More than postpartum: mental health in pregnancy.
Photo by Ömürden Cengiz on Unsplash
As the host and founder of Perinatal Stories Australia, I have the honour of interviewing mothers about what is often the hardest time of their life, during what is supposed to be the best time of their life.
Something I hear far too often is how the symptoms of mental ill health in pregnancy were largely ignored - even by mothers themselves.
It's just hormones, right? Maybe birth anxiety? This will all go away when the baby is here... won't it?
And yet as a society and in health circles, the focus is usually only on postpartum.
Maternal mental ill health is more than 'postpartum'
The facts are clear.
A 2001 study about maternal mental health, cited in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), discovered that only fifty percent (50%) of major depressive episodes have an onset in postpartum.
The other fifty percent (50%) of episodes actually begin in pregnancy, prior to the delivery of the baby.
This finding definitely took me by surprise. Based on my own experience of antenatal anxiety, I knew perinatal depression and anxiety (PNDA) was possible in pregnancy, although I didn't realise how high this statistic actually is.
So much emphasis is placed on postpartum mental illness but this is only half of the picture. In reality, the symptoms of a major depressive episode can present during pregnancy, whether this is detected or not.
The same study behind these statistics concluded that:
"Major depressive disorder during pregnancy remains underdetected and undertreated."
I don't know about anyone else, but underdetected and undertreated are two words I don't like seeing in the context of maternal mental ill health.
So why is antenatal mental ill health "underdetected and undertreated"?
In sharing their lived experiences, several of my other podcast guests reveal why their mental ill health symptoms in pregnancy may be downplayed or ignored.
Furthermore, the incredible team at COPE: Centre of Perinatal Excellence theorise about why many remain unaware about mental ill health in pregnancy.
"It is expected that pregnancy comes with many hormonal changes, often early signs of antenatal depression or anxiety are associated with this – and, hence, the conditions go unrecognised and untreated." - COPE
This was something that Sarah, my podcast guest in episode 14, articulated so well when she described how antenatal symptoms are invalidated by this preoccupation with hormones:
"It is hard, I think, mental health in pregnancy, because your hormones get blamed for everything…. everything is like ‘you're just hormonal’ and same thing when you've had the baby, like the 'baby blues'. Yes, it's very hormonal and it's very real, but it sort of gets minimised because it's hormones... Once the hormones start to settle, it got a little bit easier, but it didn't go away."
The assumption that things will get better when the baby arrives is another potential barrier to help-seeking - as Kathryn, my podcast guest in episode 04, experienced:
"I fell pregnant with my daughter and then that's the beginning of the mental health journey, really. That's the beginning of the magical thinking in pregnancy, the superstitions, the worst case scenarios, the catastrophising of everything, feeling like I didn't deserve having her, and all of this went undiagnosed during my pregnancy... I thought if I just get to her being born then I won’t feel like this anymore… but with having her, the reduction in anxiety never came."
Unfortunately, mental ill health symptoms can be overlooked by health care providers too. This is something Jess, from episode 08, experienced first hand during an antenatal appointment with a midwife at the hospital.
"I said to her as well, 'I am quite anxious, I definitely am struggling with the anxiety'. But she didn’t question me any further... I was like, if no one is questioning me, then it must be fine."
While there is no single reason why antenatal mental health is overlooked, there are many micro-moments that have collectively led to the normalisation and/or internalisation of mental ill health symptoms in pregnancy.
This is why it’s so important to examine perinatal mental health, not just postpartum.
What does ‘perinatal’ mean?
Perinatal is a term encompassing both pregnancy and postpartum. This is why it’s so important to examine perinatal mental health, not just postpartum.
While the start and end of the perinatal time period is contentious, the standard view is inclusive of the entire pregnancy and up to one year postpartum.
Don’t ignore mental health in pregnancy.
According to COPE:
“It is important to be informed and aware of mental health conditions in pregnancy."
This couldn’t be more important in a context of dismissing ourselves or being dismissed by health care providers. An understanding of mental ill health symptoms needs to be common knowledge.
Greater societal awareness about antenatal mental ill health can also reduce shame, another unfortunate barrier to help-seeking.
We know routine screening leads to better detection and earlier intervention. This is why routine screening must begin during pregnancy, or even at pre-conception appointments, not just at the six-week postpartum check-up when it is potentially too late.
Maternal mental health is more than postpartum. Let's keep talking about it.
Reference
Yonkers, K. A., Ramin, S. M., Rush, A. J., Navarrete, C. A., Carmody, T., March, D., Heartwell, S. F., & Leveno, K. J. (2001). Onset and persistence of postpartum depression in an inner-city maternal health clinic system. The American journal of psychiatry, 158(11), 1856–1863. https://doi.org/10.1176/appi.ajp.158.11.1856
