If we want it? Of course we wanted it. There was nothing we wanted more.

We’d started trying to get pregnant three years before. It took six months to conceive my first pregnancy, which I miscarried in the first trimester. I gave up my morning latte and the occasional glass of wine, took up acupuncture, practiced restorative yoga, went on vacation, charted my temperature and cervical mucous, peed on ovulation sticks and had lots of sex. Nothing worked.

I desperately wanted to be pregnant. I fantasized about breast-feeding, about walking around my neighborhood with our baby tucked into a cotton sling across my shoulder. So I kept trying, at least for a while: two rounds of the infertility drug Clomid (known for its unpleasant side effects) and artificial insemination. I hated every minute.

Adoption seemed the perfect alternative. I needed a baby, and there were babies out there who needed mothers. I didn’t think I could handle an open private adoption, entailing ongoing contact with my child’s birth mother. Domestic adoption, through the foster care system, usually involved older children with troubled pasts and ties to family. With international adoption, babies are relinquished by their birth parents and live their first months in orphanages, or in what our Boston social worker called “nurseries.” She handed us a list of possible countries: Guatemala, China, Russia, Ethiopia, India.

India.

We made the decision immediately. India fascinated us; it was a place that, truthfully, we’d already romanticized. I’d practiced yoga for a decade, and Neil and I were both interested in Eastern philosophy. Since marrying, we’d talked about spending a year in India. Now I imagined traveling there to meet our daughter. I traded in my daydreams about pregnancy and childbirth for a new fantasy: flying into Mumbai and taking an overnight train to the orphanage, dressed in an Indian blouse and worn leather sandals; the moment in the orphanage when my eyes would lock with my child’s and, together with Neil, we’d become a family.

As we waited for our referral (and as I watched my friends and acquaintances get pregnant, one by one), Neil and I told ourselves we were better people for having chosen adoption. I didn’t care about having a child who looked like me or shared my genes. We became enamored with the idea of adoption, talking ourselves out of more critical, complicated readings of the institution. Over winter break, we took a chunk of cash we’d been saving and traveled around India for a month so we could better know the country where our daughter would be born.

A full year after that trip, there was still no referral, no baby selected to be matched with us. What’s worse, we’d recently heard from our social worker that no referrals were likely in the near future. There had been an upswing in domestic adoption in India — a good thing — but the result, combined with bureaucratic inefficiencies, was that although millions of Indian children live in orphanages, the pipeline of young, healthy orphans going overseas had just about dried up. We might get a referral sometime in the next six months, but there were no guarantees. It could be years, or it might never happen. Faced now with the prospect that I might miss out on parenting altogether, I started to wonder whether I’d given up on infertility treatments too soon.

And then, we got the call.

“I’m looking at a picture of her right now,” said our social worker. “She’s gorgeous, a beautiful child. The biggest brown eyes I’ve ever seen.”

Relief filled me: an objectively cute child. For months I’d worried — privately, and with deep shame — that we’d be matched with a child who wouldn’t strike me as adorable. A child I wouldn’t love fast or ferociously enough, who would feel like someone else’s daughter, one I’d want to give back. I worried that my heart might not be big enough to love any child placed before me. I didn’t need a child to look like me, but I did need a child who felt destined to be mine.

“And she’s healthy!” our social worker proclaimed. Undernourished, but healthy. Relinquished by her unwed mother at birth.

A healthy baby. I hardly registered that the girl was much older than we’d expected and agreed to — 21 months rather than 12 — and that she had speech delays.

Two years earlier, we’d spent all of 10 minutes discussing whether we might adopt an ill or special-needs child. The adoption form asked us to check off which health problems we could handle, and we checked “none of the above.” Like most parents, we wanted a healthy baby. Since we were adopting a child from an orphanage, we knew that “health” was relative, and we expected our daughter would need help catching up with nutrition and language acquisition. More than that we didn’t think we could handle. Of course, if we adopted a healthy child and she became ill, we would do anything for her. But with adoption come choices, boxes of illnesses to check or leave unchecked, and our preference was for a child with no serious health issues.

