The Relentlessness of Modern Parenting

THE RELENTLESSNESS OF MODERN PARENTING

Claire Cain Miller

Renée Sentilles and her son Isaac eating dinner at their home in Cleveland Heights, Ohio. She is raising him in a much more hands-on way than she was raised.

Raising children has become significantly more time-consuming and expensive, amid a sense that opportunity has grown more elusive.

Parenthood in the United States has become much more demanding than it used to be.

Over just a couple of generations, parents have greatly increased the amount of time, attention and money they put into raising children. Mothers who juggle jobs outside the home spend just as much timetending their children as stay-at-home mothers did in the 1970s.

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The amount of money parents spend on children, which used to peak when they were in high school, is now highest when they are under 6 and over 18 and into their mid-20s.

Renée Sentilles enrolled her son Isaac in lessons beginning when he was an infant. Even now that he’s 12, she rarely has him out of sight when he is home.

“I read all the child-care books,” said Ms. Sentilles, a professor in Cleveland Heights, Ohio. “I enrolled him in piano at 5. I took him to soccer practices at 4. We tried track; we did all the swimming lessons, martial arts. I did everything. Of course I did.”

While this kind of intensive parenting — constantly teaching and monitoring children — has been the norm for upper-middle-class parents since the 1990s, new research shows that people across class divides now consider it the best way to raise children, even if they don’t have the resources to enact it.

There are signs of a backlash, led by so-called free-range parents, but social scientists say the relentlessness of modern-day parenting has a powerful motivation: economic anxiety. For the first time, it’s as likely as not that American children will be less prosperous than their parents. For parents, giving children the best start in life has come to mean doing everything they can to ensure that their children can climb to a higher class, or at least not fall out of the one they were born into.

“As the gap between rich and poor increases, the cost of screwing up increases,” said Philip Cohen, a sociologist at the University of Maryland who studies families and inequality. “The fear is they’ll end up on the other side of the divide.”

But it also stokes economic anxiety, because even as more parents say they want to raise childrenthis way, it’s the richest ones who are most able to do so.

“Intensive parenting is a way for especially affluent white mothers to make sure their children are maintaining their advantaged position in society,” said Jessica Calarco, a sociologist at Indiana University and author of “Negotiating Opportunities: How the Middle Class Secures Advantages in School.”

Stacey Jones raised her two sons, now in their 20s, as a single mother in a working-class, mostly black neighborhood in Stone Mountain, Ga. She said she and other parents tried hard to give their children opportunities by finding affordable options: municipal sports leagues instead of traveling club teams and school band instead of private music lessons.

“I think most people have this craving for their children to do better and know more than they do,” said Ms. Jones, who works in university communications. “But a lot of these opportunities were closed off because they do cost money.”

‘Child-centered, expert-guided, emotionally absorbing’

“Parent” as a verb gained widespread use in the 1970s, which is also when parenting books exploded. The 1980s brought helicopter parenting, a movement to keep children safe from physical harm, spurred by high-profile child assaults and abductions (despite the fact that they were, and are, exceedingly rare). Intensive parenting was first described in the 1990s and 2000s by social scientists including Sharon Hays and Annette Lareau. It grew from a major shift in how people saw children. They began to be considered vulnerable and moldable — shaped by their early childhood experiences — an idea bolstered by advances in child development research.

The result was a parenting style that was “child-centered, expert-guided, emotionally absorbing, labor intensive and financially expensive,” Ms. Hays wrote in her 1998 book, “The Cultural Contradictions of Motherhood.” And mothers were the ones expected to be doing the constant cultivation.

The time parents spend in the presence of their children has not changed much, but parents today spend more of it doing hands-on child care. Time spent on activities like reading to children; doing crafts; taking them to lessons; attending recitals and games; and helping with homework has increased the most. Today, mothers spend nearly five hours a week on that, compared with 1 hour 45 minutes hours in 1975 — and they worry it’s not enough. Parents’ leisure time, like exercising or socializing, is much more likely to be spent with their children than it used to be. While fathers have recently increased their time spent with children, mothers still spend significantly more.

Ms. Sentilles’s mother, Claire Tassin, described a very different way of parenting when her two children were young, in the 1970s. “My job was not to entertain them,” said Ms. Tassin, who lives in Vacherie, La. “My job was to love them and discipline them.”

Of her grandchildren, Isaac and his three cousins, she said: “Their life is much more enriched than mine was, but it definitely has been directed. I’m not saying it doesn’t work. They’re amazing. But I know I felt free, so free as a child. I put on my jeans and my cowboy boots and I played outside all day long.”

The new trappings of intensive parenting are largely fixtures of white, upper-middle-class American culture, but researchers say the expectations have permeated all corners of society, whether or not parents can achieve them. It starts in utero, when mothers are told to avoid cold cuts and coffee, lest they harm the baby. Then: video baby monitors. Homemade baby food. Sugar-free birthday cake. Toddler music classes. Breast-feeding exclusively. Spraying children’s hands with sanitizer and covering them in “natural” sunscreen. Throwing Pinterest-perfect birthday parties. Eating lunch in their children’s school cafeterias. Calling employers after their adult children interview for jobs.

The American Academy of Pediatrics promotes the idea that parents should be constantly monitoring and teaching children, even when the science doesn’t give a clear answer about what’s best. It now recommends that babies sleep in parents’ rooms for a year. Children’s television — instead of giving parents the chance to cook dinner or have an adult conversation — is to be “co-viewed” for maximum learning.

An American phenomenon

At the same time, there has been little increase in support for working parents, like paid parental leave, subsidized child care or flexible schedules, and there are fewer informal neighborhood networks of at-home parents because more mothers are working.

Ms. Sentilles felt the lack of support when it became clear that Isaac had some challenges like anxiety and trouble sleeping. She and her ex-husband changed their work hours and coordinated tutors and therapists.

“Friends are constantly texting support, but no one has time,” she said. “It’s that we’re all doing this at the same time.”

Parenthood is more hands-off in many other countries. In Tokyo, children start riding the subway alone by first grade, and in Paris, they spend afternoons unaccompanied at playgrounds. Intensive parenting has gained popularity in England and Australia, but it has distinctly American roots — reflecting a view of child rearing as an individual, not societal, task.

It’s about “pulling yourself up by your bootstraps,” said Caitlyn Collins, a sociologist at Washington University in St. Louis whose book, “Making Motherhood Work: How Women Manage Careers and Caregiving,” comes out in February. “It distracts from the real questions, like why don’t we have a safe place for all kids to go when they’re done with school before parents get home from work?”

In a new paper, Patrick Ishizuka surveyed a nationally representative group of 3,642 parents about parenting. Regardless of their education, income or race, they said the most hands-on and expensive choices were best. For example, they said children who were bored after school should be enrolled in extracurricular activities, and that parents who were busy should stop their task and draw with their children if asked.

“Intensive parenting has really become the dominant cultural model for how children should be raised,” said Mr. Ishizuka, a postdoctoral fellow studying gender and inequality at Cornell.

Americans are having fewer children, so they have more time and money to invest in each one. But investment gaps between parents of differing incomes were not always so large. As a college degree became increasingly necessary to earn a middle-class wage and as admissions grew more competitive, parents began spending significantly more time on child care, found Valerie Ramey and Garey Ramey, economists at the University of California, San Diego.

Parents also began spending more money on their children for things like preschools and enrichment activities, Sabino Kornrich, a sociologist at Emory, showed in two recent papers. Rich parents have more to spend, but the share of income that poor parents spend on their children has also grown.

In states with the largest gaps between the rich and the poor, rich parents spend an even larger share of their incomes on things like lessons and private school, found Danny Schneider, a sociologist at the University of California, Berkeley, and colleagues in a May paper. Parents in the middle 50 percent of incomes have also increased their spending. “Lower socioeconomic status parents haven’t been able to keep up,” he said.

Besides having less money, they have less access to the informal conversations in which parents exchange information with other parents like them. Ms. Jones recalled that one of her sons liked swimming, but it wasn’t until he was in high school that she learned about swim teams on which he could have competed.

“I didn’t know because I don’t live in a swim tennis community,” she said. “Unfortunately colleges and universities tend to look at these things as a marker of achievement, and I feel like a lot of kids who have working-class backgrounds don’t benefit from the knowledge.”

Race influences parents’ concerns, too. Ms. Jones said that as a parent of black boys, she decided to raise them in a mostly black neighborhood so they would face less racism, even though it meant driving farther to many activities.

This is common for middle-class black mothers, found Dawn Dow, a sociologist at the University of Maryland whose book, “Mothering While Black: Boundaries and Burdens of Middle-Class Parenthood,” comes out in February. “They’re making decisions to protect their kids from early experiences of racism,” Ms. Dow said. “It’s a different host of concerns that are equally intensive.”

The growing backlash

Experts agree that investing in children is a positive thing — they benefitfrom time with their parents, stimulating activities and supportive parenting styles. As low-income parents have increased the time they spend teaching and reading to their children, the readiness gap between kindergarten students from rich and poor families has shrunk. As parental supervision has increased, most serious crimes against children have declined significantly.

But it’s also unclear how much of children’s success is actually determinedby parenting.

“It’s still an open question whether it’s the parenting practices themselves that are making the difference, or is it simply growing up with college-educated parents in an environment that’s richer in many dimensions?” said Liana Sayer, a sociologist at the University of Maryland and director of the Time Use Laboratory there. “I don’t think any of these studies so far have been able to answer whether these kids would be doing well as adults regardless, simply because of resources.”

There has been a growing movement against the relentlessness of modern-day parenting. Utah passed a free-range parenting law, exempting parents from accusations of neglect if they let their children play or commute unattended.

Psychologists and others have raised alarms about children’s high levels of stress and dependence on their parents, and the need to develop independence, self-reliance and gritResearch has shown that children with hyper-involved parents have more anxiety and less satisfaction with life, and that when children play unsupervised, they build social skills, emotional maturity and executive function.

Parents, particularly mothers, feel stressexhaustion and guilt at the demands of parenting this way, especially while holding a job. American time use diaries show that the time women spend parenting comes at the expense of sleep, time alone with their partners and friends, leisure time and housework. Some pause their careers or choose not to have children. Others, like Ms. Sentilles, live in a state of anxiety. She doesn’t want to hover, she said. But trying to oversee homework, limit screen time and attend to Isaac’s needs, she feels no choice.

