Circle of life

Perinatal mental-health disorders can affect the psychological wellbeing of the mother, infant, and family unit if left untreated. To support new mothers on a personal and professional level, Niamh Delmar explains that employer education is all important.

‘Perinatal mental health’ refers to a woman’s emotional and psychological wellbeing during pregnancy, childbirth, and the first year after birth. If untreated, symptoms may persist beyond this. It covers a wide range of conditions.

A significant number of women are affected, and many do not seek help. According to the HSE Specialist Perinatal Mental Health Services, one in five women experience mental-health problems in pregnancy or after birth. According to Maternal Mental Health Alliance, one in ten women will experience a perinatal mental-health problem, and 70% of women will hide or downplay symptoms.

The perinatal period is marked by challenges, hormonal fluctuations, and life-changing experiences. While this period may bring joy to many, for others it puts their mental health at risk and affects their daily functioning.

The causes of perinatal mental-health issues are multifactorial. Studies identify pre-existing mental-health problems as contributing factors. A previous history during pregnancy or the postpartum period have also been linked to psychological complications for women.

Psycho-social factors include ongoing stressful life events, a lack of support, a poor relationship with a partner, distress caused by a lack of involvement from a partner, low levels of emotional support, and domestic violence. The impact of previous trauma on a person’s mental health has also been found to be a contributing factor.

Treatable conditions

With appropriate interventions and support, perinatal mental-health conditions are treatable. Often, it is those closest to or living with the woman who spot complications arising. Recent studies reveal that up to 20% of women experience mood or anxiety disorders during pregnancy.

Excessive fears about the birth, and about becoming a mother, and adjustment difficulties may feature. High rates of relapse have also been observed in women with bipolar disorder. Pre-existing conditions and a discontinuation of psychotropic medications are aggravating factors.

There may be an unintended pregnancy, relationship difficulties, pre-term delivery, or miscarriage. Approximately 10-20% of pregnancies end in miscarriage. This can be a devastating and traumatic experience for the woman, her partner, and their families and friends.

Miscarriage grief is intense and associated with sadness, exhaustion, anger, shock, depression, and anxiety. Hormones are also shifting, adding to the emotional upheaval.

Weight gain and a changing body shape may be distressing for those with eating disorders. Tiredness and morning sickness affect daily functioning, and an extreme form (hyperemesis gravidarum) can cause dehydration and may require hospitalisation.

MRI imaging has found that pregnancy shrinks the brain’s grey matter. Many women report memory problems. Redirection becomes focused on caring for the newborn.

Faulty assumptions

Childbirth is a traumatic experience for some women. Assumptions that giving birth is natural and joyful are faulty. Birth trauma is often evident after a prolonged and painful labour if there was risk to mother and baby, or after a stillbirth.

Women who have experienced post-traumatic stress disorder after childbirth describe having felt a loss of control, and having received a lack of empathy and communication during the birth.

They also may have experienced physical distress and extreme pain, with episiotomies, incontinence, weakened pelvic floor, bladder prolapse, and other birth injuries. Extreme disappointment and distress may be experienced as a result of not having had the birth experience that was planned, expected, and hoped for.

Postnatal issues

Breastfeeding, exhaustion, trouble bonding with baby, biological changes, and postpartum psychiatric disorders can further complicate this vulnerable period. Breastfeeding can become a stressful event for some women due to supply issues, mastitis, plugged ducts, tongue tie, and other issues.

Challenges involve recovery from giving birth, intense infant care, adjustment, and sleep deprivation. Infants may have health or feeding issues. It can be a period of isolation and loneliness for mothers. Relationships with partners often change, and identity may get lost.

Post-natal conditions are underdiagnosed and under-treated. Approximately 50-80% of women experience postpartum blues during the first few weeks after giving birth. If symptoms of depression persist beyond this time, evaluation of postpartum depression is needed.

Anxiety disorders specific to this period, post-traumatic stress disorder, obsessive compulsive disorder, and postpartum psychosis all need specialised intervention.

Antenatal depression

While mood changes occur during pregnancy, antenatal depression is marked by specific criteria, including negative thoughts and fears about motherhood. Emotions may become overwhelming, and daily functioning impaired. Postpartum depression is the most common disorder occurring, generally in the first two to three months after childbirth.

Symptoms include a pervasive low mood, low energy, anhedonia (the inability to take pleasure in a previously pleasurable activity), sleep and appetite disruption, anxiety, and possibly suicidal ideation. Negative thoughts and excessive preoccupation about the baby, and feelings of guilt and inadequacy feature. Tearfulness is reported by many women who struggle psychologically.

