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Perinatal
Mental Health
a sourcebook for health professionals

Diana Riley
Consultant Obstetric Liaison Psychiatrist,
Aylesbury Vale Community Healthcare NHS Trust and
The South Buckinghamshire NHS Trust

With a Foreword by

Channi Kumar
Professor of Perinatal Psychiatry, Bethlem Royal and
Maudsley Hospitals

CRC Press is an imprint of the

Taylor & Francis Group, an informa business
First published 1995 by Radcliffe Publishing

Published 2016 by C R C Press

Taylor & Francis Group
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Boca Raton, F L 33487-2742

© 1995 by Taylor & Francis Group, L L C

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

ISBN-13: 978-1-87090-578-7 (pbk)

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sources. Reasonable efforts have been made to publish reliable data and
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Typeset by Acorn Bookwork, Salisbury, Wiltshire

Contents

Foreword iv

Introduction v

1 Pregnancy 1

2 Labour 26

3 The E a r l y P u e r p e r i u m 37

4 Postnatal Depression 51

5 W h a t Causes Postnatal Depression? 74

6 Puerperal Psychosis 106

7 Other Relevant Psychiatric Problems 140

8 Psychotropic Drugs 162

9 Fathers 202

10 Service Provision 211

11 Resources 226

Index 239
Foreword

There are signs of an awakening interest i n the p s y c h i a t r i c

p r o b l e m s t h a t occur i n c h i l d b e a r i n g w o m e n . Nevertheless,
despite knowledge of the sometimes devastating effects o n
m a t e r n a l h e a l t h a n d adjustment of conditions such as postnatal
depression a n d p o s t p a r t u m psychosis, a n d an awareness of
repercussions i n the developing c h i l d , the resources allocated to
p r e v e n t i n g a n d a l l e v i a t i n g such problems are p i t i f u l . I n a recent
government report on the encouragement of choice a n d the
r e c o g n i t i o n of the m o t h e r as an i n d i v i d u a l w i t h i n the context of
m i d w i f e r y care (Cumberlege Report. H M S O , L o n d o n , 1993), the
subject o f postnatal illness m e r i t s ten lines i n 108 pages.
F o r t u n a t e l y , m u c h is being done to educate professionals as
w e l l as consumers, a n d this book by D r Diana Riley should
i m m e d i a t e l y find its w a y o n to the bookshelves of general
p r a c t i t i o n e r s , h e a l t h visitors, m i d w i v e s , social workers,
psychiatrists a n d - dare one say i t - obstetricians. I t is the
balanced d i s t i l l a t i o n of m a n y years' experience of a dedicated
c l i n i c a l psychiatrist w h o has p r o v i d e d a m o d e l comprehensive
service for pregnant a n d p a r t u r i e n t w o m e n . H e r knowledge
comes t h r o u g h i n the w r i t i n g , w h i c h is always i n f o r m a t i v e a n d
clear a n d j a r g o n free. I t is also up to date a n d i t w i l l p r o v i d e an
easy b u t t h o r o u g h i n t r o d u c t i o n for any professional w i s h i n g to
k n o w more about p s y c h i a t r i c problems a n d m o t h e r h o o d ; a n d
most i m p o r t a n t of a l l , the reader w i l l find sensible advice i n
every section o n h o w to set about dealing w i t h such p r o b l e m s .
I a m often asked to r e c o m m e n d review articles or books
to people w h o are s t a r t i n g i n this field as therapists or as
researchers, a n d sometimes for mothers w h o w a n t to k n o w
m o r e . D r Riley has solved m y p r o b l e m .

Professor Channi K u m a r
October 1994
Introduction

Even a l l o w i n g for the present t r e n d towards smaller families,

pregnancy is a c o m m o n event. Pregnant a n d postnatal w o m e n
w i l l make u p a substantial p a r t of the w o r k - l o a d of a l l general
p r a c t i t i o n e r s . For example, a practice of 2 000 patients w i l l
include about 25 pregnancies each year, a n d a h e a l t h d i s t r i c t
w i t h a p o p u l a t i o n of 500 000 w i l l have over 5 000 deliveries
per year. P e r i p a r t u m care is therefore p a r t of everyday w o r k
for general p r a c t i t i o n e r s , m i d w i v e s and obstetricians. I t is not
so for mothers, w h o w i l l experience i t only perhaps once or
twice i n a lifetime, and for w h o m i t w i l l be a m e m o r a b l e and
momentous occasion.
As a result of better obstetric care, c h i l d b i r t h has become
physically safer over recent years, w i t h m a t e r n a l a n d c h i l d
m o r t a l i t y f a l l i n g to an a l l t i m e low. W o m e n are also n o w largely
i n c o n t r o l of t h e i r o w n f e r t i l i t y , l i m i t i n g the n u m b e r of pregnan-
cies i n a w a y not available to previous generations. They are
also perhaps better educated and more a r t i c u l a t e about t h e i r
expectations of pregnancy and delivery, so that each b i r t h
experience carries an even greater e m o t i o n a l loading.
However, the emphasis of most antenatal and postnatal care
has not kept pace w i t h these developments, and s t i l l seems to
concentrate exclusively on the physical health of the m o t h e r and
c h i l d , w h i l s t the e m o t i o n a l i m p a c t of such an i m p o r t a n t life
event receives l i t t l e a t t e n t i o n .
This book is an a t t e m p t to raise awareness i n those w o r k i n g
i n b o t h p r i m a r y care a n d obstetric h o s p i t a l settings of the
frequency a n d i m p o r t a n c e of the e m o t i o n a l aspects of preg-
nancy a n d c h i l d b i r t h . U n t i l this becomes an i n t e g r a l p a r t of
professional care for a l l w o m e n , the physically healthy m o t h e r
and c h i l d m a y w e l l continue to suffer f r o m e m o t i o n a l disorders
w h i c h , even i f m i l d i n nature, m a y be prolonged a n d d a m a g i n g
to the i n d i v i d u a l , to the relationship w i t h a partner, a n d to the
psychological, a n d even the physical development of the c h i l d .
T r a d i t i o n a l l y , the more serious of these postnatal disorders
vi Perinotol Mental Health

have been treated b y psychiatrists, w h i l s t m a n y of the m i l d e r

illnesses have gone unrecognized or inadequately treated i n the
c o m m u n i t y . There is n o w increasing evidence t h a t vulnerable
w o m e n can be identified i n the antenatal c l i n i c , a n d t h a t inter-
v e n t i o n by the p r i m a r y care team before delivery can prevent,
or at least lessen, the severity of postnatal p s y c h i a t r i c p r o b l e m s .
Adequate t r e a t m e n t a n d support p o s t p a r t u m can also reduce
l o n g - t e r m m o r b i d i t y for b o t h m o t h e r a n d c h i l d .
These pregnancy related illnesses f o r m a significant propor-
t i o n of a l l p s y c h i a t r i c m o r b i d i t y seen i n general a n d p s y c h i a t r i c
practice. The figures speak for themselves.

• Between 15% a n d 20% of a l l patients seen b y m a t e r n i t y

services have problems related to t h e i r m e n t a l h e a l t h w h i c h
m a y need to be taken i n t o account i n t h e i r obstetric
management . 1

• M o r e t h a n 10% of a l l pregnant w o m e n score h i g h l y enough

on screening questionnaires t o be considered 'cases' of
d e p r e s s i o n , a l t h o u g h few w i l l be identified as such.
2,3

• Between 10% a n d 20% of n e w l y delivered w o m e n w i l l

become c l i n i c a l l y depressed i n the subsequent year; 2% w i l l
be referred to a p s y c h i a t r i s t . 1

• T w o per thousand recently delivered mothers w i l l need

admission to a psychiatric u n i t .
• Ten per cent of a l l new female patients referred to p s y c h i a t r i c
services have a baby under one year of age, and 25% a c h i l d
u n d e r the age of five.