“At any given moment, everything could just fall apart,” she said.

“On the one hand, I love my work,” she said. “But the way it’s structured in this country, where there’s not really child care and there’s this sense that something is wrong with you if you aren’t with your children every second when you’re not at work? It isn’t what I think feminists thought they were signing up for.”

How to Safely Exercise During Pregnancy

HOW TO SAFELY EXERCISE DURING PREGNANCY

Melinda Wenner Moyer

THE GIST

  • Exercising during pregnancy is generally safe and can reduce the risk for several conditions including excessive weight gain, gestational diabetes and preeclampsia.
  • Always consult with your doctor before starting any exercise routine, since certain conditions can make it more risky. 
  • Doctors recommend about 30 minutes of exercise a day — or 150 minutes a week — but no more than 45 minutes per day, which can increase your risk of overheating and dehydration. 
  • Aerobic exercise, including jogging, is safe during pregnancy, but you should be able to carry on a conversation while active. Start slowly if you rarely exercised before pregnancy or are obese.
  • Avoid inherently risky activities, such as scuba or sky diving, contact sports, horseback riding, gymnastics or downhill skiing. Hot yoga and hot pilates are also unadvisable since they can increase body temperature too much and endanger the fetus.
  • If you notice warning signs of early labor or pregnancy complications, such as vaginal bleeding, breathing problems, or painful contractions, stop and contact your doctor.

Both times I’ve been pregnant, I’ve felt conflicted about exercise. On the one hand, I was often tired and nauseous; napping felt way more appealing than sweating. On the other hand, I wanted to do what was best for my baby and ward off extra pregnancy pounds. So I began hunting for the perfect prenatal workout. I tried what felt like everything — elliptical machines, yoga, power walking and even weightlifting, which elicited a number of concerned comments from gym-goers to “take it easy.”

According to Dr. Margie Davenport, Ph.D., director of the Program for Pregnancy and Postpartum Health at the University of Alberta in Canada, the belief that it’s dangerous to exercise during pregnancy is common — but it’s wrong. “We recommend beginning exercise or continuing to exercise as soon as you become pregnant,” she said. In most uncomplicated pregnancies, exercise is safe and tied to a reduced risk for many complications including excessive weight gain, gestational diabetes, preeclampsia, back pain and depression. For anyone worried about the safety of exercise during pregnancy, like those judgey gym-goers, Dr. Davenport and her colleagues recently published a systematic review in the British Journal of Sports Medicine, which analyzed 46 studies, and concluded that prenatal exercise does not increase the risk of miscarriage or death of the fetus.

The research I consulted, along with the obstetrician and maternal-fetal medicine specialist I talked with for this guide, agreed with Dr. Davenport: In most circumstances, exercise is good for both mom and baby, although there are important things to keep in mind. 

WHAT TO DO

  • Understand the differences between safe and unsafe exercise

Most of the time, exercising during pregnancy is safe, but nevertheless “it’s really important that women speak with their health care provider to see if they have any contraindications, or medical reasons that they shouldn’t,” Dr. Davenport said.

According to the American College of Obstetricians and Gynecologists, women with certain health conditions — including certain heart or lung diseases, cervical issues, pregnancy with multiples, persistent bleeding during the second or third trimester, preeclampsia or anemia — shouldn’t exercise while pregnant at all.

ACOG’s guidelines also note that if you have certain conditions or habits, such as heavy smoking, high blood pressure, overactive thyroid or are morbidly obese or underweight, consult with your doctor before exercising, because the benefits of exercise may not outweigh the potential risks.

  • Recognize how exercise can help you

Exercising during pregnancy isn’t just about keeping off extra pounds (although it also does that). According to a recent review published in the British Journal of Sports Medicine, pregnant women who exercised in various ways had about a 40 percent reduced risk for gestational diabetes, gestational hypertension and preeclampsia. Studies also suggest that women who exercise during pregnancy are less likely to become depressed and develop less severe low back and pelvic pain. Regular exercise can help with labor and post-delivery recovery, too, by reducing the odds of having an instrument-assisted delivery — a delivery in which forceps or a vacuum device is used — and lowering the risk for urinary incontinence after birth. 

  • Take precautions before and during exercise — and avoid risky types

To reduce the chance of developing low blood sugar, you should eat before exercising, said Dr. Raul Artal, M.D., a professor and chairman emeritus of the department of obstetrics, gynecology and women’s health at the St. Louis University School of Medicine. Smoothies, fruits, nuts or whole-grain crackers are good choices. Drink water to stay hydrated, too, and don’t exercise outdoors at temperatures above 90 degrees. That’s because heat stress in the first trimester, such as from saunas and hot tubs, has been linked with birth defects of the brain, nervous system or spinal cord. According to recent research, though, exercising when it’s not really hot out does not increase core body temperature enough to cause problems. In fact, research suggests that exercising during pregnancy is linked with a reduced risk for neural tube defects.

ACOG recommends that pregnant women avoid the following activities, which could pose health risks:

  • Contact sports such as ice hockey, boxing, soccer and basketball
    • Activities with a high risk of falling, such as downhill skiing, water skiing, surfing, off-road cycling, gymnastics and horseback riding
    • Scuba diving
    • Sky diving
    • Hot yoga or hot pilates 
  • Choose activities you can do regularly

“Oftentimes, women think that exercise means going to a gym, and it doesn’t,” said Dr. Diana Ramos, M.D., M.P.H., an obstetrician and medical director for reproductive health at the Los Angeles Public Health Department. “It’s as simple as walking.”

Other activities ACOG recommends include swimming, stationary cycling, yoga, pilates and low-impact aerobics such as jogging and pool aerobics. What’s most important is that you choose an activity that you’ll be able to do regularly. My favorite prenatal workout ended up being one I did in my basement — where I was conveniently shielded from intrusive bystanders and just a few steps away from the essential re-fueling station (aka my kitchen).

ACOG’s guidelines recommend that pregnant women exercise for 150 minutes a week, or about 30 minutes a day, five days a week. They caution against exercising for more than 45 minutes at a time because doing so can increase the risk for low blood sugar, which can make you lightheaded or dizzy. If you didn’t exercise much before you got pregnant, or you are obese, it’s O.K. to start with as little as 10 minutes of activity a day and “build it up at a rate that is going to be sustainable,” Dr. Davenport said. Dr. Davenport also pointed out that some activity is better than none at all — exercising for fewer than 150 minutes a week still provides some benefits.

Aerobic exercise, such as jogging, is safe for women who were active before they got pregnant. Guidelines recommend that women be able to pass the “talk test,” meaning they can carry on a conversation while exercising. More intense exercise may also be O.K., but Dr. Gregory Davies, M.D., a professor and chair of the Division of Maternal-Fetal Medicine at Queen’s University in Canada, pointed out that very little research has been done to address this question. “Most, if not all, our knowledge about safety and pregnancy benefits is based on research protocols that reflected moderate exercise, at most,” he said. The same goes for strength training, so if you’re going to lift weights, don’t overdo it. A 2015 trialfound that pregnant women can safely lift 10 pounds or less, but studies haven’t evaluated the safety of heavier weight-lifting. 

  • Remember that your body is changing

During pregnancy, a woman’s joints become more relaxed, so it’s important not to overstretch, Dr. Davenport said. It’s also wise to avoid activities that require jumping or quick directional changes, which can stress the joints, too. Balance becomes less stable after the first trimester, which is why it’s also important to avoid activities that require careful balance, such as skiing. To stay safe, invest in supportive shoes — don’t go for your daily walk in flip-flops — because “you really need the right support for your feet,” Dr. Ramos said.

ACOG also suggests avoiding exercises that require you to lie on your back during pregnancy. Doing so can restrict blood flow to the heart, which might also restrict blood flow to the fetus. Usually, if this happens, you will feel light-headed and nauseous, Dr. Davenport said, which you can take as a sign to sit up.

WHEN TO WORRY

According to ACOG, women who experience any warning signs while exercising such as vaginal bleeding, regular painful contractions, amniotic fluid leakage, difficulty breathing, dizziness, headache, chest pain, muscle weakness, or calf pain or swelling should stop and contact their health provider immediately.

SOURCES

Dr. Margie Davenport, Ph.D., associate professor of kinesiology, sport and recreation and director of the Program for Pregnancy and Postpartum Health at the University of Alberta, Dec. 5, 2018

Dr. Diana Ramos, M.D., M.P.H., medical director for reproductive health for the Los Angeles Public Health Department, Dec. 5, 2018

Dr. Raul Artal, M.D., professor and chairman emeritus of the department of obstetrics, gynecology, and women’s health at the St. Louis University School of Medicine, Dec. 6, 2018

Dr. Gregory Davies, M.D., professor and chair of the division of maternal-fetal medicine at Queen’s University in Canada, Dec. 10, 2018

Prenatal exercise is not associated with fetal mortality: a systematic review and meta-analysis,” British Journal of Sports Medicine, October 2018

“Impact of prenatal exercise on maternal harms, labour and delivery outcomes: a systematic review and meta-analysis,” British Journal of Sports Medicine, October 2018

“Effectiveness of exercise interventions in the prevention of excessive gestational weight gain and postpartum weight retention: a systematic review and meta-analysis,” British Journal of Sports Medicine, November 2018

Prenatal exercise for the prevention of gestational diabetes mellitus and hypertensive disorders of pregnancy: a systematic review and meta-analysis,” British Journal of Sports Medicine, November 2018 “Exercise during pregnancy and the postpartum period,” UpToDate.com, November 2018

The Foods to Avoid When You’re Pregnant

THE FOODS TO AVOID WHEN YOU’RE PREGNANT

Rachel Meltzer Warren

THE GIST

  • Pregnant women are more susceptible to foodborne illness than most people because their immune systems are weakened. 
  • Microbes like salmonella, campylobacter and Toxoplasma gondii can be harmful to a pregnancy, but experts are particularly concerned about Listeria monocytogenes, a bacterium that can cause infection that can have devastating consequences. 
  • To minimize listeria risk, avoid foods most likely to carry it, such as certain types of processed meats (unless they’ve been thoroughly heated), smoked fish, soft cheeses and unpasteurized milk and dairy products. 
  • Although research on moderate alcohol consumption during pregnancy is mixed, experts have said that abstinence is the safest bet.
  • Unless your doctor suggests otherwise, you can keep your morning coffee, as long as you limit yourself to 200 milligrams of caffeine or less per day. 
  • Worried you ate the wrong thing? Don’t stress. Discuss it with your doctor, who can give you tips on what, if anything, to do next. 