We were too excited to eat. Neil asked for the check and threw some cash down on the table. We had to get to the computer to see the photo of our little girl! I was high, euphoric. I was about to see my baby and, in a few months’ time, hold her in my arms.

Looking at the photo for the first time, we saw that she was undeniably beautiful.

Along with the photo were pages of handwritten documents with measurements — height and weight and head circumference — which, as first-time parents, didn’t mean much to us. Instead, we concentrated on the photo and the overall assessment: healthy. Neil and I had discussed the challenges of adoption at length, but we had focused on the emotional and cultural challenges, not developmental. How would we talk to our child about her birth mother? About having a different skin color and birth heritage? Could she feel both Indian and Jewish? Did those identity labels even matter? Health, we assumed, would come with good nutrition and medical care and our love and attention.

We celebrated the following night at a fancy Indian restaurant. We ordered the vegetarian tasting menu, and I tried not to think of the price of the meal. Or of the larger ethical issues surrounding international adoption: the extreme poverty that causes girls and women to give up their babies and the global inequalities that lead those babies to homes overseas. Although we couldn’t help being excited that our dream of having a child was about to come true, Neil and I knew we were going to benefit from an unwed mother’s impossible choice.

And yet, we celebrated. How could we not? We devoured strips of fried okra, the restaurant’s signature dish. We drank Kingfisher beer and held hands across the table, seated up on the balcony, surrounded by tables of wealthy Indians and Indian-American families. My baby, my baby, my baby, I saw in each of the children’s faces.

On the way home, I bought a parenting magazine. I sopped up the pages like the grease on the okra. The next morning we went shopping. I needed to connect to the baby, and buying her clothes was the closest I could come to touching her, bathing her, caring for her myself. After years of waiting, my daughter was coming. Touching the garments, folding them neatly in their plastic bags, I began to believe in the adoption, to believe this baby was mine. In what felt like pure formality, we sent the documents about the baby to a renowned New York pediatrician who specializes in international adoption.

And then we heard back.

“This is a special-needs referral,” the pediatrician explained. “She’s tiny. She’s not even on the chart. She’s suffering from malnutrition. And I’m very concerned about her head circumference. The brain develops from birth through age 2, and this child is already 21 months. And you won’t be bringing her home for five or six months. This child is going to be seriously delayed. I want you to know what you’re getting into.”

“I don’t understand,” I began. “Our social worker and the orphanage consider her a healthy child. And this is supposed to be the best orphanage in India. They feed the children on demand. How could she be suffering from malnutrition?”

“Well she’s not sick, so in that sense she’s healthy. But research has shown that some children do fine in an orphanage setting and others — no matter how good the care — can’t handle living in an institutional setting. They crave the intimacy of a parent-child relationship, and without that they start to go downhill, becoming depressed, withdrawn, like animals in a cage. This child was fine when she was born, on the chart for height and weight and head circumference. I consider this a case of failure to thrive.”

I wanted to turn her words around and make them change shape. I wanted to stuff the words back into her mouth.

The pediatrician told us our daughter would need speech therapy, occupational therapy, physical therapy. She would need early intervention.

“Early intervention? What does that entail?” I asked.

“The state will send someone to your house several times a week. She may need ADHD medication, assistance with speech, language and fine-motor skills, and then special education services once she’s ready for school.”

“Isn’t this something we can do on our own?” I asked. “We’re willing to do anything. I’m going to be home with the baby. Neil’s taking a semester’s parental leave. Couldn’t we catch her up?”

“Oh you’re sweet,” said the pediatrician. “Sweet, and well-intentioned and naive. Listen, I’m sure she’s an adorable child. Perhaps you should get a second opinion.”

I didn’t want a second opinion; I wanted my perfect daughter back. Back home, Neil went online and looked up head circumference and height and weight charts for rural southern Indian girls. She wasn’t on that chart either.