• W o m e n have 16 times the n o r m a l risk of psychiatric admis-

sion i n the first 30 days p o s t p a r t u m . For w o m e n h a v i n g a first
baby by caesarian section, the risk of admission to h o s p i t a l
w i t h a psychotic illness w i t h i n the first p o s t p a r t u m m o n t h is
35 times higher t h a n at other t i m e s . 4

A l t h o u g h these very h i g h risks are r e l a t i v e l y short-lived, the

r e l a t i v e risk for depressive illness i n mothers is increased for u p
to t w o years p o s t p a r t u m . 4

These i m p o r t a n t issues can be dealt w i t h by workers i n p r i m -

 Introduction vii

ary care, a n d most w o m e n w o u l d c e r t a i n l y prefer an approach

f r o m professionals they already k n o w , rather t h a n being refer-
r e d to a p s y c h i a t r i s t w i t h a l l the social stigma t h a t this entails.
Indeed, there is no other t i m e i n a w o m a n ' s life w h e n she
is under such close s c r u t i n y f r o m her general p r a c t i t i o n e r ,
m i d w i f e a n d h e a l t h visitor, or a t i m e w h e n there are so m a n y
golden o p p o r t u n i t i e s for helpful i n t e r v e n t i o n .
A psychotherapist w r o t e i n 1989:
5

'A comprehensive m e n t a l h e a l t h service m u s t be based

above a l l o n p r e v e n t i o n . I t must also p r o v i d e treat-
m e n t for those w h o have escaped the preventative net.
Prevention m u s t depend first and foremost on the
a v a i l a b i l i t y of a p p r o p r i a t e help to those w h o care for
c h i l d r e n - especially mothers of babies.'
He goes o n to state t h a t h e a l t h visitors are ideally placed to be
the 'front-line troops', a n d that, i n the course of t h e i r o r d i n a r y
duties, they c o u l d enable mothers to get things r i g h t f r o m the
start, thus a v o i d i n g problems for w h i c h they m i g h t otherwise
need (but p r o b a b l y fail to receive) more specialized t r e a t m e n t .
I t therefore makes b o t h h u m a n i t a r i a n and economic sense to
recognize, at an early stage of pregnancy, those w h o are p a r t i c u -
l a r l y vulnerable, use preventative measures whenever possible,
a n d identify a n d treat energetically and i m m e d i a t e l y , those w h o
slip t h r o u g h the preventative net. This book is an a t t e m p t to
give a l l those i n v o l v e d the skills necessary to do t h i s .
References

1. Report of the General Psychiatry Section Working Party on Post-

natal Mental Illness. (1992) Psychiatric Bulletin. 16: 519-22.
2. Kumar R and Robson K M . (1984) A prospective study of emotional
disorders in childbearing women. British Journal of Psychiatry. 144:
35-47.
3. Hrasky M and Morice R. (1986) The identification of psychiatric
disturbance in an obstetric and gynaecological population. Austra-
lian and New Zealand Journal of Psychiatry. 20: 63-9.
4. Kendell R, Chalmers JC and Platz C. (1987) Epidemiology of puer-
peral psychoses. British Journal of Psychiatry. 150: 662-73.
5. Woodmansey AC. (1989) Reversing the vicious spiral: a radical
approach to mental health. British Journal of Clinical and Social
Psychiatry. 6: 103-6.
1 Pregnancy

There is a p o p u l a r image of the pregnant w o m a n as ' b l o o m i n g ' ,

w i t h i m p r o v e d physical a n d e m o t i o n a l h e a l t h . This is often
far f r o m the t r u t h . A p a r t i c u l a r l y notable finding is t h a t w o m e n
vary enormously i n t h e i r response to pregnancy, a n d there
is a s i m i l a r v a r i a t i o n w i t h each stage of pregnancy, so t h a t
professionals need to be sensitive to women's differing needs for
e m o t i o n a l support at any p a r t i c u l a r t i m e .
There is evidence that some pregnancies m a y be related to
neurotic s y m p t o m s . A study of students found t h a t those w h o
became pregnant h a d a higher incidence of previous consulta-
tions for psychiatric p r o b l e m s . Pregnancy m a y be entered i n t o
1

as an a t t e m p t to g a i n a t t e n t i o n , as an escape f r o m an u n w e l -
come s i t u a t i o n , to m e n d a f a i l i n g relationship, or to p r o v i d e a
love object. Worst of a l l , and most likely to f a i l , is the expecta-
t i o n t h a t the c h i l d w i l l p r o v i d e the love and care that the w o m a n
has lacked i n her life so far.
Joan Raphael-Leff has identified three groups of ' p r o b l e m
2

pregnancies'. These are:

• conflicted, where the pregnancy is u n p l a n n e d , u n t i m e l y , or
w r o n g . This can be as a result of a transient or u n h a p p y
relationship, sometimes even as a result of rape or incest.
The t i m i n g can be w r o n g , as i n the w o m a n w h o is resentful
about the i n t e r r u p t i o n of her career, or a pregnancy too
soon after a s t i l l b i r t h or neonatal death, w h i l s t she is s t i l l
g r i e v i n g . A frequent p a t t e r n is a pregnancy soon after a
t e r m i n a t i o n or miscarriage i n an a t t e m p t to 'replace' the
lost c h i l d .

• c o m p l i c a t e d , b y physical or socio-economic problems, or

adverse life events. Pregnancies c o m p l i c a t e d b y a n t e p a r t u m
haemorrhage or pregnancy induced hypertension, w h i c h
require the m o t h e r to rest i n bed for long periods can be
tedious a n d w o r r y i n g . Where there are serious p r a c t i c a l
p r o b l e m s w i t h housing, finance, or lack of support f r o m
2 Perinatal Mental Health

friends or f a m i l y , the m o t h e r w i l l feel insecure a n d anxious.

The 'new house, new b a b y ' is a case i n p o i n t . Bereavement,
perhaps the loss o f a parent, d u r i n g the pregnancy w i l l
c o m p l i c a t e the mother's feelings, a n d often leads to post-
ponement of the g r i e v i n g process u n t i l after the b i r t h .

• e m o t i o n a l l y sensitized, i n w h i c h the pregnancy is over- or

u n d e r v a l u e d because of the previous experience of the
w o m a n or her close f a m i l y members, or due to her o w n
neurotic t r a i t s . A previous h i s t o r y of i n f e r t i l i t y , for example,
may mean t h a t the m o t h e r overvalues the pregnancy, h a v i n g
u n r e a l expectations about h o w wonderful i t w i l l be, yet
being u n p r e p a r e d for the r e s p o n s i b i l i t y of a c h i l d . Previous
pregnancy loss m a y lead to her w i t h h o l d i n g a t t a c h m e n t to
the baby u n t i l after the b i r t h .

Psychiatric Problems in Pregnancy

There is a s u r p r i s i n g incidence of measurable p s y c h i a t r i c m o r -
b i d i t y , even d u r i n g an a p p a r e n t l y ' n o r m a l ' pregnancy. A pros-
pective study i n a L o n d o n antenatal c l i n i c using the General
H e a l t h Questionnaire (GHQ) showed t h a t 16% of w o m e n were
'cases' of depression at 12-14 weeks i n t o the pregnancy, a n d
t h a t this severity of depression correlated w i t h previous psycho-
logical p r o b l e m s , ambivalence about the pregnancy, previous
t e r m i n a t i o n a n d m a r i t a l t e n s i o n . A s i m i l a r A u s t r a l i a n survey
3

found an even higher incidence (40%) at 3 3 - 3 4 weeks . Another 4

survey of 179 w o m e n at a booking c l i n i c showed t h a t 35% were

h i g h scorers o n the G H Q , a n d 29% were confirmed as 'cases' at
i n t e r v i e w . This is no artefact of questionnaire response. W h e n
5

the w o m e n studied are those w i t h ' h i g h r i s k ' pregnancies i n

terms o f p h y s i c a l c o m p l i c a t i o n s , 66% are found to have a clear
p s y c h i a t r i c diagnosis . 6

This degree of m o r b i d i t y i n pregnant w o m e n does not seem

to be given sufficient r e c o g n i t i o n by professional carers, perhaps
because the e m o t i o n a l c o n d i t i o n is t h o u g h t to be as s e l f - l i m i t i n g
as the p h y s i c a l state, b u t m o r e likely, because i t is not identified
or is a t t r i b u t e d to a ' n o r m a l ' o v e r e m o t i o n a l state i n pregnancy
(see Case S t u d y 1.1).
 Pregnancy 3

I t may, however, have relevance to the outcome of pregnancy.