WHAT TO DO

Take care with certain types of processed meats

  • There are dozens of bacteria, viruses and parasites that can linger in foods and cause illness. Experts are particularly concerned about listeriosis — a bacterial infection that can cause seemingly mild or even nonexistent symptoms in pregnant women, but which can be especially dangerous to an unborn baby — including causing miscarriage, preterm labor or stillbirth. 

Listeria infections during pregnancy are rare. Between 2009 and 2011, according to the Centers for Disease Control and Prevention, there were just 227 cases in pregnant women in the United States. But research suggests that pregnant women may be up to 20 times more vulnerable to a listeria infection than the rest of the population. 

“Your immunity is altered when you’re pregnant, and that makes you more susceptible to serious consequences of foodborne illness,” said Dr. Zoe Kiefer, M.D., M.P.H., an ob-gyn at Beth Israel Deaconess Medical Center in Boston. Nearly one-quarter of all listeria cases in pregnant women in the United States result in fetal loss or death of the newborn, according to the C.D.C. 

Listeria outbreaks tend to occur in certain ready-to-eat meat products such as hot dogs, sausages, and store-bought, meat-based salads such as those made with chicken or ham. Cold cuts and deli meats are a common source, too. In fact, on April 17, 2019, the C.D.C. reported that at least eight hospitalizations and one death were linked to a listeria outbreak among sliced deli meats and cheeses at several deli counters across four states. Other outbreaks have been caused by refrigerated pâtés, meat spreads, smoked seafood, carpaccio, produce like cantaloupe and lettuce, and dairy products like ice cream and soft cheeses (more on cheese below). 

Instead of cutting these high-risk foods from your diet completely, Mary Saucier Choate, M.S., R.D.N., a food safety field specialist at the University of New Hampshire Extension, recommended cooking foods that can be eaten hot to an internal temperature of 165 degrees, or until steaming, since high temperatures kill the bacteria. A hot open-faced turkey sandwich or a fully cooked hot dog would do the trick. Or, consider making your own alternatives, such as freshly prepared salmon salad (made from canned salmon), egg salad or a peanut butter and banana sandwich.

Experts have said to keep fruits and veggies (with the exception of sprouts; more on that below), in your diet unless there’s an outbreak. Cooking produce is another way to minimize potential risk, said Dr. Haley Oliver, Ph.D., an associate professor of food science at Purdue University.

In general, keeping kitchen surfaces clean, thoroughly washing fruits and veggies and properly storing them (like keeping cut melon refrigerated) can help keep you protected. 

  • Be flexible with fish choices

Fish is packed with nutrition and is an important addition to many people’s diets, especially if you’re expecting. It’s not only high in protein and essential vitamins and minerals, but supplies healthy omega-3 fatty acids that aid in your brain and heart health, and in your baby’s brain and retina development. 

That doesn’t make fish an all-you-can-eat food when you’re pregnant, though. Most fish contain some level of mercury, a metal that can cause brain damage as well as vision and hearing problems for babies exposed in the womb. But certain types tend to contain more mercury than others. Large, long-living fish like bigeye tuna, swordfish, shark, king mackerel and orange roughy have the highest mercury levels and are best avoided. 

Federal health agencies recommend that pregnant women eat two to three servings (8 to 12 ounces) of fish per week, including a variety of low-mercury fish including cod, flounder, salmon, sardines, shrimp or canned light tuna; or one serving per week of moderate-mercury fish like halibut, snapper or albacore tuna. 

There is debate, however, over whether some types of tuna are safe for pregnant women to eat at all. In 2014, Consumer Reports analyzed Food and Drug Administration data and found that while canned light tuna on average was low in mercury, the amount varied greatly from can to can, with some containing unsafe levels of the toxin. Since there’s no way to tell which can is which, or which type of tuna the can contains, the group recommends avoiding all types of tuna while you’re pregnant. Talk with your doctor about the best diet plan for you.

  • Take care with raw foods

Raw fish known to harbor parasites (such as the anisakiasis worm, which can cause abdominal pain, nausea, vomiting and diarrhea) are typically frozen before they’re sold for consumption as sushi in the United States. Freezing can also halt the growth of bacteria like salmonella, which may be present. 

But freezing is not foolproof against foodborne illness, explained Dr. Christina A. Mireles DeWitt, Ph.D., an associate professor of food science and technology at Oregon State University. And it doesn’t prevent cross contamination. Most people’s immune systems can handle the temporary G.I. distress resulting from eating a contaminated food, said Dr. DeWitt, but pregnant women and their babies are at higher risk for complications (as are young children and the elderly or immune-compromised), so it’s best to avoid uncooked fish, such as sushi and raw oysters, when you’re pregnant.

It’s also best to avoid raw or undercooked meat. While most pregnant women are advised to avoid cleaning their cat’s litter boxes due to the increased risk of infection from Toxoplasma gondii — a parasite that thrives in cat feces — about half of the yearly toxoplasmosis infections in the United States result from eating food. Common sources include undercooked pork, lamb and wild game meat; as well as raw fruits and vegetables (which could contain infected soil).

Consult the F.D.A.’s “heat chart” for instructions on how to ensure your meat is fully cooked. And wash your hands with soap and warm water after touching soil, sand, raw meat, cat litter or unwashed vegetables. The F.D.A. also recommends thoroughly washing and, if possible, peeling, fruits and veggies before eating.

  • Abstain from alcohol

While some studies suggest that light-to-moderate drinking — defined as no more than one drink per day for women — is no big deal during pregnancy, there’s enough evidence to the contrary for many experts to agree that no amount of alcohol is safe. A 2013 review of 34 studies, for example, concluded that women who drank up to three drinks per week throughout their pregnancies were more likely to have children with behavioral issues like poor impulse control or difficulty interacting with other kids than women who didn’t drink at all.

Drinking during pregnancy has been linked to an increased risk of fetal alcohol spectrum disorders, such as fetal alcohol syndrome, which can lead to facial abnormalities, improper growth and intellectual disabilities. A 2018 study published in the journal JAMA estimated that as many as 5 percent of children in the United States have an F.A.S.D. 

“We really don’t know what amount is safe,” said Dr. Kiefer. So for now, skip the booze.

  • Avoid unpasteurized drinks

Pasteurization, or the process of heating foods to kill harmful bacteria, has made many foods safe for pregnant women to consume. But be on the lookout for milks, juices, dairy and other products that haven’t gone through the process.

Raw, unpasteurized milk can harbor germs like listeria, salmonella, campylobacter or cryptosporidium. In 2014, the American Academy of Pediatrics said that since no studies have found any benefits of drinking unpasteurized milk, pregnant women who drink milk and milk products should only consume those that have been pasteurized. (The same advice goes for infants and children.)

Most juices sold in the United States are pasteurized, including all that are shelf-stable. But some refrigerated juices sold at certain types of stores like high-end chains, local organic juice joints, corner bodegas or farm stands may not be. If you don’t see a label stating a drink has been pasteurized, ask whether it has been. If they’re not sure if it has, skip it.

  • Be choosy about cheeses

As with refrigerated meat and unpasteurized dairy products, cheese can harbor listeria and other pathogens. But unlike the “cook it or skip it” recommendation for meat products, the advice on cheese isn’t always straightforward. 

In general, the softer — and wetter — a cheese gets, the more you have to worry about pathogens surviving and growing. Bacteria like moisture, said Dr. Dennis D’Amico, Ph.D., a professor of food microbiology at the University of Connecticut, so pathogens tend to grow on soft cheeses more quickly than they grow on harder ones. 

“As you go from a mozzarella with high moisture to something like a cheddar or a Monterey Jack, the risk is starting to go down,” said Dr. D’Amico. Dry, hard cheeses such as a traditional Parmigiano or a Pecorino Romano have virtually zero risk of foodborne illness, said Dr. D’Amico. 

Soft cheeses made with unpasteurized milk are by far the riskiest: C.D.C. estimates suggest they’re as much as 160 times more likely to cause foodborne listeria infection than soft cheeses made with pasteurized milk. But even pasteurized soft cheeses are not risk-free: A 2018 C.D.C. report revealed that there were 12 times more listeria outbreaks linked to pasteurized soft cheeses between 2007 and 2014 than there were between 1998 and 2006. One such outbreak in 2015 hospitalized 28 people — six of whom were pregnant. Latin-style cheeses, like Queso Fresco, have been implicated in more outbreaks than other types. 

While the F.D.A. says it’s O.K. for pregnant women to eat soft cheeses made with pasteurized milk, Dr. D’Amico and other experts have suggested that pregnant women consider avoiding them to be safe.

  • If you drink coffee, stick to one cup

Decades of research has linked consumption of coffee and other sources of caffeine to increased risks for miscarriage, preterm birth and low birth weight babies. But the research isn’t clear on how much is safe to consume. Most public health groups, including the American College of Obstetricians and Gynecologists, agree that limiting caffeine to no more than 200 milligrams per day will not majorly increase such risks. 

“I tell my patients it’s O.K. to have one cup of coffee daily,” said Dr. Kiefer, no matter your stage of pregnancy. 

But caffeine content can vary depending on what you drink. At Starbucks, a shot of espresso has 75 milligrams of caffeine; whereas its Tall-sized brewed coffee drinks have closer to 190 to 280 milligrams. The English breakfast tea I ordered at the coffee shop that day probably had around 50 milligrams. 

Also keep in mind that caffeine can pop up in unassuming places, such as in decaf coffee, colas, iced teas, energy drinks, kombucha and chocolate. 

  • Avoid raw eggs

Eggs can carry salmonella, a bacteria that can cause infections resulting in fever, nausea, vomiting, diarrhea and dehydration. And if you’re infected during pregnancy, symptoms can be so severe that they may lead to serious complications for both you and baby.

Salmonella can’t withstand high heat, so eggs cooked to 160 degrees or more will be safe to eat. Cook eggs thoroughly until the whites and yolks are firm and no clear or runny sections remain. 

Most liquid eggs sold in refrigerated cartons are pasteurized and likely won’t have the potential to make you sick. Pasteurized shell eggs probably can’t make you sick either, though these are harder to find. Also remember that raw eggs can be found in seemingly innocuous foods and drinks, too, such as Hollandaise sauce, Caesar dressing, eggnog, raw cookie dough, aioli, meringue, mousse and tiramisu. 

