Just gave birth and feel like you're a bad mother? It could be postnatal depression

Mothers often feel lonely and are hesitant to share their feelings as they think they are the only ones struggling with depression, anxiety, guilt and being overwhelmed. — 123rf.com

Post-partum depression (PPD) is considered a serious depressive mood disorder mostly experienced by new mothers after having a baby.

Sometimes, this condition, also known as peripartum or postnatal depression, can affect both the mother and father.

PPD occurs during pregnancy or after childbirth, and although it is a treatable condition, it remains largely undiagnosed and undertreated in Malaysia.

The cause of this condition can be both physical and emotional.

Physical problems include a drastic drop in oestrogen and progesterone hormones in the woman’s body after she delivers.

Her thyroid hormone levels could also be lower than normal, resulting in fatigue, sluggishness and depression, due to dysfunction of the thyroid gland during and after pregnancy.

Emotional issues can occur when a parent is sleep-deprived and feeling overwhelmed – a common situation when a newborn is in the house – resulting in them having difficulty tackling even minor problems.

For new parents in particular, anxiety over being able to care for a newborn can also be an issue.

Mental health underemphasised

Studies show that approximately one in seven Malaysian mothers experience PPD during the first six months after childbirth.

Says SOLS Health Research and Advocacy director Dr Arman Rashid: “There is general awareness about PPD, but limited knowledge about symptoms.

“Many women are aware of their emotional distress during and after childbirth, but they are unable to identify this as symptoms of PPD.”

More importantly, he adds that there is a disconnect between maternal mental health and the healthcare system.

“The healthcare system overall focuses on physical health.

“Women rely on community resources, including husbands, peers and faith leaders for emotional help during PPD.

“They rarely seek help from mental health professionals for PPD,” he says.

Dr Arman, along with his colleagues SOLS Health Research and Advocacy manager Lim Su Lin and clinical consultant Dr Leoniek Kroneman, all agree that there is widespread stigma on mental health, and even more so for maternal mental health.

“Many women feel hesitant to seek treatment for PPD as they want to avoid negative judgement from society.

“This is particularly so as motherhood is often seen as the ‘ultimate bliss’, without taking into account the emotional upheavals and physical difficulties of childbirth,” says Dr Arman.

SOLS Health is a community-based mental health centre that connects children, adults, families and communities to accessible and affordable mental health services, with an emphasis on combating the stigma of mental health in Malaysia.

It is one of the community outreach programmes under the non-governmental organisation SOLS 24/7.

The programme, along with Wanita Berdaya Selangor (WBS, previously known as Institut Wanita Berdaya), recently completed a study on identifying the barriers impeding the detection and treatment of PPD among women in Selangor.

Women in Selangor contribute significantly to the state’s socioeconomic development, as such improving detection and treatment of PPD plays a vital role in ensuring sustained development and growth, stress Dr Arman, Lim and Dr Kroneman, who were the authors of the study.

They managed to reach 183 women of childbearing age (19-44 years) residing in the state through a multilingual public online survey, focus group discussions with urban and rural participants, as well as semi-structured interviews with women who have had PPD.

Fathers of newborns can also suffer from PPD, although their numbers are far less than women. — Positive Parenting

Feeling isolated

Dr Kroneman notes that feelings of both depression and anxiety are common when new mothers suffer from PPD.

“Typically, mothers worry about whether their baby feeds well and develops healthily.

“When coupled with the usual lack of sleep and fatigue a newborn brings, one often sees mothers enter a downward spiral, in which the excessive worrying leads to sleeping problems (e.g. not being able to sleep even when the infant doesn’t need attention) and unhealthy eating habits (e.g. skipping meals).

“This in turn may increase feelings of anxiety and sadness, causing women to feel overwhelmed and unable to function normally,” she says.

Studies show that mothers who experience PPD interact less with their infant.

Dr Kroneman says they talk less and make less eye contact with their babies, which affects the emotional and social development of the child.

“In the long run, these children may develop emotional and social issues, and function poorer academically.”

Sleep deprivation and emotional distress may also lead to irritability, which in turn may cause marital problems.

“Mums often feel lonely (thinking they are the only one struggling with these feelings) and guilty towards their child, and are hesitant to share their feelings.

“This negatively affects asking for help or seeking support,” she adds.

The side effect is marital relationships that often come under strain and suffer due to the mother’s condition.

“Some spouses feel uncertain how to support each other during these challenging times,” she says.

Without adequate intervention, this may prolong and worsen over time, and have long-term consequences for all family members involved.

“A supportive spouse, who is understanding and offers practical assistance and emotional support, is one of the strongest factors in recovery.

“It is important to note that PPD can be treated, and as such, both short-term and long-term negative consequences can be prevented,” says Dr Kroneman.

