In May 2013, Kimberlynn Bolanos, 21, told her boyfriend she needed to take a shower. She placed her five-month-old son, Isaac, into his carrier and shut the door to the bathroom of a Chicago motel room. After 30 minutes, the boyfriend knocked on the bathroom door. He pushed the door open and saw his son was bloody and unconscious.

The boyfriend ran from the room screaming, “She killed my baby.” The motel receptionist called 911. Chicago police couldn’t open the bathroom door and used an axe to break it down.  Both mother and son were on the floor, covered in blood. Bolanos had slashed Isaac’s throat, and stabbed him almost 30 times in the head, neck, and chest. She also stabbed herself multiple times in a suicide attempt. Bolanos recovered from her wounds and gave a video statement to investigators in which she described having premonitions about something bad happening to her baby. She feared the state would take Isaac away because she smoked crack cocaine.

During the 2016 bench trial, she told the judge she suffered from bipolar disorder and obsessive-compulsive disorder. She also admitted to substance abuse. The judge acknowledged her mental-health status during the sentencing and said he believed the murder was a onetime incident. He found her “guilty but mentally ill” and gave her the minimum penalty of 38 years in prison. The judge urged Bolanos to live a productive life during her incarceration.

Bolanos’s sentence for killing her child was standard in the U.S. But in some other countries, there are laws recognizing that a woman who has recently given birth has undergone biological changes that may make her more vulnerable to mental illness. Approximately two dozen countries have such “infanticide laws”, including Brazil, Colombia, the United Kingdom, Germany, Italy, Japan, South Korea, New Zealand, the Philippines, and Turkey. These laws are designed to allow for more lenient penalties in cases where a court determines the postpartum mother suffers from mental illness. Exactly what those penalties are varies by country.

The United Kingdom’s Infanticide Act of 1938, for example, limits the charge against a postpartum mother to manslaughter if the killing occurred while the mother’s mind “was disturbed by reason of her not having fully recovered from the effect of giving birth to the child.” In such a situation, a manslaughter charge could lead to life in prison. But in the past few decades almost all UK women convicted of infanticide are given hospital orders, probation, or supervision.

Postpartum psychosis is a mood episode with psychotic features such as paranoid thoughts, auditory hallucinations, or disorganized thinking. It occurs in one to two mothers per 1,000 who give birth, according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. Although not all women who kill their children suffer from mental illness, mothers who suffer from postpartum psychosis sometimes hurt themselves or their children during a psychotic episode.

“They have confused thinking,” says Susan Benjamin Feingold, a licensed clinical psychologist in Chicago who specializes in perinatal mood and anxiety disorders. “They often have delusions and hallucinations. We consider it a clinical emergency. They are at risk of hurting themselves or their children.”

Medical researchers estimate that untreated postpartum psychosis leads to an estimated 4 percent risk of infanticide, and a 5 percent risk of suicide.

“Suicide is a major contributor to maternal death in the first year postpartum. [And] postpartum psychosis increases the risk of suicide,” says Cara Angelotta, a psychiatrist at Northwestern University’s Feinberg School of Medicine, who treats women with postpartum psychosis.

Andrea Yates was a Texas mother with psychotic hallucinations of voices telling her that Satan wanted her to kill her five children. In 2001, she drowned her children in the bathtub and told a caseworker she believed she had saved them from the fires of hell. She also said she thought the mark of Satan, 666, was visible on her scalp and requested a razor so that she might shave her head.

Postpartum psychosis is associated with major-depressive disorder, schizophrenia, and bipolar disorder. Medical researchers estimate that 72 percent of women with postpartum psychosis are diagnosed with bipolar or schizoaffective disorder, and 12 percent have schizophrenia. But although some women, like Yates, endure depression for years before experiencing a psychotic episode after birth, some women who go through this have no prior history with mental illness.

“The women I’ve treated in my practice with postpartum psychosis are often very high-functioning. They have spouses, jobs, other children, and then they get hit with this gross illness and it’s a rapid change in their behavior,” Angelotta says. Sometimes that change can go undetected, though. Angelotta says postpartum psychosis “waxes and wanes”—a woman can be lucid long enough to hold a conversation and then hallucinate hours later. Because of that inconsistency, “people have a hard time attributing the behavior to mental illness,” Angelotta says. If a woman doesn’t seek treatment for herself, those around her might not recognize what’s going on either.