After handling raw eggs, wash your hands and disinfect surfaces they’ve touched to prevent cross contamination. 

  • Go nuts

Past A.A.P. guidelines have advised pregnant women to avoid eating peanuts — and to delay introducing them to high-risk children (such as those whose parents have allergies) until age 3 — so as to prevent peanut allergies in their children. But as peanut allergies increased despite this advice, and more research emerged, the A.A.P. rescinded that recommendation in 2008 (and reaffirmed their stance in 2019). 

However some pregnant women still haven’t gotten that memo. 

If anything, newer research suggests that allergen exposure may reduce food allergy risk. A 2014 study of more than 8,000 women and their offspring published in JAMA Pediatrics, for example, found that moms who ate peanuts and tree nuts (like almonds or walnuts) five or more times per week during, shortly before or shortly after their pregnancies had kids who were 69 percent less likely to develop nut allergies than those whose moms ate them less than once per month. 

That’s good news, since nuts are good sources of the protein, healthy fats and vitamins and minerals that pregnant women need. 

  • Avoid sprouts

All raw sprouts — including alfalfa, mung bean, radish and clover—are risky for pregnant women. “Seeds may become contaminated by bacteria in animal manure in the field or during the postharvest stage,” said Choate, the food safety field specialist at the University of New Hampshire Extension. These bacteria can grow to high levels during sprouting, and are impossible to wash out. To play it safe, ask for your sandwich with no alfalfa sprouts, and for the bean sprouts to be left off your pad Thai.

  • Review the recalls

Every few days it seems there’s another healthy food we’re told to avoid due to an outbreak, from romaine lettuce to tahini to sliced melon. To stay on top of the latest news, sign up to get notified about alerts and recalls from both the F.D.A. and the Department of Agriculture by email here. You’ll also get an email when the recall is over, so you won’t unnecessarily need to limit your diet for longer than you have to. 

WHEN TO WORRY

Ate something on the “do not eat” list? Don’t freak out. The chances that one slip-up will damage your pregnancy are relatively slim, said Dr. Kiefer. “If a patient calls me and says, ‘I had a ham sandwich,’ I try to reassure them that they’re probably O.K.” 

You do need to worry, however, if you experience symptoms that could signal actual food poisoning, such as nausea, vomiting, diarrhea, fever, chills or dizziness; or any signs of preterm labor such as cramping or bleeding. If you have any of these symptoms or if you’re unable to keep fluids down for more than a few hours at a time, call your doctor or head to the E.R. so you can be monitored for hydration and treated as needed. 

As for that before-you-knew-you-were-pregnant party night, bring it up with your doctor. While experts have said that no amount of alcohol is safe, one isolated exposure to alcohol may not cause problems for you or your baby, said Dr. Kiefer. Talk with your doctor about concerns you have regarding drinking at any point in pregnancy, especially if you’ve had any significant alcohol intake since your last period. 

SOURCES

Dr. Zoe Kiefer, M.D., M.P.H., an ob-gyn at Beth Israel Deaconess Medical Center in Boston, January 2019

Mary Saucier Choate, M.S., R.D.N., a food safety field specialist at the University of New Hampshire Extension, January 2019

Dr. Christina A. Mireles DeWitt, Ph.D., an associate professor in food science and technology and director of the Oregon State University Seafood Research and Education Center, January 2019

Dr. Dennis D’Amico, Ph.D., a professor of food microbiology at the University of Connecticut, January 2019

Dr. Haley Oliver, Ph.D., an associate professor of food science at Purdue University, March 2019

“A.C.O.G. Practice Advisory: Update on Seafood Consumption During Pregnancy,”The American College of Obstetricians and Gynecologists, March 2019

“Talking About Juice Safety: What You Need to Know,” Food and Drug Administration, March 2019

“Consumption of Raw or Unpasteurized Milk Products by Pregnant Women and Children,” American Academy of Pediatrics Policy Statement, January 2014

Listeriosis Outbreaks Associated With Soft Cheeses, United States, 1998-2014,” Emerging Infectious Diseases journal and the Centers for Disease Control and Prevention, June 2018

“Cheese Microbial Risk Assessments — A Review,” Asian Australasian Journal of Animal Science, March 2016

“The Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Hydrolyzed Formulas and Timing of Introduction of Allergenic Foods,” Pediatrics, March 2019

“Listeria (Listeriosis),”Centers for Disease Control and Prevention, March 2019

Postpartum Body Changes You Should Know About

POSTPARTUM BODY CHANGES YOU SHOULD KNOW ABOUT

Anna Nowogrodzki

THE GIST

  • Many women who’ve given birth have postpartum pelvic floor issues that can require physical therapy. Look out for peeing when you laugh, sneeze or exercise, or for very frequent urges to pee.
  • Treatment for pelvic floor issues isn’t just Kegels (and a lot of people do Kegels wrong).
  • If penetrative sex hurts after the first few times, go slow, use lube and try non-intercourse forms of sex. If it still hurts, see a pelvic floor physical therapist.
  • If you feel like something is falling out of your vagina, you may have prolapse. Consult your doctor for a referral to a pelvic floor physical therapist.
  • Scar pain is common after both C-sections and vaginal births even up to a year postpartum. Scar massage may help.
  • If your back, shoulders or hips hurt, make sure you’re carrying your baby and baby gear on both sides of your body equally, and see a physical therapist.

When I was pregnant, I read four books on pregnancy and two on childbirth. I read no books on what my body would be like during the first year postpartum, because I had never heard of any. During that first year, many people are underinformed about their own bodies, even as they learn vast amounts about their babies. Many of us are cleared for sex and exercise at six weeks postpartum, but a body that grew another human can take much longer than that to heal — and can be permanently changed in some ways. 

For this piece, I discussed health in the first postpartum year with two ob-gyns, a nurse, two physical therapists who specialize in treating postpartum bodies and two mothers. All the experts said many people have questions about what is normal, and they recommended calling your obstetrician, midwife or primary care provider if you’re concerned about something specific. For many symptoms, a next step will be a referral to a physical therapist. The experts stressed that you don’t have to live with pain, discomfort or leaking urine, and that your health is as important as your baby’s.

WHAT TO DO

  • Don’t ignore concerning changes.

Peeing a little when you sneeze, laugh or exercise is such a classic postpartum symptom that many assume it can’t be fixed. Not so. It’s called stress incontinence, and it’s a symptom of a problem with your pelvic floor, a set of muscles that stretch, bowl-shaped, between the tailbone and the pubic bone. Urge incontinence, in which you feel the need to urinate very frequently, feel you have a very small bladder or feel you can’t hold it, is also due to pelvic floor muscle stress.

If you have any kind of incontinence, a good first step is a referral to a physical therapist who specializes in pelvic floor issues. “Being pregnant puts stress on your pelvic muscles” because of the weight of the fetus, said Dr. Tamika Auguste, an ob-gyn at MedStar Washington Hospital Center in Washington, D.C. Vaginal delivery or a C-section can further stress your pelvic floor, especially if the C-section was unplanned and occurred after some amount of labor. “Oftentimes women don’t always recognize immediately how much of a toll that still took on their vaginal canal and pelvic floor,” said Alison Colussi, D.P.T., a physical therapist specializing in pelvic health. Muscles that stretch during delivery can either remain too loose or over-tighten in response.

  • Do pelvic floor exercises — but not just Kegels.

When you think pelvic floor, you probably think Kegel exercises — in which you contract your pelvic floor muscles. But Kegels are not always helpful, and they’re hard to learn how to do properly on your own, Colussi said, so it’s best to visit a physical therapist if possible. Some women’s pelvic floors are overly tight, “in a constant state of mini-Kegel,” as Colussi puts it, which Kegels would only exacerbate. Even when pelvic floor muscles are weak and need strengthening, “the focus is much more on finding the full range of motion of those muscles, which includes both relax and contract,” Colussi said.

The relaxing part is hard. I tried to do it while on the phone with Colussi. “I’m not entirely sure if they’re relaxed or not,” I told her. “Am I actually trying to contract something accidentally?” She laughed. “I hear that 10,000 times a day,” she said.

Often, Colussi said, patients come in looking for an exercise to do for 10 minutes every day. “But the question is not what’s a good exercise,” she said. It’s more about how people move in every one of their daily activities, from getting out of bed to picking up mashed fruit off the floor to lifting babies out of their cribs. The proper way to pick up that mashed fruit or a baby in a car seat is to squat down, keeping your center of gravity over your hips and not tilting forward. Then exhale, engage your abs and straighten up using your leg muscles, not your back. 

  • Don’t put up with painful sex.

It’s common to feel discomfort or pain the first few times you have penetrative sex after childbirth, but after that, don’t put up with it. The first step is of course to go slowly and be gentle with yourself. Often ob-gyns will advise using an over-the-counter lubrication product, because breastfeeding suppresses estrogen production, and estrogen produces lubrication, explained Dr. Alison Stuebe, associate professor of obstetrics and gynecology and chair of the taskforce that wrote the newest American College of Obstetricians and Gynecologists guidelines for postpartum care. But lube is just a beginning, our experts all agreed.

In addition to dryness, pain during sex can be caused by pelvic floor dysfunction, other tight or stretched muscles or scar pain from a tear or episiotomy during a vaginal birth. Sex can hurt for patients who’ve had C-sections as well, because both C-sections and the process of pregnancy can stretch or tighten muscles. Ask your obstetric care provider for a referral to pelvic floor physical therapy.

Dr. Stuebe also directs patients to “The Parents’ Guide to Doing It,” an episode of “The Longest Shortest Time” podcast with sex advice columnist Dan Savage as a guest. Savage discusses types of sex other than penetration. Unfortunately, some women experience pain with any kind of sex, usually from increased nerve sensitivity, said Colussi.

  • Seek help if you feel pressure in your vagina.

Some women come to Colussi saying they feel pressure in their vagina, like something is obstructing their bowel movements, “or like a dry tampon is half falling out of me,” she said. Sensations like these could mean a pelvic organ prolapse, when an organ (uterus, bladder or urethra) shifts from its original position or presses against the vaginal wall. “Prolapse is probably the thing women are least prepared for,” said Colussi.

