with the mom and the family. We give it a lot of thought, but sometimes it is a big part of the answer.

Aviva: I’m encouraging all of you listening to at least keep it in your toolkit of things that you would consider. Paige, you have said that it was like a life and death situation for you.

Paige: I mean, it was my life preserver. For those who come and learn more about The Motherhood Center, you'll see that our logo is a life preserver – not just because of medication, but because of treatment overall. For me, medication made all the difference. Of the thousands and thousands of women that we've treated, many of them who have taken medication continue to take it during pregnancy and in postpartum. Medication is life changing. It is a life preserver that will allow you to have the experience of motherhood that you have always wanted to have – to get back to your baseline and feel good. As we always say to pediatricians and other providers, a well mom is a well baby. That's when you can actually show up, be present, and have the experience and bonded attachment that you always hoped for.

Aviva: I'm going to ask each of you one quick question before we wrap up. If there was one thing you could each tell your younger self, perhaps your pregnant or new mother self, what would that be? Paige, do you want to go first?

Paige: I would perhaps steal some of the slogan of Postpartum Support International. You're not alone – this isn't your fault, and you can and will get better with the right support.

Catherine: Ditto. I would tell my younger self, “Be honest with yourself. Admit that you're having a hard time and tell somebody. Ask for help. Don't just try to shoulder it all.” That’s my M.O., and I didn't have to. I didn't have to be having such a hard time; nobody needs to be struggling alone. There are so many things and people out there – community to help hold you. We can do it together.

Aviva: You two are so beautiful. Thank you for being here. For those listening who want to reach out to you and The Motherhood Center, what are the best ways to do that?

Paige: They can give us a call at 212-335-0034. They can visit our website at www.the motherhood center.com. We offer support groups, outpatient treatment, inpatient therapy and medication management with reproductive psychiatrists and perinatal mental health experts. We also have a day program, which is a more intensive level of care for new and expecting mothers that are having a really hard time caring for themselves and/or their baby. We are serving all of New York state and New Jersey, and we're looking to expand. Even if you're out of state and are curious to learn more, you can give us a call and we'll help connect you to the care you need wherever you live. Please, please reach out. Call us. If you're struggling, we wanna help get you back on the path towards enjoying motherhood as you want to – the way you’re meant to.

Aviva: We're going to put the links to all of the things in the show notes, so you can find those folks over at www.avivaromm.com/174. Thank you both for joining me. As always, it's been such a pleasure to talk with you. I hope that we do some collaborative things. Stay in touch, and I  wish you both so much goodness in everything in your lives. Thanks for all of the goodness you're bringing to mamas, as well as pregnant and birthing people.

Paige: Thank you so much, Aviva. It was a pleasure to be here. Thanks for giving us the opportunity to talk about something that's so important.

The post Perinatal Mood and Anxiety Disorders (PMADS): The Hidden Motherhood Struggle appeared first on Aviva Romm, MD.

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There are the stories we tell out loud, and then there are the ones we keep tucked away—the ones that ache the most, because we’ve carried them with shame and in silence.

On this episode of On Health, we’re breaking the silence—and the stigma—around some of the most vulnerable, hidden experiences women carry: miscarriage, illness, identity loss, perfectionism, aging, and the shame and loneliness so many of us feel but rarely name.

I’m joined by the phenomenal Dr. Jessica Zucker, clinical psychologist and author of the groundbreaking memoir I Had a Miscarriage, and her latest book, Normalize It, which is just what we need: an invitation to stop apologizing for what we’re going through—and start talking about it.

Together, we explore:

• How grief grows in silence—and thrives in stigma
  Whether it’s miscarriage, anxiety, or a private health struggle, when we don’t talk about  it and feel shame, we end up carrying the weight alone. This conversation is about setting that burden down—and finding healing in honesty.
• What it means when you don’t feel like yourself
  Jessica opens up about the disorienting fog of anxiety and identity loss—and how unsettling it is when your mind and body no longer feel familiar. Whether hormonal, emotional, or something else entirely, it’s real. And you’re not imagining it.
• Why midlife isn’t a decline—it’s a reckoning
  In our 40s and 50s, something profound shifts. The world may expect us to shrink, to quiet down—but there’s power in slowing down, reclaiming our presence, and stepping into this next chapter with intention.
• What being a “good girl” has cost us
  We’ve been taught to be pleasing, perfect, and silent. But at what cost? It’s time to name the pressure, challenge the roles we’ve inherited, and free ourselves from outdated expectations.
• Why loneliness is a serious health issue
  From new motherhood to menopause, even in full homes or busy lives, many women feel deeply alone. Female friendship isn’t frivolous—it’s essential. It’s soul medicine.
• Why we are more than what we do
  Stage fright in midlife, memory lapses, or slowing down doesn’t make us less—it invites us into a new rhythm. We don’t always have to perform. Just being is enough.
• How perfectionism is stealing our joy
  From body image to birth stories, we’re fed the idea that we have to get everything “right.” But what if the real freedom lies in letting go of those impossible ideals—and embracing the beautiful mess of real life?

This one’s for all the women tired of pretending they’re fine.
Who are aching to be seen.
Who are ready to stop carrying the weight alone.

Links and Resources

• Jessica's book: Normalize It
• Jessica's Website

Join The Conversation 

• Tune in to the full conversation to learn from Jessica and me 
• Let us know your thoughts on this episode on social media! Tag me @dr.avivaromm and Jessica @ihadamiscarriage
• Don’t forget to share this episode with someone in your life, be it a new mama, a curious grandparent, or a caregiver who could learn about the power of nurture

Don’t Miss Out 

Make sure to subscribe to On Health wherever you listen to podcasts, and if you found this episode helpful, please leave a review—it helps us reach more women like you who need this information.

The Transcript

This transcript has been edited for length and clarity.

Aviva:  There are things we say out loud and things we keep to ourselves, and often it's the things that we don't say that weigh the most. The body struggles, the silent grief, the exhaustion of trying to be everything to everyone. So often these aren't just personal though there are cultural too. From the moment we're born, we're taught how to be good girls.

We absorb silent lessons about what our bodies should look like, how we should behave, and what we should want. These expectations run deep, so deep that we often don't even realize we've internalized them and yet they shape everything. Our sense of self, our worth, our relationships, even the way we process loss, illness, and trauma. We're taught to silence ourselves.

So what happens when we stop hiding? What happens when we say, here's what I've carried, here's what I still carry. When we finally speak? When we refuse to let stigma dictate our shared experiences?

Welcome back to On Health. Today I'm joined by Jessica Zucker, PhD. Jessica is a Los Angeles based psychologist specializing in reproductive health and the author of the award-winning book, I Had a Miscarriage, a memoir, a movement. Jessica is the creator of the viral hashtag #I Had a Miscarriage campaign. Her writing has appeared in the New York Times, the Washington Post, New York magazine, Vogue and Harvard Business Review among others. She's been featured on NPR, the Today Show and Good Morning America and earned advanced degrees from New York University and Harvard University. Her latest book is Normalize It: Upending the Silence, Stigma and Shame that Shapes Women's Lives, and that's what we're going to talk about today.

Jessica, as we hopped on, you shared a piece of information with me that I know you want to share with our listeners, and when you shared that information with me, I shared with you how I had a recent podcast interview where I literally effed up the entire intro. I couldn't even articulate it. My guest, Emma Seppälä, who is a meditation teacher, started out just saying, “do you want to do a breathing practice together?” I'm really wanting to have this podcast be women connecting as if we were in each other's kitchen right now, as if we've known each other for 20 years – not that I expect you to tell me things that you would tell your best friend you’ve known for 20, but just having that real, honest, relaxed, go deep with it conversation.

And hopefully that's something that our listeners will really appreciate. I think we all need to just be able to let our hair down a little bit right now, even if mine isn't a ponytail. So welcome to On Health. It is truly a pleasure and a privilege to have you here. I've followed your work for a long time.

I was very moved when you launched the #I Had a Miscarriage campaign because as someone who's been involved in helping women for 40 years, including through pregnancy losses, I was just like, yes, someone is speaking honestly and vulnerably and opening the door for women to be real and true and honest. So thank you and welcome.

Jessica:  Well, thank you so much for having me, and thank you for this wonderful introduction. I'm so happy to be here with you.

Aviva:  I feel like we could talk all about our credentials and those are important. We can share those. I can share them in an intro later or have them on the show notes, but who are we as women? And I'm here to open that space for you, so I know you're going through something right now that you want to share about. So please.

Jessica:  Well, I'll just start from the beginning. But it's not the beginning of my life; it's the beginning of my career. So, as you probably know, I'm a psychologist. I specialize in women's reproductive and maternal mental health and have done so for about over 15 years at this point. And I have a background in public health. When I decided to go for my PhD and wanted to have a more clinical life, my vision was to marry my background in public health with my interest in clinical practice. At that point my vision, my interest, my sort of academic study was all theoretical. So it's like I just knew I wanted to work with women.

Had I lived through something specifically that inspired that? Not necessarily until I was 16 weeks into my second pregnancy and had a miscarriage while I was home by myself. So that sort of changed the course, of course, of my life and my work life. As you mentioned then I think two years later, I launched the #I Had a Miscarriage campaign and began talking endlessly about the topic.

Every aspect of the topic, the platitudes, people are met with the shame, the isolation, the feelings of guilt people report. The research shows that most people are blaming themselves thinking that they somehow did something to cause this, to deserve this. The list goes on and on in terms of the ramifications of culture, not talking openly about such a pervasive topic. And as you know, miscarriage, pregnancy loss, infant loss, these are not diseases. This will not be cured. So I think the ultimate “cure” is to talk more openly about it so that people aren't feeling so alienated and so alone and so isolated in its aftermath.

Aviva:  Even the term miscarriage, I find, I mean it's a common term, so we use it when we're speaking and women relate to it, but I feel like miscarriage sounds like something we've done wrong, whereas I say pregnancy loss because I feel like that is much more what the experience is for most women going through a pregnancy loss. So thank you for also sharing that term as you were speaking.

Jessica:  Yeah, it is interesting. It's true. I mean, you miscarry, right. So somehow it's your fault which is unfathomably not anything true about the experience of pregnancy loss.

Aviva:  You blew something wide open, which isn't just talking about pregnancy loss, but it is really the silences that we live with, and these silences can be everything from an eating disorder that a woman is struggling with alone and with shame and her own.It's not just like you have the struggle, but the shame of the struggle of it or body size, image issues or career achievement issues or something you shared with me that you're going through now, which is that you're on tamoxifen.

I do feel when we talk about the term miscarriage, it's almost emblematic of the way that our culture and medical culture and beauty culture, if we want to call it “beauty,” in air quotes here, forces us to blame ourselves for either phenomena that are medical out of our control, biological or culturally driven.

So when we started this conversation, you almost started with an apology, which I want to emphasize that you do not need to apologize at all, but you shared that you're on tamoxifen, which for listeners who are not familiar with that, is for breast cancer – it's an estrogen modulating medication – and you were apologizing for saying that maybe you would have some “Chemo Brain.”

Jessica: I felt like it was sort of like a, just so you know, if I don't make any sense, it's tamoxifen’s fault. No. Well, basically what happened was after all of my work in the miscarriage space, which of course my clinical practice is still dedicated to, but I was writing and writing and writing, and that eventually led to my first book. Two weeks after that book came out in 2021, I was diagnosed with breast cancer.

So in so many ways, we are in 2025 now. It seems like so long ago. It does seem like it's in the rearview mirror. However, the beauty of breast cancer, or at least those who have to be on tamoxifen, it's a gift that keeps on giving. So unfortunately the side effects of that, it's weird. I would say for me personally, that the experience of tamoxifen is worse than all of my surgeries put together, and I had four of them. So it's like I would sooner go back and have a surgery than stay on this.

Aviva:  Is it the side effects? Is it the estrogen suppression? What are you going through with it?

Jessica:  I talk with my oncologist about this monthly. It feels like, I mean, I meet with her every few months, but we have a back and forth online all the time. It's like I'm always trying to figure it out. It's like, how is it that I slept from 9:30 to 6:30 and I wake up feeling like I didn't sleep for an hour? The side effects in the beginning were very different than they are now. In the beginning, I had muscle pain and joint aches, and I felt suddenly like 90 years old, or at least what I would think that might feel like. That did fade and now it's morphed into this kind of, I just don't fully feel like I have access to my DAV that I've always had my entire life.

And interestingly in my cancer, I don't use the word journey, but I don't know a better word for it right now, throughout navigating breast cancer, I was fortunate enough to not have to go through chemo, and yet I'm hearing that maybe some of this kind of heavy brain fog and even feelings of disorientation and stuff are similar to that. I went through radiation, but I did not go through months and months of chemo or anything.

So anyway, all of that to say that there are times now where I have a new sense of anxiety coming into conversations, coming into even social situations, and I did try to include that in the book. I did not want this second book. I was approached to write the second book. It's not a memoir. I do include breast cancer on purpose, and I mentioned that I went through it, but I don't go into my details so much in the book, but it's definitely, it seems that it's changed the course of my life.

