Having a healthy baby - and many of them - is regarded as the greatest bliss and positive commandment for many religiously observant Jewish women here and abroad. But soon after pregnancy, some develop a type of cognitive dissonance in which they suffer from the baby blues (80 percent), postpartum depression (20% to 30%) or, in very rare cases, pregnancy psychosis. It can happen to every woman, but it may be even more devastating in women raised to believe in the necessity of observing the commandment "be fruitful and multiply" and the dictum that every additional child, whether the second or the 12th, always brings joy. But postpartum depression (PPD) and the related conditions are a taboo in the haredi and even modern Orthodox community and knowledge about them is minimal. Now a couple, Rabbi Baruch Finkelstein and his wife Michal, a nurse-midwife, along with social worker Doreen Winter have just written a 210-page softcover volume called Delivery From Darkness: A Jewish Guide to Prevention and Treatment of Postpartum Depression. Published in English by Feldheim of Jerusalem and New York with a simultaneous Hebrew translation, the $20 book sets the perfect tone to reach religious women on this very sensitive subject. The Finkelsteins previously authored two hefty and well-received books for the religious Jewish public - B'Sha'ah Tovah: The Jewish Woman's Clinical and Halachic Guide to Pregnancy and Childbirth and Third Key: Jewish Guide to Fertility. Beginning with signed endorsements from prominent rabbis (such as Dr. Abraham J. Twersky), the comprehensive book will surely be welcomed by a large audience, not only of affected women and their husbands but also rabbis, psychologists, psychiatrists, obstetricians, nurses, social workers and other professionals. Offering both clinical and halachic information, the book includes personal stories, explains various types of treatment and even discusses prevention in women who are still pregnant. At the end, it supplies an English glossary of Hebrew terms used. Twersky, a prominent American Orthodox psychiatrist and rabbi, notes in his foreword that "while many new mothers experience the 'baby blues,' which usually remit within two weeks, a significant number develop postpartum disorders of varying severity. These are primarily due to the hormonal changes that occur during and after pregnancy. Because the symptoms of postpartum disorders are behavioral, many people think of them as being due to a mental abnormality. Given the stigma that this carries, the symptoms are often overlooked or explained away. The tragic result is not only that the new mother suffers, but also what was taught was wrong. The bonding of a mother with a newborn infant is crucial for the child's optimum physical and emotional development. Anything that obstructs the formation of this bond can have far-reaching effects." Michal Finkelstein poignantly and frankly relates on page one of the book that she herself suffered from PPD. "It was as if I were buried alive, sinking in quicksand, unable to find my way out. That's how I felt after the birth of my sixth child," she recalled her feelings 15 years ago. "I was irritable; I cried; I was exhausted yet had trouble sleeping. Getting through each day seemed nearly impossible. My children avoided me; my husband tiptoed around me. I was convinced that my family and the world would be better off without me." If it happened to her - a person who was so happy, positive and energetic - it could happen to anyone, she states. Among the other symptoms are regular feelings of sadness, anger, agitation, moodiness and irritability, as well as fear of dying and even thoughts of suicide. Sufferers often feel they are drowning in helplessness and hopelessness, the authors write. They recommend that women with PPD focus on accomplishing only the most important tasks of the day, keep open the lines of communication with family members and speak with an objective third party - especially a professional - who can help. The last page of the book presents information about NITZA, the Jerusalem Postpartum Support Network and Israel Center for Maternal Health based at 3 Rehov Gesher Hahaim in the capital's Mekor Haim quarter (tel. (02) 500-2159. The nonprofit organization for religious married women has more than 100 trained, multilingual volunteers plus professionals and rabbis who give counseling, run support groups and provide a variety of treatments (including some from complementary medicine) for suffering women. It also works toward prevention, with teams going out into the community to present lectures on PPD. This is helpful, as numerous rabbis without a secular education may just advise PPD sufferers: "It will pass by itself. Just pray harder." Michal Finkelstein briefly mentions that PPD became a public subject around the world recently when the well-known American actress Brooke Shields disclosed that she suffered from a serious case after giving birth to her daughter and wrote a book about her personal experience that she called Down Came the Rain. But her story certainly is not suited to observant Jews. Delivery From Darkness certainly puts stress on God (Hashem, in Hebrew), encouraging women to "talk to [Him] out loud. Find time every day to talk to Hashem as if you were talking to a friend. Hashem listens. Tell Hashem everything. Tell Him how you feel about yourself, your family, your relationship with Him. Tell Hashem about your day, your plans, your moods. Tell Hashem your deepest fears and desires. This will be an enlightening and rejuvenating experience," the authors promise. There is a whole chapter on the wisdom of Rebbe Nahman of Breslov ( the 18th-century grandson of the founder of Hassidism, the Baal Shem Tov) who "sees depression as a necessity for ascent. Depression should be viewed as a growth stage. It is a process all people must go through, especially the righteous. 