Physical changes during pregnancy and early motherhood are hard to ignore, from the swelling breasts and enlarging bump to the loosening of ligaments and emergence of varicose veins in unmentionable places.
There is no shortage of week-by-week guides to bodily changes and to how the baby develops. Ante-natal check-ups, in addition to scans, will focus on physical indications such as blood pressure, protein in your urine and the baby’s heartbeat.
However, unless a pregnant woman or new mother has a history of mental health issues, she is unlikely to be screened for what’s going on in her head.
Yet up to 20 per cent of women experience perinatal mental illness – that is mental illness during pregnancy and/or the first year of their babies’ lives – according to the Royal College of Midwives in the UK. The National Institute for Health and Care Excellence (Nice) there estimates that 13 per cent of women experience anxiety during pregnancy, and almost the same number – 12 per cent – suffer from depression. Many are affected by both.
Clinical psychologist Aoife Menton, who has a particular interest in perinatal mental health, says her own research indicates women in Ireland would experience levels of distress similar to those reported internationally.
She believes perinatal anxiety “is the silent epidemic”. It can be difficult to distinguish anxiety from low mood depression, because the two can come together, she explains.
“The thing that can separate them is the quality of thought a person might be having, but the feelings and effect might be similar.”
Of course, from the moment a pregnancy test shows a positive result, worry is an inextricable part of the bargain. Is the baby developing properly? Do those pains signify something sinister? How am I going to get this baby out?
But when do natural worries about the potential for things to go wrong become clinically significant anxiety?
"It becomes problematic when it starts to interfere with your daily functioning, your ability to engage with your life and with the people you know, love and care for; when it starts to affect your sleep, your appetite," says Menton, who is chairwoman of a special interest group within the Psychological Society of Ireland (PSI) on perinatal and infant mental health.
Phases of anxiety
“It’s well known that women can experience post-natal depression but, certainly within the academic world and in other countries, there has been a real growing acknowledgment that anxiety is something that is quite common to experience during pregnancy,” she explains. “For most women it resolves as the pregnancy progresses and as everything works out well.”
However, if it doesn’t resolve, women can experience difficulty soon after the birth, or up to a year after the baby’s arrival, says Menton. While sometimes post-natal depression seems to come out of nowhere, if you track back, there may have been things that could have been done to support a woman, had there been mechanisms in place to ask the right questions during the pregnancy.
But too often the right questions are not asked and the relevant information is unlikely to come from the woman herself.
There’s evidence that women won’t tell healthcare professionals if they are feeling anxious or have emotional concerns during pregnancy, says Patricia Leahy-Warren, senior lecturer and director of postgraduate education at UCC’s school of nursing and midwifery. The stigma of being a “bad mother” is already there.
As the greatest predictor of post-natal depression is ante-natal depression or ante-natal anxiety, it would be really important if we could pick it up in the ante-natal period, she points out.
“Every woman has the potential to be anxious, so I think it is on a continuum,” she says. If women’s anxieties are not identified and dealt with, they can get out of hand, she warns. Overthinking things and negative thoughts can lead to low self-esteem, which increases the risk of post-natal depression.
There are no perinatal psychiatrists working outside the three Dublin maternity hospitals. Latest available figures for the National Maternity Hospital’s perinatal mental health service show that new referrals rose to 684 in 2014. About two-thirds of these were referred ante-natally and the biggest source of referrals was the hospital’s public clinic (208), followed by GPs (164) and the hospital’s wards (90).
The most common reason for referral was to have mental health assessed (207), followed by a history of treated depression (149) and those currently on medication for depression (110).
The Association for Improvements in Maternity Services Ireland wants women’s mental health to be on the radar wherever she is going through the maternity services, and also after she returns as a new mother to the community.
Currently, "there is no standardised way of saying to a woman, 'tell me how you are feeling'," says the association's chairwoman, Krysia Lynch. "Some women will be asked that question but many won't be.
“A lot of women are not well in pregnancy and after pregnancy,” she adds. “We are not capturing them and we are not helping them heal.”