Aviva:  Did it throw you into menopause?

Jessica:  Oh, right. So that's what I was going to say. So see, I lost my train of thought for….

Aviva:  No, it's okay. It's all good, girl. You are not the only woman who loses their train of thought in this podcast or in life. I promise.

Jessica:  I know. I mean, because I didn't have to do chemo. I wasn't thrown into menopause, and I actually do still menstruate. So that's what is even more confusing and confounding for me. It's like, are some of these side effects, actual side effects, or are they perimenopause? Would I be feeling this way even if I stopped taking tamoxifen?

Aviva:  Yeah, that's tricky to sort out, isn't it?

Jessica:  It's very tricky and I feel you're playing with fire when you think about going off of a life, a potentially lifesaving drug.

Aviva:  Let's talk about this feeling that you're having – not to equate anyone who is going through normal natural menopause with someone who has had a breast cancer treatment and is on tamoxifen. The parallel is the anxiety around the speaking and the brain fog.

When somebody looks at the trajectory of my work since I was 18 years old and teaching publicly and had my first book come out at 26 or 28 getting up, I always used to joke, if I were to go to a concert at Carnegie Hall and see Lauren Hill, which happened, I did go and see Lauren Hill.

Jessica:  Lucky.

Aviva:  I know. But say the opening act just couldn't show up, and they saw me sitting in the front row and they're like, you get up here. We need an opening act. Just talk about women's health. I would've been like, all right, I'm up there. And I wouldn't have thought twice about it. I would've just felt so confident in my physical presence, in my speaking ability, in my communication.

And then in the last year, I have found myself really struggling with getting on camera, speaking direct to camera without a script. I'm really working through what these menopausal changes are and really understand that anxiety, maybe mine is different than yours, but I'd love to talk more about this because from my work as a midwife and physician working with women in menopause, even just going to a menopause conference recently, how many of the menopausal women got on stage and in some way actually did start with an apology. If I trip over my words, dah, dah, dah….

And I think we're not actually doing it as much as we are more self-conscious about it, and that can exacerbate it. That makes it worse too. What is your experience and why do you think, I think we need to talk about this more for women who are going through it, but also for younger women to be compassionate about it and also understand it, they're going to get there someday too.

Jessica:  Yeah, I couldn't agree more. I mean, for me, the process has actually been, well, it's anxiety producing because as you just said, I would've jumped to the stage at 20 something or even 30 something or even 40 something. I was diagnosed at 47, I believe it was, and now I would probably run out of the concert hall if they asked me to get on the stage. And the thing is though, when I do it right now, I'm totally comfortable.

I feel so present. I feel so connected to you and your words and what you're sharing. It's the anticipation. I think it's that anticipatory anxiety that's ratcheted up in the last couple of years for me. And you're right. Yet another thing that we're not talking enough about in culture, and so for me, it's actually resulted in anxiety, but also sometimes feelings of depression because it's like a loss.

Where has that sense of me gone and will I ever get it back? I feel like I'm too young to be like, okay, that's gone. So it's like I ask my oncologist half joking, but just like, is this dementia? It's like to the point where I'm trying to understand if I were to go off this drug, would I recover that energy I've had my entire life?

Aviva:  Yeah, that's hard and that's really hard. And I wonder, could you go off of it for a month or a week or just to give yourself that glimpse and say, okay, a week I can do this for one week. I mean, I'm not suggesting that you do. Obviously talk with your doctor, but just like what would that be just to see does it creep back up. And then there's a placebo, so it's a little hard to know. Right?

Jessica:  Right. Well, I'm actually glad that you as a physician just said that. I am in talks with my oncologist about going off between now and when the book comes out because it's like in order for me to show up to all of these experiences and events and I want to mean I'm so used to doing radio and TV and podcast, it's like that's where so much of the joy comes from in communing with women on these topics. So I don't want to cut myself off from it. So I may take a tamoxifen break to see how I'd feel.

Aviva:  As you're saying this, I'm working on a book right now on menopause. It's called Force of Nature. It's not coming out until the fall of 2026. And I was actually thinking about this a couple of days ago and I was like, oh my God, I'm going to be 60 when that book comes out and thinking about some of this anticipatory anxiety and all the things. And as I'm hearing you and as we're sharing this space together, first I could just cry.

The honesty of it is so beautiful and profound for me as well. A really significant number of women that exit the workplace in menopause because of feeling like they're aging out and they're going to get replaced by, and I'm doing quotes here you guys, air quotes by a “younger model.”

We know that women in their 50s feel a tremendous amount of pressure to do things that change their physical appearance, facial changes with Botox or filler or surgery to actually look younger to state what is perceived as relevant in the workplace, but also the workplace becomes a different struggle when you have the perception That you are not the same when you have the perception that you're being looked at differently or the perception that culture has put on that we've become irrelevant or the fears that we may be articulating differently. And what I'm thinking of is I'm having this image of a council of elders, of women who are in their late 40s and beyond, mid 50s and beyond.

I'm 58, I'm kind of imagining this kind of age group and maybe something happens that until menopause, we are presenting ourselves in a way that keeps up with the masculine energy of the workplace, the masculine energy of the world. We're articulate, we're on it, we're sharp, we're like a certain way, and then this change happens and we feel out of it and self-conscious, but maybe it's actually, it's just time for more relaxed, honest conversations like this.

Jessica:  I think for me, I'm still in this wrestling with it. I feel like I'm in the boxing room just being like, no, I won't let this go. Because to see a version of yourself just a few inches away that you can no longer fully embody is like, no one told me this was going to happen. No one talked about this. I mean, you can read the literature on brain fog and various aspects of menopause, but for me, I think, and I would imagine a lot of women, it's the identity piece. Absolutely.

Aviva:  For me, that's the biggest piece. I have a friend who is by any standards just gorgeous and tall, and she is a very fit athletic woman, and we've been doing salsa class together once a week and we were in class and we were getting ready to start dancing, and she made a disparaging comment about having to look in the mirror the whole time that we're in class. There's giant mirrors up front, and she was saying how she can't believe it.

She looks at pictures, she's 58 also, and she looks at pictures of herself from two years ago and has that feeling of physically what happened to that woman. And it is that I read something recently that said, nobody told me how fast it would happen once you're in it, how fast.

And I want to just clarify for women who are listening who aren't in perimenopause, it's not all gloom and doom, but like becoming a new mother or becoming pregnant and realizing you're losing the autonomy you had, or going into puberty and realizing that you can't just necessarily run around in the school yard without a bra if you've grown boobs and not get attention that you don't want.

These transitions are not discussed and this transition into, I think the transition into puberty like, oh, I'm a woman now. The transition into motherhood – that's socially validated and celebrated, but the transition into this is not something that we are prepared. So I think what you're saying is you're in the boxing ring right now. It doesn't mean we're going to stay there, but it, it's a reckoning with something new and this transition.

Jessica:  Well, it's interesting too though. I think that's a wonderful point and one we could unpack further. It's like, because even the transition to adolescents, I have a daughter who's 11. There's so much, and Carol Gilligan's amazing writing and research topic is so profound and life-changing really. It's not easy.

And then the transition to motherhood, or let's go back and say even pregnancy – so many people as you know are struggling with depression, anxiety during or after pregnancy. And so it's almost in most of these, if not all of these transitions, we somehow do feel alone. Cultures say, just do it. Get your old body back, get your original body back after you have bounce back. Yeah, you should be able to just be glowing and do it on your own. And like, maternity leave is vacation time.

Women are reporting feeling so isolated and so alone despite the fact that a majority of people do have children. And so, what is that? That goes back to what you said about getting the elders together. I would love to sit around with these elderly women looking back, telling us, and I mean even more elderly than us, being able to impart some wisdom.

What are we doing wrong? What can we do differently? And of course, I don't think in my time on the planet I'm going to somehow truly change culture, but I want to be part of changing it. And I'm just so curious and driven to understand the roots of this.

Why can't we turn it over? Why can't we somehow figure out a way, for example, for girls to know what they know, as Carol Gilligan says, without sort of bopping up against this wall or this kind of ceiling at that age that makes them question who they are or takes a part of themselves sort of underground and begins to have self-doubt and start judging themselves and become very self-conscious of the bodily changes.

I don't know that we have answers to these things.

Aviva:  But I think we have insights though. First, I just want to say when I saw that you studied with Carol Gilligan in your bio as I was getting ready for this podcast, I went a little fan girl. Carol's work was incredibly influential to me as a young mom, and also I did my undergraduate work in women's health studies. My mentor, my primary mentor in that undergraduate work was a woman named Anita Landa, who was a colleague of Carol's. So Carol's book Meeting at the Crossroads was I think the earliest one I read.

One of the things that really struck me, that kind of sticks with me now, 30 something years later, is that she did studies or looked at data on the shift in girls in mathematics and science once they start menstruating and the self-silencing and the upper limiting that happens in that transition through puberty. Do you know much of that? Do you feel like you can talk to that a little bit?

Jessica:  Well, you just did it perfectly. I mean, that's exactly what I've read. I am very keen on her book. The book that I know about that I read as a young person, I think I was 18, was In a Different Voice.

Aviva:  I read that one, too.

Jessica:  Very powerful. It just gave me chills when I thought about it. It's like this idea that culture begins to again, consciously or not, but begins to sort of create a level of self-consciousness that previously wasn't there.

Aviva:  Well, this is what was coming to me as you were saying, where is this coming from? And so what kind of comes to me is that as we start going through these various transitions, things are happening in our bodies, whether that is menstrual blood, which can mean odor. If you haven't had a minute to change your pad, you've been in class all day, or it can be leaking through your pad.

That actually happened to me in sixth grade, and then it happened to me once in perimenopause, thankfully the second time was in my house, the first time was in a classroom and an older girl classmate saw it and wrapped her sweatshirt around my waist and escorted me to the bathroom very kindly and had a pad with her.

I didn't think, oh, when you get those irregular periods early on, your body does things at these various junctures that society has deemed taboo. I mean, we didn't even show the color red in menstrual pad commercials until recently. It was just blue water. And so I think that there's, the silence suggests that it's something that we should be embarrassed about.

Jessica:  Right?

Aviva:  And so there's that, we're embarrassed. We're not talking about it. So we don't know if we're the only ones who have that odor or have that cramp, have that symptom. And then on top of it, as women, we're kind of taught to put a happy face on it and not complain. It feels like complaining or overly self-conscious rather than just like, this is normal shit we're all going through. Let's just talk about it and get real.

Jessica:  But it's true that when you get your period, I mean, not everybody's getting their period at the same time. Not everybody is having the same symptoms. Not everybody's families are talking openly about it at home. So it's like I think that that creates even more sort of stigma and shame and silence that bleeds into, no pun intended, the next phase of one's life.

And I think it's so true what you said about this pressure to remain a good girl. So it's like even if you're in pain, or let's say you have endometriosis and you're going through excruciating pain and none of your friends are, nobody's talking about it, you feel forced to put on a smiley face or at least continue to be attentive in class. There isn't room for these things that women go through including let's say miscarriage leave.

You lose a pregnancy, and in my case, second trimester pregnancy. I mean, I'm a small person. It was very obvious to my patients that I was pregnant. It was 16 weeks along. It's obvious when I'm like six weeks. So giving birth, being postpartum, having milk come in, bleeding, but not having a baby to show for it is profound. And no one's talking about that.

I mean, I understand from a medical perspective that it's so common, it's a normative outcome of pregnancy, miscarriage, early miscarriage especially, but that doesn't make it less painful emotionally, and it doesn't make it less confounding when it comes to the psychological sequelae.

Aviva:  Yeah. Well, I run a program called the Mama Pathway, and it's an online perinatal education class really about advocacy and having the birth that you really want, and that can be home birth, hospital, birth, birthing up, really trying to be really empowered about it.

We have a support group every two weeks, which is live, and what's fascinating is how many women have asked me the question – when is it okay to tell people that I'm pregnant? And it's all around this issue of what if I miscarry? And when I was pregnant with my first, I remember distinctly my mother saying, well, don't tell anybody until you're five months. That's kind of like a Jewish tradition thing, but this isn't in many, many worldviews. And that to me just speaks to this. Don't tell anyone you're pregnant because you might have a miscarriage. You're not going to want to tell anybody. And that means you just live with it alone.

Jessica:  And it means that that's right. The messaging is do not share about your fears of miscarriage until you're quote out of the woods into the second trimester, which any of the listeners who have experienced later losses know that there is no such thing as out of the woods. But why should we not share our news now? It's one thing if you want to be private about it.

Aviva:  Exactly.

Jessica:  I mean, I don't think everybody has to put ultrasounds on Instagram, but I do think that if people aren't sharing because of the fear that if they lose the pregnancy, then they have to keep it to themselves. I mean, it's so backward.

Aviva:  And then they're living through a potentially three-five months of a subsequent pregnancy, keeping that one to themselves and now living with all the anxiety that women who have had a previous pregnancy loss compounded in the next pregnancy, it's horrible.

