The mental health of mothers needs to be protected

“I would say it’s happening here too — 100%,” says Dr Krysia Lynch, maternity care advocate and doula trainer.

“Our maternity services focus on low mother and baby death rates as indicators [of success]. They don’t focus on how a woman’s mental health is affected by going through the services, or on how her mental health is accommodated.”

Lynch is clear that everybody who works in the maternity services is doing their best. “They’re all striving for excellence in their very specialist care.” 

But the problem, she says, lies in how services are structured. “Very rarely, if ever, does the mother’s mental health and the effects of [clinical] procedures and processes — and the way these are done — play a part in clinician decision-making.”

In the woman’s perinatal journey through the maternity services, care is compartmentalised, Lynch says. 

“They see their GP and maybe have some continuity of care. But the ante-natal midwives in the hospital aren’t the ones who’ll be there when she’s having her baby. And the ones who are there [at the birth] won’t be there when she’s trying to feed her baby afterwards, and absolutely not when she’s going home from hospital.”

In such a fragmented system, she says it can be difficult to pick up on emotional or mental health issues the woman may be experiencing.

Covid’s effect on birth process

Lynch says births have become more medicalised since covid: “High numbers of women are having C-sections or inductions since covid. The number of unplanned C-sections has risen enormously. For first-time mums in some Irish maternity units, numbers of C-sections are almost the same as vaginal births.”

The World Health Organization (WHO) said in 2021 that Caesarean sections were critical to save lives in “situations where vaginal deliveries would pose risks”.

“But not all the Caesarean sections carried out at the moment are needed for medical reasons,” said Dr Ian Askew, a director of the WHO’s Department of Sexual and Reproductive Health and Research. 

“Unnecessary surgical procedures can be harmful, both for a woman and her baby.”

Increased medicalisation of birth is relevant for perinatal mental health because the way women experience childbirth will impact how they cope emotionally afterwards. 

“When birth has been difficult, when women feel it has been physically, emotionally traumatic for them, they go into parenthood not feeling their best selves,” says Lynch.

There are no figures for peri-natal depression (PND) prevalence in Ireland — data is not collected here — but estimates put it at one in six women. 

“It’s estimated 3% of all vaginal deliveries and 6% of all C-section births result in PTSD (post-traumatic stress disorder). Up to one-third of unplanned C-section births may result in birth trauma,” says Lynch.

In other ways too, the maternity services response to covid has not been favourable to perinatal mental health. 

“Women were denied having their partner with them — only very recently have partners been able to attend the ante-natal appointment. But some [covid] protocols still remain. Even now, women are asked, ‘If you wouldn’t mind your partner waiting outside — that’d be helpful’. But why? Why would that be helpful?” asks Lynch.

Women undergo huge personal/emotional change in having a baby, says Lynch — yet other covid era-initiated practices create isolation at this vulnerable time. 

“Mental health flourishes by being with others, by having peer groups, realising others have the same experience. Pre-covid, women would have booked for in-person ante-natal classes with their partners. They smelt the smell, saw the doors of the [maternity unit], experienced the place where they would have their baby. During covid, ante-natal classes went online — a lot of this has been maintained. But is it best for women?”

Normalisation of ‘baby blues’

Lynch believes education is needed about what is normal in the postpartum phase — because normalisation of ‘baby blues’ can be a factor in women’s depression and anxiety going undetected. 

“Women undergo a hormonal adjustment in 12-48 hours — and that’s it. Like a menopause in 48 hours. If it persists it’s not normal, yet people assume it is.” 

And this isn’t limited to perinatal mental health, she says. “Many physical conditions, for example thyroid function, also go undetected under the guise of ‘normal tiredness’.”

The RCM report highlighted that 70% of women hid or downplayed the severity of their mental health problems. Lynch has seen this play out here too. 

“Women do it for many reasons. There’s an expectation mismatch — women feel, ‘this is supposed to be the best time of my life…why am I not in love with my beautiful baby? Why don’t I feel like other mothers do?’

“They want to be the best mother they can and they don’t want to admit, ‘I’m not the mother I wanted to be’.”

Red flags for perinatal mental ill-health include:

• Anxiety — persistent, fearful, low mood.
• Lack of interest — in baby, in going out, in socialising.
• Repeated persistent thoughts — of self-harm, of harming the baby, excessive concern, for example about hygiene, baby’s health.

Extend maternity care

Most women’s care ends six weeks postpartum. According to researchers Susie Hannon, Agnes Higgins and Deirdre Daly from TCD School of Nursing and Midwifery: “Women find that they haven’t had an opportunity to think about whether the changes to their emotional and mental wellbeing are due to experiencing a big life change, and likely to resolve in time, or are symptoms that need to be addressed.

"Having one or two appointments at three and six months postpartum would give women time to recognise what is and isn’t normal for them, and provides an opportunity for them to bring up concerns with a healthcare professional.

"We also know that women benefit from direct and intentional questions from healthcare professionals about their mental health. It can be worrying to talk about feelings of anxiety or depression, and women prefer for healthcare professionals to initiate the conversation about symptoms of mental ill-health. Mothers often describe postpartum healthcare appointments as ‘baby-focused’, with little time given to mothers’ health and wellbeing. Direct, mother-centred questions show mothers that their health, and their care matters too."

Irene Lowry, counsellor and member of Irish Association for Counselling and Psychotherapy is founder of Nurture Health, which works with women and partners in areas such as conception, pregnancy and childbirth. 

Lowry says when women in the postpartum phase make contact, they often say they don’t “recognise who they are”.

“They say, ‘I was able to do this professional job, now I’m not able to cope, not able to mind my baby. I’m struggling.’ They have irrational thoughts and ask, ‘how can I stop these thoughts — like something tragic is going to happen, my baby’s going to die’.”

When women in a difficult place contact Lowry, she always encourages them to first make an appointment with their GP, and to understand that their public health nurse is there to support them. “Take that support,” she urges.

• exa.mn/HSE-PND-help
• aimsireland.ie/postnatal-period
• nurturehealth.ie