For example, late b o o k i n g or poor attendance at the antenatal
c l i n i c is one w a y i n w h i c h the mother's e m o t i o n a l state m a y
influence fetal h e a l t h . There is also some evidence that physical
c o m p l i c a t i o n s are more frequent i n e m o t i o n a l l y d i s t u r b e d
w o m e n . One s t u d y has shown anxiety i n pregnancy to correlate
7

w i t h pregnancy induced hypertension, and a n o t h e r 8

that
anxious w o m e n are more likely to opt for elective i n d u c t i o n of
labour. Research also shows t h a t w o m e n w i t h significant
adverse life events (and hence increased stress) i n the year
preceding delivery are more l i k e l y to suffer p r e m a t u r e l a b o u r . 9

A special case is t h a t of pregnant w o m e n w h o have suffered

f r o m previous psychotic illness. Careful follow-up studies show
t h a t i n general they also v a r y i n t h e i r reactions to pregnancy.
A b o u t 30% r e p o r t some i m p r o v e m e n t i n t h e i r m e n t a l health,
most of these being i n the older age group, and w i t h previous
depressive or manic-depressive illness. Negative effects were
associated w i t h lack of social support, s i t u a t i o n a l problems a n d
interpersonal d i f f i c u l t i e s . Psychotic episodes can, a n d do,
10

occur d u r i n g pregnancy b u t are relatively rare c o m p a r e d w i t h

t h e i r serious increase i n frequency and severity p o s t p a r t u m .
Previous neurotic illness has been examined less closely, b u t
there is some evidence to show that panic disorder a n d
obsessive-compulsive symptoms actually i m p r o v e d u r i n g preg-
nancy, o n l y to worsen again after delivery. W o m e n w i t h pre-
vious anorexia often react b a d l y to the changing body shape
associated w i t h pregnancy, a n d w i l l be preoccupied w i t h w e i g h t
a n d diet.
On the positive side, the incidence of suicide i n pregnancy is
extremely l o w . Over a 12-year p e r i o d , 14 suicides were reported,
m o s t l y i n the second trimester, whereas the expected n u m b e r
was 2 8 1 ; thus, pregnant w o m e n have only 5% of the expected
risk of suicide. The numbers were highest i n the 15-29 age
groups . 11

Society seems to assume t h a t a l l w o m e n w i l l feel equally

h a p p y a n d fulfilled as soon as the pregnancy is established, b u t
even the most stable a n d m a t u r e m o t h e r w i l l have times of self-
d o u b t a n d t r e p i d a t i o n , a n d w i l l need support for herself i n order
to deal w i t h the demands of her new a n d u n f a m i l i a r role. Some
of the ' n o r m a l ' positive a n d negative responses are s u m m a r i z e d
4 Perinatal Mental Health

First trimester
Pleasure at fulfilment or reproductive role
Increased status and attention from family and friends
Successful transition to adulthood
Increased feeling of well-being
Sharing an experience w i t h her own mother
Second trimester
Increasing attachment to the fetus
Pleasure at quickening and seeing baby on scan
Increasing detachment from work commitments
Social acceptance by other mothers
Beginning preparations for the birth
Third trimester
Realistic anxiety and pleasure at impending delivery
Making stronger links w i t h other mothers
Increasing attachment to her own mother
Coming to terms w i t h loss of status and income from work
'Nesting' activities
Table 1.1 Positive changes in pregnancy

i n Tables 1.1, 1.2. Most w o m e n w i l l fluctuate between these

positive a n d negative feelings at different stages of the preg-
nancy depending o n t h e i r o w n personality, past experience, a n d
socio-cultural setting.

Contributory Factors to Psychological

Problems in Pregnancy
A w o m a n ' s reaction to the c o n f i r m a t i o n of pregnancy varies
w i t h her socio-cultural m i l i e u . For example, the status of preg-
nancy i n society is different i n some ethnic a n d religious groups,
a n d w i l l also v a r y w i t h t i m e , the size of the existing f a m i l y , a n d
perhaps even the sex of the existing c h i l d r e n .
S u p p o r t f r o m the p a r t n e r has been shown i n m a n y studies to
be an i m p o r t a n t factor i n e m o t i o n a l h e a l t h d u r i n g pregnancy.
Those experiencing depression c o m m o n l y r e p o r t r e l a t i o n s h i p
p r o b l e m s , a n d there is clearly a need i n pregnancy, above a l l
 Pregnancy 5

First trimester
Rejection of, or ambivalence to, pregnancy
Perception of fetus as 'invasive' and unwelcome
Adoption of 'invalid' status
Fear of fetal abnormality; guilt about alcohol, smoking
Anxiety about repeat of miscarriage, perinatal death
Guilt about previous termination
Competitiveness with own mother
Second trimester
Dislike of changing shape, especially if previously anorexic or
bulimic
Public awareness of sexual activity
Perceived loss of attractiveness; low self-esteem, possible morbid
jealousy syndrome
Withdrawal of attachment to fetus i f threatened by pregnancy com-
plications
Resentment at limitation of activity and leaving work
Loneliness i n home situation; envy of partner's and peer group's
continuing work role
Third trimester
Phobic anxiety about labour, pain or hospitals
Fear of 'loss of control' during labour
Fear of fetal abnormality, still birth and neonatal death
Preoccupation with desired sex of baby
Reduced sexual activity; fears of loss of partner
Concern about recurrence of postnatal depression
Anxiety about parenting capacity
Table 1.2 Negative aspects of pregnancy

other times, for e m o t i o n a l as w e l l as domestic and financial

security. I t has also been s h o w n t h a t w o m e n are more sensitive
at this t i m e to adverse life events such as h e a l t h problems,
losses, crises or domestic difficulties.
Anxieties about the n o r m a l i t y of the pregnancy w i l l be
increased i f there have been previous pregnancy disasters, i f
there is a f a m i l y h i s t o r y of b i r t h t r a u m a or a b n o r m a l i t y , or i f
there is d o u b t about the results of any of the antenatal predic-
tive tests. Concern about the baby's size o n the scan, persistent
v a g i n a l bleeding, or raised b l o o d pressure w i l l affect psycho-
6 Perinatal Mental Health

logical w e l l - b e i n g a n d cause anxiety, self-blame a n d even

resentment t o w a r d s the fetus.
Prospective studies have s h o w n t h a t w o m e n w h o have frequent
doubts about t h e i r a b i l i t y to handle the demands of pregnancy
a n d p a r e n t h o o d e x h i b i t the most severe depressive s y m p t o m s
i n pregnancy. However, this m a y have a positive effect postpar-
t u m , as the w o m a n 'rehearses' antenatally some of the negative
aspects of m o t h e r h o o d . Other c o n t r i b u t o r y personality factors
m a y i n c l u d e over-dependency on p a r t n e r or parents, a n d an
over-sensitive, anxious or pessimistic personality.
Depression m a y accompany a l l physical s y m p t o m s , a n d the
m i n o r p h y s i c a l problems of pregnancy, such as nausea, heart-
b u r n , varicose veins a n d backache, w i l l c o n t r i b u t e to a l o w e r i n g
of m o o d . Of p a r t i c u l a r i m p o r t a n c e for e m o t i o n a l w e l l - b e i n g is
the r e d u c t i o n o f Stage I V (the deepest level) sleep w h i c h occurs
c o m m o n l y i n late p r e g n a n c y . 12

There is l i t t l e factual i n f o r m a t i o n about the direct effect of the

changed h o r m o n e levels i n pregnancy o n m o o d . I t is t h o u g h t
t h a t raised oestrogen levels give rise to nausea a n d e m o t i o n a l
l a b i l i t y , w h i l s t increased progesterone m a y cause sedation a n d
l e t h a r g y . T h y r o i d h o r m o n e levels are raised i n p r e g n a n c y a n d
13

m a y c o n t r i b u t e to anxiety s y m p t o m s ; raised Cortisol levels,

w h i c h also occur i n pregnancy, are also k n o w n to correlate w i t h
depression.

Treatment of Psychological Problems in

Pregnancy
V e r y s i m p l e interventions can often be most helpful i n i m p r o v -
i n g depressed m o o d or anxiety. The first r e q u i r e m e n t is to listen
a n d t o v a l i d a t e the feelings of the pregnant w o m a n b y g i v i n g
her t i m e a n d a t t e n t i o n .