Jessica:  Exactly.

Aviva:  When you had the pregnancy loss, did you actually feel shame and embarrassed? How did you feel? And then I'm curious not to lump them together, but also when you were diagnosed with breast cancer, because a lot of women feel shame as if they brought it on themselves or they did something wrong. And I wonder if you went through those feelings at all.

Jessica:  No, I did not feel the shame luckily. But what I did feel was incredibly alone despite being surrounded by a community of incredible women, family, friends, colleagues. So it's like I think that pain and the hormonal shifts too can create this sense of alienation even when you have wonderful people at your fingertips. So it's just an interesting thing that I do think happens in these traumatic transitions.

Aviva:  It's that dark cloak of cloud of grief that makes us self-isolate, I think.

Jessica:  Exactly. It's like, and also just because the platitudes come rushing in, even from your best friend, even from your mom, people who you think get it, and you thought you got it, but you had never been through it until now, and then you're like, oh, did I ever say something like that to somebody who had a miscarriage?

I understand why people get it wrong, because everyone's just trying to be loving and supportive and helpful, but saying stuff like at least you're young, you know, can get pregnant or God has everything happen for a reason, all of these things. And then when I was diagnosed with breast cancer, no, I did not feel a sense of body hate or shame, and I do hear a lot about my body failed me. I didn't feel that way at all with my miscarriage, especially. In fact, I felt like, wait, my body knew that there was a chromosomal abnormality and therefore ended the pregnancy. And so that almost felt like it made it easier on me. I didn't have to be the one to make a decision because I was going to have an amniocentesis two weeks later.

Then with breast cancer, it was determined that I have a gene, not the BRCA gene, but another gene check to that people don't seem to know a lot about, and it's in my family, but I am the first woman to have breast cancer in my family. So that's why it was so surprising.

So learning about the gene actually helped me not feel any of the shame or self-doubt, or did I drink too much during the pandemic or did I have too much coffee or whatever people seem to think can create either pregnancy loss or cancer, whatever. I didn't go down those roads luckily, but I found that all of this warrior language that came my way when I was diagnosed with fighting breast cancer.

Aviva:  Yes, yes, I know.

Jessica:  What are we talking about? I'm not a lawyer. I'm showing up to my appointments. This isn't a choice. So I think it's interesting, and again, this came from mostly women, but I think we so badly don't want to see our loved ones suffer. We too do not want to have to imagine losing that person. Just like with pregnancy, we want to think, oh, you'll get pregnant again. Of course you will.

And it's interesting though, because the language that surrounds it sort of diminishes the intensity or the complexity of the situation. So you're a warrior as if you're going to battle with your body.

I have a lot of feelings about all of that language, and it doesn't resonate with me at all. If anything I've found that I needed to choose to kind of lean into this time in my life – not into cancer, not letting it take over my body, but meaning I need to be really present for this, and I don't want to think of it as a fight.

I want to think of it as I'm going to do the things that I need to do to be well: to rest and actually take care of myself through this arduous process. I find the language antithetical to what we really need. What we really need is nurturance. We need emotional intimacy. We need connection, and we need to break this pattern of silent stigma and shame so that we can actually love ourselves through these challenging times.

Aviva:  You talk about female friendship deeply in this book, and another really important piece of this is the loneliness. And we know from studies now that loneliness for women is more significant, a predictor of a heart attack, first or a second heart attack, then diabetes, smoking, obesity combined. This is big. So talk to us about female friendship and loneliness and the intersections of those.

Jessica:  Oh, wow. Yes. So in the book I include, and these are all sort of, you could say fictitious patients. They're not based, I mean, they're based on…

Aviva:  I call them amalgamations.

Jessica:  Exactly. And I'm sort of talking in the friendship chapter about when connections go a little awry, what do we do? And that can even be, they can be historical friendships or it could be somebody has close friends in a particular city and then moves across the country for a job, and then they're sort of, yes, you can FaceTime, but you can't really go out to dinner on FaceTime.

So it's finding new community and establishing that and how the loneliness can eat us up. And again, this can bleed into motherhood, right? Because in motherhood, even if you've had this sort of longstanding cadre of women in your life, motherhood can kind of consume you to the point where you're home all the time or you're not able to go out, or you're breastfeeding or you're sleep deprived, all the things that make it difficult.

So yes, I think that female friendship – can we dare to when things don't feel good in those relationships that mean so much to us that are the core of our existence at so many points in our lives – can we talk about it? So, it's like my hope with this book is to normalize talking about the things we don't talk about.

And one of those things is the complexities of relationships and daring ourselves to be vulnerable enough to say, Hey, I love you and here's all the reasons why. And when you said you're a warrior, you're going to get through this. Here's why for me, that doesn't sit well. Or I mean, maybe that's not how one would say it, but I'm just trying to think of an example and see where that takes us. Because see, my hope is that we can change culture just ourselves, just with our friends, just with our families, just in our small groups by doing these very things.

Aviva:  I think friendship is so interesting. The friendships that I forged when my kids were little and we were raising kids together were so powerful. I mean, I can just call up so many different images of a friend bringing me food after a baby was born, or me being there with a friend during her birth or the kid having a fever and calling the friend because all the things then some of those friendships are still active in my life, but in some of them circumstances changed. I moved, they moved.

And it can feel like a failure, but also recognizing that you can have somebody who you hold really dear in your heart and in your memories, and you'd still drop anything from them if they called you and they needed you tomorrow, but who aren't necessarily active in your daily life anymore. And that that's not actually a failure. That's sort of like a…

Jessica:  …natural evolution.

Aviva:  It is a natural evolution, and especially in a culture where many of us do move and things are more transitional.

Jessica:  I think the problem comes when maybe we don't have enough emotional intimacy that's accessible to us. And we do begin to feel this incredible crushing loneliness.

Aviva:  And I do think it takes effort. I live in a place now, and I've lived here for 12 years now, but when I moved here, my kids were already grown and out of the house. So, it wasn't like we moved into a community where my kids were in school and were not part of any religious affiliation. So it wasn't like we were joining a church or a synagogue or mosque.

And so forming friendships has to be intentional in a different way often for many of us at a certain age. And what happened for me interestingly, was I actually read Barbara Ehrenreich’s book, and I apologize, I don't remember the name of it, but she wrote it in her later years about how when she got to a certain age, her 70s and 80s, she had a group of women that she was close with. They did something together once or twice a year in an away trip. But by that age, quite a number, not to be morbid, but quite a number of their husbands had passed already, or partners had passed, usually their male partner. That is common for women to outlive a male partner and how those friendships were the rock in her life.

And I was living in this community, and because my work is very national and because I have lived a long life where I have friends from other places I live who are my “ride or die” people, even if they had become more… we Zoom regularly, we talk on the phone regularly, we text all the time. I hadn't built that local community of deep friends.

I woke up in the middle of the night one night and was really struggling with my husband's 10 years older than I am. Not to say he would pass before me, but statistically I would live longer. And I live rurally. And I was having a little bit of, I wouldn't say panic attack, but an overwhelming sense of dread about this. I actually got up and I got out my journal. I actually had this thought of, oh, it's miserable….

I'll be up at three in the morning. And then I was like, no, wait. Buddhists say that the best time for meditation is at three in the morning. And a lot of monasteries, people get up and meditate at three in the morning. So I'm like, all right, I'm going to use this time intentionally.

I got out my journal and I wrote pages and pages of presenting the problem to myself, not… but presenting my feelings to myself as if I were my best friend and saying, okay, what can you do about this? And I became deeply intentional about reaching out to and spending time with the women in my community who I had formed a relationship with to intentionally deepen those relationships.

And yes, sometimes it meant I didn't feel like going out in the evening after a full day of work and teaching and seeing patients, but I needed to do that.

Jessica:  Yes.

Aviva:  And boy, it has really been transformative in my wellbeing to have done that.

Jessica: That is so wonderful. And to have that realization and then to act on it is so…. Well, I look forward to doing that at some point when my kids are not here. I know because my son is 16, I actually think about this a lot because I can feel his graduation at my fingertips, and I want to really make the best of now and make sure to do all the things before he leaves for college.

And I also find myself thinking about looking forward to more time with my husband as well, because once there's kids in the mix, I mean, I have found such a change, obviously in the relationship in terms of you become kind of co-managers or totally or whatever. And so I look forward to having that sort of unencumbered time where we can just play and be together.

Aviva:  It's really sweet to have that. It's pretty special. And now we've had 10 years of it or so more so it's funny. We so love it when the kids come home and they're home for however extended, we're like, we love it. I go right into mom mode and I'm cooking and I'm suspending all my work. I just want to be present with them. And then when they go, we're like, Ooh, we're back to ourselves. And we kind of love that. It's fun.

I would love to dive into something that I've talked about quite a bit on the podcast probably because I think that not just so many women do experience this, but I am not even a recovering perfectionist. I like to pretend I'm a recovering perfectionist, but it's something that definitely impacts me. And perfectionism shows up in so many ways. It's body image. Our body's perfect.

Did I have the perfect pregnancy? How is miscarriage a reflection of our perfectionism? How is having breast cancer? I've had patients who have had breast cancer and had a mastectomy, even a lumpectomy say, I don't feel like a woman anymore because I don't have what is considered parts of a perfect woman.

Jessica:  Definitely.

Aviva:  How do you experience perfectionism? Or I'm assuming you do since you wrote about it in the book.

Jessica:  Well, that's an deep and important question. I have to think on that. Do I struggle with perfectionism? I feel like from the dynamics of my family, I think that I wanted to be the good kid. My sister was a bit of a more rebellious type, I guess, and she's older than me.

Aviva:  …The hellion of the family.

Jessica:  She isn't now at all, but way back then. So I think in looking at that and seeing my family's response to it, I think inevitably I sort of fell into a role of I'm not going to make waves. I'm going to make it easier. I'm going to comfort people. I mean, I guess it's no wonder this is my job, but I guess that could be seen, I guess, as a version of perfectionism. I think motherhood has humbled me to no end.

And just in terms of I'm never going to do this perfectly. And my goal in motherhood, to be honest, and I evaluate this a lot with myself, it's like my aim is to do better than my parents did, and to have them know that they are unconditionally loved and that I am here to talk about anything. So it's like, yeah, once in a while I'll raise my voice if my son isn't listening or I'll still find myself doing things that I'm not proud of.

Aviva:  Things? You mean human mother.

Jessica:  Yes, like the human mother thing. But I really try to come back to does he feel loved through and through? Does he feel confident and comfortable coming to me to talk about anything? It seems he does. I mean, you just don't know, but I feel like how do we sort of wrestle with perfectionism?

Aviva:  What made you include it in the book as a chapter, a primary chapter?

Jessica:  Well, because I think in our culture, it is one of the most antithetical to our mental health, to our own personal thriving. We are told from the get go, we see images on billboards, on Instagram, on TikTok of the we're supposed to have, of the faces, we're supposed to have the outfits, the lifestyle, the whatever.

And so I think that whether it's born out of family dynamics and feeling a pressure to be a certain way or cultural pressures, it's ubiquitous. I mean, I feel like we're hard pressed to find girls who don't sort of veer in that direction even for a time. Even with my own children, my son is not hard on himself the way my daughter can be. And so she'll get upset that she got one word wrong on a spelling test.

And I'm like, is this coming from, I don't say out loud, but I'm just like, why is she expecting herself? Why does she have to get it right all the time? And so I try to understand it in her, is it from looking at me? Sure as f hope not. And is it sort of environmental? Is it what she's seeing at school? Is it what she and her friends are talking about? And could it be the pressure from her female teachers? It's so hard to know.

Aviva:  Yeah, it is. And it's interesting too because you were saying that in your family you took on to simplify it, kind of the good girl or the peacemaker role. I think that for each of us, sometimes our families of origin, our stories of origin push us into these roles. And for some people it is the peacemaker. For some people it's perfectionism.

Jessica:  Yes,

Aviva:  There are these sort of different survival modes, if you will, that we get into that kind of shape our lives. I'm wondering, I mean, you do a lot of really deep and profound work in perinatal psychology, women's psychology.

What are some of the themes that you feel right now are kind of putting wind in your sails that you feel like, wow, I'm seeing this over and over and I would love to see women be able to not feel this way or heal this or the strengths that you're seeing?

Jessica:  I mean, the truth, it's like every single topic we've touched on today, I mean, it's like for me, the most disheartening is the shame after pregnancy loss or the shame in perinatal and postpartum mood and anxiety disorders. I don't know. I'm just like, no, this can't persist.

Aviva:  I was at a conference teaching a few years ago when I got there. There was a whole line of young mamas and women waiting to meet me and have me sign their books. It was very sweet and very lovely. And one of the mamas in that line, I'll never forget, she came up to me with her six-month old baby.