I wished we were different people, the kind who would welcome this child, welcome the risks, with no questions asked. I wanted to help her, to make her OK. But what if I couldn’t? Could I love her anyway? To a parent, this question must be unthinkable. You love your child no matter what, accepting all limits and gifts. But we had a choice, and the magical thread that had spun us around this child for the previous two days was beginning to unwind and tangle. Until we signed the referral papers, until an Indian judge granted us legal guardianship, she was not ours. We had a choice.

Neil and I had each had our share of hardships. Neil’s mother died suddenly when he was in college, and his father died when Neil was in his 20s. My father had violent rages, and my mother stayed with him; I no longer speak to my parents. But such difficulties are mere speed bumps when compared with the poverty we saw in India. I couldn’t imagine what this little girl had already endured. Neil and I were, unquestionably, the lucky ones.

Are we bad, selfish people for wanting our luck to continue, for wanting a child with a normal IQ? How could we refuse a baby whose only “fault” was to be born to a mother too poor to keep her? And yet, we knew that if we said no, she’d likely be matched with another American couple, one more eager to welcome this child despite the risks.

Neil didn’t think we should accept the referral, and I couldn’t bear the responsibility of being the one who said we should. I wanted to be the person who would take on such a parenting challenge, who would prove the doctors wrong. I wanted to be the one who would convince Neil, and myself, that this child was ours. But already, in my mind, she’d become a burden. She was no longer adorable and perfect. Her needs frightened me.

Neil, a university professor, asked a colleague in the medical school who specializes in brain development issues to evaluate the referral. The colleague reported that there is a high correlation between a head circumference far below the mean and below-average intelligence. Mental retardation was a definite possibility. Another doctor, an expert in international adoption and the father of children adopted from India, told us she might be able to bounce back, but that she seemed different to him from a typical child in an Indian orphanage.

Our social worker read the reports, and reassured us that she wanted the best match for everyone, that if we didn’t feel right about this referral we shouldn’t take it. The baby would be matched with another family, and eventually we’d be matched with another child. But, she said, this baby might be fine.

It wasn’t the baby who was lacking something, but I. Although I understood the fears, my weaknesses and selfishness were still fanned out in front of me like playing cards. I was filled with sadness, but also with growing certainty about what choice we would make.

We turned down the referral.

Our social worker couldn’t predict when the next referral might come, and I wouldn’t wait patiently any longer. My hunger for a healthy child felt primal and all-consuming. We’d waited long enough; I wanted a doctor to fix me.

The next day Neil and I called an in vitro fertilization clinic in Denver. A week later, still adrenaline-fueled, we flew to Denver for a series of medical exams. We began to conjure up a new dream: a biological baby from the Denver clinic and an adopted baby from India. Whichever comes first, we told ourselves. Hopefully both. While remaining at the top of the waiting list for an adoption referral, we signed up for our first IVF cycle two months later, after I’d be finished with a writing residency in Tucson, Ariz.

In the desert, I thought about babies nonstop. The one we lost to miscarriage, the one we said no to and the ones we hope to have soon. I couldn’t get the photo of the baby in India out of my mind. The child I decided not to mother has made her mark on me. I am more aware of my limits and weaknesses, more in touch with my strengths.

In April, we found out that I was pregnant. I was shocked, elated. The years of waiting melted away. The morning of my first ultrasound I confided in our social worker about the nascent pregnancy, and she said the adoption would have to be put on hold for a couple of years. The baby inside of me, already mine, needed me now. That afternoon, we saw a heartbeat pulsating on the ultrasound screen. Still, I remain haunted by images of the little girl to whom I said no.

Of course I’ll try my best to do everything I’ve been told — I’ll try not to “overthink” breast-feeding but will aim to achieve a “good latch,” I’ll try to pump early and often, I’ll nap when my baby is napping, I’ll make my husband change every single diaper and walk the baby in a million little circles, I’ll treat motherhood as my brand-new, overtime, around-the-clock job, I won’t attempt to vacuum or shower or pay bills, I won’t guilt myself into thinking I should be back at work prematurely — but even so, I’m told that I’ll feel angry and sullen and overwhelmed. I’ll cry over nothing, or over the fact that there’s a lamprey-like beast sucking my will to live straight out of my sore breasts.

