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TRANSCRIPTS

CHAPTER 13

Kathryn's story
My name's Kathy and I work as a Clinical Nurse Con-
sultant in perinatal and infant mental health.

Overview of perinatal mental

health disorders
So just to start with, I just want to make the comment
that perinatal mental health issues can occur anywhere
from conception up to 1 year after baby is born. Anxiety and depression are some of the most common perinatal
mental health issues women may face. Anxiety could occur on its own and depression could occur on its own. Or
women may experience symptoms of both. The symptoms are always on a continuum, so some women may experience
the symptoms in a mild to moderate form. Others may experience these disorders in a more severe form, meaning that
it affects their day-to-day functioning and also their relationship with the baby.

There is a small number of women, so probably 1 or 2 per 1000, that might experience a postnatal psychosis. So those
women may-it's quite a rapid onset-so those women might start to become quite confused very quickly and also lose
touch with reality. And that obviously needs quite urgent attention.

So for women with pre-existing mental health issues, such as schizophrenia and bipolar disorder, the perinatal period
is a time when they're more vulnerable to relapse.

There's a range of risks that have been identified that place some women at risk of perinatal mental health issues. And
I guess the more risks identified, then the greater the vulnerability for that woman, for developing perinatal mental
health issues. So factors like a previous history of anxiety, depression or another mental illness. There might be psy-
chosocial factors such as lack of support, financial issues, housing issues, domestic violence.

There's also women who have experienced childhood abuse and trauma. So for those women, becoming pregnant might
reactivate memories and feelings of their own experiences of being patented. So often then they will start to think
about, 'Will I be a good enough parent?', 'Will I know how to be a parent?' And often these kind of thoughts will cause
them to start feeling anxious and depressed.

So the signs and symptoms of perinatal mental health issues I guess will depend on the particular issue that the woman
is presenting with. If we think about anxiety, anxiety can manifest in a number of different ways. So a woman may
experience generalised type anxiety, so worrying excessively about a particular issue. So in the perinatal context that
might be worrying about the birthing experience, for example .

For some, anxiety might manifest as panic attacks. So these are kind of sudden, unpredictable attacks of anxiety that
manifest physically. So women might experience a sudden onset of shortness of breath, feeling sweaty, trembly and
they might start to have thoughts that they're losing control or they're going mad. Other women might experience
unpleasant or intrusive thoughts that they feel they can't control. And then to alleviate those intrusive thoughts, they
might engage in behaviours, like ritual behaviours, such hand-washing, to alleviate that.

Depression, there's a number of symptoms that people might identify if they become depressed. There'll be changes
in sleep and appetite, feeling teary a lot of the time for no good reason, feeling a lack of energy, lack of motivation,
lack of confidence, feelings of hopelessness and helplessness. And I guess, at worst, feeling like they don't want to be
here anymore.

Symptoms, midwifery care and resources available

The symptoms might go unrecognised 'cause they can develop slowly over time. And sometimes for the women them-
selves, or the people around them, might describe them as being hormonal or the normal ups and downs of pregnancy.
So people will let symptoms go. Often on the outside, the woman might appear to be functioning quite normally, and
so they go unrecognised.

I think often if people are experiencing the symptoms, they might feel a lot of shame. So to say that they're not enjoy-
ing their pregnancy or, in the postnatal period, they're not enjoying their baby, they're feeling motherhood's difficult,
might be hard for them to say to the people around them. And so people tend to hide their symptoms.

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Stories in Midwifery: Reflection, Inquiry, Action

So from a clinician point of view, sometimes we can be quite busy with the task that we need to attend to. So, for
example, in an antenatal setting, there's very physical checks we need to attend to. There's time constraints, so there
may not be space to ask the woman about how she's feeling. So, if she's not given that space, perhaps, she might not
disclose really what's happening for her. I think there's a number of reasons why, perhaps, they can go unrecognised.

Midwives can provide information to women about the signs and symptoms of perinatal mental health issues, and who
they can approach, should they identify these issues in themselves. So midwives can talk to women about, not only how
to take care of themselves physically during pregnancy, but also emotionally. And I think the psychosocial screening at
the first antenatal visit is vital for identifying risk factors. And through that process, midwives can have a role in direct-
ing women to the appropriate resources or services to support them in minimising those risk factors.
I also think midwives can have a role in identifying protective factors and strengths through that screening process. So,
for example, if a woman has been depressed before and seen a psychologist, then it's likely that she has some under-
standing of the symptoms of depression and is likely to be able to identify them again, should they occur. And also
have some understanding of what support's helped her in the past, so she can draw from that experience in the future.
I think there's a number of resources that women could access in the community, if they were to become concerned
that they were developing a mental health issue in the perinatal period. Firstly, obviously the midwife, then there's the
local general practitioner. I think it's really important that women make connections with their local child and family
nurse as well, who could also be a good resource, in terms of letting them know who they could see in the community
that might be able to assist them. Different states may offer specific perinatal and infant mental health services and
women could access those resources as well.
Midwives can help by asking a woman about how she's feeling and making it part of routine care. The midwife can
also be a resource for the woman, in terms of being able to give her information about where she can access appropri-
ate resources to support her, with whatever the particular issue is. And the midwife can also be that consistent, reliable
person that the woman can turn to during the pregnancy, and feel that she can talk to about any potential issues that
arise.
And I do actually think that sometimes that relationship can be enough, depending on the particular issue, to support
that woman through the pregnancy. So, for example, if it's very much anxiety, say for example, around the birthing
process, then I think the midwife can actually hold that woman throughout the pregnancy and manage that anxiety, in
that relationship.

Treatment
The course of treatment for perinatal mood disorders will vary according to the severity of the symptoms and also
how those symptoms are impacting on the woman's level of functioning. And also the relationship with her baby. So
for some women, they may need to increase their social networks and they might need some practical support.

Other women may need counselling around how to manage the symptoms that they're experiencing. But also counsel-
ling around the factors that might be contributing to the feelings they're having. Some women may need medication,
such as antidepressants. And for some women they may need a combination of all these treatments.

Importance of treatment
It's really important for babies to have consistent, reliable and responsive caregivers. And this helps them to form a
secure attachment. And we know that for babies, a secure attachment helps lay a foundation for good social and emo-
tional development across the lifespan. If mum is depressed, it could manifest in a number of different ways in terms
of the impact on the relationship with her baby.

So she might become quite withdrawn from the baby, feel resentful towards the baby. On the other side, she may become
very vigilant about the baby's welfare and become quite intrusive in her parenting style. So those interactions will affect
that developing attachment relationship and, therefore, potentially impact on that baby's social and emotional
development.

In terms of partners, partners can also be at increased risk of developing depression if the primary caregiver is depressed.
Their workload might increase, because they're not only caring for their partner, but also perhaps taking on some of
the responsibilities of the baby. And also, perhaps engaged in paid work as well, so their workload is going to increase.
I think partners can also feel quite helpless and hopeless, and not know what to do.

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