By Vashni Benjamin
Motherhood is a period of new beginnings. With their bodies changing to turn themselves into new homes for a new life, and emotions running at an all-time high, it’s no surprise that many mothers find it hard to adapt to their new role. While many embrace it gladly, there are many more who struggle with the unvoiced burdens of maternal depression.
“Perinatal mental health, referring to a woman’s mental health during and after giving birth, is one of the largest emerging mental health issues globally. One in five women in the world suffer from a mental health problem during pregnancy and in the first year following the birth,” said Niluksha Perera, a behavioural health research consultant who places special focus on the importance of perinatal mental health. Though no exact numbers were tabulated in Sri Lanka, the American College of Obstetricians and Gynecologists estimates that 14-23% of pregnant women experience depression during pregnancy, and 5-25% experience depression postpartum.
What to expect when you’re expecting
Antenatal (antepartum) depression is a form of clinical depression that occurs during pregnancy. Bodily changes, hormone fluctuations, alterations in sleep patterns and eating habits, paired with other factors such as maternal anxiety, work-related stress, and other addictions can all contribute to antenatal depression.
It often goes unnoticed in women and when untreated, affects not only the unborn child, leading to premature births, lower-weight babies, and complications during pregnancy, but also becomes a precursor for postpartum depression.
After the bun’s out of the oven
Postpartum psychiatric disorders that occur after childbirth are categorised into three stages: postpartum blues, postpartum depression, and postpartum psychosis.
Postpartum blues is the stage that lasts till about four weeks after childbirth. It is when this condition persists and develops beyond four weeks that it is classified as postpartum depression.
As Perera stated: “The period of ‘baby blues’, which generally all new mothers go through, is a period of few days of feeling a little sad and confused, which is completely normal, but if this feeling of sadness persists for more than a few weeks and if you have trouble connecting to your baby and are feeling helpless more often than not, then you should seek help.”
According to psychologist Nivendra Uduman, postpartum depression can be identified when the mother shows signs of exhaustion, sleep difficulties, loss of appetite, irritability and anger, loss of interest, decline in personal hygiene, difficulty in caring for one’s self and the child, physical aches, frequent headaches, anxiety, feelings of emptiness, trouble bonding with the baby, and has thoughts about harming one’s self and the child.
Postpartum psychosis, generally used to describe the most extreme stage of depression, is accompanied by delusions, hallucinations, anorexia, and intense suicidal thoughts.
“In Sri Lanka, maternal suicide is a grave issue where it is one of the leading causes of maternal deaths. While a majority of the suicides are under-reported, a study in 2015 in Sri Lanka indicated that 31 out of 206 maternal deaths were due to suicide,” explained Perera. Furthermore, studies conducted by the Canadian Paediatric Society have shown that women who go through postpartum depression are at a 50-62% risk of suffering from depression later on in their lives as well.
It’s not just her
Maternal depression can be harmful not only to the mother going through depression, as “it also affects men,” said Uduman. “It impacts the daily life of the parent/s, infant, and the larger family.” The Canadian Paediatric Society uses the following chart to identify the different ways a child can be harmed throughout various stages of their life due to maternal depression.
|Consequences of maternal depression|
|Prenatal||Inadequate prenatal care, poor nutrition, higher preterm birth, low birth weight, pre-eclampsia and spontaneous abortion|
|Behavioural||Anger and protective style of coping, passivity, withdrawal, self-regulatory behaviour, and dysregulated attention and arousal|
|Cognitive||Lower cognitive performance|
|Behavioural||Passive noncompliance, less mature expression of autonomy, internalizing and externalizing problems, and lower interaction|
|Cognitive||Less creative play and lower cognitive performance|
|Behavioural||Impaired adaptive functioning, internalizing and externalizing problems, affective disorders, anxiety disorders and conduct disorders|
|Academic||Attention deficit/hyperactivity disorder and lower IQ scores|
|Behavioural||Affective disorders (depression), anxiety disorders, phobias, panic disorders, conduct disorders, substance abuse and alcohol dependence|
|Academic||Attention deficit/hyperactivity disorder and learning disorders|
“Antenatal or postpartum depression in a parent can have an impact on the child, also because the parent may neglect self-care. This would mean that the child would not receive adequate warmth, nutrition, and care and is deprived of a bond which is crucial for healthy development. This can potentially lead to attachment difficulties later on in life,” said Uduman.