Practical Intervention
S i m p l e advice-giving about h a v i n g sufficient rest, p a r t i c u l a r l y
i n the later stages of pregnancy, a n d a v o i d i n g m a j o r life
changes, can be useful. The h e a l t h v i s i t o r a n d the general p r a c t i -
 Pregnancy 7

t i o n e r are i n an ideal p o s i t i o n to identify antenatal anxieties a n d

to offer reassurance a n d support. W o m e n new to the area are
p a r t i c u l a r l y vulnerable; they lack a support n e t w o r k , a n d they
m a y benefit f r o m being i n t r o d u c e d to other mothers at p r e n a t a l
classes or m o t h e r a n d t o d d l e r groups.
Social workers can p r o v i d e help w i t h financial matters, a n d
support for housing applications. They can also r e c o m m e n d
the p r o v i s i o n of p r a c t i c a l support i n terms of home help, or
attendance at Social Services' f a m i l y centres. Playgroups or
c h i l d - m i n d i n g for older c h i l d r e n can p r o v i d e welcome relief,
p a r t i c u l a r l y for the socially disadvantaged m o t h e r .

Psychotherapy
Where there are more specific psychological issues t o be ad-
dressed, counselling or psychotherapy can be of benefit. This
can be o n an i n d i v i d u a l basis, or can also include the partner.
G r o u p therapy is less suitable because of the inevitable exit
f r o m the group at delivery, a l t h o u g h mothers i n a postnatal
support group w i l l often continue to attend t h r o u g h a subse-
quent pregnancy.
Some therapists are reluctant to e m b a r k o n a n a l y t i c a l
psychotherapy d u r i n g pregnancy because of the m a n y 'real-life'
changes going o n at the same t i m e , b u t some find i t more
advantageous because the w o m e n are h i g h l y m o t i v a t e d , a n d
have a sense of urgency to change before the b i r t h .
B r i e f cognitive b e h a v i o u r a l therapy m a y be b o t h more prac-
t i c a l a n d acceptable t h a n a n a l y t i c a l psychotherapy.
B e h a v i o u r a l psychotherapy has a place i n the t r e a t m e n t of
antenatal agoraphobic or obsessive/compulsive s y m p t o m s , a n d
m a y be effective i n p r e v e n t i n g a postnatal exacerbation.
T r a i n i n g i n deep r e l a x a t i o n or auto-hypnosis can be helpful
i n the management o f hyperemesis, a l l o w i n g the w o m a n to feel
' i n charge' of her s y m p t o m s rather t h a n at t h e i r mercy.
C o m m u n i t y psychiatric nurses are invaluable i n p r o v i d i n g
m a n y of these interventions i n the mother's o w n home.

Medication
M e d i c a t i o n is r a r e l y i n d i c a t e d , a n d should c e r t a i n l y be avoided
where the m o t h e r has p a r t i c u l a r concerns about the n o r m a l i t y
8 Perinatal Mental Health

of the fetus. Every a t t e m p t should be made to a v o i d m e d i c a t i o n

d u r i n g the first trimester. Later i n pregnancy, the risks of t o x i -
c i t y , teratogenicity a n d possible longer-term neurobehavioural
effects o n the infant have t o be balanced against the degree of
m e n t a l disturbance i n the m o t h e r .
S m a l l doses of beta-blockers are helpful for anxiety symp-
toms, as are m i l d sedatives such as promethazine 20 m g o r
temazepam 10 m g at n i g h t for sleep disturbance.
T r i c y c l i c antidepressants are not k n o w n to be associated w i t h
congenital a b n o r m a l i t i e s , b u t l o n g - t e r m b e h a v i o u r a l effects
have been r e p o r t e d i n a n i m a l s t u d i e s . I f r e q u i r e d , the medica-
14

t i o n s h o u l d be avoided i n the first t r i m e s t e r unless the m o t h e r

was already t a k i n g i t at conception, the dose should be kept as
l o w as possible, a n d discontinued t w o weeks before d e l i v e r y to
a v o i d w i t h d r a w a l effects i n the baby (see Case S t u d y 1.2).
I n w o m e n w i t h pre-existing psychotic illness, where con-
t i n u i n g m e d i c a t i o n is needed, i t is p r o b a b l y better to give depot
m e d i c a t i o n w h i c h avoids the 'peaks a n d troughs' of s e r u m levels
o c c u r r i n g w i t h o r a l drugs.
L i t h i u m is a special case. A l t h o u g h the absolute incidence
of congenital a b n o r m a l i t i e s is not higher t h a n i n the general
p o p u l a t i o n , cardiac a b n o r m a l i t i e s are over-represented . The
15

most usual advice is to stop m e d i c a t i o n w e l l before conception.

However, where the risk of manic-depressive relapse is h i g h , i t
m a y be preferable to continue l i t h i u m t h r o u g h o u t the preg-
nancy, a r r a n g i n g for a detailed scan at 16 weeks to detect the
p o s s i b i l i t y of cardiac a b n o r m a l i t y i n the fetus. The dose m a y
need adjustment for the expansion of plasma v o l u m e d u r i n g
pregnancy, a n d be reduced near the t i m e of delivery to a v o i d
toxic levels d u r i n g the diuresis i n the first postnatal week. The
use o f diuretics for hypertension m a y also increase the serum
level, w h i c h s h o u l d be checked more frequently t h a n u s u a l . 1 6

The p a e d i a t r i c i a n should always be i n f o r m e d about mothers

w h o are t a k i n g psychotropic m e d i c a t i o n i n late pregnancy i n
case of u n t o w a r d effects o n the neonate at delivery.
 Pregnancy 9

Special Situations
The Teenage Mother
A survey of 79 pregnant teenagers revealed t h a t o n l y 22% h a d
17

actively w a n t e d to conceive; 35% h a d not w a n t e d to, a n d the

r e m a i n d e r ' d i d not m i n d ' or 'had not t h o u g h t about i t ' . Over
h a l f of the 17-year-olds were i n the l a t t e r category. I n those w h o
h a d not used contraception i t was social considerations rather
t h a n lack of knowledge t h a t prevented t h e m f r o m doing so.
W a n t i n g sex to be spontaneous, fearing t h a t parents w o u l d find
out t h a t they were sexually active, a n d difficulty i n o b t a i n i n g
supplies were a m o n g the reasons quoted. Sex education a n d
contraceptive advice alone is therefore insufficient to prevent
u n w e l c o m e teenage pregnancies; counselling about relation-
ships a n d responsibilities is also i m p o r t a n t , a n d c o u l d take
place w i t h i n school or i n the general p r a c t i t i o n e r ' s surgery i f the
parents are unable or u n w i l l i n g to discuss such matters.
T w e n t y per cent of a l l teenage pregnancies occur w i t h i n one
m o n t h of becoming sexually active, a n d 50% w i t h i n six m o n t h s
of first intercourse. A large study i n the U S A showed t h a t 55%
1 8

of a l l teenage conceptions result i n b i r t h , the r e m a i n d e r being

t e r m i n a t e d . Over 50% of w o m e n under 18 years have no ante-
n a t a l care u n t i l the second trimester, and 2% have l i t t l e or none
t h r o u g h o u t the w h o l e pregnancy.
There is a higher incidence of pregnancy c o m p l i c a t i o n s , es-
pecially pregnancy induced hypertension, a n d of assisted
deliveries a n d p e r i n a t a l m o r t a l i t y i n the under 16 age group,
even w h e n antenatal care is a d e q u a t e ; l o w b i r t h w e i g h t babies
19

a n d s t i l l b i r t h s are t w i c e as c o m m o n .
M a n y adolescent girls have unreal expectations about the
partner's reaction to the pregnancy. Far f r o m her fantasy of
b r i n g i n g t h e m closer, she m a y end up alone, u n s u p p o r t e d a n d
w i t h problems w i t h a c c o m m o d a t i o n and finance. She m a y be
less w i l l i n g to a t t e n d antenatal classes, a n d i f her f a m i l y of
o r i g i n is not helpful, she m a y need i n d i v i d u a l support a n d
education f r o m the m i d w i f e , h e a l t h v i s i t o r or social w o r k e r .
She w i l l also need support a n d counselling i n deciding about
t e r m i n a t i o n or a d o p t i o n .
10 Perinatal Mental Health

S i x t y per cent of teenagers w h o give b i r t h before the age of

17 w i l l have a repeat pregnancy before the age of 19.

