Maternal Mental Health
Understanding the most common complication postpartum
You may not have guessed that the number one complication in the postpartum period was mood and anxiety disorders. Maternal mental health conditions in both pregnancy and postpartum are a major issue, often going undiagnosed. Maternal suicide is actually the leading cause of death in pregnancy and the first year postpartum. Some research suggests we are only actually catching about 25% of depression cases. Assessment in both pregnancy and postpartum, followed by appropriate care and treatment, is crucial.
How do we diagnose?
According to the Diagnostic and Statistical Manual (DSM) of Mental Disorders, postpartum depression is considered a major depressive episode with mood symptoms starting in pregnancy or in the 4 weeks following delivery. Many researchers believe we should really be extending this to one year postpartum.
Understanding risk factors, screening in both pregnancy and postpartum, addressing underlying contributing factors and timely treatment are all important factors in supporting maternal mental health.
Is this more than the “baby blues”?
Pregnancy and postpartum can be a vulnerable time – often new mothers experience intense biological/hormonal, emotional, social and financial changes. Up to 70% of new mothers experience what we call the “baby blues.” This is a short-lasting condition – typically only 1-2 weeks – that does not interfere with daily activities. This is typically caused by the physiological changes that occur after delivery. Postpartum depression, on the other hand, is physically and emotionally debilitating and can last for months. To be diagnosed, patients will have five or more of the following symptoms, present most days for longer than two weeks:
depressed mood (e.g., sad, tearful)
diminished interest or pleasure
weight/appetite changes*
insomnia or hypersomnia nearly daily
psychomotor agitation or retardation
fatigue or loss of energy
feelings of worthlessness or guilt
difficulty concentrating or indecision
recurrent thoughts death/suicidal ideation
So, how do we predict who will be impacted?
There are a number of risk factors that might increase likelihood of a person experiencing depression in pregnancy or postpartum. A number of these factors impact risk, and therefore also impact pregnancy and/or birth outcomes and infant health.
In pregnancy, the number one risk factor is a history of previous mental health concerns. Other risk factors include lack of social support, history of abuse or violence, unplanned pregnancy, high perceived stress, past or present pregnancy complications or previous loss, low socioeconomic status, alcohol or drug use and smoking.
Many of these risk factors carry into postpartum risk - although postpartum does carry a few unique additions. Postpartum depression is more likely in those who have had moderate to severe symptoms of premenstrual syndrome (PMS) prior to pregnancy. Because postpartum involves as massive shift in our hormones, those susceptible to PMS may be more at risk for associated mood changes in the postpartum period.
How the pregnancy and delivery went can also impact risk of postpartum depression. Risk was higher when there were complications, but it was also higher based on how the mother experienced and perceived the events. Risk is higher when there was a C-section – but more so when the C-section was emergent. A mismatch between expectations and what actually transpired can be associated with higher risk as well. Having a supportive team and education around options during pregnancy and birth can reduce some of this risk. We often talk about birth “aspirations” versus a birth “plan” – which allows for education and preparedness around all the possible outcomes.
From a more physical perspective – nutrition, low iron, poor sleep, vitamin D deficiency, and gestational diabetes can also increase the risk of depression postpartum.
All this said, it’s still important to remember that mental health concerns can happen for anyone – this is why screening is so important. Many women, especially in pregnancy, feel a heightened stigma around speaking about mental health. In some ways, there is an asynchrony between the bliss and excitement they are “supposed” to feel, and the sadness or irritability that they are actually feeling. Screening allows the opportunity to raise some concerns.
So we’ve screened… now what?
Conventionally, there are a few medication options, as well as cognitive behavioural therapy – which has been shown to be quite effective! Many women feel they need to stop their mental health medication when they fall pregnant, or are skeptical about taking one to manage their symptoms in pregnancy. This is a conversation to have with your doctor as there are some safer options that could significantly improve how you feel. One thing you definitely don’t want to do is abruptly stop your medication. Always speak with a doctor or nurse practitioner before stopping any medication.
From a naturopathic perspective, we often make referrals to therapy and nurse practitioners or physicians (for medication discussions) but we also discuss lifestyle, rule out underlying causes, and provide support.
We will likely test iron and vitamin D as both of these play a significant role in depression in pregnancy and postpartum. Bringing levels up to a satisfactory level tends to reduce risk of depression substantially!
We also talk about sleep! You may be thinking, “what new mom doesn’t have sleep issues!?”, but we talk about optimizing the sleep that you can get. Past six weeks or so, we want to see that sleep improving. Even talking about sleep hygiene and how you can set yourself up for success, can be helpful.
Lastly, exercise is also important for prevention (among other benefits in pregnancy!) in both pregnancy and postpartum.
You can start to see how building a circle of care around a pregnant/postpartum person could make a big difference in terms of their risk for mental health concerns. This circle can include your obstetrician, family doctor, therapist, family, friends, naturopath, pelvic floor therapist, massage therapist, doula etc. If you would like to discuss how we can help you build your team, you can book a meet and greet with one of our naturopathic doctors.