Yes, just four weeks from now, if the predictions of my mother friends are accurate, I should feel like a total impostor, a crappy mom, a complete failure at my “new career,” but I’ll also be so spaced out and slow that I’ll wonder if I can ever return to my old career again. I’ll have to let my husband wash the lamprey, just in case I turn into Andrea Yates in a weak moment. I’ll be just like Brooke Shields was after her first baby was born, except that I’ll look like shit and I won’t have the energy to write a book about it — and even if I do, no one will buy it.

Occasionally, I’ll make desperate, weepy calls to friends, barely able to string enough words together to describe the feeling of walking around underwater, spaced out, stuck in some hazy existential crisis. My closest friends, who are childless, will sigh sympathetically, then hurry off the phone, depressed by the prospect of procreating. My friends who are moms will chuckle sympathetically, then hurry off the phone to prevent their toddler from sticking a fork into the nearest electrical outlet.

Now and then, I’ll go out for a walk, lamprey in tow, just like I’m supposed to do. My lamprey will whine and then explode into tears, but I’ll sally forth, determined to make it to the local coffee joint, even though I can’t actually drink any coffee, since I’m breast-feeding and the caffeine is sure to give my lamprey ADHD or autism or asthma. I’ll stumble over to the “child play area,” which always seemed to be full of moms trading epidural stories when I worked there on my laptop — you know, back when I was a successful writer with a flourishing career and a life of endless promise stretching out before me. There’ll be one mom there with a toddler and a camera-ready model baby, sleeping in its expensive stroller. She’ll point out that I have my Baby Bjorn strapped on incorrectly, in a way that’s known to increase the risk of suffocation. While she readjusts my Bjorn, she’ll ask me polite questions about the lamprey sucking the life blood out of me, as if it’s not strange at all, as if I’m not clearly starring in some sci-fi horror flick that ends badly.

Then she’ll launch into her enthusiastic views of attachment parenting and other all-consuming child-rearing techniques that I know nothing about, other than the fact that they demand that mothers annihilate their egos and bend the laws of space and time in order to accommodate their children. While she talks, she’ll begin unpacking a seemingly endless array of tiny Tupperware containers from her leather diaper bag, each housing a different organic, wheat-free, lactose-free snack, and she’ll pull out several scent-free sanitary wipes and a sippy cup full of juice and a very expensive breast pump, and she’ll (very discreetly) feed her very attractive baby with one breast while (efficiently and effectively) pumping the other breast, and she’ll hand out small, tasty chunks of food to her toddler, all of them rich in Omega-3 and iron and vitamin C. Watching her will suddenly make me feel very faint, and my lamprey and I will hit the floor with a sickening thud that causes everyone in the entire coffee joint to turn their heads and gasp and vow never, ever to forsake their very promising and brilliant writing careers in order to procreate.

But things will get better for me a few months later, don’t you worry! The lamprey will start sleeping for two-hour stretches at a time (What a luxury!), enough time for me to actually call my few remaining friends and tell them I can’t make it to whatever fun-sounding event they’re planning. I’ll blame it all on the lamprey, of course, and I’ll describe, in excruciating detail, how cute the lamprey’s expressions are these days, especially when it has gas. I’ll even check my e-mail, just like I did in the old days! Of course, once I get tired of reading old messages, I’ll just delete them all and send out a group e-mail announcing that I can no longer be expected to return calls or e-mails in a timely fashion and I can’t drive for more than three minutes without the lamprey crying (unless I sing “Farmer in the Dell” in a very happy, high voice, but that only buys me another two minutes), so anyone who wants to talk to me or see me will have to come to my house, where I’ll be distracted constantly and will have one or the other of my bloated, pale, blue-vein-covered boobs out at all times.