The Older Mother

There are as m a n y reasons for h a v i n g a baby late i n life as there
are older mothers. However, they can be b r o a d l y grouped i n t o
those w h o have delayed pregnancy for reasons connected w i t h
career prospects, those w i t h previous f e r t i l i t y problems, a n d the
u n p l a n n e d 'menopausal' p r e g n a n c y . 20

The 'last chance' pregnancy of the career w o m a n w h o finds

herself i n her late t h i r t i e s w i t h the o p t i o n of a baby n o w or
childlessness for ever is fraught w i t h e m o t i o n a l l o a d i n g . She
may have a m b i v a l e n t feelings about the pregnancy, a n d w i l l
u s u a l l y be aware of the increased risk of fetal a b n o r m a l i t y .
There is often an idealized v i e w of pregnancy, and m i n o r physi-
cal l i m i t a t i o n s m a y be magnified. She m a y grieve for the degree
of c o n t r o l t h a t she has h a d over her life so far, a n d at the same
t i m e be d e t e r m i n e d to show t h a t she can be as successful at
m o t h e r h o o d as she was i n her career.
Because she has been w o r k i n g , she m a y not have established
the local social networks t h a t other mothers have, a n d m a y
o n l y take m a t e r n i t y leave late i n the pregnancy, g i v i n g herself
l i t t l e t i m e to make the e m o t i o n a l t r a n s i t i o n f r o m w o r k i n g
w o m a n to m o t h e r . I t is even more i m p o r t a n t for these w o m e n
to be p a r t of an antenatal group, a n d to w o r k t h r o u g h w i t h the
m i d w i f e some of the negative as w e l l as the positive aspects of
motherhood.
The w o m a n w i t h a previous h i s t o r y of i n f e r t i l i t y or repeated
miscarriages m a y see herself as a 'failure', b l a m i n g herself a n d
b e i n g unable to believe t h a t this pregnancy w i l l be successful.
There is p r e l i m i n a r y evidence t h a t mothers aged over 35 a n d
expecting t h e i r first babies show decreased levels of a t t a c h m e n t
to the f e t u s . A n older m o t h e r m a y w e l l w i t h h o l d b o n d i n g to
20

p r o t e c t herself f r o m further d i s a p p o i n t m e n t , b u t she w i l l also

deny herself the pleasure of a n t i c i p a t i o n , a n d the necessary
a n t e n a t a l 'rehearsal' for the r e a l i t y of m o t h e r h o o d .
Where the older m o t h e r already has teenage c h i l d r e n , her
daughters m a y be envious of the mother's a b i l i t y to procreate
w h e n they themselves are discouraged f r o m doing so. Adoles-
 Pregnancy 11

cent c h i l d r e n m a y be embarrassed for t h e i r peer group to k n o w

t h a t t h e i r m o t h e r is s t i l l sexually active, a n d resentful of the
change to the status quo. A good f a m i l y relationship w i l l resolve
these issues, b u t , where there is a n o r m a l adolescent s t r i v i n g for
i n d i v i d u a l i t y , this m a y even lead to older c h i l d r e n leaving home
p r e m a t u r e l y (see Case S t u d y 1.3).
The m o t h e r herself m a y have worries about h o w she w i l l
cope p h y s i c a l l y w i t h the demands of m o t h e r h o o d yet again,
but m a n y feel rejuvenated a n d are excited about the prospect
of being an even better mother, w i t h increased m a t u r i t y a n d
coping skills.

The Immigrant Mother

There have been few studies of i m m i g r a n t w o m e n a n d t h e i r
e m o t i o n a l experiences of pregnancy and b i r t h . However, i n t u i -
t i o n tells us t h a t i t must be difficult for t h e m to adjust to the
management of c h i l d b i r t h i n the U K , especially w h e n n o r m a l
practices are i n conflict w i t h t h e i r o w n religious or ethnic
t r a d i t i o n s . Asian mothers, for example, usually give b i r t h at
home, do not expect the p a r t n e r to be present, a n d are attended
for the first 40 days p o s t p a r t u m by female relatives. D u r i n g this
t i m e they do n o t c a r r y out domestic chores, a n d are expected to
r e m a i n w i t h i n the home.
One study of Asian w o m e n i n L o n d o n showed t h a t they
2 1

accepted the ' m e d i c a l i z a t i o n ' of pregnancy , a n d were regular

c l i n i c attenders. Most of the husbands were present at the
delivery, a n d the w o m e n appreciated t h i s . There was more
emphasis o n the sex of the baby - pleasure at h a v i n g a boy and
d i s a p p o i n t m e n t w i t h a g i r l - t h a n i n a comparable Caucasian
g r o u p . Some felt isolated i n the postnatal w a r d because of
language problems, a n d some were unable to keep the seclusion
rules p o s t p a r t u m because female relatives a n d friends were not
available.
I t is i m p o r t a n t to be aware of c u l t u r a l and religious differ-
ences, a n d to ask mothers i f they have any objections to r o u t i n e
antenatal practices. They m a y , for example, prefer to see a
w o m a n doctor i n the c l i n i c i f one is available, a n d to have a
female c o m p a n i o n d u r i n g labour.
12 Perinatal Mental Health

The Anorexic or Bulimic Mother

Pregnancy d u r i n g the active phase of anorexia is of course
u n u s u a l because of the suppression of o v u l a t i o n associated w i t h
the c o n d i t i o n . However, there are m a n y w o m e n w h o have h a d
an adolescent eating disorder i n the past, and then go o n to start
a f a m i l y . M a n y of these w i l l be concerned about t h e i r changing
w e i g h t a n d shape, a l t h o u g h perhaps less so i n the later stages
w h e n pregnancy is more obvious (see Case Study 1.4). M a n y
w i t h anorexia have anxieties about the a d u l t role, and sexuality
i n p a r t i c u l a r . They m a y feel shame a n d g u i l t about t h e i r chang-
i n g shape a n n o u n c i n g t h e i r sexual a c t i v i t y to the w o r l d at large.
A f o l l o w - u p of w o m e n w i t h previous a n o r e x i a has s h o w n
22

t h a t they were less l i k e l y to w a n t c h i l d r e n t h a n a comparable

c o n t r o l group, a n d they were older at the t i m e of the first
pregnancy. T w i c e as m a n y l o w b i r t h w e i g h t babies were b o r n
t o the anorexic mothers, a n d the p e r i n a t a l m o r t a l i t y rate was
increased sixfold. S u r p r i s i n g l y , there was no difference i n the
p r o p o r t i o n of mothers choosing to breast feed, n o r i n the l e n g t h
of t i m e t h a t l a c t a t i o n c o n t i n u e d , b u t the previous anorexics
r e p o r t e d 28% of the c h i l d r e n to have h a d 'eating p r o b l e m s ' .
B u l i m i c patients r e p o r t anxiety about possible damage to the
fetus f r o m the eating d i s o r d e r . The c o n d i t i o n appears to
23

i m p r o v e d u r i n g pregnancy i n the m a j o r i t y , and, i n a q u a r t e r of

the sample, pregnancy appeared to be ' c u r a t i v e ' . Nevertheless,
s y m p t o m s r e t u r n e d p o s t p a r t u m i n over h a l f the patients, a n d
m o r e t h a n h a l f expressed anxieties about t h e i r babies being
overweight.