In addition, as Perera pointed out: “The child also has a higher likelihood of developing depression, anxiety, or substance abuse disorders as they grow older. So if we don’t intervene and address this problem of maternal depression now, it can lead to a vicious cycle that would be difficult to stop.”
Speaking on how maternal depression affects relationships and marriages, Nivendra Uduman and Niluksha Perera had this to say: “Marriages and relationships are affected because it can be difficult to feel connected to each other during the period of illness. One partner can experience rejection from the other and have difficulties in bonding, physically and emotionally.
“Mental health difficulties like depression associated with childbirth can also cause immense stress on both partners, leading to difficulties in communication. It is crucial that a newborn has both parents involved in its care. Parents should be encouraged to work on their relationship, seek marital counselling if needed, and speak out about their thoughts and feelings, because dealing with depression requires support and understanding.”
In Sri Lanka
Sri lanka is very slowly waking up to the dangers of maternal depression. The Edinburgh Postnatal Depression Scale is a screening tool used in the country to detect maternal depression. It is a questionnaire filled by postpartum mothers who are referred to a psychiatrist if the marking scheme indicates such a need. Even though this system has been implemented, due to the lack of awareness on the subject and the general stigma surrounding it, not many people reap the real benefits of it.
We asked Uduman and Perera to give us some answers to some pressing questions regarding maternal depression and what we as friends, family, and citizens of Sri Lanka can do to help.
What are some steps that we can take to help protect mothers from the damages of maternal depression?
NU: Our primary goal should be to encourage the mother/father to seek treatment as early as possible. There is treatment available in the form of pharmacology and psychotherapy and it is of vital importance that the mother is supported in seeking treatment. There is a greater chance for faster recovery if treatment is begun early.
This then reduces the impact on the child. Other family members, while supporting the mother, should also ensure that the child is given adequate time with the mother, to avoid complete separation as much as possible. The mother can also be encouraged to breastfeed, after consultation with medical professionals if the mother is on any medication for depression. The mother also can be supported to engage in basic self-care and also in activities like physical exercise.
NP: Ideally, screening your mental health before having children can be the first step. Screening the children for any potential physical or mental health issue in their developmental stages would be advised.
What are some steps employers should take to help women through these times?
NU: Time off from work is something employers can offer to help women through difficult times during or after pregnancy. There can also be support available within the workplace (counsellors) who women experiencing mental health difficulties can have access to. Some workplaces now offer a crèche where a mother can bring her baby to work. This would drastically reduce the stress levels of a new mother. An employer also can encourage good relationships at work so that the mother does not get isolated.
NP: Be understanding and supportive. Improve company policy to include any adjustments a mother may need. Pregnancy and the early stages of parenthood are fairly large transition periods in a person’s life, so being aware of struggles that women might face (e.g. missing their baby when at work, feeling guilty, being tired) would definitely help.
There’s proven to be a drop in the number of women who return to work after pregnancy. Does this help a mother take care of her child better? Would you recommend this to mothers who struggle with maternal depression?
NU: Patriarchal norms and other cultural nuances sometimes dictate whether a mother should go back to work after child birth or not. Financial issues, family dynamics, and other factors would determine whether returning to work is permissible or not.
In my opinion, not going back to work does not necessarily decrease childcare as long as the mother has adequate spousal support. However, the way of thinking is different in the rural areas. Beliefs that a woman’s role is only to reproduce and care for the family hinders a great deal of women from achieving their career goals and so not returning to work after childbirth can cause emotional and psychological problems for a mother.
Going back to work post recovery would really help a mother reintegrate and also have access to activities and relationships outside of her home environment which can prove to be healthy.
NP: All I can say is that one is definitely not better than the other. Doing what feels right and best for you and your baby is what is important. If you or your baby is at any risk, addressing and resolving that should be your first priority.
Sri Lanka still has a certain level of stigma surrounding mental health. People are often told that it’s just another part of pregnancy and are expected to ‘suck it up’ and power through it. Where do we draw the line between getting help and powering through it?
