Mental health problems in pregnant women and those who have just given birth are common, yet services to treat them are patchy – and not getting the right help can lead to longer-term issues. By Kathy Oxtoby.
Pregnancy, and the first year looking after a baby are often portrayed as the happiest time of a woman’s life. But for some women this ideal is in stark contrast to their lived experiences.
This can be a time of great change for women, and for those who have existing mental health issues or who may develop problems during their pregnancy and after they have given birth, it can also be a period of great trauma and stress. And these problems are common: perinatal mental health issues can affect up to one in five women in pregnancy and the postnatal period up to one year after childbirth, according to the London School of Economics and Political Science.
These problems range from a mild depressive illness to postpartum psychosis – an episode of severe mental illness that occurs after the birth of a child. There are many reasons why women develop mental health problems during pregnancy and after giving birth. These include having a family history of mental illness, hormonal changes to the body during pregnancy, sleep deprivation, or having a relapse of a pre-existing mental health condition, triggered by, say, giving birth.
For any woman, being pregnant and becoming a mother can have a huge impact on their lives. But having a mental health problem “adds an extra layer of complexity as to how these women make that transition to parenthood,” says Liz McDonald, chair of the Perinatal Faculty at the Royal College of Psychiatrists and chair of the Pan London Perinatal Clinical and Mental Health Network.
The challenges women with a mental health problem face during pregnancy and after giving birth are many and varied. The idealisation of pregnancy and motherhood within society can mean the woman feels she will be always be happy and never be unwell again. “When in fact childbirth can be a trigger for a relapse – particularly those conditions related to mood,” says McDonald.
Having a baby can also have the opposite effect on a woman with mental health issues – prompting concerns that they will be a ‘bad mother’ or may pass on their problems to the child. “Women may worry that they are not going to be a good mum because they have depression, and feel that their baby ‘deserves better’,” says Jo Black, a consultant perinatal psychiatrist at Devon Partnership NHS Trust.
Women’s fears that they might not be meeting the perfect ideal of motherhood often stem from the stigma that is still associated with having a mental illness. This stigma may result in women with mental health problems “feeling concerned their baby will be taken away from them, which is very frightening – and that they won’t want to receive help for their condition,” says Dr Jo Luckie, London Perinatal Mental Health Network co-ordinator.
Getting the right support
Some women during pregnancy and after giving birth may not even be aware that they have a mental health problem and need support. “Often women don’t recognise that they’re ill. They don’t know what is and isn’t normal, particularly if they’ve not had a baby before,” says Judy Shakespeare, a retired GP in Oxford, and the Royal College of General Practitioner’s clinical champion in perinatal mental health.
Those who do seek help from a health professional may find their consultation is too short – that they are feeling rushed to express how they are feeling, or encouraged to believe their feelings are just ‘normal’. This can be due to the clinician’s “lack of time and workload pressures, or an assumption that the woman has also talked about their issues with another health professional,” suggests Dr Shakespeare.
But it isn’t just a lack of time and knowledge preventing these women receiving the best care. “Unfortunately not all areas have perinatal mental health services, which means that many women are not getting access to the right services at the right time,” says Dr Luckie.
In addition, there are only a handful of psychiatric units for mothers who are experiencing severe mental health issues and their babies. As a result, mothers may be admitted to a unit many miles from home, which can create extra problems for partners and the wider family.
Without support at the right time, in the right place and in the right form, women with mental health issues who are pregnant can become very unwell. “If problems are not detected and not treated this can lead to chronic long-lasting problems, such as unresolved depressive illness,” says Ian Jones, professor of psychiatry, and director of the National Centre for Mental Health, Cardiff University, and vice-chair of the Perinatal Faculty, Royal College of Psychiatrists.
Concerns about the impact of taking medication – such as anti-depressants – on their unborn child, or when breast feeding, may result in women deciding to stop taking their treatment, which can have an impact on their wellbeing. “All too often pregnant women with pre-existing mental health problems come off medication. This can lead to problems with relapsing, or an exacerbation of a mental health problem. It can also have an impact on the development of the foetus, the baby, the partner and the rest of the family,” warns Dr Jones.