Stifling self-stigma

Lim says stigmatising self-beliefs about PPD and mental health in general were common among women in the survey.

“For example, two-thirds agreed with the statement that ‘new mothers who experience anxiety and sadness would be viewed negatively by others’.

“Nearly half of all mothers agreed with the statement that ‘when I am anxious or depressed, I am a weak person’,” she shares.

Women who agreed with these statements were also found to be more likely not to seek care due to denial and fear.

She adds that cultural beliefs appeared to be the strongest predictor of stigma, when compared to other demographic factors like ethnicity, religion and age.

A significant number of mothers agreed with the statement that “it is not in our culture to discuss feelings of sadness and anxiety as a new mother”.

Cost was also an issue as 48.6% of women were not likely to seek care due to concerns about high costs.

However, almost an equal percentage of women said that they would not seek care due to “wanting to solve it themselves” and “being afraid”.

According to Lim, women from a higher socioeconomic background were more likely to choose the latter two statements.

Strengthening access and support

One key finding that emerged from the study is that both professional mental healthcare and informal support can help women experiencing PPD.

Practical and emotional support from husbands is crucial in alleviating the pressure on mothers after delivery as they juggle their multiple responsibilities. — Filepic

“In fact, it is important to mobilise community resources given the shortage of mental health professionals,” says Dr Arman.

“Many women seek informal support, given the difficulties in accessing maternal mental healthcare within the existing healthcare system.”

Based on the study results, the authors prepared a policy brief to help improve PPD detection and access to care for women in Selangor.

In the brief, the authors proposed several recommendations to improve maternal mental health in the state by strengthening the five key pillars of:

• Knowledge and access to maternal mental health services
• Maternal mental health screening and referral within the healthcare system
• Family support systems
• Workplace support, and
• Traditional support systems.

This is as the study revealed that mothers found it difficult to determine if their levels of exhaustion, anxiety and sadness were “normal” temporary feelings associated with motherhood, or persistent symptoms warranting professional help.

In addition, the study found that there was inadequate screening for PPD by maternal healthcare services, as well as a lack of needed referral to appropriate mental healthcare providers.

Both these findings reinforce the need for more awareness and information on identifying PPD.

Factors increasing the risk of developing PPD include low socioeconomic status, stressful life events, a poor marital relationship, inadequate social support, neuroticism, as well as depression or anxiety before or during pregnancy.

As for family support systems, husband support was found to be mostly helpful in terms of alleviating pressure on mothers in their juggling of multiple roles after childbirth.

However, women in the study felt largely unsupported in the workplace during childbirth despite being granted mandatory maternity leave.

They were also least likely to share their emotions with colleagues during their postpartum period, compared to their spouse, friends, family members and religious leaders.

A safe space to share

Siti Kamariah (standing, left) found that participants of the focus group discussions (seen here) preferred meaningful experiences such as sharing of motherhood experience, when it came to their overall health, especially mental health, rather than just attending lectures. — WBS

During the focus group discussions for the study, many of the women from rural areas, such as Felda settlements, said they would be more than willing to return to a similar setting to understand more about PPD.

WBS chief executive officer Siti Kamariah Ahmad Subki notes that the women sought more meaningful experiences when it came to their overall health, especially mental health, rather than just attending lectures.

“I was surprised by their feedback.

“We did not question or enquire too much, instead we gave them space to share their experiences and a few mothers revealed how they were sad, weepy, anxious and suffered from mood swings, and thought it was common ‘women’s problems’.

“It is important for them to know that PPD is treatable, although it is not something they felt they could call a medical professional to get an appointment to address, fearing they might be labelled as bad mums.

“Most of the women did not know they had it because more often than not, family members brush it aside as women being emotional or just tired,” she says.

Siti Kamariah stresses that it is important PPD is integrated more into the public health system.

“Confinement ladies offering postnatal care to new mothers do not offer counselling support as part of their service, which many cannot afford anyway because the fee can range between RM500 for three days to RM20,000 for the entire duration.

“As comparison, the rural poor women sometimes have better family and husband support, compared to urban poor like those who live in PPR (Program Perumahan Rakyat) flats, because some (of the latter) have strained relationships and live in less conducive spaces.

“The women in Felda settlements, from what we saw, were more than willing to hold each other’s hands to offer support in dealing with PPD.

“They gained a sense of confidence from those who have experienced motherhood before.

“This peer support is very important as we find many mothers are more likely to seek help from those around them instead of professional services,” she says.

The study authors stress that policymakers and local healthcare practitioners, along with the community, have a crucial role to play in reducing barriers for women in seeking care and support for maternal mental health issues, which can have a considerable impact on their and their family’s quality of life.