This variability also causes issues for the legal system when a mother hurts her child during a psychotic episode. Two women in different states with similar cases might be treated in drastically different ways based on how their jurisdictions define their mental state in terms of responsibility, and how mental illness can be used as a defense.

In some jurisdictions, women have received shorter prison sentences with the intention of leniency. In New York City, for example, Lisette Bamenga received an eight-year sentence for the poisoning and drowning deaths of her four-year-old son and four-month-old daughter. The judge in the case acknowledged the postpartum psychosis diagnosis offered by expert witnesses for the defense.

In other cases, women are sent to prison for life. In California, Carol Coronado received three life sentences for the killing of her three daughters, all under the age of three. Prosecutors sought the death penalty.

Coronado’s attorney, Stephen Allen, says his client was diagnosed with postpartum psychosis immediately after her arrest. Another psychiatrist treated Coronado for the following year while she awaited trial and also diagnosed her with postpartum psychosis.

“I didn’t think there was any chance we could possibly lose this case given the doctors who saw her at the time,” Allen says.

The prosecution, however, offered a medical-expert witness who examined Coronado a year after the murders and testified she was sane and knew right from wrong, Allen says. Another complication for the defense was that immediately after the murders, Coronado held the knife up to her mother and husband, which the prosecution argued was an indication she knew she had done something wrong. Allen says he believes this is why Coronado was found guilty. Her appeals are now exhausted. Unless the California Supreme Court intervenes, Allen says Coronado will spend the rest of her life in prison.

At Coronado’s trial, mental-health advocates gathered outside the courthouse with empty strollers to protest the justice system’s punitive approach to defendants with postpartum psychosis. Advocates such as Feingold say prosecutors often fail to acknowledge postpartum psychosis as a legitimate mental illness. “People don’t get it,” Feingold says. “They see baby killers. These women are really sick and need treatment, not punishment.”

In some instances, women do avoid punishment. Yates, for example, initially received a life sentence. False testimony from a witness for the prosecution prompted a judge to order a new trial. During the second trial, she was found not guilty by reason of insanity and committed to a state institution. The sentence prompted a strong response from critics, particularly those who felt there was no justice for the murdered children.

The National Review’s editor-at-large, Kathryn Jean Lopez, called the verdict an injustice and criticized the media’s focus on Yates and her former husband. “Absent in our national consciousness—if media chatter is any indication—are the Yates children,” she wrote. “When we read or hear of a ‘Yates,’ it’s anyone but the murdered innocents.”

The outcry in Texas grew louder in 2009 when a state house committee passed a law intended to limit penalties for women who committed infanticide during a mental health crisis. The bill was partially written by Yates’ defense attorney and received criticism from religious organizations and right-to-life groups for reducing the maximum penalty to two-years.

The head of the Texas Right to Life told the Catholic News Agency the bill had the potential to communicate that newborns and infants were “less valuable people than others.” Texas Right to Life urged readers to contact their local representative and demand the bill be defeated. The bill was never sent to the legislature for a vote.

Unlike other countries, the U.S. criminal code varies by state, says M. Eve Hanan, a former public defender who is now an associate professor of law at the William S. Boyd School of Law at the University of Nevada, Las Vegas. This, she says, is a major reason why women with postpartum psychosis are often punished rather than rehabilitated.

“The first key is to realize is there is no one body of criminal law in the U.S.,” Hanan says. “We often talk about the criminal-justice system as a monolith, but there are 50 states plus territorial jurisdictions and a federal system. They have different ways of looking at mens rea, which is the guilty state of mind required to convict somebody of a crime.”

Although definitions vary by jurisdiction, Hanan says homicide laws include specific language regarding intent. “In first-degree murder, even if it’s for a brief period of time, the [accused] contemplated and made a decision to kill,” she says.

For women with postpartum psychosis, the specifics of these definitions can lead to convictions. Windows of lucidity can be interpreted later in court as sanity and used to demonstrate premeditation. Bolanos, for example, appeared lucid when she carried her son into a Dollar Store the afternoon before the murder. A security camera recorded her buying knives and razor blades, both of which she used to kill her son.