NU: Well, I think we need to first acknowledge privilege and class differences when it comes to mental health problems being diagnosed. Differences in social strata also determine whether a mother sucks it up and powers through depression during or after pregnancy, or whether they seek help and support.
Gender norms that exist in our society sometimes lead to a mother feeling like she has to bear the entire brunt of a pregnancy and its aftermath, and this is reinforced by her partner, extended family, and wider society.
So, how does one then seek help? There is also a lack of awareness, especially in the rural areas of Sri Lanka and also in the more disadvantaged sectors in cities like Colombo, where maternal depression would not be recognised, a mother’s feelings will not be validated, and most importantly, a father’s mental health will be completely ignored and sometimes joked about.
It is not easy to distinguish between seeking help and just going through the motions because there is a complex web of social, cultural, religious, gender, and economic factors at play. Unfortunately, mental health as a whole is not given priority in Sri Lanka by the Government, which of course includes some healthcare professionals. Most medical professionals do not ask about mental health, and it is still not the norm for people to visit a counsellor or a doctor for mental health concerns.
Fathers are often completely left out of the conversation. Their fears, anxieties, and concerns are not taken into account in the discourse around maternal mental health. Masculine norms also sometimes do not allow fathers to seek help.
So, there is really no clear way to define where the line should be drawn.
NP: One of the biggest barriers in addition to the stigma around mental health is that women and families are afraid that the baby will be taken away from them if they seek help for mental health issues.
I can assure that, in healthcare, we strongly believe in NOT separating the mother and the baby unless there is a significant risk to the health of the baby.
A baby needs the mother the most and every health system and care provider will try their level best to keep the mom and baby together. Parents should be encouraged to share their stories of the difficulties of pregnancy and parenthood in order to understand the true reality of this life milestone.
The concept of “powering through” may eventually result in bottled up emotions that will manifest in different ways without us even knowing it. We need to draw the line between listening to other people interpreting your emotions and making decisions for you.
Are we as a country doing enough? What other steps do you think our healthcare services should take to reduce this issue?
NU: It makes me sad to say this, but we as a country are not paying sufficient attention to issues that really matter, one of which is mental health.
Healthcare services must be better equipped to screen both mothers and fathers for mental health problems associated with pregnancy and beyond.
This must happen across the board, and not just in the urban areas. It is also important that healthcare workers are sensitised about how certain cultural norms increase the distress felt by parents experiencing depression, because in my experience, there are instances where healthcare workers themselves perpetuate distress and shame associated with maternal and paternal mental health by bringing in harmful cultural and gender related stereotypes.
I think this also calls for a wider perspective, where mental health in general must be promoted and families must also be educated. There is a great deal of work to be done, and the healthcare services play a massive role along with other sectors.
NP: Globally, Sri Lanka is severely lagging behind in proper perinatal mental health support and care. In Sri Lanka, we have only one mother and baby unit at the National Institute for Mental Health which houses mothers suffering from serious mental health issues. The provision of resources for mental health is also limited.
The public health midwives (PHM) in Sri Lanka play a pivotal role in our healthcare system and provide excellent care for our mothers and mothers-to-be.
In my opinion, training midwives and other frontline health professionals on how to deal with and detect maternal mental health issues is one of the key steps we can take as a country. Further, incorporation of trained psychologists, counsellors, and other key mental health workers into the system can help ease the burden of a limited resource.
Nilushka Perera (MPH – UK, BSc Psych – USA) is behavioural health research consultant with a background in international public health and psychology. She is currently working for a maternal and child healthcare charity in the UK while also teaching global health and health psychology in several Sri Lankan universities. She is also a workshop facilitator in community mental health for numerous organisations and has a special focus and passion for perinatal mental health, digital health, and behavioural health in developing countries.
Nivendra Uduman is a counselling psychologist with an independent practice working at Shanthi Maargam, and is also the founder of “Footsteps to Freedom”; a movement created to raise awareness on mental health and suicide prevention. He has years of experience in the field of mental health and has worked towards training, facilitating workshops, creating mental health awareness, and writing about mental health.
Contact: 13-33/Sumithrayo/The national mental health helpline – 1926 if you want to talk to someone urgently.