The Epileptic Mother

A w o m a n w i t h epilepsy c o n t e m p l a t i n g pregnancy s h o u l d have
pre-pregnancy counselling about the m a n y difficulties t h a t she
m a y encounter. She m a y be concerned about the effects of her
d r u g r e g i m e n on the fetus, the risk of increasing numbers of fits
d u r i n g pregnancy, her a b i l i t y to cope w i t h the demands of
m o t h e r i n g , a n d the genetic risks for the c h i l d . I t is sensible to
give folate supplements before conception.
There is an increased risk of epilepsy i n the c h i l d of between
3% a n d 6%, depending o n the nature of the mother's epilepsy
a n d the level of the seizure t h r e s h o l d . 24
 Pregnancy 13

Most anti-epileptic drugs are p o t e n t i a l l y teratogenic. Pheny-

t o i n , for example, carries a t w o - to threefold increase i n the
rate of congenital m a l f o r m a t i o n s , p a r t i c u l a r l y cleft l i p a n d
palate, a n d cardiac m a l f o r m a t i o n s . N e u r a l tube defects m a y be
associated w i t h valproate, and g r o w t h r e t a r d a t i o n w i t h
carbamazepine. There is an increased p e r i n a t a l m o r t a l i t y rate.
The frequency of fits is increased d u r i n g pregnancy i n 45% of
w o m e n , perhaps as a result of increased plasma v o l u m e a n d
l o w e r d r u g levels. I n the presence of hypertension a n d oedema,
i t is i m p o r t a n t to bear i n m i n d the differential diagnosis of
eclampsia.
A w o m a n w i t h epilepsy w h o wishes to e m b a r k on a pregnancy
should ideally be o n a single d r u g , w i t h serum concentrations
m a i n t a i n e d w i t h i n the o p t i m u m range a n d checked m o n t h l y .
E x t r a care should be taken i n labour w h e n the serum a n t i -
epileptic levels m a y f a l l . The drugs are excreted i n breast
m i l k , b u t r a r e l y cause problems. Drowsiness i n the infant is an
i n d i c a t i o n for a r t i f i c i a l feeding, at least o n a t r i a l basis.
Despite a l l of the above, most epileptic w o m e n negotiate
pregnancy, c h i l d b i r t h and b r i n g i n g up a f a m i l y very h a p p i l y
a n d successfully.

The Alcoholic Mother

The alcohol c o n s u m p t i o n of young fertile w o m e n has increased
over recent years, as has the incidence of alcohol dependency.
There are severe hazards to the fetus f r o m excessive alcohol
c o n s u m p t i o n i n the m o t h e r i n the very early days of the preg-
nancy, and possibly even i n the pre-conceptual p e r i o d . The
f u l l b l o w n p i c t u r e of fetal alcohol syndrome, w h i c h includes
pre-and postnatal g r o w t h r e t a r d a t i o n , facial deformities a n d
i m p a i r e d psychomotor development, is t h a n k f u l l y rare, b u t
there are more c o m m o n complications amongst mothers w h o
d r i n k moderate amounts of alcohol. A Swedish s t u d y showed 25

t h a t w o m e n w h o took alcohol 'at least 4 - 5 times a m o n t h ' h a d

babies w h o were s m a l l for gestational age, weighed less, were
shorter a n d h a d smaller head circumferences t h a n a compar-
able c o n t r o l g r o u p . The incidence of congenital anomalies was
also increased, and there was a t r e n d towards a higher neonatal
death rate, a l t h o u g h there were no actual cases of fetal alcohol
syndrome.
14 Perinatal Mental Health

M o r e i m p o r t a n t l y , the alcohol intake was not recorded i n the

a n t e n a t a l notes. People i n general are unreliable about report-
ing t h e i r alcohol intake, and w o m e n a t t e n d i n g an antenatal
c l i n i c m a y be even more so, fearing c r i t i c i s m and rejection. O n l y
a t r u s t i n g r e l a t i o n s h i p w i t h the c l i n i c staff w i l l reveal the t r u t h
a n d a l l o w suitable i n t e r v e n t i o n .
W o m e n are perhaps less likely t h a n men to have a h i g h
alcohol intake as p a r t of t h e i r social activities. More of t h e m
m a y use alcohol as 'self-medication' for anxiety, depression a n d
stress. U n f o r t u n a t e l y , a l t h o u g h i t m a y i n i t i a l l y relieve anxiety,
i t is a cerebral depressant, leading to frank depression and sleep
disturbance, a n d hence often an escalation of c o n s u m p t i o n . N o
a t t e m p t to encourage w i t h d r a w a l w i l l then be successful unless
the u n d e r l y i n g m e n t a l state and/or social pressures are addres-
sed. Carers w i l l need to be n o n - c r i t i c a l i n order not to c o m p o u n d
the w o m a n ' s g u i l t a n d distress; praise and encouragement for
her efforts w i l l be more h e l p f u l . Counselling on an i n d i v i d u a l
basis a n d p r a c t i c a l support m a y be needed.

The Management of Drug Abuse in Pregnancy

The n u m b e r of pregnant w o m e n dependent on narcotic drugs
has increased over recent years, and m a y be a real p r o b l e m ,
p a r t i c u l a r l y i n i n n e r c i t y practices. A p a r t f r o m the direct prob-
lems of d r u g abuse, these w o m e n often have m u l t i p l e social
difficulties i n c l u d i n g poverty, unsuitable a c c o m m o d a t i o n and
lack of social support. They are at higher r i s k of physical com-
p l i c a t i o n s ; obstetric complications, p a r t i c u l a r l y placental
a b r u p t i o n , are more c o m m o n . They m a y also have h a d previous
p s y c h i a t r i c illness. A l m o s t a l l have a p r o f o u n d m i s t r u s t of
a u t h o r i t y figures, a v o i d i n g c l i n i c attendance, and f a i l i n g t o
co-operate w i t h t r e a t m e n t programmes. Nevertheless, there are
a significant n u m b e r w h o w i l l welcome the pregnancy as a t i m e
for change.
I t is c r u c i a l t o a successful outcome to b u i l d u p an atmosphere
of t r u s t w i t h the client, and to be u n c r i t i c a l and supportive.
A l l those i n v o l v e d should have a coherent a n d carefully w o r k e d
o u t p l a n for d r u g w i t h d r a w a l ; regular meetings between d r u g
counsellors, general practitioners and social workers w i l l m i n i -
m i z e the r i s k of m a n i p u l a t i o n by the c l i e n t . One w a y of
2 6
 Pregnancy 15

ensuring c l i n i c attendance is to issue methadone prescriptions

at the antenatal c l i n i c , together w i t h regular u r i n e tests to
screen for i l l i c i t drugs. A g r a d u a l l y reducing dose is given,
a t t e m p t i n g to stop m e d i c a t i o n altogether before delivery.
H I V testing after suitable counselling is advisable. M i d w i v e s
should f a m i l i a r i z e themselves w i t h guidelines on the manage-
m e n t of the H I V positive pregnant w o m a n . 2 7

F o l l o w - u p o n opiate addicted w o m e n p o s t p a r t u m shows t h a t

nearly 50% resume t h e i r d r u g h a b i t after delivery, and t h a t
those w h o do are more l i k e l y to have the baby placed i n the care
of o t h e r s .
28

Implications for Antenatal Care

W o m e n themselves have very clear ideas of the k i n d of mater-
n i t y care they w o u l d prefer. Sadly, m a n y are frustrated and
discontented w i t h the care they receive. L o n g w a i t i n g times i n
h o s p i t a l antenatal clinics appear to be the n o r m , a n d the consul-
tations are often rushed a n d impersonal. W o m e n m a y see a
different doctor or m i d w i f e on each occasion, a n d often report
a feeling as i f they are 'on a conveyor belt'. W o r k i n g w o m e n , i n
p a r t i c u l a r , c o m p l a i n about the length of t i m e away f r o m w o r k
for r o u t i n e checks. I n a l l comparisons i n a large postal s u r v e y 29

attendance at general p r a c t i t i o n e r clinics was more appreci-

ated. M o r e w o m e n felt t h a t w a i t i n g times were more acceptable,
t h a t they were given adequate i n f o r m a t i o n , a n d were able to ask
sufficient questions.
So h o w can this general dissatisfaction be improved?