She started crying, and she said she was in a natural mama online group, and she had a long and difficult labor, chose to have an epidural and ended up with a cesarean, and she was kicked out of the mom group. She was kicked

Jessica:  Out. No, I mean, it just makes me enraged. And yet, it's not surprising, but this is where I get sort of like, what are we doing when women are turning on women? I mean, that's a whole book in itself, but it is, it's like this binary view of birth has got to stop, right? It's like, oh, natural or not natural. It's like, wait,

Aviva:  Well, there's a value signaling or virtue signaling. The part that I struggle with is we do know that there is a significant overuse of intervention. There is a significant overuse of cesarean. How do we educate and talk about that without adding to shame or adding to the binary? And why does it have

Jessica:  To be shameful?

Aviva:  It doesn't. It shouldn't be.

Jessica:  And it's like to not want to physically be in pain is a choice. Somebody wants to make that choice, let them, and if they call that a natural birth still, then it is. And I don't know, I think all this pressure around having an unmedicated birth or feeling ashamed of a C-section

Aviva:  Success around breastfeeding

Jessica:  Using that term success. Exactly, exactly. It's interesting because with my son, I had thought I wanted an unmedicated birth. And then the Pitocin, it got too intense and I wanted the epidural, and it was fabulous. And again, I mean this is sort of a trigger warning, but I don't use that phrase, but in case anybody's listening that doesn't want to hear this. So my miscarriage was home by myself.

The fetus came out and my OB, GYN, instructed me how to cut the umbilical cord myself over the phone. I was too scared to call 9 1 1 and have fire people, men running through my home that I didn't know with my pants down and whatever. So it was too sort of intimate a situation. I didn't want that if I could avoid it. And then my husband came home and we got me to my doctor's office, and I had to then undergo an unmedicated DNC.

Months later when we decided to try again, it did become very important to me to have an unmedicated birth with my next child. Again, though it was a personal thing. It wasn't because it was like, Ooh, interventions are bad. Or like, Ooh, I'm not successful if I don't, whatever. It just became for me this way of, I went through the pain of an unmedicated DNC, and that was an ending.

And I wanted this next sort of pain to be about a beginning, and I wanted to feel as present for it as I could. Not that the medications make you feel not present, but I just wanted to physically be fully there. And that happened. But I never think of my births in this binary way. Like, ooh, the one with my son was unsuccessful and the one with my daughter was successful. I just think that we are creating more silence, more stigma, more shame.

Aviva:  I want to have a whole other conversation with you someday about retelling our stories and how we can use storytelling for healing.

Jessica:  Yes.

Aviva:  But you are a real doctor, as am I, and you have patients in meetings and things to get to. But I want to ask you one question before we go, because I asked this of all my guests, and I have this dream of this compilation of these questions. And so here's the question. If you could tell your younger self anything, how old would she be and what would you say?

Jessica:  Wow, you've stopped me in my tracks sometime in the teen years, like 11 or 12 or something, I think, and I don't know. I'm going to get emotional. Like what? My first thought is to say, you're going to go through hard stuff, but you will persist. But it's like, I think the main message is really stay true to what you believe in.

Stay the course in terms of trying to make this world a better place and do what you can to make a dent in the cultural problems that even then I sort of identified. And I think I am doing those things in my career now. Luckily.

Aviva:  Thank you. And this conversation and your honesty and your transparency, and for all so many women, you're helping to realize that they're not alone.

Jessica:  Thank you so much for having me. This has been wonderful.

Aviva:  An absolute pleasure. Thank you for joining me, everyone, for this powerful conversation about not living in silence and shame and for creating spaces where we can normalize talking with each other. And I'll see you next time. I hope you enjoyed this episode, that it helped you to feel seen and heard, and perhaps that it even brought you some aha moments.

The post Normalize It: From Miscarriage to Midlife—Owning Our Stories Without Shame with Jessica Zucker appeared first on Aviva Romm, MD.

Listen to the full interview where we open up about the realities behind breastfeeding —and what it takes to create a truly supported experience.

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What if you already have what it takes to breastfeed your baby—and just need the right support to unlock it?

This question is at the heart of my conversation with Lisa Paladino, Certified Nurse Midwife, IBCLC, and a fierce advocate for women and babies. Lisa has decades of experience helping families navigate the powerful, joyous, and sometimes confusing, emotional, and occasionally challenging terrain of breastfeeding. Not just a brilliant clinician, but a graduate of both my Women’s Integrative and Functional Medicine and Herbal Medicine for Women training programs… and now, a lifelong friend.

Lisa Paladino is a Certified Nurse Midwife, International Board Certified Lactation Consultant (IBCLC), and the passionate founder of Tongue Tie Experts. She’s spent decades supporting parents through the intense, sacred, and often confusing path of breastfeeding—especially when things don’t go as planned.

Lisa’s journey from hospital-based nurse and midwife to fierce advocate for women’s rights and breastfeeding education is one you won’t forget. And what we unpack in this conversation might change how you see everything from nipple pain to infant sleep—and even adult airway health.

In this episode, we dive into:

• What exactly is an IBCLC—and why it matters

Lisa breaks down the “alphabet soup” of lactation credentials and what sets an IBCLC apart when you’re facing breastfeeding challenges.

• The silent struggle of mastitis, milk supply issues, and pain

We share personal stories, hard lessons, and the real-world gaps in medical education that leave new moms without the support they need.

• How breastfeeding shapes your baby’s airway—and possibly lifelong health

From tongue ties to sleep apnea and ADHD, Lisa reveals fascinating insights about how early feeding impacts development in ways most people never hear about.

• The heartbreak of not making enough milk—and how to support yourself

If you’ve ever felt guilty, overwhelmed, or like you were failing, this is the segment you’ve been waiting for. Lisa offers compassionate guidance that’s as real as it is relieving.

• Setting yourself up for breastfeeding success before the baby comes

We talk about what really matters in postpartum prep (hint: it’s not the matching outfits) and how to build your “village” even if you’re doing it solo.

• Why so many moms stop breastfeeding before they want to—and how we can change that

With more than 60% of moms ending breastfeeding earlier than planned, we get honest about policy gaps, shame culture, and how to reclaim your power.

• And yes… we go there with nipple toughening myths, lactation cookies, pumping in broom closets, and airplane glares.

Because we’ve all been there—or know someone who has.

Favorite Quotes

“Breastfeeding is a vital sign of the infant-maternal dyad. If it’s not working, we need to ask why.” — Lisa Paladino
“Each baby is a new experience. Every drop of breastmilk counts—but guilt doesn’t belong here.” — Lisa Paladino
“We’re grown-ass women. Nobody should be telling us what we’re ‘allowed’ to do in birth or postpartum.” — Aviva Romm

What We Want Every Mama to Know

• You deserve real, informed support—not just platitudes or formula handouts.
• Breastfeeding might be “natural,” but that doesn’t mean it’s easy or intuitive.
• Trusting your instincts is medicine.
• Whether you breastfed for two years, two days, or not at all, you’re still a phenomenal mama.

Connect with Lisa

• tonguetieexperts.net
• @tonguetieexperts on Instagram
• Listen to her podcast: Tongue Tie Experts

If this episode spoke to you, please:

• Share it with a mama in your life.
• Leave a review to help other women find this message.
• Join the Mama Pathway and our community of women reclaiming their power in postpartum and beyond.

Because you—and your baby—deserve nothing less.

Episode Highlights

What Is an IBCLC, and Why Does It Matter?

Let’s be real: The world of breastfeeding support can feel like alphabet soup. Lisa unpacks the difference between various credentials (like CLC vs IBCLC), and why the IBCLC—International Board Certified Lactation Consultant—is the gold standard when you’re dealing with real challenges like latch issues, milk supply, or suspected tongue tie.

Key insight: Not all “lactation consultants” are created equal. Make sure your support person is truly trained to evaluate and guide you.

The Silent Struggles Moms Face

From plugged ducts and mastitis to overwhelming exhaustion and pressure to perform, we talk about what so many moms experience—but few feel safe saying out loud.
Lisa shares her own early struggles and how misinformation (even from pediatricians) shaped her journey. I share my first postpartum experience and the real fear that came with not knowing what was happening to my body—and not having a place to turn for help.

“You can only do what you can do for each baby. Guilt doesn’t belong here.” – Lisa Paladino

Breastfeeding and the Airway: A Hidden Connection

This was one of the most eye-opening parts of our talk. Lisa reveals how breastfeeding shapes a baby’s facial and airway development, possibly reducing risks for snoring, sleep apnea, and even ADHD later in life. Through her work with the Airway Revolution Foundation, she’s helping to raise awareness about the structural impact of early feeding—and how something as “simple” as a poor latch may be a red flag for deeper airway concerns.

Bottom line: Breastfeeding is about so much more than nutrition.

When Breastfeeding Doesn’t Work—and the Shame That Follows

While over 80% of babies in the U.S. receive some breast milk, only 25% are exclusively breastfed by six months and staggering 60% of women stop breastfeeding earlier than they intended to.

The reason? Most moms want to breastfeed, but they’re not getting the support they need.
Lisa and I talk candidly about the guilt, pressure, and overwhelm women face—especially those who return to work early, struggle with low supply, or face complications like tongue tie, colic, or postpartum anxiety.

“Every drop of breastmilk counts—but guilt doesn’t help anyone.”

Preparing for Breastfeeding Success (Before Baby Arrives)

Instead of nipple-toughening myths and lactation cookie fads, Lisa shares real, practical ways to prepare:

• Learn hand expression before birth
• Identify a local IBCLC (or online support) in advance
• Prep your “village” and be clear about how they can help
• Stock your freezer with food, not matching baby outfits
• Educate your partner and family on what support looks like
• And remember: You don’t need to have it all figured out. You just need someone who has your back.

Is Your Baby Getting Enough Milk?

Here are Lisa’s 3 signs that your baby is feeding well:

1. Baby latches, feeds, and releases contentedly
2. 6–8 wet diapers + several poopy ones a day
3. Your breasts feel full before, and soft after feeds

If any of these are off—or feeding is painful—it’s time to connect with a lactation professional.

Boosting Milk Supply: What Really Works

Forget the hype. Lisa’s top 3 evidence-based strategies:

1. Remove more milk, more often – milk production = demand
2. Nourish your body – eat enough, hydrate, replenish nutrients
3. Check for root causes – thyroid issues, anemia, stress, or anatomy concerns in you or your baby

And yes, herbs like moringa or fenugreek may help—but nothing replaces the basics of good latch, regular feeding, and real rest.

Breastfeeding in Public: Breaking the Stigma

Lisa’s advice? Breastfeed boldly—and if you see a mom doing it, give her a thumbs-up.

Final Words of Wisdom

“Trust your instincts. You know your baby better than anyone. If something doesn’t feel right, it probably isn’t.”
“Each baby is a new experience. You can only do what you can with the resources and support you have. Be kind to yourself.”

The post Breastfeeding Challenges, Tongue Tie, & Trusting Your Instincts appeared first on Aviva Romm, MD.

Search This Article

• The Power of Words to Heal and to Harm
• The Placebo Effect: The Power of Positive Thinking
• The Nocebo Effect: Medical Hexing in Action
• Sticks and Stones May Break Our Bones, But Words Can Also Harm
• The Neurobiology of the Nocebo Effect
• The Complexity of Chronic Illness
• Protecting Yourself from the Nocebo Effect: The Role of Mindset 
• Reclaiming Your Power

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I want to start with a story that has really stuck with me. Over 35 years ago, a pregnant woman came to me, and she was clearly carrying a burden. She'd been to her obstetrician for a prenatal checkup, and he, during a routine pelvic exam in the first trimester – which, by the way, isn't always necessary for healthy pregnancies that early on – told her, based on her slight build, around 5'2″, and her husband's 6'2″ height, that she'd “never be able to push that baby out” and would need a cesarean. Now, that's not a legitimate prognosis, right? You can’t assess someone's ability to birth vaginally in the first trimester based on those parameters.

Fortunately, her intuition kicked in. She switched to me, a midwife, and prepared for a home birth. She really found her power and confidence throughout her pregnancy. She had a beautiful labor, progressing smoothly, overnight and into the early morning hours. But just before her baby's head emerged, she froze, terrified, and whispered, “Is this baby too big for me to get out?” That seed of doubt, planted by an authority figure, had lingered throughout her pregnancy.

I immediately reassured her that her baby’s head was well on its way out – crowning in fact – with plenty of room, and that she could toss that concern away forever. Then, with one more gentle deep breath and spontaneous push, her beautiful boy was born. A few days after the birth we discussed how she’d been secretly and not even fully consciously burdened by this worrisome seed of doubt planted deeply in her psyche, by an authority figure, for her entire pregnancy.

But imagine if she'd been in a hospital with that obstetrician. It makes you wonder, doesn't it? Could these negative beliefs, this “medical hexing,” be contributing to our alarmingly high national cesarean section rate of 32 percent than has been acknowledged and studied. And it’s not just in obstetrics that women hear similarly discouraging and disparaging comments about their bodies, health, and healing potential – negative messaging is rampant in medical care. 

