Suffering in Silence - Still ‘mum’ about Maternal Mental Health?

I watched a small, apparently ‘happy’ family come by to spend time in the park. No sooner than these thoughts had set in, I noticed the father walk away engrossed in a telephonic conversation. After a few moments, this ‘happy’ family got my attention again. This time the mother was mercilessly spanking the older kid, while the infant on her lap cried inconsolably. The father was nowhere in sight and soon the drama came to a pause with the mother herself breaking down into pitiful sobs. I have been no stranger to these scenes, but today, I felt a mix of emotions - remorse, grief, pity or anger. Remorse for being an onlooker like many others, grief for the children’s agony, pity for the mother’s state or inability to handle herself and the situation, and anger because maternal mental health is stigmatized, still being ignored and rarely discussed.

Women suffer in silence, gullible and often ignorant. Though, it seems most likely a healthy mother is the reason for a healthy child, healthy family and a healthy society, maternal mental health issues constitute a huge social and economic burden, a key public health challenge. Maternal health in the context of mental health is a major cause for concern as it directly or indirectly increases maternal morbidity and mortality. It is therefore vital to attribute careful attention to the mental health of pregnant women and mothers. This, in many ways lacks in current maternal health programs and activities, thus crying out for the need to strongly institute such programs into mainstream maternal programs.

Maternal mental health – figures: While mental disorders are similar in men and women, women’s mental health requires special considerations due to the greater likelihood of suffering from depression and anxiety disorders and the impact of maternal health problems on childbearing and childrearing. Depression and anxiety are approximately twice as prevalent in women as in men, the highest rates during the childbearing years, from puberty to menopause. About 5% in non-pregnant women and about 8-10% during pregnancy suffer from depression and anxiety, the highest being 13% in the year following delivery. Suicide is a common cause of maternal death in the year following delivery in developed countries; and psychosis, though rare occurs in 1 to 2 women for every 1000 giving birth. The rates of psychosis following delivery are higher in less developed countries, where infection may be a contributing factor.
Mothers at risk: Nearly any women can develop mental disorders during pregnancy and in the first year following childbirth however factors such as poverty, stress, exposure to violence -domestic, sexual and gender-based, natural disasters, and low social support generally increase risks. Domestic violence experienced by the mother and antenatal depression carry the greatest risk factor for adverse neonatal outcomes, particularly low birth weight.

Consequences of maternal mental disorders on the mother, child and family: The mother’s health, both physical and psychological, and the child’s wellbeing are a direct consequence of maternal mental disorders. Pregnant mothers affected are more likely neglect their general health, sometimes eating or sleeping inadequately. They often fail to gain adequate weight to carry on the pregnancy. Lacking in nutrition and general hygiene due to depression, these women increase the risks of infection and anaemia during pregnancy. Prenatal care is often affected and such mothers fail to seek help for the birth. Women with maternal mental disorders are likely to attempt to injure or kill herself. The reason for adverse behavior of mothers with maternal mental illness is due to the raised levels of stress hormones that predispose her to increased blood pressure, pre-eclampsia, early and difficult labor.

The earliest environment of children largely represented by the mother depends on quality of care. In mothers with maternal mental disorders, the effects on the children may vary from low birth weight, abuse and mental disorders such as depression. Prolonged and severe conditions may affect mother-infant attachment, breastfeeding and infant care. Maternal mental disorders also take a toll on relationships and often the entire family. Psychotic illnesses pose a risk of infanticide. A number of studies suggest that infants of chronically depressed mothers have low socialization traits and may be more irritable and do not perform as well in school when compared to infants born to normal mothers. A mother with maternal mental illness also affects older children in the family, expressed as neglect, abuse and slower social, emotional and cognitive development. Maternal mental disorders also take a toll on relationships and the entire family. Psychotic illnesses pose a risk of infanticide.

Tackling maternal mental illnesses: Prevention methods include identifying risk early during pregnancy and negating as much of the risk through counseling and support. A number of studies have identified preventive interventions including social support, as well as educational, psychological and pharmacologic models of care. Early diagnosis plays a vital role in prevention. Care management is essentially by counseling and follow-up with the mother and immediate family.
Way forward: Diagnoses and management of maternal mental disorders integrated into general health care can largely reduce stigma. Eliminating stigma and discrimination surrounding maternal mental illness allows women to become more forthcoming and open to discuss symptoms. Normally, maternal mental illnesses are picked up by healthcare workers in the advanced stages and rarely by family, friends. Regular risk assessment and screening provides a platform for timely intervention and the current system demands for one. The healthcare system must develop capabilities to facilitate the referral of these women to higher care when needed. Most important, education about maternal mental health should be integrated into counseling during antenatal and perinatal programs. At the governmental level, maternal mental issues should take priority by providing for adequate services.

References:
Prince M et al. No health without mental health. Lancet 2007; 370: 859-77.
Alder J et al. Depression and anxiety during pregnancy: a risk factor for obstetric, fetal and neonatal outcome? A critical review of the literature. J Matern Fetal Neonatal Med 2007; 20: 189-209.
Slade EPand Wissow LS. Spanking in early childhood and later behavior problems: a prospective study of infants and young toddlers. Pediatrics. 2004;113:1321-30.