Pregnancy is an emotional time. There is an expectation that women should be happy and excited about their new arrival. The reality is that one in six pregnant women are at risk of some form of depression during their pregnancy or after their baby is born.
Perinatal and postnatal depression (PND) affect women in different ways, but the symptoms can arise at any stage. A recent paper published in the journal Midwifery by Ursula Nagle, mental health support midwife at Rotunda Hospital in Dublin and DCU lecturer Mary Farrelly explored the views and experiences of women when discussing or seeking help for mental health issues during pregnancy.
Screening tools used to assess levels of depression were viewed with mixed opinions by women as though they were a box-ticking exercise and did not effectively explain how they felt. Participants said they did not want to be placed into “the mental health patient” box and feared that social workers would become involved. Fear of their baby being taken away was common.
However, screening tools also gave women the opportunity to disclose their feelings and start the conversation once they felt their midwife or healthcare provider was listening.
Currently, there are no national guidelines, local practice varies, and the guidelines Ireland currently refer to — NICE, RCOG and SIGN — differ in practice.
According to the research, women often speak to a partner before seeking help from a healthcare professional, with many cases undetected and untreated. Shame or not understanding why they are feeling as such are cited as being a factor.
Kate Lyons, acting clinical skills facilitator, Cork University Maternity Hospital, advises that the Whooley questions for the identification of depression are completed by women at their first hospital visit, with the current state of their mental wellness questioned and their history of mental health discussed.
“Antenatal clinics are, however, busy,” she says. “Often, women wait a couple of hours to be seen. Their visit with the midwife or doctor may seem rushed, due to the pressure on the system as a result of short staffing.”
While mental health issues are discussed more now than in the past and referrals are made as appropriate, Lyons believes the lack of continuity of midwifery care can make it difficult to establish a relationship with a woman and her family, which may stop her from expressing her true feelings at appointments. Trust, respect and the belief that their feelings are understood and recognised go a long way to helping a mother who is confused, scared and unable to make sense of her own emotions.
To optimise maternal mental health and infant mental health, open communication between the woman, her partner, and the midwife is essential
Information and cost are two of the biggest barriers to women receiving support for PND, according to Cork-based psychologist Sally O’Reilly. “Also, it is unlikely that a woman in the throes of depression will feel motivated to support herself sufficiently. PND robs women of energy, clarity and self-compassion. By its very nature, it is in and of itself a barrier to obtaining the help that women need.
“The Wonder Woman myth we have at present,” is another hurdle, she adds.
We live in a society where women are praised for being able to have it all and, while that’s great and positive, it is not possible to be Wonder Woman
As the situation stands, many women who are affected by perinatal and postnatal depression go undiagnosed.
“Nationally, women are not sufficiently screened and it is also hospital dependent,” says counselling psychotherapist Susi Lodola. “Some hospitals use the Edinburgh Scale, but would ask women to fill this out just after the birth of their baby, before they go home. It would be better if this was done the first time the woman presents to the hospital and then at every antenatal and postnatal visit. This would be standard practice in many other countries.”
Lyons agrees, adding: “Women usually visit their GP to confirm their pregnancy. I think screening should begin here, because the GP will be known to the woman and, if mental health issues are known or develop, the GP will be aware of it first.
“However, during pregnancy and postnatally, women’s ability to cope can change and so screening needs to be assessed continuously.”
Perinatal mental health has an effect on the relationship between mother, baby and the family unit as a whole. Its impact has often been grossly underrated. Researchers Nagle and Farrelly’s recent findings suggest that, while screening tools can be used to adequately assess a woman’s risk of developing perinatal mental health issues, they must not become a box-ticking exercise. They recommend that in order to effectively support women throughout pregnancy, childbirth and after, regularly enquiring about their emotional wellbeing at every antenatal and postnatal appointment is vital, along with continuity of care.
Pamela Lynch suffered symptoms of depression, anxiety and low mood while pregnant with her son Oscar. It was only when she looked back over her pregnancy that she realised how depression was affecting her.
“As I had previously suffered with depression and anxiety,” she says,
I was aware that, statistically, I was more at risk of postnatal depression and from about four months pregnant my anxiety really came to the fore
She felt an impression of being judged with the stigma of perinatal and postnatal depression hanging over her. “I had been very open about my previous mental health difficulties, however, I felt
different about admitting I was suffering with perinatal and postnatal depression. I was afraid people would think I was a bad mother. I was afraid people would judge me. I was afraid people would be watching my every move and commenting on everything I did.
“Upon discharge from the hospital after having my baby, I was asked if I was feeling okay, and if I wanted to be assessed by the mental health team. I believed I was okay. I was leaving the hospital having been in for five days. I’d had a traumatic experience and I was finally going home with my baby and my husband. I was happy to be leaving. If anything, this was absolutely not the right time to ask me if I was feeling okay. I didn’t have time to think, I didn’t want to think, I wanted to begin life with my family.”
Lack of support in the community, no support groups and very little information about perinatal and postnatal depression led Pamela to set up an anonymous Instagram account to document her journey with perinatal and postnatal depression. “This proved to be the best thing I could have done. So many women contacted me in the initial weeks saying they felt the exact same as I did,” she says.
Medication, counselling, mindfulness, meditation and self care played a big part in her recovery but the turning point was seeing she wasn’t alone. Along with her Instagram, she also set up a Facebook group, Postnatal Depression and Anxiety Support Group Ireland, in support of women who suffered perinatal and postnatal depression and found the group invaluable to her recovery.
“I dread to think had I not known, or recognised that I was beginning to struggle how long I would have continued on for, and how much worse I may have become.”