Hey everyone, and welcome back to On Health for Women. Today, we're diving into something that's been on my mind for a long time, something I've seen play out in the lives of so many women who reach out to me about their experiences receiving healthcare – and in the wider world of medicine. It’s the power of words, and how they can both heal and harm. Are we, in a way, being medically hexed?

The Power of Words to Heal and to Harm

Words are among the most powerful healing tools we have in medicine. They can inspire hope, inform and empower you, catalyze healing, and offer comfort. But as Bernard Lown, MD said, “…words, like a two-edged sword, can maim as well as heal.”  Words, used without care, can instill fear, create doubt, and perpetuate suffering. And, as you'll learn, they may even have an impact on our health outcomes. 

This power of language and belief in shaping health outcomes raises an urgent question: Are we being medically hexed? At first glance, the idea of medical hexing may sound far-fetched or ‘woowoo,’ but as we dive deeper into the neurobiological, psychological, and cultural aspects of healthcare, it becomes clear that this phenomenon is not only real, but scientifically validated. From the nocebo effect – the harm caused by negative expectations – to the entrenched power dynamics between doctors and patients, it’s clear that the words and beliefs surrounding health can have profound consequences.

This (episode/article) asks us to take a bold look at the messages we receive about our health and ask whether they could be – unwittingly or intentionally – disempowering us. And while it explores the risks, it also offers a path forward: how to break the spell and reclaim our power.

The Placebo Effect: The Power of Positive Thinking

The best place to begin to understand medical hexing is with the opposite: the placebo effect, which you’ve likely heard of. The word placebo translates literally as “I will please,” and is the phenomenon whereby the positive belief in a treatment or substance to improve health, alleviate a symptom, or cause a positive outcome, is associated with an improvement in health related to that intervention.

The placebo effect is well-established and well-studied. Thousands of scientific papers demonstrate its existence. In fact, about 30 percent of the positive outcomes seen in clinical trials are thought to be due to the placebo effect. That’s why in medical research, the placebo-controlled study is the gold standard for demonstrating the effectiveness of an intervention. To be considered effective, a treatment or medication must have an effect greater than the placebo, usually an inert substance or sham treatment that in some way mimics the actual treatment.

Studies that demonstrate the power and pervasiveness of the placebo effect are many and varied – from sham open heart surgery in which patients who underwent a surgical incision to the chest but had no procedure demonstrated the benefits that were expected with the actual surgery, to reduced pain with analgesia when the patient is told “this will not hurt much.”

The Nocebo Effect: Medical Hexing in Action

The nocebo effect has sometimes been called “the evil twin” of the placebo effect. Though not as robustly studied as it’s more famous ‘sibling’, there is a wealth of research on its impact.

I refer to the nocebo effect as medical hexing. In fact, some of the earliest research on the nocebo effect was inspired by the phenomenon of voodoo ‘curses.’

Voodoo (or voodon, as it is called in Haiti) is just one of many spiritual belief systems and forms of practice that can be found around the world, rooted in the deep belief that an external power, deity, or authority has profound power over our consciousness and health, enough so that it can cause illness and death simply by believing it will.  

In the 1940s, Harvard Researcher Walter Cannon (a major force in the research behind the adrenal stress response) proposed a scientific explanation for the seemingly “magical” phenomenon of “voodoo death” – sudden, unexplained death resulting from a voodoo curse – suggested that the mere fear of death could, through physiological response mechanisms initiated by fear, cause death itself. 

Soon after, in 1961, Harvard researcher Walter Kennedy first coined the term “nocebo reaction” to describe negative health effects that occur as a result of the expectation that they will. The term nocebo means “I will harm,” and simply put, could be summarized as ‘If you believe harm will happen, it appears to increase your risk that it will.' 

The nocebo effect is a neurobiological phenomenon tied to the perception or anticipation of harm. As neuroscientist Robert Hahn, author of the article The Nocebo Phenomenon, says, “Beliefs and expectations are not only conscious, logical phenomena, they also have physical consequences.” 

The nocebo effect can arise in various ways. In some cases, negative expectations are created by prior experiences – if we had a bad experience with a treatment in the past, that can influence how we respond in the present through conditioning. This is why people with cancer who are being treated with chemotherapy sometimes experience nausea when they enter the room even before they get hooked up to the IV. 

But, in clinical settings, the nocebo effect is often induced by a health care provider verbally setting up a negative expectation. For example, in a 2010 study involving women in labor receiving epidural anesthesia, researchers found that the way the anesthetic was described significantly impacted the women’s perception of pain. Some women were told, “We are going to give you a local anesthetic that will numb the area, and you will be comfortable during the procedure.” Others were warned, “You are going to feel a big bee sting; this is the worst part of the procedure.” The women who were warned about the “bee sting” and “worst” part reported feeling more pain. In contrast, those given a more positive and reassuring description experienced less pain. This example underscores how language and framing can profoundly influence physical sensations and outcomes.

One dramatic example of the nocebo effect was seen in a study in the 1990s when researchers discovered that women who believed that they were prone to heart disease were almost four times as likely to die of heart disease as women with similar risk factors who didn't have this belief. This was regardless of their age, blood pressure, weight, and cholesterol levels. What did they share? The belief that they were likely to get sick. 

The nocebo effect is the part of the reason that people often report more side effects from a treatment when they’ve been told what side effects to expect – or even experience side effects when they haven’t even received an active drug. For example, in a 2003 study of beta-blockers, among patients told that side effects might include erectile dysfunction, there were twice as many patients reporting this problem compared with those not given information about ED risk. A 2022 review of clinical trials found that 29 percent of people reported having fatigue and 27 percent reported a headache after being given a placebo (inactive) coronavirus vaccine.

Frighteningly, the effect also appears to sometimes become “contagious.” In a study done at a university in the UK, a group of students was instructed to inhale a sample of air, which they were told contained a “suspected environmental toxin” that could cause headache, nausea, itchy skin and drowsiness. Half of the students then watched a woman inhale a sample of this air, after which she immediately appeared to exhibit those symptoms. While the sample contained regular, run-of-the-mill, uncontaminated air, students who then inhaled the air were more likely to develop these same symptoms, particularly women who had seen another student inhale it and show symptoms!

Sticks and Stones May Break Our Bones, But Words Can Also Harm

The nocebo effect is, often unwittingly, imposed on patients by doctors in the form of direct statements that are commonly inherent to the communication style and facts that doctors have been taught. For example, doctors will often say, “This is because you’re a women, and you’ll just have to get used to it,” when discussing a condition like endometriosis, period pain, menopausal symptoms, and more, or, “Why are you using herbal remedies – those things never work,” when discussing unconventional approaches. Fixed labels, such as designations like “high risk” or “advanced maternal age” for childbearing women, can have a nocebo effect by planting the suggestion of risks that may not apply to the individual. Even indirect verbal cues, for example, a condescending verbal tone, and indirect non-verbal cues, like a dismissive shrug of the shoulder or even a subtle eye-roll or eyebrow raise, may have a nocebo effect.

The greater the power differential between the person making the statement or facial expression, and the person receiving it, the greater the nocebo effect may be. And in our culture, we have been deeply acculturated to believe that medical doctors have a tremendous level of not only knowledge, but authority. The “Doctor as God” phenomenon is well recognized and goes far back in the history of medicine. We too often inadvertently (and culturally) hand over a staggering amount of power to physicians – all the more so when we are in a medical exam setting, or are concerned about a possible diagnosis, which accentuates the power differential: We’re in an exam gown, butt naked in the back while the doctor is clothed; we address the doctor with a title, while we’re addressed often by our first name, unless we’re elderly, then as Mr. or Mrs, and we feel vulnerable – even scared. 

Our risk of nocebo effects is even higher when we feel at risk, because we are more open to negative suggestions, vague communications, and misunderstandings. Why? All of us, when we are in an extreme situation or we feel exceptionally vulnerable go into a semi-trancelike state that makes us even more susceptible to the power of unclear communication, imposed doubt about our health and body, and negative suggestions.There may also be gender differences in response. A 2017 systematic review concludes that “males responded more strongly to placebo treatment, and females responded more strongly to nocebo treatment.”

Here are just a few ways medical hexing commonly show up: 

• Negative Prognoses: When healthcare providers say, “You’ll never recover fully,” or “You’ll have to live with this condition,” it plants a seed of doubt and fear. This can lead to the nocebo effect – where negative expectations worsen outcomes.
• Overemphasis on Disease: Conventional medicine often focuses on diagnosing and treating pathology rather than fostering health. This can lead to people over-identifying with their diagnosis, viewing it as their destiny rather than one piece of their overall story.
• Disempowering Language: Phrases like “Your body is failing you,” “You’re too old for this to change,” or “You’ll need this medication forever” can strip people of agency and hope.
• Fear-Based Messaging: Whether it’s from pharmaceutical companies, wellness influencers or brands, or health or medical practitioners, fear-driven language can cause people to feel inadequate, at fault,  and overwhelmed – and doomed – if they don’t ‘comply’ with certain protocols or purchase specific products.

Sadly, since the medical model is steeped in fear-based communication, there’s a good chance that you – or someone you love – has experienced, or will experience, some level of medical hexing, at some time. As stated in an article in the American Journal of Bioethics in 2012, “The physician’s words not only describe reality, but they modify and create reality.” It’s not just sticks and stones that can break our bones. Words can harm too. 

The Neurobiology of the Nocebo Effect

The power of words is not just metaphorical; it’s hard-wired into our neurobiology. The areas of the brain that process language are deeply intertwined with the systems that regulate our internal organs, our stress responses, and even our immune system. Words can influence how fast or slow your heart beats, the amount of glucose, adrenaline, and cortisol entering your bloodstream, and the immunoglobulins supporting your immune function. The words we hear and internalize directly shape our physiological state – often without our conscious awareness. This makes communication not just a tool for connection, but also a profound mechanism for regulating health.

The impact of both the placebo effect and the nocebo effect is visible using PET scans of the brain. The placebo effect increases dopamine and opioid activity, to name just a couple of the changes, leading to a sense of well-being and pain alleviation, whereas the nocebo response is associated with both reduced dopamine and opioids, and a sense of dread and, depending on the setting, increased perception of pain. 

Also impacted are the adrenal stress response system leading to changes in cortisol production, the immune system, and the cardiovascular system, including changes in blood pressure and heart rate. The neurobiologic and physiological bases for the nocebo effect are actively being explored and likely have to do with various aspects of individual programming, from past perceived negative medical experiences, even going back the being an infant and receiving repeated ‘sticks’ for lab work, to adult medical trauma, to historical programming (i.e., fear of medical treatment based on historical evidence of medical harms as in the Tuskegee experiments) to activation of the HPA Axis (the stress response) which is very common in chronic illnesses. 

These can all impact the brain in such a way as to cause us to lean in a direction known as ‘negativity bias’ that may impact us in complex ways. As a result we may experience: 

• Stress and Hormonal Disruption: Fear activates our stress response, leading to inflammation, hormonal imbalances, and suppressed immune function.
• Loss of Self-Trust: We stop listening to our intuition and natural rhythms, becoming overly reliant on external systems rather than cultivating inner knowing.
• Discouragement: Believing we’re doomed can cause us to stop pursuing lifestyle changes or integrative strategies that could genuinely help. 

The Complexity of Chronic Illness

The placebo effect and the nocebo effect illustrate how the mind can influence physical health, but I want to emphasize that this is nuanced. For many individuals, especially women, the suggestion, prevalent in the wellness world, that one can “think themselves sick” or, conversely, that positive thinking alone can cure illness, can also cause harm. These oversimplifications can diminish the very real struggles of those living with complex, mutlifactorial conditions such as ME/CFS, endometriosis, PCOS, chronic Lyme disease, depression, and anxiety, to name just a few. 

Women, in particular, have historically faced dismissal or minimization of their symptoms and conditions, with phrases like “it’s all in your head” weaponized to invalidate their lived experiences. Many of the patients who reach out to me have already long struggled with thinking they were doing something wrong that caused or perpetuated their symptoms or condition, while simultaneously, the burden of long-term symptoms has created a sense of disconnection from their previous, healthier selves. It’s important to avoid language that implies blame or suggests that mindset alone is cause of illness, or the key to recovery, as this can perpetuate stigma and discourage women from seeking needed care.

At the same time, it’s worth exploring how external factors, such as diagnostic labels and health care providers' words, shape our experience of illness – and our beliefs in our ability to heal, or find hope and optimism and wholeness within the context of an ongoing health concern.

Protecting Yourself from the Nocebo Effect: The Role of Mindset 

Importantly, we have to break the spell of seeing doctors as gods, as having greater power over, or wisdom about our bodies, than we do. It’s an illusion based on centuries of medical hegemony, not truth. Medicine is not infallible. Guidelines are not set in stone. Prognoses are not divine. And doctors are not gods. Let’s stop giving over our power as if they are, and instead work in healing collaborations. We’re all just human.

So how can you start to do this? 