In my e-mail, I’ll explain that, yes, I recognize that some women in Africa only pause for half a second to give birth, and then they return to toil in the fields while their baby is raised by their 3-year-old or their grandmother or their dog, but that’s only because those women have very mellow babies, not colicky, fussy little creatures like my lamprey, and besides, studies have shown that babies in Africa often develop emotional insecurity from being raised by their 3-year-old siblings, who also don’t tend to notice when they’re getting loose stools or eczema or painful rashes from their non-hypoallergenic burlap bedding. I will remind my friends that American children have the distinct advantage of being the center of their parents’ universes, and without overzealous, overbearing helpings of attention and care, they’ll never grow up to be neurotic, overachieving, ulcerous mutants that fit neatly into our society’s soulless, workaholic culture.

It will feel good to reconnect with my dear friends through the convenience of a mass e-mail! But best of all, every week or so, I’ll venture out of the house without the lamprey! I’ll get to take luxurious half-hour strolls down to the pharmacy for more diaper rash cream. It will feel so nice to get away from home, every corner of which is now filled with brightly colored plastic devices and discarded butt wipes and little radios that play happy baby songs that make you want to beat someone’s head in with a tire iron.

Sure, I’ll sometimes wonder if the lamprey is still breathing without me there, watching it closely, monitoring its every breath. I’ll picture my husband, dropping the lamprey on the floor and then tripping over it. I’ll picture the dogs, fighting over the lamprey like a chew toy. And then, while I’m in line for the cashier, I’ll catch a glimpse of that Vanity Fair cover with Katie Holmes and Tom Cruise and that creepy, overstyled, wise little elf Suri tucked between them, the whole family looking painfully smug and rich and scary, and I’ll break down sobbing and I won’t be able to stop. I’ll rush back home to the lamprey and I’ll feel relieved that it’s still alive, but I’ll notice that it’s got spit-up on its onesie and its diaper hasn’t been changed, and I’ll fly into a rage and accuse my husband of being a shitty father.

But things will get better after that, don’t you worry! Eventually, I’ll get divorced, and the lamprey will start to talk, babbling on about Teletubbies and Pokemon and other really tedious stuff, and then the lamprey will become a sullen big kid who proclaims that it’s “bored” all the time, so I’ll rush around to keep it busy and happy, and sooner than you know it, the lamprey will be an angry, temperamental teenager with a seriously overblown sense of its own importance. Finally, one day in the not-so-distant future, maybe after it has a particularly helpful therapy session, the lamprey will call me to tell me that, as part of its “healing process” it needs for me to understand that I was a crappy mother. On top of being seriously stupid and uncool, I was incredibly injurious to its sense of self, and I would’ve been a way better parent if I hadn’t worried about it so much or driven it to piano lessons (which it fucking hated), because all of my energy and focus on it were just a total nightmare and that’s why it was driven to drink and drive and shoot drugs and shoplift and catch venereal diseases from scary losers with gun collections and bad hair and corn-chip breath. When I start to get defensive, saying that maybe I made some mistakes, but really, all I wanted was to do my best and love my kid with all of my heart, the lamprey will scream that I don’t understand anything — I never understood anything! — and then it’ll hang up on me.

Several birthdays and holidays and Mother’s Days will go by, unmarked, as I hobble around my cluttered, dusty, cat-filled house, but don’t worry! Things will get better when I go to live in a nursing home, and my lamprey comes by one afternoon to introduce me to its lampreys (all grown up now), who seem to hate its guts almost as much as it hates my guts. And when the little (full-grown) lampreys cringe as they watch me unwrap and eat my apple sauce out of its plastic cup without the aid of my dentures, which are disinfecting in a glass by my adjustable bed, my lamprey will shoot me a sympathetic look. No, my darling lamprey won’t say, “I’m sorry” or “I love you, Mom” or anything like that, but that look it gives me will more than make up for all of the pain and sacrifices I went through as a mother! I’ll get a warm glow deep down inside, and I won’t even feel bad later, when I discover that my antique gold watch and the roll of $20 bills I save for Bingo are both missing from my sock drawer.

To think, in just one month, the joys of motherhood begin at last! How blessed I feel, to be poised on the precipice of this wonderful new adventure!

