Pregnancy and mental health

Dr Meesha Haorongbami *

Pregnancy is often considered to be a wonderful and exciting time in any woman’s life. Pregnant women are said to emit a “pregnancy glow” (due to hormonal changes and increased blood flow) and this “glow” is often meant to signify the joy and satisfaction of carrying a new life within. Unfortunately, not every woman is lucky enough to feel this way.

The period during pregnancy and after delivery (post partum period) brings a mix of feelings in many women most of which tends to be not-so-good. Around the world, 10% of pregnant women and 13% of women in post partum period undergo some form of mental health problems. Prevalence is slightly higher in developing countries: 15.6% and 19.8% respectively.

Mental health issues during and after pregnancy causes tremendous suffering and disability along with reduced response to child’s needs. This ultimately negatively affects newborns and young infants who are highly sensitive to the environment and the quality of care.

Though every woman is susceptible to mental health problems during and after pregnancy, the following appears to be risk factors:

1. Lack of social support
2. First time pregnancy
3. Unplanned pregnancy
4. Lower socioeconomic status
5. Exposure to violence or conflict situations or natural disasters
6. History of mental illness
7. Family history of mental illness
8. Relationship difficulties
9. Unrealistic expectations of motherhood
10. Traumatic or complicated birth
11. Sick or unsettled baby

Various hormonal, emotional, and physical changes take place during pregnancy, delivery and the period thereafter. This inevitably takes a toll on your day to day life. Struggling with a mental health issue on top can make you feel even more isolated. Pregnancy itself may trigger or worsen a pre-existing mental health issue.

Eg. Eating disorders such as anorexia nervosa may be triggered by the stress of pregnancy. Pregnancy or post partum stress can either trigger mood disorders in a predisposed woman or worsen the disorder.

Some of the debilitating mental health problems encountered during and after pregnancy are:

1. Anxiety

Pregnancy and childbirth are major life events. They require numerous life-changing decisions to be made and numerous accommodations to be considered. At the same time, it puts women into situations outside their comfort zone. These factors, along with the various hormonal and physical changes accompanying pregnancy and childbirth, can lead to anxiety.

30% of women have some form of anxiety during pregnancy while a minority has severe anxiety which might prompt a healthcare professional to diagnose her with an anxiety disorder. Some women would have had anxiety before the pregnancy, some would have during the pregnancy and in others pregnancy can worsen a pre-existing case of anxiety.

It is seen more in genetically predisposed women and those undergoing some stressful event(s) such as financial difficulties or interpersonal relationship problems. Those with an anxious temperament usually manifest with anxieties during pregnancy and childbirth and their anxieties are usually concerned with their baby’s health or fear of the birthing experience. They might have anxieties leading up to birth, and fears, worries and insecurities about being a parent. Medical checkups can be stressful for them too.

2. Baby Blues

This is a fairly common mental health problem affecting 30%-75% of women who give birth. Symptoms occur 3-5 days after delivery and are usually characterised by tearfulness, mood swings, anxiousness and feeling overwhelmed. There might be occasional sleep disturbances or mild feelings of guilt and/or inadequacy. Suicidal thoughts or thoughts of harming the baby are rarely, if at all, present.

Baby blues are present in all cultures and socioeconomic classes. It is due to the rapid changes in women’s hormonal levels, the stress of childbirth, and the awareness of the increased responsibility that motherhood brings. The good news is that these symptoms resolve on their own and no specific treatment is required other than support and affirmation from your spouse and family members.

If, however, the symptoms don’t shift or worsens even after a week, seek help from a mental health professional as it could be a sign of progress to depression. Having a newborn is hard work and feeling low and overwhelmed is all part of being a new parent. Yet, those feelings shouldn’t simply be taken for granted.

3. Post Partum Depression (PPD)

This affects 10%-15% of women who give birth. Symptoms start within 3-6 months after delivery and may persist for months to years, if left untreated. Lack of support to new mothers is the major stressor for development of PPD. It is also strongly associated with a past history and/or a family history of mood disorder.

Common symptoms include:

(a) Low mood for most time of the day for several days and weeks
(b) Decreased desire for social interaction
(c) Insomnia
(d) Poor appetite
(e) Fatigue
(f) Irritability
(g) Thoughts of harming yourself or the baby
(h) Decreased concentration
(i) Problems with decision making capabilities, etc.

Women with PPD may have difficulty bonding with their baby and get no sense of enjoyment in the company of their baby. They may also feel indifferent towards the needs of their baby. This can further cause emotional problems in the mother and thereby continue the circle.

While there is no conclusive evidence that baby blues will lead to a subsequent episode of depression, it is advisable to seek professional help if baby blues do not subside in two weeks. Treatment should be started at the earliest as PPD may lead to the most lethal and heartbreaking, yet preventable, of all outcomes- suicide and/or infanticide.

Treatment depends on the severity of the illness and can include counselling and antidepressants. Due to the risk of transmitting antidepressants to newborns during lactation, the risks and benefits will be heavily considered by the treating doctor. You can rest assured that the safety and welfare of you and your baby will be given the highest consideration.

4. Post partum psychosis (PPP)

Also known as puerperal psychosis, PPP is one of the most serious psychiatric events seen in post partum period. It is characterised by the mother’s depression, delusions, and thoughts of harming either herself or her infant. Such ideation of suicide and infanticide, though rare, requires prompt intervention as there have been reports of women acting on these ideas.

Thankfully, the incidence of PPP is rare i.e. 1-2 per 1000 childbirths. The symptoms begin within days of delivery and almost always within 20 days of delivery. Characteristically, the new mother begins to complain of fatigue, restlessness, insomnia, tearfulness, and mood swings. Later, suspiciousness, confusion, irrational statements, delusions, and hallucinations may appear.

Once the florid psychosis occurs, she may be a danger to herself or to her baby. PPP is caused by interplay between various factors such as genetic predisposition, severe sleep deprivation, rapid hormonal change post-delivery and the physical stress of delivery. It is a psychiatric emergency and it requires prompt consultation and treatment. Drugs are the treatment of choice in the acute stage.

Close monitoring of the mother to prevent harm to herself or to the newborn is absolutely vital. The mother is usually helped by contact with her baby if she so desires, but the visits must be under close supervision. Psychotherapy is initiated after the period of acute psychosis and therapy is usually directed at helping the woman accept and be at ease with the mothering role.

As stated above, mental health issues are common during pregnancy and after pregnancy. This doesn’t mean that they should be considered normal or just another part of your pregnancy. In ideal circumstances, physical, mental, social, and financial factors should be taken into consideration by couples before conceiving a child.

One should be mentally prepared to undergo a journey like pregnancy and motherhood which can be as exhausting as it is rewarding. Even if your obstetrician doesn’t ask you about your psychological status during and after pregnancy, it is essential to speak up about how you’re feeling- for the good of your own as well as your baby and your family.

It is understandable that one would feel scary and hesitant about broaching up a topic which feels stigmatizing but it is imperative to know that you are not alone. Mental health problems, during or after your pregnancy, doesn’t have to be a problem for you or your baby.

With the support of your loved ones and adequate and timely management by healthcare professionals , your experience of pregnancy and motherhood can be positive rather than filled with dread.