Severe prolapses can be fixed with surgery or alleviated with a pessary (a support in the vagina to prop up the prolapsing organ), but milder prolapses can be managed just by lying down more frequently and avoiding high levels of pressure in your abdomen, Colussi said. “Oftentimes for a woman it feels a lot worse than it actually is,” she said, but in other cases prolapse can be more severe than it feels, so it makes sense to see a health care provider. To better manage pressure levels in your abdomen, don’t bear down when pooping; and exhale instead of inhaling or holding your breath when you exert yourself. If you find yourself grunting and then holding your breath when you lift something heavy, try exhaling instead. 

  • Ask your doctor about scar pain.

If you feel pain in your C-section scar or scar from a tear or episiotomy, see your medical provider. A doctor may recommend scar massage or scar mobility treatments from a postpartum physical therapist. However, be aware, scientific data on the effectiveness of scar massage is limited because it has barely been studied, Dr. Stuebe said. A 2011 paper concluded that scar massage is “anecdotally effective” but found that surgical scar massage of any kind had only been studied in a tiny sample size of 30 patients. Scar pain is common. A year after giving birth, a study found, 18 percent of women who had C-sections still had pain at the incision site, and 10 percent of women who had vaginal births still felt pain in the vagina or perineum (the area between the vagina and the anus).

  • Learn to carry your baby on both sides.

Carrying a baby, lifting a baby and holding a baby while breastfeeding are hard physical work, especially for women who were pregnant. Your posture and movement habits change during pregnancy from carrying around extra weight in new places, and your body also produces the hormones relaxin and progesterone, which loosen your ligaments and joints.

Baby product design doesn’t help. “Car seats and cribs have changed drastically” in recent years, said Colussi. They’re carefully designed for infant safety, but not for parent ergonomic safety. Infant or “bucket” car seats are heavy, and usually parents carry them in their nondominant arm, causing muscle imbalances. She recommends that parents practice early and often carrying their babies on both sides equally. “Cribs are hard because the rails can’t go up and down anymore,” she said. Colussi recommends that parents, especially shorter ones, place a step aerobics stepper next to the crib.

If pain persists after making these changes, physical therapy is a good idea.

  • Use proper form for sitting up.

If you feel a gap in your abdominal muscles, you may have diastasis recti, in which all the layers of the abdominal muscles, the rectus abdominus, separate in the middle. This happens normally during the latter part of pregnancy to make room for the growing uterus, but if it persists at your six-week postpartum checkup, ask your provider, who may refer you to a physical therapist. To avoid putting too much pressure on these muscles, avoid crunches or sit-ups, and when you sit up, don’t sit straight up using just your abdominal muscles: Roll onto your side first and use your arms.

WHEN TO WORRY

  • If you have shortness of breath, pain in your chest or seizures, call 911.
  • If you have an incision that does not heal, a temperature above 100.4F, too much bleeding (soaking one pad per hour or a blood clot the size of an egg or larger), a red or swollen leg that feels painful or hot, or a headache that does not get better with medication or is accompanied by vision changes, call your medical provider.
  • If you had gestational diabetes, make sure you get screened for diabetes according to your medical provider’s advice.
  • If you had high blood pressure (pre-eclampsia) during pregnancy, make sure your blood pressure is monitored according to your medical provider’s advice. (You are still at risk for pre-eclampsia up to six weeks postpartum.)
  • If you quit or tapered smoking or other drugs during pregnancy, see your medical provider for a postpartum support plan. The stresses of life with a baby can lead to relapse. 

SOURCES

Debra Bingham, Dr.PH., R.N., professor of nursing at the University of Maryland and executive director of the Institute for Perinatal Quality Improvement, Aug. 23, 2018

Tamika Auguste, M.D., obstetrician-gynecologist at MedStar Washington Hospital Center, Aug. 27, 2018

Alison Colussi, D.P.T., physical therapist at Physical Therapy Center of Rocky Hill in Rocky Hill, Conn., Aug. 27, 2018

Alison Stuebe, M.D., M.Sc., associate professor of obstetrics and gynecology at the University of North Carolina School of Medicine, Aug. 27, 2018

Holly Herman, D.P.T., physical therapist at HealthyWomen HealthyMen Physical Therapy, Aug. 27, 2018 “Save Your Life: Get Care for These Post-birth Warning Signs,” the Association of Women’s Health, Obstetric, and Neonatal Nurses, 2016

When a New Mother’s Joy is Entwined With Grief

WHEN A NEW MOTHER’S JOY IS ENTWINED WITH GRIEF

Claire Zulkey

Maggie Nelson’s Mother’s Day tradition is to take a family photo at the grave of her daughter Emily, who was stillborn.

Every Mother’s Day, Maggie Nelson, her husband Mike, and their three young children head to the cemetery to take a family photo at the grave of their daughter, Emily. She was stillborn in 2010, but her twin, Mikey, now 7, survived.

“People say, ‘That’s kind of sad,’ but I can say, ‘I’m a proud mom of four. Here I am with all of them,’” Ms. Nelson, 39, said of the photos of her and the kids gathered on the grass by Emily’s stone plaque. A Bloomington, Ill., kindergarten teacher, she is a member of an unofficial sorority of women who experienced acute grief while postpartum.

The grief of fathers, adoptive mothers and other relatives after a family death is no less real, but postpartum women in mourning endure a particularly complicated blend of physical and emotional duress.

First, there are factors that can affect any new mother: the physical discomfort of childbirth, the lack of sleep and anxiety about the baby.

After giving birth, a new mother experiences rapid drops in levels of estrogen and progesterone and steep increases in prolactin. This can result in strong feelings of fatigue, irritability, insomnia and sadness known as the baby blues, which the National Institute of Mental Health says affects up to 80 percent of women.

This is not the same as the more intense, ongoing postpartum depression, which doesn’t reveal itself immediately, says Christiane Manzella, a senior psychologist who specializes in bereavement at the Seleni Institute, a women’s counseling center in New York.

Grief disrupts the body in different ways, with effects that can include a weakened immune system, a perilous situation for a new mother.

“I was a mess, to put it in a nutshell,” said Gayle Brandeis, 50, a Nevada writer whose mother committed suicide in 2009, days after Ms. Brandeis gave birth to a son. She experienced bouts of dizziness and had difficulty catching her breath. “I was really worried that my milk would dry out. I had a lot of stitches and walking was very painful,” she said. “I felt so disoriented in my body.”

Bereaved new mothers need people to remind them that there are no wrong feelings.

“It feels incredibly isolating because you’re supposed to be happy,” said a Boston-area 47-year-old mother of two who works in marketing and asked to be identified only by her first name, Susan. In 2012, when Susan was on bed rest with a high-risk pregnancy while living overseas, her mother died unexpectedly. She could not travel for the funeral and was able to attend only via Skype. When Susan eventually gave birth to a daughter, her relationship to her baby was not what she expected. Her daughter had acid reflux, screamed a lot and slept little.

“I thought there would be this bond that I wouldn’t want to break because she was somehow my mom incarnate. It wasn’t that at all.” Throughout this experience, Susan, like most grieving new mothers, wondered, “Is this normal?”

Pediatricians are on the front lines of spotting signs of postpartum depression in new mothers, since they see babies and mothers sooner and more frequently than obstetricians. Dr. Dafna Ahdoot, a Los Angeles pediatrician, has helped grieving new mothers who were anxious about their surviving baby’s health, concerned over whether they could take their newborn to an out-of-town funeral, or worried that their grief would negatively affect the baby. She advises grieving new mothers to prioritize their own eating and sleeping by securing help with night feedings and switching to formula feeding as needed if breast-feeding is too difficult.

Many therapists specialize in postpartum depression or grief and can address both. “It’s so hard to tease those symptoms apart,” says Juli Fraga, a San Francisco psychologist who specializes in postpartum depression.

A woman may think: “‘Why wouldn’t I be crying? I’m not sleeping.’” She helps her patients try meditation or breathing exercises to reduce levels of cortisol, the stress hormone, and then discuss, as needed, next steps like seeing a psychiatrist or integrative medical options.

Not all women have access to or even desire professional support. With initiatives like Therapy for Black Girls, the mental health community is working to build a bridge to African-American women who may mistrust medical institutions.

“African-American women are at higher risk for premature birth, and so we are losing our babies,” says Keisha Wells, a counselor in Columbus, Ga. “If you’re dealing with that and you don’t have anybody to talk to and you’re a person of color, that’s added sorrow.” Ms. Wells did not have access to this type of mental health care 11 years ago when her twin sons, born prematurely, both died. But she said she found comfort in faith-based support.

In the first weeks after a birth paired with a death, close loved ones can lighten a new mother’s load by making thoughtful executive decisions. Ms. Nelson’s twins’ room was painted half pink and half blue, and set up with two cribs. Friends repainted it and removed Emily’s crib. “Nobody asked,” Ms. Nelson said. “I didn’t know if I wanted to be asked. It had to happen, and friends and family had to take care of it.”

More than anything, most grieving new mothers need to express their grief. After Ms. Nelson took Mikey home, a friend brought over a picnic dinner.

“She put the basket on the counter, took both my hands in her hands and said ‘Tell me about Emily,’” Ms. Nelson recalled. She said she appreciated that opportunity. Other well-intentioned people misunderstood and said, “I didn’t mean to make you sad,” when she’d start to cry. She said she wanted to tell them: “Emily’s death makes me sad. You talking about her makes me hope-filled, it makes me proud. The tears are going to come, but let me do that.”

Many grieving mothers find solace in the stories of others, be they in books, online or in groups.

Ms. Nelson was intrigued by the show “This Is Us,” in which the main characters lose one of their triplets at birth and impulsively decide to adopt an abandoned baby. “The first episode made me angry that they were like, ‘We’ll just take this baby home instead,’ but when they later showed the raw emotions that she had, I was a little more on board,” Ms. Nelson said.

Mourning new mothers eventually find a way to honor both their lost loved one and their child using what is known as a continuing bond grief paradigm. Dr. Manzella said that it can be compatible with the ongoing waves of grief many mothers who have gone through loss experience, and that the thinking about grief has evolved from the “accept and let go” ideas in the classic “five stages of grief” model of the Swiss psychiatrist Elisabeth Kübler-Ross. “Why not continue loving in absence and getting solace from the sense of love?” she said.

Sometimes, finding a way to mark the loss can help.

Each year, Ms. Nelson and her family honor Emily’s birthday a day before Mikey’s, since her heart stopped beating the day before he was born.

“I have my day to be sad,” Ms. Nelson says. “We go to the cemetery with balloons. The kids are fully involved. Then the next day is all about Mikey.”

