By C Chandrawala
Artwork by @ms.alwar
So here's the thing: Everyone will tell you that giving birth is one of the most beautiful moments a woman can experience.
And don’t get me wrong, the outcome? A whole new human? Totally on board with that. But let’s not lie. The process is a bit of a mess. To put it very mildly.
Over 9 (it’s actually 10) months, your body plays hostel to what feels like a very entitled backpacker. You spend a few months where your best friend becomes the toilet bowl, and then, when you’re finally able to hold your soup, your ribcage starts to physically expand and you’re back in the same bathroom peeing every four minutes, but now, with the added benefit of all your critical internal organs being smushed into a third of the living space they regularly enjoy.
And all of that is just the pregnancy part of the process. Because then,
And just when the rest of the world thinks you’ve crossed the finish line, your body (and mind) enters what is now loosely called “the fourth trimester.” Joy of joys. For those who’ve had a C-section, the idea of being post-op is really just an afterthought. And for those who’ve had a natural birth...ouch. So we all need to take a minute to recover.
And all of this, on its own, is more than enough for anyone human to recover from. But what’s hard to remind ourselves of is that this, the above, is just the baseline. This is the foundation from which we walk into motherhood. (Hopefully) Without Postpartum Depression.
So when that walk is already uphill, it becomes really important to stop and pay attention to the obstacles that might arise. To keep track of the boulders that might come rolling down the hill and flatten us in the process: Postpartum Hemorrhage. Stroke. Pulmonary Embolisms. And Postpartum Depression. Shall we take a quick guess at which of those four is most likely to go undiagnosed?
Both, in the clinic and at the dinner table, PPD remains an invisible threat to new mothers. Because when you’re running on two hours of sleep and haven’t showered in a few days, who’s really to say which part of your distress is just the newfound joys of motherhood and which is PPD? Oh yes, a doctor - that’s who.
So, we asked one.
First off, what is PPD?
The extreme physiological changes new mothers undergo can also lead to more severe symptoms of anxiety, fearfulness, sadness and crying bouts, which, if diagnosed as such, is medically termed Postpartum Depression (PPD). It occurs with different levels of severity but is a longer lasting period of depression, mood swings, a possible loss of appetite, difficulty connecting with your baby, withdrawing from social situations, insomnia or too much sleeping, severe fatigue, irritability, and fear of being a bad mother (among the many symptoms and sensations). As per psychiatric nomenclature, PPD comes under Major Depressive Disorders. Its ideal onset is said to be within the first month of the postpartum period, and it affects on average 15% of mothers
Okay, why does PPD happen?
Although the exact reasons for PPD are largely unknown, an amalgamation of physical, mental, genetic and social factors is thought to induce PPD in new mothers. In the Annex to this article, you’ll find a more detailed listing of the factors leading to PPD which fall under the following categories: genetics, social factors and obstetric factors. To be 100% clear, it has nothing to do with 1) a mother’s love for her child, 2) a mother’s ability to be a good mother, or 3) a mother’s lack of strength, fortitude, or any other aspirational trait which society often heaps upon new mothers. From a 2018 report submitted to the World Health Organisation, 22% of new mothers in India suffer from PPD.
A Broader Look at Perinatal Mental Health
For many, pregnancy and childbirth can be a beautiful experience. Both mothers and fathers evolve mentally and physically as they prepare to guide a new human through life. For the mother, however, these changes are (obviously) much more severe. According to the 2018 report, the most commonly reported risk factors for PPD include financial difficulties, domestic violence, past history of psychiatric illness in the mother, marital conflict or lack of support from the partner. These factors all have varying degrees of influence, which can lead to mental health worsening or being neglected.
All the emotional, physical and hormonal changes contribute to the mental health of the mother and are manifested in the form of anxiety. While mild forms of these clinical symptoms are often known as ‘baby blues' and they tend to go away within a few weeks of the postnatal period, many women experience these mood episodes in an extreme manner. On average, PostPartum Blues affects 30-75% of new mothers. Approximately 20% of new mothers with baby blues are prone to PPD in the first postpartum year.
In the most severe cases, PPD can contribute to a psychotic state of mind called Postpartum psychosis which affects approximately 2 out of 1000 new mothers. The presenting symptoms are typically rapid highs and lows in mother’s mood, disorganized behaviour, and hallucinations. Although it happens rarely, it increases the risk of maternal suicide, miscarriage in prenatal stages and infanticide in postnatal stages, which is why early diagnosis is key ensuring to effective treatment.