In their book The Nocebo Effect, researchers Michael H. Bernstein, Charlotte Blease, Cosima Locher, and Walter A. Brown urge individuals to protect themselves from the nocebo effect by remembering that doctors have a limited arena of expertise. “First, remind yourself that you are the expert on who you are, not the doctor,” they write. “They may be an authority on how a certain condition affects a certain group, but they truly do not know you. And they cannot know your future. Even if the practitioner is a clinician whom you admire, if they are casting negative comments inadvertently, say to yourself as they speak, ‘You don’t know me.’”

And here’s an important point we don’t always give ourselves permission to do: If your doctor is consistently negative, find a new one. You have the right to a provider with both a healing attitude within the context of being honest, direct, and giving you the whole picture and all the facts you need to make the best decisions for yourself. In fact, trusting a doctor is considered to generate positive placebo effects. So, if your doctor isn’t instilling a sense of trust, or your doctor is instilling a negative belief about your ability to heal, either have the courageous conversation that you need with him or her to be more uplifting, healing, and supportive, or change practitioners. This nocebo stuff is no joke and staying in a bad relationship just to be polite is not in your best interest. It can, in fact, be deadly. And a trusting one can be therapeutic on many levels.

Reclaiming Your Power

In order to reclaim our power, we must develop a sense of health self-efficacy and agency.

Your health journey is yours, and you’re an active participant in it. Learn to ask questions, seek clarity, and trust your instincts. When you make decisions that feel aligned with your values and needs, you’re fostering a sense of self-reliance and resilience that strengthens your ability to navigate challenges.

The medical profession, from which most of the healing and disease beliefs we have been instilled with since childhood arise, has led us to believe that our bodies are lemons or machines that are going to chronically break down, that disease is inevitable, that the only ‘real solutions’ and ‘right answers’ are pharmaceuticals, surgery and other potentially invasive interventions, and that science always trumps nature. We do not, as a culture, hold and nourish the belief that the body has an innate healing capacity, and that we can enhance and support, or dampen and destroy this capacity, with our thoughts, feelings, and beliefs. 

Yet the science on the placebo effect and the nocebo effect leaves no doubt that this is the case. 

A quote that I often share with my patients, because I have seen the incredible healing capacity of the body, women’s power to give birth, goes like this: 

Your body has the capacity to heal beyond what you’ve ever been led to believe.

Digest that for a minute. Turn it over in your mind. Let it sink into your being. It’s a powerful dose of medicine you can give to yourself every day, whatever the healing journey you’re on.

The post Have You Been Medically Hexed? The Power of Words to Heal and to Harm appeared first on Aviva Romm, MD.

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What if friendships were just as vital to our health as sleep, nutrition, and exercise? Research suggests they might be. But in our fast-paced, modern world, nurturing deep and lasting friendships can feel overwhelming.

In this episode, I sit down with journalist and author Anna Goldfarb to explore the evolving landscape of friendship—why it can be so challenging to maintain meaningful connections as we move through different life phases, and what we can do to strengthen the relationships that nourish us the most.

Anna’s book, Modern Friendship: How to Nurture Our Most Valued Connections, gave me so many “aha” moments about why friendships shift, how we can show up for each other in a more intentional way, and how to release the guilt we sometimes feel when friendships change.

Join us as we unpack:

• How relationships have changed over time—why past generations had built-in social structures that kept friendships steady, and how today’s hyper-fluid, fast-paced world has reshaped the way we connect.
• How understanding the difference between “bathtub friends,” “swimming pool friends,” and “memorial friends” can ease the strain in relationships and help us let go of unrealistic expectations.
• Why some friendships fade over time (and why it’s not your fault!) and how to cope with changing relationships.
• The impact of social media on our lives and how having ‘friends’ online can leave us feeling more lonely than not. 
• How we can keep connections alive through life changes—from motherhood to career shifts, big moves, and more.
• What to do when a connection feels out of sync—how to know whether to repair it or let it go.

If you’ve ever felt lonely, longed for deeper relationships, or struggled to navigate the shifting nature of connection as life evolves—this conversation is for you.

Quick Tips for Nurturing Your Relationships

• Connections evolve—and that’s okay. Research shows we lose about half of our close relationships every seven years. Instead of taking it personally, recognize that life phases naturally shift our social circles.
• Building strong bonds requires intentionality. Unlike childhood friendships that form effortlessly, adult relationships require conscious effort. Make time, check in, and prioritize those who make you feel seen and valued.
• Show up in ways that matter. Instead of generic invites like “Let’s get dinner,” support others in a way that reflects their reality—bring a meal to a new mom, offer career support to a job-seeking friend, or simply sit in silence with someone grieving.
• Not all connections serve the same role. Some people are for deep talks, others for shared hobbies. Recognizing the different “tiers” of relationships—bathtub friends (deepest confidantes), swimming pool friends (social companions), and memorial friends (people we cherish but may not see often)—helps set realistic expectations.
• Don’t be afraid of a “pause.” Not every relationship needs a dramatic ending. Sometimes, life circumstances change, and stepping back without guilt allows room for reconnection down the road.
• Express appreciation. Tell people what they mean to you! Knowing they are valued strengthens the bond and makes them more likely to invest in the connection, too.
• Quality over quantity. In an era of social media “friends,” true connection matters more than ever. A few close, meaningful relationships can have a greater impact on your well-being than a hundred surface-level acquaintances.

The way we connect in our modern lives is changing, but meaningful relationships are still the key to a healthy, fulfilling life. Have a listen to learn how to nourish the connections that truly matter. If this episode resonated with you, share it with a friend who might need a reminder of their own power. And if you loved it, leave a review on Apple Podcasts or Spotify—it helps other women find this show!

Links Mentioned in Show:

Connect with Anna:

• Instagram: @annagoldfarb
• Substack: annagoldfarb.substack.com/
• Book: Modern Friendship: How to Nurture Our Most Valued Connections (Available wherever books are sold)

The Transcript: Holding On and Letting Go: Modern Friendship in Women’s Lives with Anna Goldfarb

This transcript has been edited for length and clarity.

Aviva: I was recently interviewed by Gabrielle Espinoza on her podcast Pleasure in the Pause, and she asked me what I felt was the most important thing for me while moving through menopause. My answer came swiftly and easily—I said, “My female friendships.” And it is the truest thing I can say.

My partner is great; we’ve been together for 40 years, but there are just edges where he doesn’t get it. Being aligned with other women who are going through similar things in my phase of life has been a lifesaver. It’s been so healthy and normalizing.

When I think back on it, the same can be said for all the other big transitions in my life. Puberty—it was my best friend, who I’ve known since sixth grade. We went through menopause at the same time. Motherhood—I had my couple of motherhood best friends. Even through midwifery and medical training, lifelong friendships were forged.

For so many women, our friendships anchor us in ways that our partners, children, and families sometimes can’t. In my experience, female friendships hold space for things only other women can truly understand—the invisible labor we carry as mothers, the body shifts we go through at various phases of our lives, the hormonal rollercoasters, the midlife reinventions. Our best friends walk beside us through heartbreak, healing, and transformation.

But truth be told, friendships aren’t always so easy. When I think back on my best friends from when I was raising kids, those women are deeply important, but they’re not front and center in my life in the same way anymore. Different women are front and center in my life right now.

We all know the pain and confusion of friendships that don’t last—the self-searching, the what did I do wrong? and what’s going on? Research shows that after age 20, we lose about half of our close friends every seven years. A lot of us aren’t replacing those friendships nearly as fast as we move into our thirties, forties, and beyond.

We’ve also been fed many myths and expectations about friendships, some of which lead to anxiety, confusion, and disappointment. More people than ever report having fewer friends or feeling that the friendships they do have aren’t as fulfilling as they once were.

In fact, in one study, 40% of people said they don’t feel as emotionally close to their friends as they’d like, and many wish they had more time to spend with their friends. Researchers call that longingness—that quiet ache for deeper connection, even when you technically have friends.

So if you’ve been feeling isolated or disconnected, you’re not alone. Here’s the thing—and this is really important—our friendships are vital to our well-being. Some researchers suggest they may even be as important as sleep, nutrition, or exercise.

But in our fast-paced world, where motherhood, careers, and life transitions keep us stretched thin, friendships sometimes take a backseat. In a world of social media “friends,” we can still feel lonely. When friendships falter, it can feel like a part of ourselves is missing.

Yesterday, after three weeks of travel, I finally had the chance to pick up Modern Friendship by Anna Goldfarb to prep for my interview today. I have to say, I thought, Alright, it’s about friendship. I’ve read some of her articles. I’ll do a little light reading.

This was around two in the afternoon, and, y’all, I could not put the book down. It’s fresh, funny, and filled with perfect little swear bombs tucked in. It’s so real. It felt like Anna had cracked open my journal and started reading my most secret fears about friendship, my peeves, and my desires about having—and being—a friend.

Which is why I’m so excited to welcome Anna Goldfarb to the show.

Anna is a journalist and author of Modern Friendship: How to Nurture Our Most Valued Connections. She’s here to help us unpack why friendships falter, why they matter more than ever for our health, and, importantly, how to rebuild, deepen, and nurture the friendships that sustain us through every stage of life.

Whether you’re craving deeper connections, grieving a friendship drift, or wondering if you’re the only one struggling to make new friends in your thirties, forties, or beyond, I deeply hope this episode reminds you that you’re normal—and that you’re okay. Even when friendships change over time, it’s okay to have a smaller group of friends.

Many of us have to navigate busy lives while nurturing friendships and struggling with the fact that some of our dearest friends may live thousands of miles away.

So however your friendships are showing up in your life right now, I truly hope this conversation helps you feel more sane, more seen, and, frankly, more normal—just like Anna’s book did for me. Anna, welcome!

Anna: That was beautiful. I’m tearing up. That means so much to me.

Aviva: Well, thank you!

Anna: That you said such wonderfully kind, lovely words about my work—thank you so much.

Aviva: You’re so welcome. You are a really talented writer. It’s rare that a book makes me feel like I’m actually sitting with someone who is being truly authentic. The way you weave in little personal reflections that are honest, transparent, and so normalizing—I think that’s why I just couldn’t put it down. I kept thinking, Okay, where is she going next? What is she going to say?

Even the little things—like a product you were buying at the store, the connection you had around it—you were so explicit about the details that it felt like, Oh, she just invited me into her bathroom. She just invited me into her kitchen. I loved that.

Anna: That means so much to me because you’re right—there are so many friendship books out there. My mantra when writing this book was: Don’t be boring. I wanted to say new things, tell new stories, and have it feel fresh.

Aviva: I felt the weight of this opportunity—this was my chance to really talk to people, to make them feel validated and seen. I know we use this word all the time, but I wanted them to feel empowered. I wanted to explain these big concepts about society and culture in ways that feel personal and true.

Anna: That means so much to me because you’re right—there are so many friendship books out there. My mantra when writing this book was: Don’t be boring. I wanted to say new things, tell new stories, and have it feel fresh. Even my title is a little bit boring, really, but I wanted to under-promise and over-deliver.

Aviva: I like the title!

Anna: Modern Friendship—okay, what’s this going to be? But I wanted it to be like, Oh my God, this is actually really relatable. I felt the weight of this opportunity. This was my chance to really talk to people and make them feel validated, seen. And I know we use this word all the time, but empowered—like, this is the gig, this is what’s up. I wanted to explain these big concepts about society and culture in ways that feel personal and true.

Aviva: Yeah, it does all of that. I felt like it grounded me in a context of, You’re totally not alone. There’s nothing wrong with you in the different iterations you’ve gone through in friendships in your life. It was very… I felt like part of something, which is really beautiful.

And I have to say, among your little token swear bombs, which I loved—I’m a New Yorker, and I spent decades of my life intentionally not ever cursing. Then I went to residency, where it was just sort of part of life, and I really find it can be fun and therapeutic to just speak that way.

And here’s something hilarious—so, we live in a very rural area, and we have big hills. It’s a very popular area for bike riding, but some of the hills are just too steep for me. So, I ultimately got an e-bike, which is really nice. But I was on my regular bike trying to go up a hill to get back to my house, and there were these five telephone poles.

I got from the first telephone pole to the second one, which was my first landmark. Then, the second one got steeper. And I literally hop off my bike, stand there, and go, Okay, yo. And I’m saying—okay, cover your kid’s ears—Yo, bitch, you’ve got this! Get on your bike. Be a baller.

I’m literally having this whole, I don’t know… I’m rap-motivating myself.

Anna: You’re hyping yourself up! You’re like your own hype man.

Aviva: Yep.

Anna: The Flavor Flav of bike riding.

Aviva: Exactly! And then I got a study in my inbox yesterday that actually showed how cursing while you exercise can increase your exercise capacity. I showed it to my husband, and he was like, There you go.

Anyway, I think you keep it real in a really fresh way. Also, I dressed up for you today. I’ve never dressed up for a podcast interview before!

Anna: That was the first thing I noticed—you look really pretty today.