Dealing With Interfering Grandparents

DEALING WITH INTERFERING GRANDPARENTS

Carla Bruce-Eddings

How to navigate a challenging relationship.

Parenting can often feel like trying to survive amid barely controlled chaos, so having a wise, experienced grandparent to help out can be lifesaving. But if that grandparent has trouble adhering to basic boundaries, it can feel as if the chaos has maddeningly multiplied.

When families expand, there is a significant shift in roles and responsibilities — one that is easy to make light of until conflicts emerge. Frustrating as these conflicts may be, it’s important to keep in mind that lots of families experience them. Joanne Gottlieb, L.C.S.W., a New York-based licensed clinical social worker, cited religious practices, disciplinary styles, technology and diet as some of the most common areas for intergenerational parenting conflict.

“I would place ‘intrusive grandparents’ in the general category of challenges that adults and couples face in managing relationships with their respective families of origin, and with parents in particular,” she said. “This is a constant theme of therapy.”

So how to best navigate the convergence of these new roles so that everyone feels respected and valued?

  • The moment you notice a negative pattern emerging, deal with it quickly. Don’t wait until you are ready to tear your hair out to approach Mom or Mom-in-Law.
  • Choose a time when everyone is calm to discuss conflicts — and remember that your parent or parent-in-law has your best interests at heart, and your child’s too. Put the child’s needs first – not your own.
  • Bear in mind that child-rearing advice often changes from one generation to the next, so there are bound to be some ideas that a grandparent subscribes to — most likely ones that you were raised with — that you find outdated now.

It’s vital to remember, in the thick of it, why grandparents’ presence in your child’s life is so crucial. “Grandparent love and knowledge is essential to a child’s self-esteem and self-identity,” said Roslyn Hunter, L.C.S.W., a psychotherapist in New York. “They need to see themselves as part of something larger than their parents. They need to find their place and feel part of a family that has a history.”

To try to resolve conflicts, therapists suggest you should say what you need to say — clearly, respectfully and, if necessary, more than once. Meagan Hammerbacher, mom to a 3- and 5-year-old, is committed to clear and consistent communication with her mother-in-law — even if it hasn’t yielded the desired results just yet.

“I have asked my mother-in-law multiple times to please refrain from giving my children sweet treats and sugary drinks, and to consider the food that she generally feeds my children. Sadly, she rarely listens to my requests,” she said. Enlisting her husband to join the discussion was difficult at first, but she encouraged him to attend a few therapy sessions to feel more comfortable about opposing his mother, and now they are on the same page.

Such harmony between partners is the ideal first step in approaching tough conversations with a parent or parent-in-law, but it has not led to harmony in this case. “In all honesty I do not see the situation being resolved because his mother is of a different era,” Hammerbacher said. “I have realized that she is never going to listen to me and follow my directive, and it is not worth the constant fight with my partner because he does not want to fight with his mother.”

Until she feels ready to re-approach this conversation, Hammerbacher has decided to back off: “The only other resolution is to teach my children about healthy eating so they can advocate for themselves,” she said. “It is more likely that she will listen to my children when they tell her ‘Grandma, that food is not good for me!’ ”

Other parents live with their frustrations for the sake of the overall relationship. For Tanya Copenhaver, 41, continual conversations with her mother about her 4-year-old have been stressful, but she has decided she can deal with the dynamic. “I often feel judged by my mother when it comes to my parenting,” she said. “I used to let these things really bother me, and often, I still find myself starting to defend myself.” But she has come to realize that her mother truly does have the best intentions, misguided as her efforts sometimes feel.

“Often I bite my tongue and remind myself she means well and loves my daughter dearly,” Copenhaver said. “And I remind myself that the benefits of having my mom so involved in our lives far outweighs the frustration I feel.”

Grandparents find navigating this relationship tricky, too. Keesha Davis has strong opinions when it comes to her 1-year-old granddaughter, but over the course of her first year, she has intuited the best times to speak up and to remain silent. “I’m still adjusting … I’ve learned to just be quiet, observe and chime in when I really think I should chime in,” she said. Recently she had a disagreement with her daughter and daughter-in-law about giving their daughter apple juice while babysitting. While the mothers stood firm — no juice — Davis told me that they are open to advice in other areas. “I think they’re coming to terms with saying, ‘You know what, my mother is very logical when it comes to certain things,’ ” she said. “I’ve raised kids, I babysit kids. … So they do sit back and say, ‘Wait a minute. What she is saying is correct and we can benefit from listening.’ ”

Try to bear in mind that each generation has its own parenting beliefs, and parenting advice has changed over the years. Today’s grandparents put their babies to sleep on their stomachs and used crib bumpers — practices that are no longer followed. Parental bans on corporal punishment can also be perplexing for grandparents, many of whom adhered to the “spare the rod” justification for spanking.

In these cases, making your stance crystal clear from the start is of utmost importance, Gottlieb said. “The parent needs to communicate clearly that physical discipline is not permitted,” she said. “If the parent is not sure that the grandparent, or any caregiver, will respect this wish, then I would advise that the parent not leave their child alone with that person.” Try to avoid long explanations or arguments; your rationale can be as short as a simple reminder that cultural norms have changed, so much so that a child’s mentioning in school that he was hit could prompt a call to child protective services.

“I would say that one of the frequent issues is cultural, particularly for immigrant families,” Hunter said. “Grandparents expect parents to follow cultural traditions from the old country. Parents often resist because old traditions are not practical for modern life.” In these cases, it’s important to avoid the instinct to be dismissive or overly critical of a practice that you may not understand. After all, your parent raised you. Talking through the reasons for your parenting decisions, and listening to grandparents talk about their own philosophies, may not lead to a quick solution, but it will help promote understanding and reduce discord.

Hunter reminds parents that they have the final word. “It’s important to remember that grandparents do not actually hold more power than the parent — even if the grandparent in question is providing some kind of support,” she said. If a parent asserting herself to advocate for her child jeopardizes the relationship with the grandparent, or vice versa, that is a different issue. “In either case the child’s needs are not being put first,” Hunter said. “The adult’s needs are being put first with the child being used as a tool.”

Parenting is a lifelong job; it doesn’t end when a child has entered adulthood. You are charged with creating a safe, nurturing environment for your child, as well as learning from the wisdom and, yes, missteps of your parents. A three-generation dynamic should feel fluid and mutually supportive, especially during times of conflict, experts stressed. Demonstrating positive examples of communication and compromise with a parent or parent-in-law will help your child navigate her own approach to problem solving, as these are skills that “make emotions and the world feel manageable,” Gottlieb added.

Finally, it always helps to take a deep breath and remember that your child has different needs from the other people in her life. Despite Tanya Copenhaver’s occasional misunderstandings with her mother, she is willing to turn a blind eye from time to time for the sake of offering her daughter a crucial childhood benefit: “Grandma’s house isn’t home, and grandparents get to have a different relationship with our children than we do,” she said. “When I’m not there, it’s O.K. if my daughter eats an extra candy or gets to eat applesauce, graham crackers and a marshmallow for lunch. Those are memories she will have forever.”

Remembering her own loving relationship with her grandmother, she added: “I can only hope that my daughter gets to experience that special bond with my mom.”

How to Be a Supportive Partner During Pregnancy (and Beyond)

HOW TO BE A SUPPORTIVE PARTNER DURING PREGNANCY (AND BEYOND)

David Howard

THE GIST

  • Numerous studies have shown the benefits of having a partner who is supportive or perceived to be supportive. Conversely, having a partner who is perceived to be unsupportive is a predictor of depression and anxiety both before and after a child’s birth.
  • Start early. Being a supportive partner begins in the months before delivery, when an expectant mother’s anxiety levels may be rising about giving birth and the changes a baby brings.
  • Make a plan for your supportive role both during and after the baby’s arrival, but be flexible. There’s no script for how things are going to go.
  • New research indicates that supporters may need support of their own: They can feel isolated or rejected but question the legitimacy of their experiences.

If you’ve watched any movies with birth scenes, you may have noticed that the partner’s role often fits into one of two categories: He — and it’s always a he — is a comically inept second fiddle, fainting just when he’s needed most, or else absent entirely, inhaling a cigar in a nearby pub. 

These dated archetypes exist for a reason. What actually comprises a supportive partner has only come into focus in recent years, as fathers and same-sex partners have become more central to the birth and all that comes after. But the research is resoundingly clear: A strong mate makes a difference. Having a supportive partner is good for everyone involved, including the baby.

The scientific literature is less clear on what specific strategies best support pregnant women — it’s tough in a clinical setting to isolate the benefits of, say, a well-timed hug or a promise to handle 3 a.m. feedings. But the three researchers I spoke to distilled their studies into some real-world advice.

WHAT TO DO

  • Connect with each other well before the due date.

This should be even more of a priority than buying the right stroller. “The focus is so much on practical needs,” said Dr. Pam Pilkington, Ph.D., a perinatal psychologist who practices at the Centre for Perinatal Psychology in Melbourne, Australia, and founder of Partners to Parents, a resource site developed by a team of researchers and psychologists at Australian Catholic University to provide guidance for partners. “During pregnancy, people perhaps don’t focus on the couple relationship, or supporting each other emotionally as much as they could.”

In practical terms, this means talking often and openly about how you’re both feeling — anxious, excited, uncertain, whatever it is, Dr. Pilkington said — then validating each other, making sure you both feel heard and accepted. An example: After a month at home, a new mother might say, “I feel trapped here all day while you’re at work.” The supportive answer here is not, “I need to work so we can pay the bills. Why don’t you get your mother to come help?” Rather, a validating answer would be: “I’m sorry that you’re feeling pinned in place. It sounds like you’re missing seeing your friends at the office.” 

Trying to build mirroring-and-validating skills during the relative calm before your child’s arrival will help cement your bond for the challenges to come, Dr. Pilkington said.

  • Make your good intentions known.

Making yourself of service to another is what’s known in scientific vernacular as “offering social support.” Researchers call it a mysterious force that has tangible benefits. “There’s a magic about social support,” said Dr. Christine Dunkel Schetter, Ph.D., a professor of psychology and psychiatry at UCLA who has studied its effect on stressful situations, including pregnancies. “And the magic is that when it’s really working in these kinds of situations, it’s about things that take place between two people. And it’s about what one person says to the other, or does, that makes them feel better.”