Individuality
Above a l l , i t has to be remembered that each pregnancy has its
o w n p a r t i c u l a r m e a n i n g for the i n d i v i d u a l w o m a n at this p a r t i -
c u l a r t i m e i n her life. Pregnancy a n d b i r t h are m a j o r life events,
not j u s t m e d i c a l procedures. Adequate t i m e for each w o m a n to
be treated as an i n d i v i d u a l i n the antenatal c l i n i c w o u l d be a
b e g i n n i n g . Shifting the emphasis on physical h e a l t h to include
questions about the mother's e m o t i o n a l w e l l - b e i n g is a v i t a l
p a r t of good antenatal care.
16 Perinatal Mental Health

Flexibility of Care
F l e x i b i l i t y o f a p p o i n t m e n t times w o u l d also be of benefit. There
m i g h t even be a good case for evening clinics for w o m e n w h o
w o r k or w h o have other young c h i l d r e n a n d no available c h i l d -
m i n d e r . Other specialties such as d e n t i s t r y a n d g e n i t o - u r i n a r y
m e d i c i n e already follow this p a t t e r n . I f we r e a l l y value good
antenatal care, a n d are r e a l l y concerned about the m o t h e r as a
person, i t w o u l d be w o r t h the inconvenience to staff.

Continuity of Care
W o m e n say h o w m u c h they appreciate c o n t i n u i t y of care f r o m
the f a m i l y doctor. They can also develop a good r e l a t i o n s h i p
w i t h a c o m m u n i t y m i d w i f e , b u t this is less easy i n the consul-
t a n t u n i t setting. Some m a t e r n i t y u n i t s have set u p a system of
w o r k i n g i n teams, i n w h i c h each m e m b e r of the t e a m rotates
duties between the antenatal c l i n i c , the l a b o u r w a r d a n d the
p o s t n a t a l w a r d . Thus each i n d i v i d u a l w o m a n is more l i k e l y to
encounter a f a m i l i a r face w h e n she is a d m i t t e d for delivery. This
system also makes for better c o m m u n i c a t i o n w i t h i n the t e a m
about p a r t i c u l a r l y anxious or sensitive mothers. Another alter-
n a t i v e w o u l d be sectorization, w i t h smaller teams w o r k i n g i n
designated parts of the catchment area.

Antenatal Education
The m a i n a i m o f antenatal classes is to increase confidence i n
w o m e n , b u t s u r p r i s i n g l y there has been l i t t l e e v a l u a t i o n o f this
cost a n d t i m e c o n s u m i n g p r o g r a m m e . There is some evidence
t h a t the classes are p r e d o m i n a n t l y attended b y more m i d d l e -
class t h a n working-class mothers, a n d t h a t the l a t t e r show a
greater ' d r o p - o u t ' rate.
I t has been s h o w n t h a t the w o m e n r e p o r t i n g most benefit
f r o m antenatal classes are those w h o have a positive a t t i t u d e to
m e d i c a l care i n g e n e r a l , so t h a t a sensitive approach f r o m
30

professionals i n p r i m a r y care is very i m p o r t a n t for its 'knock-

o n ' effect. The same study has shown t h a t there was a consider-
able increase i n knowledge after the classes, b u t there was no
c o r r e l a t i o n between knowledge level a n d satisfaction w i t h out-
come; attitudes reflecting confidence i n h e a l t h professionals a n d
 Pregnancy 17

h o s p i t a l care were more relevant. Another s i m i l a r study found

t h a t confidence increased w i t h t i m e and anxiety levels f e l l . 3 1

N e i t h e r of these studies h a d c o n t r o l groups, so i t is not possible

to a t t r i b u t e the changes solely to the classes.
There was t h o u g h t to be an a d d i t i o n a l benefit f r o m local,
c o m m u n i t y based classes, w h i c h created friendships a n d social
support. I t is c e r t a i n l y possible t h a t more mothers f r o m a w i d e r
range of social class m i g h t a t t e n d evening meetings, or d a y t i m e
classes where a creche is p r o v i d e d .

Dealing with Negative Aspects

W o m e n often say t h a t antenatal classes do not include t i m e
for the expression of negative feelings, such as anxieties about
the n o r m a l i t y of the baby, s t i l l b i r t h and t h e i r o w n physical
i n t e g r i t y . They have concerns about being cut, stretched or t o r n ,
a n d perhaps w h e t h e r t h e i r husbands' feelings w i l l change after
the b i r t h . They question t h e i r o w n capacity for m a t e r n a l feel-
ings, a n d w o n d e r i f they are really m a t u r e enough to care for a
c h i l d . I f a m o t h e r is not able to p u t i n t o practice a l l t h a t she has
been taught, w i l l the staff react w i t h impatience; w i l l she herself
feel a 'failure' i f she needs an assisted delivery? A l l of these are
real a n d acceptable fears, not m o r b i d or m i s t r u s t f u l , a n d should
be a l l o w e d free v e n t i l a t i o n d u r i n g the pregnancy.
I t m a y be t h a t m i d w i v e s a n d health visitors are u n w i l l i n g to
look at these issues themselves because of t h e i r o w n fears, or
because they are concerned to i n s t i l confidence i n t h e i r clients.
I t is i m p o r t a n t t h a t professionals are aware of t h e i r o w n feel-
ings, a n d prevent t h e m f r o m i n t r u d i n g i n this s i t u a t i o n .
M a n y w o m e n w i t h p o s t p a r t u m e m o t i o n a l problems c o m p l a i n
t h a t they were not given sufficient i n f o r m a t i o n d u r i n g the preg-
nancy about the risk a n d symptoms of postnatal depression.
M i d w i v e s a n d h e a l t h visitors, o n the other h a n d , insist t h a t they
do so, b u t the mothers 'block o u t ' w h a t they say, not w a n t i n g
to accept any negative i n f o r m a t i o n . The t r u t h p r o b a b l y lies
somewhere between these extremes.
I n an a t t e m p t to overcome this c o m m u n i c a t i o n p r o b l e m , a
single page i n f o r m a t i o n sheet has been prepared, a n d is i n c l u -
ded at the end of this chapter (see Appendix 1.1). I t should be
given not less t h a n four weeks before delivery, to be kept w i t h
18 Perinatal Mental Health

the co-operation c a r d a n d referred to at a later date i f need be.

I t has deliberately been kept b r i e f a n d non-threatening, b u t
s h o u l d help w o m e n i n d o u b t about t h e i r reactions. I t also
suggests helpful interventions, a n d gives details of self-help
organizations.

And Finally...
M o t h e r s need n u r t u r i n g i n order to be able to n u r t u r e . I f the
f a m i l y or p a r t n e r is not able to offer this, i t is even more
i m p o r t a n t t h a t the professionals i n v o l v e d include this n u r t u r i n g
aspect w i t h i n the f r a m e w o r k of ' w h o l e person' antenatal care.

Case Study 1.1

A patient who experienced severe postnatal depression wrote an
account of her pregnancy as follows:
'During the pregnancy I was physically very well, playing
hockey up to the 5th month. At that stage, I was affected by
what was described as a 'hormone imbalance' and had a total
change of personality. Instead of my normal extrovert self, I
became clinging and dependent on my husband and family. I
could not bear to be on my own for any length of time, and
wept frequently. Life seemed to have no point, and had I not
felt a deep moral responsibility for my unborn child, I would
not have cared whether I lived or died.'

She made a full recovery following treatment for her postpartum

depressive illness.

Case Study 1.2

A 30-year-old nurse married to a much older husband had had a
salpingo-oophorectomy some years previously for an ectopic preg-
nancy. The early stages of her pregnancy were complicated by severe
abdominal pain. Eventually an exploratory laparotomy was per-
formed, and her appendix with adherent ovary and fallopian tube was
removed. She was thus pregnant with no possibility of any future
natural pregnancy, and her severe abdominal pain persisted after the
operation. She was very pessimistic about a successful outcome of
 Pregnancy 19

the pregnancy, constantly checking for fetal movements, and having

recurrent nightmares about death.
She was encouraged to ventilate her ambivalent feelings about the
pregnancy. Small doses of amitriptyline helped her poor sleep pattern
and raised her pain threshold. A healthy boy was delivered at 38 weeks
by caesarian section. She is currently pregnant again with a GIFT
pregnancy.