If these women do not receive support, the outcome can be fatal: suicide is one of the leading causes of death up to the postnatal year. “Tragically, sometimes women kill either themselves, or they kill their children in the belief they are protecting them,” says Dr Luckie.
But now these issues are being recognised as a national priority. The government has pledged £290 million over the next five years to provide mental healthcare for new mums. And the perinatal faculty of the Royal College of Psychiatrists and NHS England is looking at innovative ways of improving the education and training of psychiatrists.
Clinicians continue to champion best practice. For example, in 2009, Dr Luckie set up and developed an integrated perinatal parent infant mental health service that covers London boroughs. Dr Luckie works closely with local maternity services, developing links with joint obstetric and psychiatric clinics so that women are able to receive psychiatric, as well as care obstetric and maternity care.
While good practice and extra funding are positive steps to improving perinatal care of women with mental health issues, more needs to be done. “We need to make sure that the government’s money is spent in the right way - that is focused on specialist mental health services and teams, such as developing new mother and baby units for those with mental health issues in parts of the country where they don’t exist,” adds Dr Jones.
Clinicians would like to see integrated care for women with perinatal mental health problems. This means all health professionals recognising their issues, and working together to identify and support their needs. Training of all health professionals is also crucial, not only to raise awareness about perinatal mental health issues, but also to equip them with the skills to recognise when someone is unwell or know how to ask the right questions, according to Dr McDonald.
An open, non-judgemental approach, advice about adherence to medication based on the latest evidence, a prompt referral if necessary, and conferring with other healthcare professionals – providing they have patients’ consent – are just some of the ways healthcare professionals can support these patients.
Whatever their job title, Dr Black urges all health professionals to: “recognise a woman has emotional and physical health needs throughout their pregnancy. Be interested in their worries and concerns. Because it’s about giving the same quality of care to all women, whatever their questions or fears are, including emotional wellbeing and mental health.
“Death by suicide is one of the main causes of maternal death in this country. We have a duty to work as hard as we can to reduce maternal mortality – and that includes mental illness.”
Sarah Deardon, a registered nurse living in Wrexham, North Wales, talks about her experience of postpartum psychosis.
“In 1994, I qualified as a nurse, and then found out I was pregnant shortly afterwards. I was quite sick all through my pregnancy and was also stressed and having problems sleeping. But I thought once I’d had the baby things would be fine.
I continued to have sleep problems after my son was born. I was elated to have my baby, but my mind just wouldn’t switch off. I didn’t realise the warning signs. I’d never heard of postpartum psychosis.
After I was discharged from hospital I still couldn’t sleep. One night I went downstairs to make a hot drink and try and relax. I put on the TV and saw myself on the news talking about how I’d won the lottery. I was hallucinating, but everything seemed so real. My partner knew something was very wrong, and called an ambulance.
Unfortunately, at that time there were no mother and baby units. I was admitted to a general psychiatric hospital. It was horrendous not having my baby with me. I was given mind-numbing drugs to slow down my thoughts. I didn’t know if I was alive or dead.
I stayed in hospital for three weeks – normally the stay is several months for this illness – but I begged to go home. Gradually, with the help of my mum and partner I began to recover. But I would still have manic episodes, where I’d become dangerously high and then my mood would come crashing down.
Luckily, my partner found an expert in postpartum psychosis and bipolar disorder. I was admitted to a mother and baby unit, started on lithium, and within weeks felt much better. I went back to nursing. I got my life back.
I believe all health professionals and new parents should be aware of this relatively rare condition, and know what signs to look for – such as inability to sleep – so that they can identify it in the early stages and help prevent tragedies. The charity Action on Postpartum Psychosis (of which I’m a trustee) is helping to raise awareness about this and offers lots of information and support to families.
All too often women with postpartum psychosis don’t ask for help because they don’t want people to think they’re not coping. The stigma associated with mental health is a big problem. But by talking openly about this condition hopefully we can tackle this stigma, and make people aware that it can happen to any ordinary mum.”
About the author
Kathy Oxtoby is a freelance health writer