Aviva: Thank you! I love boy bands and punk music. I love girl band punk music too. And as I was reading your book, you had these little kind of threads where you had this best friend you went to the punk scene with—although I think you had some not-so-good things happen with that particular friend and a guy. But you dropped it a few times, and I thought, I’m going to pull out my British little punk tie.

Anna: Yes!

Aviva: So, I dressed for you—plus red lipstick. I went all in.

Anna: Beautiful.

Aviva: Alright, you. So, let’s take it from the top. First, who are you? You’re a journalist—you could be writing about anything. What is it about friendship? Was it something personal that happened? Something you read about, witnessed, that made you think, Okay, I’m going to spend however long it takes to write this book talking about friendship?

Anna: Yeah. I’m obsessed with friendship, and part of that is because I’m a pinball. I’ve moved around a lot. I was born in upstate New York, which I low-key hated. Then I moved to outside Chicago, which I loved. Then I moved to New York City, which I loved. Then I ricocheted to Philly, which I love now. I mean, I love it—it has a charm.

Aviva: And this was for changes in your family situation—like, your parents moving—and then later, for work, college, grad school?

Anna: That, and I made these really deep, intense friendships in all these different spaces in my life, but then I’d have to renegotiate them as I moved around—or they moved around. We go to college and meet such deeply interesting people who are into the same stuff we’re into, and then we’re blasted apart from one another.

I’d spend a lot of energy keeping up these friendships—visiting my friends in the different cities they moved to. And I just felt like my friends became these wild stallions that were dragging me through the dirt. Like, Am I doing enough? Are they doing enough?

I felt disappointed—Why isn’t my friend making more of an effort to see me? I could say this friend was my best friend three years ago, but today I’m not sure. And there was so much uncertainty that it was something I thought about all the time. I felt really out of control, and I just wanted to learn more about it.

I used to write about romance and dating. I had a blog that was turned into a book about my dating life called Clearly, I Didn’t Think This Through. I was more interested in dudes and dating. But then once I met my husband, that was settled. I didn’t need to decipher the dating world anymore.

Then, I turned my attention to my friendships. And I was like, Whoa. This is really a lot.

I was kind of a people-pleaser. I’d say yes to things I didn’t want to do, out of fear that I wouldn’t be asked anymore if I didn’t say yes. I felt held hostage by these relationships that I cared about so much.

I had four friends at my wedding in 2017, and I only talk to two of them now.

It was this buckling of friendships—Why aren’t these friendships holding? Usually, my friends were having more complicated problems that I didn’t know how to address or support. I didn’t know how to show up for them in the right way.

I felt like I was saying the wrong thing all the time, which created distance. The stakes felt really high. We live in a culture that says, Oh, your friend disappointed you? You don’t need them. Get rid of them.

And I felt this panic—friendships are so easy to shed. I didn’t grow up in Philly. I don’t have school ties, I don’t have neighborhood ties. It’s so transient. And so, what do people like me do? How do we navigate this?

I started reporting on friendships in 2017 for The New York Times, and that was the first time I interacted with a friendship expert. I didn’t even know that such a thing existed! I was like, Wait, what? It was Shasta Nelson—she still writes books, she’s very active in the friendship space—and it just blew my mind that friendship was something knowable. Friendships had always felt so unknowable, so mysterious.

And to think that there’s logic here, that we could diagnose things—I could push on one lever and see a result, pull back in another way and see a result. The more I learned about friendships, the more questions I had.

Then, the pandemic happened, and all of us collectively had to renegotiate our friendships. Our routines were disrupted. We had to figure out, Which friend am I going to see? Which ones am I going to keep in touch with? I mean, it was a life-and-death situation with this virus going around. The stakes were insanely high—Who am I going to invest in? Whose friendships am I going to keep afloat?

A lot of the advice we got during the pandemic was, Reach out to people! This is the time to reach out to old friends! But I sensed that advice was incomplete. It was like, Well, why did you lose touch in the first place? And what’s going to change now?

So, you have this really great conversation for two hours, you catch up on everything… but how does that translate to an active friendship? If anything, more time ends up passing because you’re like, Okay, you’re cool. You sound like you’re good. You’re busy. You’re doing your thing. I’ll see you around. It didn’t lead to more connection. So, that’s what I wanted to investigate with this book—What is going on here?

Our phones are full of friends we love, but we don’t reach out to them. Why? This is crazy!

Aviva: Yeah, there’s so much to unpack here. First, I’d love to start at the top where you started, which is that you had ping-ponged around a lot. And I think there are few people these days who grew up in the same place, stayed for college in the same place, went to grad school—if they did—lived in the same place, and stayed there.

There are some people like that. I meet them sometimes, and every now and then, I feel these deep pangs of envy. And I know my kids do too, because my kids grew up in a variety of places. They don’t have one place where all of them grew up, with friends they can all return to and say, This is home.

So, is that part of what’s happening with modern friendships? Have we lost that? I don’t mean to romanticize, but when I look back at my grandparents, for example, they lived, grew up, and spent their lives within a very small radius around New York. They had their “Friends Club,” they had their “Cousins Club”—and these were friends and cousins they’d had since childhood. Once a month, they’d get together with the Cousins Club and play cards, and once a month, the Friends Club would play cards. They’d rotate houses, and as a little girl, I was under the table while they were playing cards or watching TV in the next room. Or I was invited to go spend the night at a cousin’s house.

So, there was this deep stability.

Whereas for me—I grew up in New York, but I went to college early in Massachusetts. I was really young—I went to college at 15.

Those friendships didn’t necessarily follow into motherhood. The friendships I had when I became a mother didn’t necessarily follow into medical school. A lot of my mother-friends couldn’t relate to what I was doing when I went to med school. They were loving, but our lives just weren’t aligned anymore.

And then there’s proximity. That changes everything.

What are some of the things you’re seeing about how friendships evolve? And one thing I’ve noticed lately—politics is even dividing friendships.

What are some of the broader cultural and circumstantial factors at play? Because I think a lot of people assume, It’s me. I must be doing something wrong. But actually, there’s something bigger going on.

Anna: Yes, yes—well said.

What I’ve learned is that our grandparents didn’t have to work this hard at friendships. They lived in a community, went to a synagogue, or had their neighborhood group. They didn’t have to try very hard to keep friendships afloat because there were built-in social structures—institutions that helped facilitate socializing.

Now? We live in hyper-fluid society. One of the trade-offs is that we can befriend almost anyone, anywhere.

For example, I’m in several video groups with other authors. We meet every week, and we talk about our books and what it’s like having them out in the world. But we live all over the country! We can talk about anything we want, and it’s great—it’s cheap, it’s free. But the trade-off is, I can’t just go out for coffee with them. I can’t give them a hug.

Aviva: That’s so funny you say that because I’ve become friends with a woman who was a guest on my podcast. She lives in California, and we didn’t know we’d both be at an event recently in New York. We were standing next to each other in line for water, and she looked at me, and I looked at her. If it were my best friend who I’ve known forever, it would have been instant recognition. But instead, we had this split second of, Wait, I know you… Then we hugged—this huge hug—and then we both realized: Oh my God, we’ve actually never met in person before.

It’s crazy.

There are friendships we have now where we’ve never met the people in real life. And then there are friendships that are deeply important to us, but those friends live a thousand or two thousand miles away. And a lot of us work on computers all day long. At the end of the day, it’s not like we necessarily want to get on Zoom just to catch up. So, it creates these spaces and distances.

And then, at least for me, I start thinking, Well… are we actually close anymore? Or am I just imagining that we are? I mean, we might only talk once a month or every two months.

So, for me, there’s some confusion. Does this space and distance mean we’re not as close? What does it all mean?

Anna: Our grandmothers did not have to navigate this. They didn’t have to question whether someone was still their best friend because they saw them all the time. Their best friend lived two doors down, and they had known them for 40 years. They didn’t have to juggle a variety of connections from different parts of their life like we do now.

We live in what’s called a spoke network, like a bicycle wheel. We’re in the middle, and all of our friendships branch out from us. The problem? They only share history with us, not necessarily with each other.

So we have to be the cruise director. We have our clipboard, figuring out:

• Which friendships do I want to keep active?

• Why do I want to keep them active?

• How much time and effort am I putting into this?

We don’t have the help of institutions and cultural norms to guide us in the way our grandparents did.

And one of the biggest shifts? Friendships used to be built around obligation.

Aviva: Right!

Anna: In our grandparents’ generation, you didn’t just drop a friend because they disappointed you. They were part of your community—your neighborhood, your synagogue, your church, your extended family. But today? Friendships are built more around entertainment value.

Aviva: That’s such a shift!

Anna: Right? Instead of, Who can I rely on? Who is in my everyday life?, it becomes, Who is fun to go out to dinner with? Who do I like to go to concerts with? Who shares my interests?

So when that entertainment piece fades—when the circumstances that brought us together change—the friendship sometimes fizzles out.

Aviva: Oh my gosh. That’s huge.

Anna: Right? So, instead of integrated friendships that serve multiple purposes in our lives, we now have these segmented, compartmentalized friendships.

It’s like, This is my yoga friend. This is my hiking friend. This is my book club friend. And that’s great! But it also means that if we stop doing that thing together, we often don’t know what else to talk about.

Aviva: That is so insightful. And it makes me think of something else, too—our grandmothers had to work through conflict with their friends. If there was a disagreement, they still had to see each other at temple, at church, at the grocery store. Now? We can just… disappear.

Anna: Exactly. Ghosting isn’t just for dating anymore!

Aviva: Yes! If a friend hurts us or if we have a falling out, there’s no forced reconciliation—no external force pushing us to repair the relationship.

Anna: Yes. And, of course, some friendships should end—some aren’t healthy. But we’ve also lost some of the skills needed to work through difficulties in friendships because we’ve been conditioned to think, If they disappointed me, I don’t need them. I’ll just move on. But sometimes friendships just need a reset, not an ending.

Aviva: That’s so powerful.

And I’ve experienced this personally. I have a dear friend who I absolutely love, but we’re in different life stages. She has a young child, and I have grown kids. And I noticed myself feeling like, Is she pulling away? Does she not care about me anymore? Then I took a step back and realized—no, she’s just exhausted. She’s navigating a completely different season of life, and she doesn’t have the same time and energy for our friendship that she did before.

So instead of taking it personally, I started asking, How can I show up for her in a way that makes sense for where she is in her life right now?

Anna: That is such a healthy way to look at it. We have to move away from this all-or-nothing mindset with friendships. Just because a friendship isn’t the same as it used to be doesn’t mean it’s over. It might just mean it’s in a different phase.

Aviva: That reminds me of something you talk about in your book—social identity support.

Anna: Yes!

Aviva: Can you explain that concept?

Anna: Absolutely. Social identity support is one of the most important ingredients in a lasting friendship. It means seeing your friend for all the roles they play in life—their career, their family responsibilities, their cultural background—and actively supporting them in those roles.

So, for example, if your friend is a new mom, instead of saying, Let’s get dinner sometime, you say, Hey, I know you’ve been up all night with the baby. Can I bring you some food? Can I hold the baby for a bit so you can take a nap? Or if your friend just lost their job, instead of saying, Let me know if you need anything, you say, Hey, I know you’re in between jobs. Do you want to come over for dinner this week? My treat.

It’s about making your friendship work within the reality of your friend’s life.

Aviva: Wow. That is so powerful. And it makes so much sense!

Anna: Right? It’s about being intentional.

When we were younger, friendships just happened. We were in school together, in the same dorm, on the same team. As adults, we have to be deliberate. We have to ask ourselves, How can I show up for this person in a way that makes them feel seen, valued, and supported?

Aviva: I love that. And I feel like we don’t talk about that enough. People assume friendship should just be easy—but really, great friendships require effort and intention.

Anna: Exactly!

I always say, if we applied the same level of intentionality to friendships that we apply to romantic relationships, we’d have much stronger friendships. Think about it—when you start dating someone, you put in effort. You plan dates, you check in, you make time for them. But with friendships, we often take a passive approach.

Aviva: That is such a good point. And I love that your book gives actual tools—practical strategies for maintaining and deepening friendships. Because we aren’t really taught how to do that.

Anna: Exactly! And my hope is that it makes people feel less alone. Because if you’re feeling like your friendships are shifting, or you’re struggling to make new friends, or you’re wondering, Is it just me?—the answer is no. This is something we are all navigating.

Aviva: That is such a reassuring message.

Anna, I could talk to you for hours about this, but I want to respect your time! Tell everyone where they can find you and your book.

Anna: Thank you so much! You can find me on Instagram, @annagoldfarb. I also have a Substack called Friendship Explained, where I write about all things friendship. And my book, Modern Friendship, is available wherever books are sold!

Aviva: Amazing. And I just want to say—your book is truly wonderful. It made me feel so seen and gave me so many tools for navigating friendship. Thank you so much for being here today.

Anna: Thank you! This was such a joy.

Aviva: And to everyone listening—I hope this conversation helped you feel more normal and less alone in your friendships. We’ve got this!

The post Holding On and Letting Go: Modern Friendship in Women’s Lives appeared first on Aviva Romm, MD.