My pregnancy with Abraham was an accident that coincided with my initial diagnosis of bipolar disorder. After a lifetime of struggling with my moods, of cycles of rage and euphoria, of bouts of optimistic productivity alternating with pessimistic despair, things finally got to the point where they threatened the stability of my marriage and my family. I began taking a low dose of the SSRI Celexa two weeks before I realized I was pregnant, and I noticed the change right away. I no longer found myself exploding with unwarranted anger at my husband, my children, or bank tellers. I did not wake in the morning and consider my life, my family and my work with a morose and helpless gloom. On the contrary. I felt light. It was as though the acrid gray fog that had been poisoning my perception simply blew away and I could finally see and be myself.

Then, after two weeks of pleasant calm, I found myself sitting in my bathroom, pants around my ankles, staring in shock at a pregnancy test flashing two cheerful pink lines.

I stopped the drugs right away. I made this decision on my own, not so much consulting my psychiatrist as informing him of my decision. I’d never allowed myself to indulge in anything during my other pregnancies. I didn’t drink coffee, I went off ahi and gorgonzola, I avoided the products of both Napa and Humboldt counties. It never occurred to me to stay on the meds. I wasn’t profoundly mentally ill; I wasn’t about to leap off the Golden Gate Bridge. I was just mean and unpleasant, given to fits of weeping and flashes of inexplicable rage. And isn’t that how pregnant women are supposed to feel?

Except that I’d had two weeks of something different. I had had two weeks of contentment, two weeks of being in control. For two weeks when my older children fought over whether to watch “Thomas the Tank Engine” or “The Simpsons,” when my husband forgot to pick up the dry cleaning, when an editor passed on one of my short stories, I responded with equanimity, with disappointment, perhaps, but never with apoplectic gall or soul-crushing misery. I now knew what it was like to be a person whose happiness was governed by the conditions of her life not by those of her brain chemistry. Even more important, my family now knew what the experience of stability was like. Did we really have to give it all up?

I turned to the Internet. The pregnancy Web sites gave forth with a chorus of reassurance. Care should be taken, of course, but if my well-being required it, I should go ahead and take my antidepressants. Define require, I thought as I read. How bad did things have to be before I could safely put myself in that category? I read further and found a Danish study that showed no damage to infants from maternal use of SSRIs. An analysis of Swedish birth records confirmed this. I was especially comforted by this last report. Think about it. The folks who make the Volvo, the very architects of safety consciousness, seemed to be telling me that even if I wasn’t in danger of slitting my wrists without it, I could still take my medication. I didn’t have to be suicidal; miserable and unpleasant did the trick. The Swedes gave me the green light.

This time, before I did anything, I called both my obstetrician and my psychiatrist. The research I found reassured them, too, and they agreed I could go back on the meds. I took Celexa for the rest of the pregnancy, and managed to weather events, among them the death of my best friend, that would otherwise have sent me rocketing into bouts of volatile despair.

Now, two years after Abe’s birth, the British medical journal the Lancet has published a study indicating that infants exposed in utero to SSRIs may suffer withdrawal symptoms at birth. Emilio J. Sanz, a professor of clinical pharmacology from the University of La Laguna in Spain, evaluated the World Health Organization’s database of adverse drug reactions, and came up with 93 cases where SSRI use was associated with either neonatal withdrawal syndrome, which is characterized by irritability, abnormal crying, tremor and feeding problems, or neonatal convulsions. The vast majority, 64, of these cases involved the drug Paxil. Sanz and his colleagues concluded that doctors should avoid prescribing Paxil to pregnant women, or should prescribe it at the lowest possible dose. In a comment accompanying the study, two Yale University School of Medicine doctors expanded that suggestion to question the “uncontested SSRI hegemony,” and suggested that doctors should “perhaps recalibrate our personal prescription thresholds (especially during pregnancy, lactation, or early childhood).”

Abe had no convulsions, no constant crying or breathing difficulties. But he did have feeding problems, and he never learned to nurse, despite six months of aggressive intervention. When this study showed up on the front pages of newspapers, I felt a nauseating twist in my gut.