'Know that all the descents, breakdowns and confusion are required in order to enter the gates of holiness, and all the great tzadikim went through them...'" If one were "neutral," not to happy and not too depressed, "never suffering a serious emotional blow, then one might never think that it is necessary to improve; one might never rise to higher spiritual levels," they write. "Only after hitting rock bottom, only when one is confronted with the misery of lowliness, will one begin the climb of improvement." Giving Rebbe Nahman's famous quote that "the most important thing is to strengthen oneself with simha [joy]," the authors give PPD sufferers the legitimacy for seeking professional help despite concerns that the condition is "something to be ashamed of" and not to admit due to the common fear that family members of haredim with psychological problems will not find a good marital match. This worry and others are projected from several personal stories in a chapter titled "Voices of Depression." A woman lawyer named Mazal and married to a loving, kind pharmacist husband recalls that two years before, they were happily raising their 18-month-old son. With a lot of support at home and at work, she completed her pregnancy and had an uncomplicated delivery. The baby even slept for five hours at a stretch, and the parents had found good child care services for when maternity leave ended. But something went wrong. Mazal had no strength for housekeeping chores and would often cry from frustration. Then she was angry with herself for complaining and failing to cope. The pediatrician came to the rescue, who "just listened and kept nodding his head" when she broke down in tears. He recommended a PPD support group, and although they had never herd of such a thing, she agreed to attend. She found the group like "an anchor in a storm" and felt safe enough to confide all her feelings. Today, Mazal does not fear having more children but will be careful to seek help if she needs it. She has even joined a volunteer organization that helps new mothers who may be overwhelmed and at risk for developing PPD. Yael, who was pregnant with her fourth child, said that with PPD, she had to deal "with a Yael I never knew existed" even though she "like[s] being pregnant." After having three healthy boys, she delivered a beautiful girl, "which was such a nice surprise, since we didn't know ahead of time!" But when her maternity leave was about to end, something went awry. She started to shout at the boys and even hit one. "I was so ashamed of myself, so frustrated, so angry with myself," she writes with her recollections. But she cried often in the bathroom and had no patience for her husband. She dreamed that her mother "had taken the baby to sell him at the market because I wasn't a good mother" and woke up in a cold sweat. She also became paranoid about imaginary dangers to her children. Things got so bad that her husband had to "trick her" into going to a psychiatric hospital. She was forcibly given an injection to calm her down and became an inpatient in a unit specializing in postpartum psychosis. "I felt as if I had been hit by a ton of bricks,"she remembers. After six weeks of medications, psychological treatment and being told she was "not to blame," she began to smile. Eventually, she was discharged, and six months later, she is "getting better every day." She still has "hopes for more children, but I know that any future pregnancy will have to be monitored by my psychiatrist. I think I'll just take it one day at a time and be thankful for the blessings I have." While PPD victims cannot treat themselves, the book does offer a self-administered version of the Edinburgh Postnatal Depression Scale (EPDS) with 10 questions that can be filled out and self-scored in less than five minutes. The authors note that it will not produce an official, foolproof diagnosis but can give indications and help screen women for the condition who need to be referred to professional help. The book presents listings of prescription drugs obtainable only from a psychiatrist; they including drugs in the family of tricyclic antidepressants, selective serotonin-reuptake inhibitors (SSRIs), sedatives and other medications, as well as side effects. An important chapter for the Orthodox audience is devoted to consulting a rabbinical authority about PPD patients using birth control to space births and get a much-needed rest. Each case is unique, the authors conclude, but in general, many rabbis are willing to approve contraceptives to delay - and in rare cases to prevent - pregnancies because women are ill or unable to cope with more children. "If a woman is suffering from depression, she and her husband should not feel that they are doing anything wrong by using contraception. Their being together is a great [mitzva] and a beautiful expression of love. Sometimes birth control is a necessity that will facilitate a loving, healthy bond between husband and wife and foster a strong, happy family in the present and future."

When 'Mazal Tov' seems to be a curse

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