Search This Article

• Tylenol Use During Pregnancy, ADHD and Autism: Is There a Connection?
• Did the the FDA or the “Tylenol Company” or Say Not to Use Tylenol?
• So, What's a Mom to Do?
• Are there Natural Alternatives to Tylenol in Pregnancy?

Tylenol (acetaminophen, paracetamol)— most people reach for it for everyday headaches and fever like it's no big deal, and two-thirds of women have used it in pregnancy.

While not an entirely benign medication — overuse is one of the major contributors to liver disease and the most common cause of liver transplantation in the US every year. However, used appropriately, acetaminophen has long been considered generally safe for use during all stages of pregnancy, making it a first-choice pain and fever medication for pregnant women.

But concerns have been raised over the safety of this medication when it comes to fetal development, particularly in relationship to neurodevelopmental disorders (NDD) such as ADD, ADHD, and autism, when used by pregnant women. Given the large number of pregnant women using the drug, even a small increase in risk of adverse outcomes in offspring can have important implications for public health. So, it's important to take this seriously.

At the same time, it's critically important. for context, to recognize that we live in an era in which there's an unprecedented and rapid spread of not only information, but misinformation, poor interpretation of data, and fear mongering based on biased politics and hidden agendas – not true public interest.

We have a President who is telling women to “fight like hell not to take” pain relief in pregnancy and just “tough it out.” That’s not good medicine — and why is that an opinion we’d listen to? We already know that women's pain is too often overlooked and under treated. Further, we have a Secretary of Health and Human Services, who has no training or background in health care at all, hell-bent on proving that he knows that the causes of autism are Tylenol and vaccinations. Behind him we have a wealthy, influential movement known as Make America Healthy Again (MAHA), known for it's inaccurate and interpretation of data, literally made-up science, hyperbolic claims and conspiracy theories, and a whole lot of profiteering based on our health concerns.

What's especially dangerous about MAHA's messaging is its ability to weave in the concerns that pull on our heartstrings — we want to protect ourselves and our children from environmental toxins, food additives, and medication side-effects. But small facts woven into a web of misinformation, and laced with dose of fear mongering, is at the heart of why propaganda has always worked. And it will continue to if we don't sort fact from fiction and continue to support trustworthy research.

But let's unpack the issue at hand: Is it safe to use Tylenol in pregnancy — or are we putting our children at risk?

Tylenol Use During Pregnancy, ADHD and Autism: Is There a Connection?

First, if you don't know who I am – my name is Aviva Romm, I think it's important that I tell you. I'm a Yale trained medical doctor with a Yale Internal Medicine Internship with a residency in Family Medicine at Tufts. I am also a midwife. In total I have 40 years of cumulative experience in women's and children's health, and am formally trained in Integrative Medicine through the University of Arizona, as well as being a pioneer in the field. I have 4 children, all of whom I raised as naturally as possible, had 4 home births, and breastfed my children, as I joke, ‘practically until they went off to college.' I also midwifed my grandchildren at home, their mom a Harvard trained pediatrician with a Master's in Public Health, also from Harvard. I've written many books, including a NYT Bestseller, and a textbook, and I have written the Yale Pediatric Residency integrative medicine curriculum section, used in over 150 residency programs, for 15 years. I've been around the block and have seen fads, trends, misinformation, and conspiracy theories come and go. Rinse and repeat. I get why mamas want to go ‘all natural' and I practice a balanced, evidence-based care approach to integrative medicine. And when needed, I believe that, given the evidence we have to date, Tylenol can be used safely in pregnancy, in moderation, when needed.

Let's dig deeper.

The questions about Tylenol safety first began to surface about a decade ago, when I published the ‘first edition' of this article. I specifically remember the day, because my pregnant daughter-in-law was visiting, and had a headache. She asked if I had Tylenol, and told her I did not happen to – but that also a new study had just come out days before raising some concerns. Rather than immediately venture out for Tylenol, she decided to apply a few drops of lavender oil to her temples, at my suggestion, accept a neck massage, and she felt better.

It was in 2018 that significant concerns were really raised when observational, cohort data was published suggesting a potential association between Tylenol use in pregnancy, and an increased risk of NDDs including ADD, ADHD, and autism in babies born to pregnant mothers who had used it. Based on this review, a team of 13 scientists cautioned against the use of pain relievers with acetaminophen by pregnant women, citing a growing body of research that suggests the drug may alter fetal development. Again, I wrote about this issue.

Then in 2021, a consensus statement was published in the journal Nature Reviews Endocrinology, supported by 91 researchers, clinicians, and public health experts from around the world. They alerted the medical community that acetaminophen may be at least partially responsible for rising rates of male reproductive disorders (like undescended testes, an increased risk factor for infertility), as well as cognitive, learning, and behavioral problems among children (like ADHD, ADD, and ASD) over the past several years. Their concluding statement was a recommendation for pregnant women to avoid acetaminophen altogether unless otherwise prescribed it by a medical professional.

However, in medicine, there's an important maxim: Correlation does not equal causation, and when it comes to observational studies, this is often true. In other words, something can be true-true, and unrelated. Neurodevelopmental disorders are likely due to a complex constellation of factors. It's also important to keep in mind. there’s data to support an association between untreated maternal fever in pregnancy, especially when the fever is high, and neurodevelopmental disorders in those offspring, as well as maternal health complications. And yes, I went back in for another round of updates – to make sure you're always informed with the latest data.

Then, in 2024, publication of what was considered higher quality data than the previous study, led to a ‘switchback' on the concerns: The study, published in JAMA in April of that year, had used a sibling analysis across nearly 2.5 million children in Sweden born to singleton pregnancies (that’s one baby to a pregnancy) between 1995 and 2019. This means they compared children born from the same mother, with one being exposed to acetaminophen while in the womb and the other not. This data was self-reported, meaning mothers were asked several times during pregnancy to report their intake of acetaminophen, which was compared against the child’s medical records later on.

What did they find? In total, 185 909 children (7.49%) of children had been exposed to acetaminophen in this study. In models without sibling control, similar findings to previous data still ring true: there was a modest increased risk for autism, ADHD, and intellectual disability. However, in models with sibling control, they found no evidence that acetaminophen use during pregnancy was associated with autism, ADHD or intellectual disability. There was also no evidence of a dose-dependent pattern in models with sibling control, meaning more acetaminophen exposure didn’t increase the risk of diagnosis. 

While a sibling analysis is not a gold standard, double-blind, randomized control trial, it was an improvement on the previous observational or cohort based study designs where associations between Tylenol use and NDDs were found. More updates! Do we have a theme here? Yes – the data keeps shifting and evolving.

Now, an even more recent report published in BMC Environmental Health in August, 2025, is throwing the findings into question once again. This carefully conducted review from researchers at the Icahn School of Medicine at Mount Sinai, in partnership with Harvard T.H. Chan School of Public Health, analyzed 46 studies encompassing more than 100,000 children to explore potential connections between prenatal acetaminophen use and neurodevelopmental outcomes, including autism (ASD) and attention-deficit/hyperactivity disorder (ADHD). This study applied the rigorous, transparent Navigation Guide methodology—a gold-standard framework for evaluating environmental health evidence—to systematically assess study quality, bias, and strength of evidence.

Of the studies reviewed, 27 found significant associations with outcomes such as ADHD, autism spectrum disorder (ASD), or other NDDs. Nine studies found no association, and four suggested possible protective effects. Importantly, the higher-quality studies—those with stronger designs and fewer sources of bias—were more likely to report links between prenatal acetaminophen exposure and later NDDs.

While the review cannot prove that acetaminophen directly causes these conditions, the overall weight of evidence suggests that frequent or prolonged use during pregnancy may carry some risks, and that further research is both needed and warranted but, the authors cautioned, the conclusions did not mean that acetaminophen was causing autism — that other factors unique to the women themselves, for example, possible prenatal exposures, to infection, are important to consider. At the end of the day the authors suggest that “Appropriate and immediate steps should be taken to advise pregnant women to limit acetaminophen consumption to protect their offspring’s neurodevelopment.”

Again, this doesn't mean that Tylenol has any causal relationship to autism – but as with anything in pregnancy, when in doubt, limit or avoid it if you can, until we have more information. This is true with most pharmaceuticals, as well as herbs and supplements in pregnancy.

Did the the FDA or the “Tylenol Company” or Say Not to Use Tylenol?

The answer to both of these questions is definitively, no. In the FDA Responds to Evidence of Possible Association Between Autism and Acetaminophen Use During Pregnancy, Marty Makary MD, and Trump's appointed FDA Commissioner stated: “The FDA is taking action to make parents and doctors aware of a considerable body of evidence about potential risks associated with acetaminophen.” He added, “Even with this body of evidence, the choice still belongs with parents. The precautionary principle may lead many to avoid using acetaminophen during pregnancy, especially since most low-grade fevers don’t require treatment. It remains reasonable, however, for pregnant women to use acetaminophen in certain scenarios.”  

Misinformation is floating around on the internet, that Kenvue, the parent company that produces Tylenol, stated that Tylenol should not be used in pregnancy. The company asserts, however, that comments made back in 2017 in a social media post about using their products during pregnancy have been entirely distorted, and they, continue to recommend Tylenol as the safest option for pain and fever in pregnancy when medically necessary, with the caveat of always checking with a healthcare provider first.

So, What's a Mom to Do?

All mothers want to do everything we can to protect our babies from any possible risks, and all of this information puts mothers in a tough decision-making position when it comes to fever and also pain treatment in pregnancy.

And yes, here I am again, updating this information for you.

The beauty of research is that we’re constantly learning, acquiring new insights, and gathering higher quality data from more thoughtfully run studies. Ultimately, until we know more, sometimes when data is so contradictory, it may be best to err on the side of practical caution.

I think the safest approach at this time is to be sensible and thoughtful – to use Tylenol only sparingly and judiciously when truly needed during pregnancy, for fever, pain, etc. I do not think a pregnant mother who is suffering from either needs to avoid any Tylenol at all costs. It's what I've suggested to the women in my care as a midwife and medical doctor for decades.

Importantly, mothers should not be retroactively beating themselves up for having used Tylenol in pregnancy – the factors that contribute to neurodevelopmental issues are vast and complex — and to date we have no evidence to suggests that modest use of Tylenol in pregnancy is harmful to our babies. Even if you did require a higher amount, you did what was needed at the time, and there is no fault or blame in that!

The bottom line is that the best choice is the one you’re most comfortable with. 

Are there Natural Alternatives to Tylenol in Pregnancy?

Headaches and fever can both occur during pregnancy and other commonly used pain medications like ibuprofen are not recommended for use. So, what can you do? 

With fever, if a low fever, it may be enough to use simple comfort measures at home, but for higher fevers, again, discuss options with your healthcare provider, and it still seems that acetaminophen is a safe and appropriate choice for short term use at a low to moderate dose.

If you’re experiencing a headache, or having a fever and choose to take acetaminophen, statistically speaking you’re in the clear. Tylenol is still considered the safest prenatal option for fever and headache. With headaches, particularly if they are recurring, it’s important to address any medical or root causes with your healthcare provider, making sure you’re getting enough sleep, adequate hydration, addressing stress and nutrition, including protein and iron, and looking into environmental allergies or other triggers, and make sure your blood pressure is in a healthy range, while later in pregnancy make sure pre-eclampsia is properly ruled out.

If you have a sudden onset headache, a more severe headache than usual, any visual changes or upper abdominal pain with your headache, or a history of high blood pressure, please see your midwife or physician promptly as these can be signs of more serious illness, like pregnancy induced hypertension or preeclampsia.

Here are 4 tips that you can safely try to help reduce headaches in pregnancy:

1. Apply 1-2 drops of lavender oil or peppermint oil to the temples. These have been shown to safely and effectively reduce headaches and can be used topically in pregnancy. Alternatively, take a warm relaxing bath with 5-7 drops of lavender essential oil added to the bath water.

2. Take 2 ginger capsules if you feel a headache coming on and repeat again in a few hours. It is a natural anti-inflammatory and pain-relieving herb that’s considered safe in pregnancy in a dose of up to 2 grams per day.

3. Many headaches are a result of neck and shoulder tension, so don't overlook the value of addressing posture, sleeping positions, a change of pillows, and massage for headache prevention and relief. Avoid chiropractic neck treatments in pregnancy.

4. If you suffer from migraines, Riboflavin (Vitamin B2) at 400 mg/day has been found effective for prevention, and safe for daily use in pregnancy. You can also do a migraine journal to identify and remove any potential triggers.

You may also consider working with an integrative Obstetrician or Family Doctor, midwife, or nurse practitioner skilled in pregnancy care, and join me online in the Mama Pathway community for ongoing support and answers to questions like those in this article.

And please, please, be savvy and know who to trust. I can tell you from my vantage point — it's not the MAHA movement, RFK Jr, or our current administration when it comes to health information.

The post Tylenol: Does it Cause ADHD and Autism, or Is it Safe During Pregnancy? appeared first on Aviva Romm, MD.