All along I’d been watching Abie, wondering if his chin failed to drop forward at 7 weeks’ gestation when it should have because of the medication I was taking, wondering if his failure to latch on to my breast was a sign of something deeper and more profound. I’d googled the words “hirsute” and “birth defect.” I’d cupped his sweet, long foot in my hands and worked his little ankle, trying to figure out how its deformity could be blamed on womb positioning as the doctor said, and if, somehow, the drugs that make me feel so good could have caused my baby to hover uncomfortably in the very place in which he should have been most secure. Now, here was the Lancet telling me that I may have made a terrible mistake. In seeking to spare my other children and myself nine months of unhappiness, had I put my child in harm’s way?

The medical community is far from unanimous in its view of the ramifications of the Lancet study. Dr. Lee S. Cohen, the director of the perinatal psychiatry program at Massachusetts General Hospital, has expressed reservations, calling into question both the methodology, in which adverse outcomes may tend to be overreported, and even the use of the term “withdrawal syndrome.” He said that what SSRI-exposed babies experience has so little in common with acute heroin or methadone withdrawal, for example, that to use the same terminology is confusing at best. Cohen’s concern is that mothers who are at risk for severe depression will avoid SSRIs not just in the immediate peripartum period (the third trimester), when exposure may carry the most risk for their newborns, but throughout their pregnancies.

Recently, I asked my own obstetrician, Dr. Arzou Ahsan, if in light of the Lancet study, she would still advise me to stay on Celexa through a pregnancy. Her answer was immediate and clear. Yes, she would still recommend a low dose of any SSRI other than Paxil. She said she had concerns about the Lancet study, saying it was difficult to determine its clinical significance. The conclusions drawn from a study that mines large databases for instances of drug reactions are less clear than those that could be made from, say, a double-blind study where researchers have more information on individual patients. Unless and until there is more convincing evidence of harm, the benefits of SSRI use are so great that she feels comfortable recommending them to her patients who really need them.

My psychiatrist, on the other hand, was less sure that his advice would remain the same given the recent study. He reminded me that the decision to take any medication during pregnancy, indeed my decision to take Celexa during my pregnancy with Abraham, involves a risk-benefit analysis. Does the benefit to the mother outweigh the risk to the baby? The Lancet study pushes that analysis further in one direction. My psychiatrist pointed out that Sanz and his colleagues did not study the prevalence of neonatal withdrawal syndrome, how common it is among infants exposed to SSRIs. From their study we know that it occurs in some number of cases, but we know nothing about how frequently. Further, no one has yet determined if there is a consequence to the child beyond the initial exposure, or if it is an effect that passes with the withdrawal syndrome.

So many of us in our 30s and 40s have photographs of our mothers, a Doral burning merrily between their index and middle fingers, a martini glass balanced on their pregnant bellies. Now, those pictures seem absurd, even shocking. Most of us don’t smoke when we are pregnant, we don’t drink or take drugs. We modify our diets, sometimes drastically. But to a woman who suffers from depression, even minor depression, and realizes relief from medication, the thought of forgoing it can be daunting. Withdrawal syndrome necessarily means that the infants exposed in utero to SSRIs have undergone some physical changes, but as my psychiatrist perhaps facetiously pointed out, we don’t know for sure that those changes are negative. It is conceivable, albeit unlikely, that it does a developing fetus good to be bathed in a steady stream of extra serotonin. At the very least, so far no studies have shown any long-term harm beyond the period of withdrawal.

Still, I feel for the pregnant women facing a decision that is suddenly much more complicated. It’s hard enough to be either pregnant or depressed, let alone both, without having to make sense of conflicting medical research and objectively evaluating the quality and seriousness of your own despair. Had the Lancet study been published before I became pregnant with Abraham, I think I would have tried harder to do without my medication, at least in the last trimester, that peripartum period that the study deemed the most crucial. I would have tried, knowing the toll it would have taken on my older children, my husband and myself, in order to spare Abraham any potential harm. I would have done this, whatever my doctors’ considered sound advice, bracing myself for months of upheaval and unhappiness and strapping my family in for a very bumpy ride. But the very idea makes me queasy.