Stigma of difficulty
Raising awareness about the importance of making psychological support an integral part of the maternity services is one of the aims of the PSI’s special interest group.
“I think there is a huge stigma around women saying ‘I don’t enjoy being pregnant’ or ‘this isn’t really what I wanted’,” says Menton. Likewise, in the post-natal period, women feel it is taboo to say “this is really difficult” or “I don’t feel as connected to my baby as I had expected”.
Women feel they can’t admit it because they fear it makes them a bad parent.
“Having mental health difficulties does not make you a bad parent but because there isn’t enough conversation, I believe, in Ireland around all of this it makes it difficult to broach the subject.”
Menton believes that men can also struggle in the transition to parenthood and this is even less likely to be acknowledged.
Neither gender is immune to the “panic” that Leahy-Warren says people feel coming home from the hospital, “when they walk in their front door, put the carry-cot on the kitchen table, look at one another and think ‘what are we going to do, it’s only us . . .’” Rescue dogs and dishwashers come with more instructions.
While “do-gooders” and celebrities gush about how marvellous motherhood is, anybody feeling less than elated keeps quiet.
“You have these women sitting at home crying, thinking what’s wrong with me, why am I not feeling like this? They are afraid to say anything.”
A key question, Leahy-Warren suggests, is “When your baby is sleeping, are you sleeping?”
“If she can’t sleep when the baby is sleeping it means her mind is on overdrive. She has entered that cycle where she can’t come off it. She is overexhausted; even if somebody takes the baby she is wondering are they managing okay.
“If you are not getting sleep, the mind starts playing tricks on you, then you begin to have low self-esteem, then you begin to have panic attacks.”
And so the downward spiral continues.
It’s okay to say you are not okay, she stresses, and your public health nurse can play a vital role, assessing symptoms and recommending further help.
In an effort to stave off emotional problems, it is important that couples start thinking early on in the pregnancy about the fundamental changes to their lives that the birth will bring, says Leahy-Warren
“Every new mother needs support and it is not always feasible that it will be from your family, so you need to build your network. That is why you need to go to ante-natal classes, ante-natal massage, ante-natal yoga – you name it, it doesn’t really matter – and build a network of people with children who are under two years of age. Then, when it comes to the post-natal period, you have your network.”
Parent-to-parent support group
runs coffee mornings specifically for women feeling anxious or low after having a baby.
"It's not a place where they have to be the 'up mum'," says Cuidiú president Catherine Wells. "They can be the mum who is a bit teary, feeling anxious and they are in a safe place to express their feelings without being judged."
Typically they find two types of women attending these groups – those with a history or diagnosis of depression and those for whom pregnancy and birth has triggered high levels of anxiety.
The latter are often high-performing individuals with high expectations of themselves, she explains, and go under the radar. They may be borderline for an anxiety disorder but are highly functioning – until pregnancy causes their anxiety to overflow.
Wells encourages any new mother feeling low to contact their local branch of Cuidiú, to be put in touch with somebody trained in peer support.
Women suffering perinatal anxiety who ring Parentline also typically fall into two categories, says its chief executive, Rita O’Reilly. One is the older mother, well established in a career whose life is very organised and she feels she is losing control. The other is the young mother who may not yet be telling people she is pregnant; it wasn’t planned and she is fearful about the future.
The advice to both is “go to the doctor, don’t suffer anxiety”, she says. “Tell yourself, and get other people to tell you, that things can’t be perfect. Just be as good as you can and look for all the support you can get – practical and emotional.”
Perinatal anxiety: Know the symptoms . . . and where to get help Symptoms of perinatal anxiety include:
Anxiety that interrupts thoughts and daily tasks Irritability and a feeling of being constantly on edge Panic attacks, heart palpitations and chest tightness Difficulty relaxing and sleeping Compulsion to check on the baby constantly Fear of leaving the house with the baby
Sources of voluntary support include: Cuidiú: cuidiu.ie or 01- 8724501 Parentline: parentline.ie or 1890-927277 Nurture: nurturecharity.org or 01-8430930 The Samaritans: 1850-609090