Maternal Mental Health: creating more awareness and addressing the stigma
By Francesca Murenu & Annemarie Schumacher Dimech
Empathy, leadership, multitasking, communication skills, problem solving, creativity, emotional intelligence – and so much more. No CV could ever list the never-ending skills a mother demonstrates, 24/7. But who takes care of those who care?
The role of motherhood is an everlasting adventure, a travel through everchanging perspectives. Still, in spite of the rhetoric, mothers are not superheroes, and, as humans, they have to cope with all kinds of challenging situations. Let’s celebrate Mother’s Day by talking more about maternal mental health.
1/7 women experience depression and anxiety in the perinatal period
Every minute, 250 babies are born somewhere in the world. Childbirth has a huge impact on a woman’s life, and it can give rise to the widest spectrum of emotions, from joy to fear in her unique journey. Every year, 20 million mothers experience postpartum depression or other mental disorders, and most of them live in Low to Middle Income Countries (LMIC). All over the world around 10% of pregnant women and 13% of women who have just given birth struggle with mental health, and in developing countries numbers rise up to 15.6% and 19.8% respectively.
Maternal mental health is a global public health challenge, and the focus will become greater in the next few years, having a key role in integrated maternal and child healthcare. In fact, antenatal and postnatal mental health problems are associated with individual suffering, increased risk of preterm delivery, difficult mother-infant bonding, impairment in infant care and delays in the child’s development and other negative maternal and child outcomes. Postpartum depression (PPD) is one of the most common mental health issues that may happen during the perinatal phase. A mother with PPD experiences great distress, and it may be hard for her to perform routine and self-care activities. Moreover, a parent’s struggle with a mental condition affects the whole family and the family’s dynamics, as partners and relatives have to cope with their own worries and face the new challenges related to this mental illness at the same time.
Perinatal mental health issues can show up in a variety of ways, ranging from baby blues, to anxiety, depression, postpartum psychosis and maternal suicide. In particular, postpartum psychosis is a medical emergency, as the patient may be dangerous to herself or others, whereas suicide is one of the most leading causes of maternal death within a year of childbirth. Still, all of these conditions can be recognized and completely treated.
Who is at risk?
Every woman may theoretically suffer from mental disorders during pregnancy and in the first year of the newborn. Yet, there are some risk factors that increase the chances of having to deal with these conditions. Those include stress, low income, migration, exposure to violence, emergency situations, natural disasters and low social support, as well as having a previous history of mental illness. Other non-physiological factors include the significant changes in one’s life due to the pregnancy and new baby, high self-expectations, traumatic birth experience, baby’s health issues, breastfeeding difficulties, excessive infant crying and partnership problems. At societal level, there could be risk factors linked to societal pressures and expectations relating to motherhood and fatherhood, or parenthood in general. Furthermore, PPD is increasing in women under 25, possibly due to societal changes, isolation and lack of employment.
Postpartum depression and stigma
It is important to underline that postpartum depression is not a result of a personality trait, weakness or defect. PPD is the consequence of a complex interplay of biological, psychological and social risk factors.
On a biological perspective PPD can be seen as a reaction of the body to the sudden increase and drop in stress and reproductive hormones that happens during pregnancy, childbirth and in the weeks after. As the body tries to maintain balance, mood fluctuations and depression may arise.
The word “stigma” refers to ‘an attribute that is deeply discrediting’ (Goffman, 1963); and has been found to be one of the barriers for women to seek help and talk about their symptoms leading to delays in diagnosis and treatment. Women may not seek help due to shame or feelings of guilt, particularly at a time in one’s life when one is expected to feel happy. Mothers should be supported, and encouraged to ask for assistance: all of these conditions can be managed.
Moreover, it is important to keep in mind that men or partners can also suffer from postnatal depression and it is recommended, that healthcare professionals screen for depression in the mother’s partner during the first year after childbirth. There are also specific risk factors that put men at risk for postpartum depression (e.g. unemployment, relationship problems, poverty and sleep deprivation). Having said that, the mechanism behind postpartum depression differs between men and women and therefore the individual characteristics need to be considered at all stages of prevention, diagnosis and treatment.
Thus, we need to increase awareness about the impact of perinatal mental health as well as address the associated stigma.