Anxiety disorders

Research has found that perinatal anxiety disorders are under-diagnosed. Fears about birth, motherhood, the newborn, and the future can become excessive and all consuming.

Postpartum post-traumatic stress disorder is generally characterised by stress, nightmares, flashbacks, and hyper-arousal. It may be associated with a significant fear or terror of going through childbirth again. Partners may also experience symptoms.

Obsessive and compulsive symptoms can also arise during pregnancy and after childbirth. Rituals can take up significant time and energy. Mothers may be severely disturbed by intrusive thoughts and images, and those who have revealed these in therapy with this author have been so distressed.

Such mental intrusions are relentless and repetitive, and can result in high levels of anxiety, panic attacks, and sleep disturbance. There may be a reluctance to disclose intrusive thoughts for fear of being judged. Some relief is reported when these are named, understood as symptoms, and treated.

Post-partum psychosis is a serious illness requiring urgent medical attention. Symptoms include hallucinations, delusions, agitation, confusion, behaving out of character, mania, and low mood. The woman may not realise she is ill, so it is vital that those close to her spot the signs.

Returning to work

This can create emotional upheaval for some mothers. Separation anxiety may feature for both mothers and babies. Mentally and physically, the woman may not be ready. Each baby has different needs.

Childcare has to be arranged, and a whole new system organised. Feelings of guilt, ‘juggling it all’, and increased stress affect mothers. It is often not a choice for women to return to work.

Research conducted by DCU Business School identified three main negative transition experiences: career derailment, unconscious bias among colleagues, and a deterioration of professional relationships.

Personal support

If there is any history of mental-health conditions, it is essential that expectant mothers discuss this with their GP, healthcare professionals, or the perinatal team at the maternity hospital. Mothers can be educated on signs and symptoms.

Screening, monitoring, and early intervention are key components to stabilising symptoms and alleviating distress. Biological, psychological, and social factors need to be assessed and supported. The focus on the physical health of the mother and baby needs to be accompanied by a focus on her mental wellbeing. Expectations of pregnancy, childbirth, and the period after are more realistic if women are prepared.

Making a ‘wellbeing plan’ is recommended by the National Institute of Clinical Excellence. Partners, friends, and family members can monitor the woman throughout her pregnancy, the birth, and beyond. Daily mindfulness practice and mindfulness-based therapeutic interventions, physical activity, and interests are all preventative measures.

People need to avoid assumptions that this is a joyful time for all women. Reframing scripts – such as changing, say, “you must be over the moon” to “I am here for you, it can be a stressful time” – opens the door for more women to open up.

Practical help, such as cleaning, shopping, driving, cooking, or minding the baby to let the mother nap is a huge help. Awareness of perinatal mental health, actively listening, checking in, encouraging the mother to go for a walk or to engage in other activities she enjoys, finding out information on support groups, parent and baby groups, and other community and online initiatives, are positive ways to support. Empathy, being non-judgmental, and genuineness are key.

Workplace

Engaging with women during pregnancy, identifying needs, adjusting roles as necessary, and promoting a maternity-friendly environment all foster a perinatal-friendly and safe workplace. Rest areas and ergonomics can be provided. Best practice dictates appropriate communication with the woman, facilitation of appointments, and provisions made for mental-health care.

Psycho-education ensures all managers are familiar with symptoms and can respond professionally. Perinatal maternal mental-health and wellbeing protocols set the tone. Re-entering the workplace after maternity leave is made smoother if the organisation facilitates a respectful, equitable work environment, and offers flexible hours, an understanding of childcare and sickness, private pumping rooms, and job-sharing or part-time options.

In studies conducted, the majority of mothers reported that flexible working arrange-ments and a phased easing back into the job would aid reintegration. Pre-return-to-work meetings and workshops to prepare employees are also beneficial.

Employers and managers need to avoid making assump-tions about the woman’s ambitions, preferences, and goals. Fair treatment, open communication, and a psychologically safe environment promotes a culture of positive care for perinatal mental health.

Maternity-protection legislation in Ireland means employers could be held accountable if maternity matters are mishandled. Creating an inclusive organisational environment yields long-term gains, less absenteeism, and enhanced productivity.

Playing a positive part

Perinatal mental-health issues include depression, anxiety, and post-traumatic stress disorder. Life stressors can contribute to psychological upheaval during the ante- and postnatal phases. Childbirth itself poses risks and a plethora of mental-health issues.

Women are often reluctant to disclose symptoms, and are not asked about their mental health in appropriate ways. Partners, families, friends, healthcare professionals, and employers can play a positive part by being informed, guiding the woman to access intervention, actively listening, observing, exploring the mother’s needs, and providing practical and emotional support.

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