Postpartum mental illness has a 19th century history

The murder of three young children by their own mother lies at the center of an ongoing trial that has gripped the nation. Lindsay Clancy, a white, 36-year-old former labor and delivery nurse from Duxbury, Mass., stands accused of first-degree murder for strangling her 5-year-old daughter, Cora, and sons, 3-year-old Dawson and 8-month-old Callan, at their home on Jan. 24, 2023.

Following the deaths, Clancy attempted suicide by jumping from a second-story window, an act that has left her paralyzed from the waist down. The prosecution argues that Clancy’s actions were premeditated. Her defense team says that a months-long struggle with severe postpartum mental illness culminated in Clancy’s violent, psychotic break.

The gravity of these allegations has garnered widespread attention and shocked the public. Significantly, the case has also reignited a familiar public debate: Can postpartum mental illness explain an act that many find unimaginable?

The Clancy case is hardly the first to provoke this question. Twenty-five years ago, Andrea Yates infamously drowned her five children in the bathtub of her Houston home, prompting many commentators to draw comparisons between the two cases. Initially found guilty of capital murder, Yates successfully appealed the verdict on the grounds of insanity after her defense argued that she had experienced severe postpartum depression and psychosis.

But the roots of this debate about postpartum mental illness and its role in mitigating or eliminating criminal responsibility go back even further. Beginning in the 19th century, when postpartum mental illness was explicitly linked to white motherhood, race shaped which mothers were afforded psychiatric explanations for acts of maternal violence.

In the early 19th century, French psychiatrist Jean-Étienne Dominique Esquirol and English obstetrician Robert Gooch independently helped establish the diagnosis of puerperal insanity, a term used to describe psychiatric disturbances associated with pregnancy, childbirth, and the postpartum period. Physicians’ descriptions of the disorder sound remarkably familiar today.

Women diagnosed with puerperal insanity were described as experiencing persistent sadness, anxiety, hopelessness, confusion, hallucinations, delusions, or dramatic behavioral changes. In severe cases, they also documented women who neglected, harmed, or even killed their children.

Despite being categorized as a disorder of childbearing, puerperal insanity was not believed to threaten all childbearing women. Rather, American physicians saw mental illness through a racial lens. Puerperal insanity was framed as a disorder of “civilization,” reflecting physicians’ belief that modern society weakened white, middle- and upper-class women’s reproductive systems and increased their vulnerability to mental illness.

The diagnosis allowed physicians to reconcile anti-maternal behaviors such as neglect and violence with one of the 19th century’s most deeply held assumptions: that white, middle- and upper-class mothers were naturally nurturing, domestically oriented, and morally respectable.

While this racial construction of puerperal insanity was widely accepted within the medical sphere, it posed a challenge in the courtroom.

During the 1840s and 1850s, the M’Naghten Rule — which held defendants not criminally responsible if mental illness prevented them from understanding either the nature of their actions or that those actions were wrong — became the dominant legal standard in the United States. But the line between ordinary psychological changes associated with pregnancy and legally recognizable insanity was often far less clear than the courts required. For example, in 1847, physician James MacDonald aptly observed that “during pregnancy, women without being considered insane, are often in that state of mind which precedes, if it do[es] not in fact constitute, the first stage of mental derangement.”

Sympathetic physicians and legal reformers argued that puerperal insanity rendered otherwise respectable white women temporarily incapable of exercising moral judgment.

In her widely circulated 1887 article “Forensic Relations of the Puerperal State,” physician Harriet C.B. Alexander condemned that “the mental state of the puerperal female has not received the attention its forensic importance merits” and contended that it was “obvious” that pregnant women were “subject to influences that weaken her will, engender emotional mobility, render apathetic natural affection, and give rise to [...] perverted sensations and propensities” that legally predisposed them to commit murder and infanticide.

In other words, white women’s violence was recast as the temporary consequence of a psychiatric illness.

For instance, in 1893, Lena Brown stood trial in Bordentown, N.J., for strangling her own son and her neighbor’s two children. Although she admitted to committing the deed, she was unable to explain why and was ultimately found not guilty by reason of insanity. The defense successfully argued that she was suffering from puerperal insanity and had been “in a delicate condition at the time” of the killings. When Brown gave birth to another child in prison and “treated [the infant] with the utmost tenderness,” her behavior was offered as further evidence that her violence was temporary and that she was a good mother.

The same could not be said for women whom physicians considered racially inferior. Black women, in particular, were often characterized as habitual criminals, rather than patients, who frequently committed infanticide because they were naturally violent and had no regard for the sanctity of children.

In 1905, for example, Lottie Hawkins was imprisoned for allegedly throwing her two-week-old child into the Anacostia River. Records documented that she had been admitted to and treated at St. Elizabeth’s Hospital, a psychiatric asylum in Washington, D.C., two days after giving birth and released the day before the killing. Yet no one suggested that she might have been suffering from puerperal insanity. Instead, prosecutors emphasized that she “wanted to get rid of the baby” because she neither wanted to provide care or financial support and that she consumed large amounts of cocaine and whiskey on the day of the killing to take away her senses.

In short, debates over maternal mental illness have never been simply about diagnosis or criminal responsibility. They have also been shaped by enduring assumptions about race, class, motherhood, and which women are recognized as deserving of medical explanation, public sympathy, and legal recognition.

Just four years ago, Latarsha Sanders, a Black mother from Brockton, Mass., was convicted of first-degree murder and sentenced to life without parole for the deaths of her two sons, Edson, 8, and La’Son, 5. Earlier this year, the Massachusetts Supreme Judicial Court ruled that Sanders had been denied a fair trial after evidence documenting her history of mental illness was excluded from the proceedings.

The Clancy trial’s visibility reflects the enduring political and cultural significance of motherhood in the United States. That significance also helps explain why some cases of maternal violence become national spectacles that generate public debate over the role of postpartum mental illness, while others — like Sanders — are met with comparatively little public attention or a far stronger presumption of guilt.

Udodiri R. Okwandu is an assistant professor of Women’s, Gender, and Sexuality Studies at Rutgers University–New Brunswick and a historian of medicine whose current work examines how racialized medical knowledge about maternal mental illness has shaped ideas about acceptable motherhood in the United States since the 19th century.

Made by History takes readers beyond the headlines with articles written and edited by professional historians. Opinions expressed do not necessarily reflect the views of The Inquirer.