Part of the magic of social support?Even when an expectant mother merely perceives that she has a supportive partner, she’s more likely to come through pregnancy happy and healthy, research shows. Studies have variously found that partner support is associated with better birth outcomes and lower levels of distress and depression among both mothers and infants.

But follow-up is key, too, said Dr. Dunkel Schetter. If you don’t actually come through on a promise to assume half of the diaper-changing duties, the benefits of perceived support quickly trail off.

Sometimes, supportive partners will learn that the best kinds of support are nonverbal — offering a hug during a low emotional ebb. And the support should be offered unconditionally. “The person giving it can’t say, ‘Now you owe me, you’re obligated, I’ve done so much for you,’ ” said Dr. Dunkel Schetter.

CenteringPregnancy, a program developed by the Yale School of Nursing, provides social support instruction, among other services, in a group setting for women and their partners; it’s now available in health-care facilities around the United States. (You can find a nearby location on the website.)

  • Take a birthing class — but be open-minded when the day arrives.

Classes like the Bradley Method, which teaches that childbirth can be managed through deep breathing and the support of a partner or labor coach, can be helpful in making you feel more prepared, and offering a sense of what to expect. But Dr. Pilkington pointed out that birth is not the same as being a cast member in a play. The baby sometimes rewrites the script. Things take unexpected turns, or the mother’s preferences before going into labor might change 12 hours in. The partner should avoid rigid thinking about how it was supposed to go, and instead help the mother roll with whatever’s happening and support her choices along the way, Dr. Pilkington said.

  • Have a plan for the weeks after the baby arrives…

Specifically, the partner can draw up an action plan in which he or she commits to executing certain helpful tasks. Maybe it’s late-night feedings if the mother is going to pump breast milk or your baby is on formula. Maybe it’s a daily break that the mom can count on, like taking the baby out for a walk so she can nap or take a bath, said Dr. Pilkington.

  • … But be flexible.

Planning to do those 3 a.m. feedings is one thing. The searing exhaustion that kicks in after four weeks of doing that is another. During your child’s early life, it’s best to expect some meltdowns. (The baby will cry sometimes, too.) Revisit the plan anytime based on whatever challenges you might face at each stage of your baby’s life. It’s O.K. to ask for extra support from friends and family, Dr. Pilkington said. Both parents can use a break in the first couple of months of their baby’s life.  

  • Know your role with feeding.

One task the mother generally handles alone is breastfeeding. But a 2015 studyled by the University of Ontario Institute of Technology suggested that a partner’s active involvement —learning how breastfeeding works and providing encouragement — leads to “significant improvements” in breastfeeding duration. Then think of simple, commonsense ways to step up: Helping the mother stay hydrated by offering a glass of water, bringing healthy snacks and providing a comfortable environment, Dr. Pilkington said.

For parents who can’t breastfeed or choose not to, Dr. Pilkington says it’s important to remember they haven’t failed. “How parents feed their infant is a personal choice that should be based on their specific situation,” she said. If the mother is pumping, you can help maintain the equipment and offer to bottle-feed using the milk. Parents feeding their baby with a bottle — whether it’s formula or breast milk — can split overnight duties, one taking the 9 p.m. to 2 a.m. shift, the other holding down the 2 a.m. to 7 a.m. slot, for example. Partners using formula can make sure there are adequate supplies on hand at all times and know how to mix it. Some formulas can be premixed and stored in the fridge for up to 24 hours, which could save an exhausted mom from having to drowsily scoop powder in the small hours of the night.

  • Expect that your sex life will change — for a while, at least.

This is a biological imperative, so expect the temperature to be dialed down in the marital bed post-birth (for a duration that depends on the circumstances of the delivery; consult a professional). And even after you’re medically cleared, that doesn’t mean you’ll feel the same or have much energy for sex early on. Make a point to seek out alternate forms of intimacy, like hand-holding and cuddling, Dr. Pilkington said. The key, again, is to maintain an emotional connection and strong lines of communication.

  • Look for signs of your own stress, and act on them.

The psychological effect on partners after a baby’s arrival is mostly a black hole in the scientific realm. Dr. Pilkington noted that only 19 of the 120 recent studies around pregnancy touched on outcomes for fathers or partners, and researchers openly acknowledge the need for more research. But the few studies that have been done show that fathers can struggle to navigate this interlude. Dr. Zoe Darwin, Ph.D., a lecturer in maternal health at the University of Leeds in the U.K. who has conducted some early inquiries in this area, found that men often feel stressed and detached but want to keep the spotlight on the mother and child. “The research that we’ve done,” she said, “found that although some of the men we spoke with felt excluded by maternity services, and had experienced significant stress in this period, they often questioned the legitimacy of their experiences and their entitlement to support.” If you feel yourself struggling, let your partner know, and consult a caregiver.


WHEN TO WORRY

If you’re struggling with depression or anxiety, you may need more than a hug or the sage words of a parenting class. Seek professional help from a counselor.

SOURCES

Dr. Pam Pilkington, Ph.D., perinatal psychologist who practices at the Centre for Perinatal Psychology in Melbourne, Australia.

Dr. Christine Dunkel Schetter, Ph.D., professor of psychology and psychiatry at UCLA, expert on stress processes in pregnancy

Dr. Zoe Darwin, Ph.D., lecturer in maternal health at the University of Leeds in the U.K. who specializes in mental health and wellbeing during and after pregnancy.

My Marriage Has a Third Wheel: Our Child

MY MARRIAGE HAS A THIRD WHEEL: OUR CHILD

Jancee Dunn

Jancee Dunn, left, with her daughter Sylvie and husband Tom.Creditvia Jancee Dunn

An only child can make the relationship between Mom and Dad uniquely complicated.

Here’s a typical weeknight scenario in our household: My husband, Tom, our 9-year-old daughter, Sylvie, and I feel like ordering in, and after a lengthy debate, we decide on pizza. Later, while the three of us are eating pepperoni slices and playing Bananagrams, Sylvie reminds Tom that our wedding anniversary is coming up and offhandedly mentions that my favorite flowers are peonies. After a few rounds of the game, we consider a movie. Sylvie proposes “Escape From New York,” a film that has piqued her curiosity after hearing her father repeatedly imitate Kurt Russell as Snake Plissken.

“I’ll look it up on Common Sense Media to see if it’s appropriate,” she volunteers, opening my computer. Unfortunately, she reports gravely, it’s for ages 16 and up. “‘Except for a severed head,’” Sylvie reads aloud, “‘there’s little explicit gore. An atmosphere of cynicism and darkness pervades, including a negative depiction of a U.S. President.’”

Tom points out that this sounds like his Twitter feed. But I balk at the severed head, which is a pretty big except for.

I would never have predicted that the hardest part of parenting would be that our only child would come to fully believe she is the third person in our marriage. This arrangement began roughly as soon as she learned to talk.

As family psychologists such as Dr. Carl E. Pickhardt, Ph.D., point out, only children often feel like one of the adults. As with our tripartite system of government, they view the daily running of the household as a three-way power-sharing agreement. This is an issue more parents may have to deal with, now that one-child families are gaining ground. According to a Pew Research analysis of 2015 U.S. Census Bureau data, today 18 percent of mothers at the end of their childbearing years have an only child — up from 10 percent in 1976.

Tom and I have fully enabled Sylvie to feel like one of the gang, because we go almost everywhereas a trio. We’re usually too cheap to hire babysitters, and tend to travel with Sylvie, too, as she slots fairly easily into our itineraries. As a result, Sylvie has gotten used to being included, consulted, part of our in-jokes. This is not uncommon, says social psychologist Dr. Susan Newman, Ph.D., who has spent decades studying only children — a term I loathe, as it calls to mind a kid alone in a shadowy room, whispering quietly to his sock puppet “friends.” (I think we should revive the much more sprightly “oneling,” used by 19th century author John Cole in his book “Herveiana.”)

But our efforts to “empower” our oneling and make her voice heard have begun to backfire. To paraphrase Princess Diana when asked about Camilla Parker-Bowles: There are three of us in this marriage, so it’s a bit crowded.

One reason for our fluid boundaries is physical. It’s almost impossible to maintain them in a Brooklyn apartment a realtor would euphemistically call “charming and cozy,” one with bizarrely porous doors that actually seem to amplify sound. But it’s also emotional: Tom and I, like many parents of our generation, make an effort to be open and communicative with Sylvie. (“You can tell us anything, sweetheart!”)

When I was growing up, I would never have dreamed of sharing anything remotely personal with my parents. I had two siblings, and our family dynamic was solidly Us vs. Them — my sisters and I were one unit, my folks another. I wanted a different kind of relationship with our daughter.

But one consequence of all this closeness is that our child feels insulted if Tom and I go out to dinner alone. If we’re on vacation, she balks at being “dumped,” as she puts it, in the Kids’ Club. She would be happy to Photoshop her picture into our wedding photos. If Tom and I give each other a hug, she has gotten in the habit of jumping in between us.

Jancee Dunn and her family. 
Jancee Dunn and her family. Creditvia Jancee Dunn

At least she doesn’t referee when we fight, as she did when she was smaller. A couples’ counselor put a stop to that when he advised me to put a photo of Sylvie in a drawer by my bedside table. Whenever I was about to lose my temper with Tom, he told me, I was to run to the bedroom, pull out the photo, and say to it: I know that what I’m about to do is going to cause you harm, but right now, my anger is more important to me than you are. I only had to repeat that brutal phrase a couple of times.

But Tom and I still squabble about minor stuff, like whose turn it is to empty the dishwasher — and when we do, Sylvie jumps in and takes sides. (“Mom, you did it last time.”)

As a self-flagellating parent, I was recently drawn to a book with the dire title “The Seven Common Sins of Parenting an Only Child.” Ooh, sins — what am I doing wrong? Among other iniquities — overprotection, overcompensating — Sin No. 6 resonated with me: Treating Your Child Like an Adult.

“It can become so pleasurable for parents of an only child to have a miniature adult by their side that they may lose sight of the fact that their kid needs to be a kid,” writes author Carolyn White, former editor of Only Child magazine. I read this aloud to Tom as Sylvie, nearby, perused the latest issue of Consumer Reportsready to counsel us on our next car purchase.

Sylvie may be comfortable around adults, but she is still a child, one who lacks the reasoning abilities and experience of a grown-up — so I must catch myself when I absently reply to her questions about money, or other parents, before realizing, whoops, shouldn’t have told her that.