Doubling challenges: COVID 19
The COVID-19 pandemic has disrupted day to day life in our whole society, and family life is not an exception. Challenges experienced by parents, particularly new mothers, have increased, while the support available has become less accessible due to lockdown and other preventive measures. Social isolation, fear, uncertainties, economic and financial matters, together with difficulty in accessing healthcare services have been associated with an increase in symptoms of stress, anxiety and depression. Data from Chinese and Canadian studies about antenatal mental health reported higher prevalence of depressive symptoms and increase in thoughts of self-harm and anxiety after the beginning of the pandemic and, according to a UK-based study, lockdown worsened mental health for those living with young children not attending nursery or school.
What are the main factors observed to influence mothers’ mental health during the COVID-19 pandemic?
- Risk perception plays a huge role, directly increasing maternal anxiety. Pregnant women and new mothers may be worried about contracting the virus. Other concerns include fear of losing someone, being alone during gynecological check-ups, fear of getting infected during/following the delivery (35.5%) or that the newborn child could get infected (42%), together with the anxiety about any kind of complication.
- Isolation and lack of social support, due to the reduced movement and socialization led to a decrease in psychological wellbeing and is associated with higher perceived stress. Moreover, traditional practices that accompanied mothers through pregnancy and childbirth were disrupted, for instance Seemantham and Garbhasanskaras in India, Tsao-Yueh-Tzu (“doing the month”) in China and la cuarenta in Mexico.
- Intimate partner violence has increased in many countries due to lock down and other stay-at-home measures, that had the collateral effect of isolating victims and increasing control of the abusing partner. IPV is experienced by about 30% of women worldwide, and the rate usually increases (sadly in both frequency and severity) during pregnancy, crises and emergencies.
- Discontinuous antenatal care should be also taken into account. As the health-care system desperately tried to avoid reaching saturation, non-essential visits were interrupted or reduced. At the same time, women were worried about being exposed to the COVID-19 virus during transportation to, or during the check-up itself, and tried to avoid hospitals.
- Concerns about economic and financial uncertainties weigh on the psychological burden of mothers, especially for those in low socio-economic class.Women reported stress about losing a job or loss of household income.
Women and multiple roles
According to the last McKinsey report, one woman out of four in the US is currently considering downshifting or leaving her job due to the pandemics. Covid 19 did nothing but highlighting pre-existing inequalities on the workplace, with women of colour experiencing the worst impact.
Working mothers struggle with work, housework and caregiving at the same time, frequently facing negative judgement by colleagues for their caregiver role and feeling uncomfortable in disclosing their problems.
Besides office hours, mothers are 3 times more likely to be responsible for the household tasks. Interestingly, over 70% of fathers reported that household tasks are shared equally; conversely, just 44% of women reported an equal sharing of tasks.
What can we do?
There is so much that can be done and should be done to support maternal mental health: advocacy, promotion of psychosocial well-being, education, research, integration of mental healthcare in other women and child health care services. Moreover, it is important to increase awareness on all possibilities to treat PPD and other mental illness in the perinatal phase and increase awareness on their beneficial effects.
Last but not least, it is estimated that an additional investment of 0.1/0.2 dollars per person per year would be enough to add support for perinatal depression in Maternal, Newborn and Child Health (MNCH) services.
Women’s Brain Project (WBP) advocates for a personalised medicine approach to cater for all individuals’ needs as well as to provide effective and sustainable healthcare. WBP argues that the one size fits all strategy does not work and, the same as with other illnesses, a precision medicine approach needs to be taken to address this mental illness taking into consideration the characteristics of the individual and their environment. This should also be the case for maternal mental health, which is an important theme for WBP. Apart from addressing the stigma and creating more awareness about this topic, WBP highlights the lack of clinical research in pregnant women in general and particularly in pregnant women with psychiatric disorders. WBP has addressed maternal mental health including PPD in various fora: we dedicated an expert panel in our last international forum, it is also one of the mental illnesses illustrated in our most recent publication authored by Antonella Santuccione Chadha and Maria Teresa Ferretti’s “Bambina Senza Testa”, as well as dedicating a webinar to the importance of considering the impact of the pandemic on mothers and families.