How is PPD Diagnosed and Treated?
Several psychological screening scales and tools (questionnaires for qualitative assessment) exist for clinically diagnosing the PPD in new mothers, which are often accompanied by clinician’s examination to confirm the presence of major depressive episodes in mothers. Major symptoms to look for are mood alterations, anhedonia (lack of feelings of pleasure), weight/ appetite/sleep disturbances, inappropriate guilt, tiredness, diminished concentration, or suicidal ideation.
Treatment approaches consist of psychotherapies, antidepressants and self-rejuvenation therapies such as vacations, massages, acupressure, etc.
If PPD is left undiagnosed and treated, what can the impacts be?
The effects of PPD are not purely physical. Its impacts on maternal life and interpersonal relationships are significant. For example, while each mother-child relationship is unique, the effect of maternal depression can extend beyond the infant stage into the schooling age and beyond. It is difficult to clinically assess and dissect each and every outcome of maternal depression but major documented consequences are as under:
Intrusion or Withdrawl: Depressed mothers either become overly protective of their newborn often to the extent of hostility or become disengaged and unresponsive to their infant’s needs. In either case, the infant-mother bond is affected. Due to intrusive behaviour, the infant develops aggressive behaviour as a result of the infant's normal activity and thus, turns away from the mother. Due to withdrawn maternal behaviour, infants might also develop passive or withdrawn behaviours (aloofness, looking away, sucking thumb etc).
Mothers suffering from PPD might fail to offer contingent stimulation to their prelinguistic infants and thus, might hamper their emotional competence. Such children may grow to react in an exaggerated manner to emotional and interpersonal challenges. Maternal depression may also contribute to the development of Attention Deficit Hyperactivity Disorder.
Adolescents with a depressed parent might be vulnerable to anxiety disorders, conduct disorders and substance abuse disorders.
The effects of PPD also impacts the father-mother relationship. Many mothers have described that the relationship with their partner became stagnant and strained after stepping into parenthood. The major reason being having low partner support (emotional) followed by recurrent feelings of loneliness and abandonment. Mothers have also reported that having to solely take care of babies and the household also put a strain on sexual intimacy with their partners.
If you feel worried about suffering from PPD, talk to a doctor or healthcare professional that you trust. Create a list of questions based aournd your worries, and be honest about how you’re feeling. A professional should talk through your worries and develop a plan for you on how to help mitigate them. Use the resources below to help:
When entering motherhood, a woman’s body and mind go through several changes in order to welcome this new phase in her life. Sometimes unknowingly or knowingly, this blessing starts haunting her, converting what she hoped to be a beautiful dream into her biggest nightmare. Maternal stress and depression is not only harmful to a woman’s health but considerably affects all the spheres of her life. Factors that can contribute to the onset of PPD include:
Genetic factors: Scientists have identified the possible involvement of several genes such as estrogen receptor alpha gene (ESR1), Monoamine Oxidase A (MAOA), Catechol-O-methyltransferase (COMT), serotonin transporter (5-HTT), Tryptophan hydroxylase 2 (TPH2), oxytocin (OXT), Hemicentin 1 gene (HMNC1) in the occurrence of PPD. The involvement of hypothalamic-pituitary-adrenal (HPA) glands has been implicated in PPD, which regulates the production and distribution of several hormones such as cortisol, beta-endorphins and Corticotropin-releasing hormone.
Social factors: Mother’s mental health history such as anxiety, mood disturbances during and before pregnancy, premenstrual dysphoria (feeling of uneasiness and unhappiness), low or no family/spouse support, low-income status, marital conflicts, familial depression history etc. are known to induce/reinforce the chances of PPD.
Obstetric factors: Unforeseen pregnancy-related complications can contribute to the onset of PPD. Some of them are preeclampsia (hypertension and associated complications); hyperemesis (excessive nausea and vomiting); premature contractions followed by emergency / elective caesarean/premature delivery; and excessive bleeding intrapartum.
This article is part of a collaboration between TheLipstickPolitico x Aara Health. #InvisibleConversations - a series dedicated to challenging the taboos, stigma and discrimination surrounding women’s health.
Research support provided by Divya.