As Newman advises, “Before you allow your child to weigh in, take a pause and ask yourself, ‘Is this really a topic or an issue that a 9-year-old should be involved in, or is this a decision for adults?’ ”

Sylvie needs time away from us to be a kid — time to act silly and make jokes about butts and drone on about the intricacies of Minecraft. She has a group of good friends, but I do see her picking up on her middle-aged parents’ habits, such as calculating how many hours of sleep she got every morning. Her posse at home is squarely in midlife, as evidenced by her choice of songs for her ninth birthday party — among them, Barbra Streisand’s LBJ-era “Don’t Rain on My Parade.” We are not the kind of posse a 9-year-old needs. Maybe she hasn’t yet subbed out her school backpack for a WNYC tote bag, but the danger is there.

And all of this coziness hurts our marriage, too. So I have to remind myself, sometimes daily, to cordon off our relationship. Our marriage has needs that deviate from my needs as an individual, as well as our needs as a family. I have to constantly ask, what would be good for the marriage? It’s important, as a couple, to have your own roster of in-jokes. It’s refreshing to drop F-bombs with impunity, and to gossip freely about other parents without having to hastily turn it into a teachable moment for your eavesdropping child about How Gossiping Is Really About Feeling Insecure About Your Own Life Choices. And it’s nice — no, essential — to go out to dinner, just the two of you, and speculate on which members of the waitstaff are sleeping with each other. You know, grown-up stuff.

A Better Me Makes A Better We: An Interview with Ellyn Bader, Ph.D.

A BETTER ME MAKES A BETTER WE: AN INTERVIEW WITH ELLYN BADER, Ph.D.

Kyle Benson

Interview Guest: Ellyn Bader, Ph.D., is a co-founder of The Developmental Model of Couples Therapy, which integrates attachment theory and differentiation. Through her work at The Couples Institute, she has specialized in helping couples transform their relationships since 1984.

The idealized relationship where partners are fused at the hip is not a healthy relationship, as it doesn’t allow for the unique differences of each partner. Bader highlights this fusion as a conflict avoidant stance that happens when one partner feels anxious or uncomfortable and attempts to merge with their spouse.

One way of doing this is becoming more like your partner in hopes of being loved. There’s a deep fear that says, “If I express my needs and have different needs than my partner, I’m going to be abandoned.”

The other conflict avoidant stance is loving your partner at arm’s length. The fear in this stance says, “If I become more open and vulnerable, I’m going to get swallowed up and lose my sense of self.”

As Dr. David Schnarch states in his book entitled Passionate Marriage, “Giving up your individuality to be together is as defeating in the long run as giving up your relationship to maintain your individuality. Either way, you end up being less of a person with less of a relationship.”

Fusion happens when a person is fearful of encountering differences. These can be minor differences including how one spends their time or their hobbies, or major differences such as conflict style and desire for togetherness. The opposite of fusion is differentiation.

The Risk of Growth

Bader describes differentiation as an active process “in which partners define themselves to each other.” Differentiation requires the risk of being open to growth and being honest not only with your partner, but also with yourself.

  • If you’re anxious, it could mean realizing that you lean on partner so much that if they become unstable, you both fall down. Your demands on your partner and the way you discuss conflict may be pushing your partner away, which is the very thing you fear.
  • If you’re avoidant, it could mean noticing that you neglect your partner’s needs and prioritize yourself over your relationship. As a result, you perpetuate the loneliness you feel.
    To grow in your relationship requires a willingness to stand on what Bader calls your “developmental edge” and differentiate yourself as an individual. To risk getting closer to your partner without pushing them away.

What Differentiation Looks Like

In conflict, a differentiated lover can give space to their partner who is emotionally overwhelmed while also remaining close enough to be caring and supportive, but not so close that they lose themselves emotionally. Instead of reacting with overwhelming emotion, a differentiated partner, according to Bader, expresses curiosity about their partner’s emotional state:

“Can you tell me more about what’s going on?”
“Can you tell me about these feelings?”

The more differentiated you are, the less likely you are to take things as personally. As a result, you can soothe yourself or reach out to be soothed by your partner in a helpful way. Instead of saying, “You’re such a jerk. You never care for me,” a differentiated partner would say, “I’m feeling really overwhelmed and lonely. Could you give me a hug?”

To differentiate is to develop a secure way of relating to your partner. This earned security, as highlighted by Bader, is created both internally and developed within the context of a relationship. This requires being authentic with your feelings and needs.

You can cultivate a secure and functioning relationship by recognizing and taking responsibility for your part in creating unhealthy dynamics in your relationship. When you do this, you can then express your needs, desires, and wishes in a way that allows you and your partner to work together to meet each other’s needs.

When both partners are whole, not only is there more flexibility in the marriage, but there is also more intimacy.

Getting a Good Night’s Sleep Without Drugs

GETTING A GOOD NIGHT’S SLEEP WITHOUT DRUGS

Jane E. Brody

Alternatives to prescription drugs for insomnia offer better, safer and more long-lasting solutions, experts say.

Shakespeare wisely recognized that sleep “knits up the ravell’d sleave of care” and relieves life’s physical and emotional pains. Alas, this “chief nourisher in life’s feast,” as he called it, often eludes millions of people who suffer from insomnia. Desperate to fall asleep or fall back to sleep, many resort to Ambien or another of the so-called “Z drugs” to get elusive shut-eye.

But except for people with short-term sleep-disrupting issues, like post-surgical pain or bereavement, these sedative-hypnotics have a time-limited benefit and can sometimes cause more serious problems than they might prevent. They should not be used for more than four or five weeks.

In April, the Food and Drug Administration added a boxed warning to the prescription insomnia drugs zolpidem (Ambien, Edluar, Intermezzo and Zolpimist), zaleplon (Sonata) and eszopiclone (Lunesta) following reports of injury and death from sleepwalking, sleep-driving and engaging in other hazardous activities while not fully awake.

Last July, a Georgia woman was arrested when she drove the wrong way on a highway the day after using Ambien, as prescribed, to help her sleep. Although she had consumed no alcohol, she flunked a standard sobriety test and told police she was unaware of how she ended up going the wrong way.

Although extreme reactions to these sleep drugs are thought to be uncommon, they are unpredictable and can be disastrous when they occur. Some have resulted in vehicular fatalities.

As many as 20 percent to 30 percent of people in the general population sleep poorly. They may have difficulty falling asleep or staying asleep, some awaken much too early, while others do not feel rested despite spending a full night seemingly asleep in bed. For one person in 10, insomnia is a chronic problem that repeats itself night after night. Little wonder that so many resort to sleeping pills to cope with it.

“Short sleep is not just an irritant. It has real consequences beyond just feeling crummy the next day,” Adam P. Spira, a sleep researcher at Johns Hopkins Bloomberg School of Public Health, told me.

However, Dr. Spira and other experts report that there are better, safer and more long-lasting alternatives than prescription drugs to treat this common problem. The alternatives are especially valuable for older people who metabolize drugs more slowly, are more likely to have treatable underlying causes of their insomnia and are more susceptible to adverse side effects of medications.

“Insomnia is typically undertreated, and nonpharmacologic interventions are underused by health care practitioners,” Dr. Nabil S. Kamel, a geriatrician now at Cox Health in Springfield, Mo., and Dr. Julie K. Gammack, a geriatrician at the St. Louis University Health Sciences Center, wrote in The American Journal of Medicine.

In other words, when persistent insomnia is a problem, before your doctor writes a prescription for a sleeping pill, ask whether there are other remedies that may be safer, more effective and longer lasting.

For example, if pain or other symptoms of a medical disorder are keeping you awake, the first step should be treatment of the underlying ailment to minimize its sleep-disrupting effects. I once spent three sleepless nights tortured by intense itchiness until a dermatologist prescribed medication for what turned out to be an invasion of bird mites. More recently, my middle-of-the-night leg cramps have been nearly entirely eliminated by consuming eight ounces of quinine-containing tonic water (actually, diet tonic) every night before bed. If you can’t handle that amount of liquid close to bedtime, drink it earlier in the evening or perhaps try a herbal remedy that I use when traveling: Hyland’s Leg Cramps, which contains quinine as one of its active ingredients.

Sometimes, the medication given to treat a chronic ailment interferes with the ability to get a good night’s sleep. In that case, the doctor may be able to prescribe a lower dose, substitute a different drug or adjust the timing. But when the symptoms of a chronic ailment itself disrupts sleep, treatment by a specialist, including perhaps an expert in pain management, may be needed to improve your ability to sleep. If persistent emotional problems are what keep you awake, consider consulting a psychologist, psychiatric social worker or psychiatrist before reaching for a sleeping pill.

Cognitive behavioral therapy is now considered the best treatment for insomnia, especially for older adults. It teaches people to challenge disruptive negative thinking and replace it with positive thoughts that counter arousal and induce relaxation. Before going to bed, try using soothing imagery or meditation to reduce cognitive arousal.

The American College of Physicians recommends cognitive behavioral therapy as “the first-line treatment for adults with chronic insomnia.”

It is much safer than drugs and, unlike sleeping pills that work only when taken and shouldn’t be used long-term, cognitive behavioral therapy for insomnia, or CBT-I, teaches effective strategies that continue to work long after the therapy ends.

The physicians’ college suggests that if needed, sleep medication should be used only short-term while learning the techniques of cognitive behavioral therapy for insomnia.

Also helpful is what sleep experts call stimulus-control therapy — limiting bedroom time to sleeping and sex. You learn to associate the bedroom with sleep by avoiding activities incompatible with it. If you spend too much time lying sleepless in bed, your brain starts to link the bedroom with not sleeping. Also avoid going to bed when you’re not sleepy.

If you don’t fall asleep after about 20 minutes in bed, Dr. Kamel and Dr. Gammack recommend getting up, perhaps taking a bath or reading, then returning to bed when you feel sleepy.

If all else fails, sleep-restriction therapy can be effective even after a week or two, especially at eliminating prolonged wakefulness in the middle of the night. It doesn’t restrict sleep itself but limits the time spent not sleeping by restricting time in bed to how long you currently sleep. Go to bed at about the same time every night, set an alarm to get up, and maintain that waking time every day for at least two weeks no matter how much you slept the night before. Finally, gradually extend your time in bed by 15 to 30 minutes, allowing a week between each extension, until you are able to get the amount of restful sleep you need with little or no wakefulness in the middle of the night.

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