Although Bolanos suffered from delusions, mental-illness defenses are rarely used in court—about 1 percent of the time for felony cases, according to one study. And when they are used, this study found, they’re only successful 26 percent of the time. “You really have to show that the person was so delusional they couldn’t understand what they were doing and how it was wrong,” Hanan says.

Defense attorneys, however, can use a client’s mental illness to persuade a judge to limit the sentence. But they often struggle to prove a client with postpartum psychosis should have a reduced punishment, says Barry Lewis, a criminal defense attorney in Chicago and an advocate for helping mothers with postpartum psychosis. Postpartum psychosis presents suddenly and often in women who have never had a psychotic episode in the past. For a defendant such as Yates who had years of suicide attempts and psychotic episodes behind her from preexisting mental health issues, a defense attorney generally can point to the history of behavior, depending on state laws regarding insanity defenses. But defense attorneys representing women with postpartum psychosis often don’t have a lengthy history to rely upon, Lewis says.

Even the most sympathetic judges have limited options when sentencing women with postpartum psychosis. There are few psychiatric facilities in which a woman can receive rehabilitation. In the 1950s, there were more than 512,000 patients in psychiatric hospitals. By 2005, the number dropped by 90 percent. In the following five years, the number decreased further to about 43,000 patient beds—nationwide.

Hanan says the shift from inpatient to outpatient or “community care” accelerated in the 1980s. “Community care is chronically underfunded,” Hanan says. “There are outpatient clinics, but in most jurisdictions they are overwhelmed and inadequate. At the same time [as deinstitutionalization], we began incarcerating people with mental illness.”

In the U.S., women were not always given life sentences for infanticide. In the past, a woman considered “insane” who hurt her child might be sent to a mental asylum and ordered to remain there until cured.

Catherine Zalis was one of those women. In 1928, Zalis, 21, was pregnant for the third time in three years. She lived in a decrepit Chicago apartment and paid the $12 rent by taking in laundry. Her husband did not help with the expenses, and instead busied himself with a correspondence course on hypnosis.

On a cold April morning, Zalis felt aggravated by her five-month old daughter’s crying and smothered her baby to death with a pillow. About eight months later, Zalis was sentenced to an asylum in Elgin, Illinois.

Zalis was likely suffering from postpartum psychosis when she killed her child. During the trial, psychiatrists described how Zalis laughed hysterically for no reason. At the state asylum, Zalis received treatment—possibly electric shocks—and was released in less than two years. She divorced her husband, returned to her parents’ home in Michigan, and raised her two remaining daughters.

Zalis’s granddaughter, Carolyn Johnson, remembers her fondly. She says her grandmother was an industrious woman who worked at a cannery and managed the family’s 80-acre farm. She regularly hosted her grandchildren at the farm, who enjoyed exploring the property, Johnson says. “Everyone was honored to play at Grandma Kate’s farm,” says Johnson, who lives in Ludington, Michigan. “It was our favorite thing to do.” Zalis taught her grandchildren to fish in the farm’s creek. She led them on hunts to fill buckets with blackberries and strawberries. She showed her grandchildren how to knit and embroider, and she set aside catalogs so they could make paper dolls, according to Johnson.

Zalis died of cancer on Christmas Day in 1993 at the age of 86. Her story represents what postpartum-psychosis advocates believe is possible—that a woman can live a productive life after rehabilitation.

On June 1, Illinois became the first state to enact a law that allows judges to consider postpartum psychosis during sentencing. Women currently incarcerated for crimes committed during a postpartum-psychotic episode can now petition for a post-conviction sentence reduction.  Both Feingold and Lewis lobbied for the law and testified before the Illinois Senate and House. “This law allows for another chance,” Feingold says. “We’re hoping it will get things moving throughout the country.”

Other states, however, are starting with awareness and education programs. Twelve states have new legislation or special programs intended to build awareness of postpartum psychosis among new mothers and medical providers.  Lawmakers have also considered mandatory screening for new mothers during well-baby visits.  Some public health experts, however, have described these programs as well-intended but ineffective. A 2015 study in Psychiatric Services analyzed the various programs and concluded: “Despite the abundant good will, there is no evidence that state policies are addressing this great need.”