Case Study 1.3

Joan was a woman i n her mid-thirties who was pregnant for the third
time. She had had her first baby at the age of 17, and, although the
current pregnancy was unplanned, she was excited and pleased, espe-
cially to find that she was not the only older mother in the clinic. She
looked forward to the baby in a way that she had not been able to when
so much younger; there were now no financial difficulties, and she felt
more emotionally stable. However, her daughter had reacted with
shocked disbelief, and went to live with her boy-friend against her
parents' wishes.
Joan's blood pressure rose towards the end of pregnancy and she was
admitted for rest. Whilst in hospital, her daughter told her that she,
too, was pregnant, and had decided to have a termination. Joan sup-
ported her daughter throughout the termination in the same hospital
and visited her in the adjoining ward. Both mother and daughter felt
confused about their feelings. They cried together about the 'lost'
pregnancy, but were eventually able to share in the pleasure of the new
baby in the family.

Case Study 1.4

Brenda was a 36-year-old woman with two children aged five and three
from a previous marriage. She had just entered into a new relationship
w i t h a much younger man, and was 28 weeks pregnant when first
referred. She had been uncharacteristically tearful and irritable for the
previous three months. During the consultation, it emerged that she
had been anorexic in her teens, and her current anxieties centred on
her loss of attractiveness related to her changing shape and the minor
physical disabilities of pregnancy, and hence the possible loss of her
new partner. She wore a T-shirt bearing the slogan: ' I ' m not fat - just
pregnant!'
A single counselling session helped her to confide in her husband who
was able to reassure her that he was delighted about the baby, and
found her even more attractive in her pregnant state.
Appendix 1.1

What is Postnatal Illness?

Postnatal illness (PNI) affects over 10% of a l l new mothers,
sometimes b e g i n n i n g soon after the b i r t h of the baby, some-
t i m e s weeks or m o n t h s later. The s y m p t o m s can v a r y greatly i n
type, severity a n d d u r a t i o n . They can include tearfulness a n d
deep despondency, together w i t h p r o f o u n d exhaustion a n d often
a feeling of n o t being able to cope w i t h the baby. Mothers
sometimes feel t h a t they w a n t to r u n away f r o m the s i t u a t i o n
they are i n , or at least have a short break f r o m c a r i n g for the
f a m i l y . I r r i t a b i l i t y a n d tension, over-anxiety about t h e i r o w n or
t h e i r baby's h e a l t h m a y also occur. M a n y w o m e n feel extremely
g u i l t y about feeling so b a d w h e n they have a healthy baby, a
nice house, a n d a helpful partner.
The good news is t h a t P N I does not last for ever, even t h o u g h
w o m e n experiencing i t find i t h a r d to believe t h a t they w i l l ever
recover. I t does respond to t r e a t m e n t , often q u i t e q u i c k l y , a n d
life w i t h a baby can be enjoyable again.

How to Help Yourself

• Share y o u r feelings; d o n ' t b o t t l e t h e m u p . T a l k to y o u r
p a r t n e r , m o t h e r , sister or a good friend. Y o u w i l l be sur-
p r i s e d at h o w often y o u find others w h o have h a d a s i m i l a r
experience, and have recovered.

• Take as m u c h rest as y o u can w h e n y o u get home w i t h the

b a b y . Others are often w i l l i n g to help i n the early stages, b u t
less so later i f y o u have rejected t h e m previously. Let friends
k n o w t h a t y o u w o u l d like a quiet t i m e each day, perhaps
w i t h no visitors at c e r t a i n hours, a n d w i t h the phone off the
hook d u r i n g these times.

• D o n ' t t r y to be ' s u p e r m u m ' a n d do e v e r y t h i n g as before.

Establish a comfortable r o u t i n e i n w h i c h meals are kept
s i m p l e a n d housework is kept to a m i n i m u m .
Another random document with
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onneton, sillä hereillä tekee arvosteluni minut tyytymättömäksi, aina
kuiskaten minulle, että olen poissa ystäväni luota. Mutta lempeät
uneni öisin hyvittävät minua ja saavat minut uskomaan, että olen
hänen sylissään. Kiitän Jumalaa onnellisista unistani, samoin kuin
hyvästä levostanikin, sillä ne tarjoovat tyydytystä kohtuullisille
toiveille ja sellaisille ihmisille, jotka tyytyvät vähäänkin
onnellisuuteen. Eikä liene synkkämielinen se käsitys, että me kaikki
olemme kuin nukuksissa tässä maailmassa, että tämän elämän
käsitykset ovat pelkkiä unelmia verrattuina tulevaisen maailman
tajuntaan, niinkuin unihaaveet selvän päivän tajunnan rinnalla.
Molemmat ovat yhtä erehdyttäviä, ja toinen näyttää vain olevan
toisen vertauskuva. Me olemme vähän enemmän kuin oma itsemme
nukkuessamme, ja ruumiimme uinailu tuntuu aloittavan sielun
valveutumisen. Aistimemme ovat kyllä sidotut, mutta järkemme
vapautuu, eivätkä ajatuksemme valveilla ollessamme voi kilpailla
unessa saamiemme haaveiden kanssa.

Syntymämerkkini osui Skorpionin vetiseen tähtikuvioon;

syntymiseni tapahtui Saturnuksen kiertotunnilla, ja luulenpa itsessäni
olevan jonkun verran tämän kiertotähden lyijymäisyyttä. Minä en ole
lainkaan taipuvainen leikinlaskuun, eikä minulla ole lahjoja esiintyä
pilapuheilla ja sukkeluuksilla seurassa. Mutta yhdessä ainoassakin
unessa voin laatia kokonaisen huvinäytelmän, katsella sen
suorittamista, panna merkille pilapuheet ja nauraa itseni hereille sen
hullutuksista. Jos muistini olisi yhtä uskollinen kuin järkeni on silloin
tuottelias, harjoittaisin tutkimuksia vain unissani. Samoin valitsisin
sen ajan myöskin hartauteni harjoittamiseksi. Mutta karkealaatuinen
muistimme ei kykene pitämään tallella keveämmin liikkuvan älymme
vaikutuksia, vaan unohtaa ne ja herättyämme pystyy esittämään vain
epäselvän ja katkonaisen kertomuksen siitä, mitä on tapahtunut.
 Aristoteles, joka on kirjoittanut eri tutkielman unesta, ei mielestäni
ole tarkoin sitä määritellyt. Eikä Galenuskaan, vaikka hän näyttää
oikaisseen edellämainitun käsitystä. Sillä unissakävijöillä, vaikka he
liikkuessaan nukkuvatkin, on kuitenkin aistimien toiminta jäljellä.
Senvuoksi meidän täytyy sanoa, että meissä on jotakin, mikä ei ole
Morfeuksen vallassa, ja että hurmiotilaan joutuneet sielut vaeltelevat
omassa ruumiissaan niinkuin hengetkin asunnoikseen ottamissaan
ruumiissa, joihin pukeutuneina ne näyttävät kuulevan, näkevän ja
tuntevan, vaikka elimet ovat vailla aistimiskykyä. Niinpä huomataan
ihmisten joskus lähtöhetkellänsä puhuvan ja ajattelevan asioita, jotka
ovat heidän tavallisten kykyjensä yläpuolella; silloinhan näet sielu,
joka alkaa vapautua ruumiin kahleista, puhkeaa kuin itsekseen
toimimaan ja pääsee kuolevaisuuden rajojen ulkopuolelle. Me
nimitämme unta kuolemaksi, vaikkakin herääminen meidät tappaa ja
hävittää ne henget, jotka ovat elämän varsinaisena olinsijana.
Tosiaankin tuo elämän puoli parhaiten esittää kuolemaa. Sillä
jokainen ihminen elää todellisesti juuri niin kauan kuin hän saa
varsinaisen luontonsa toimimaan tai jollakin tavalla toteuttaa
kykyjänsä. Siksi Themistokles, joka surmasi erään sotilaistaan
tämän nukkuessa, oli lempeä pyöveli. Sentapaista rangaistusta ei
mikään laki ole lempeimmilläänkään ajatellut. Kummastelen, ettei
Lucanuksen eikä Senecan mielikuvitus sitä keksinyt. Sellaista
kuolemaa saattaa kirjaimellisesti sanoa meidän itse kokevan joka
päivä, ja sellaisen kuoleman alaiseksi Aatamikin joutui ennenkuin
hänestä tuli kuolevainen; sen kuoleman nojalla elämme elämän ja
kuoleman välisessä tasoittavassa tilassa, ja se on niin tosikuoleman
kaltainen, etten uskalla siihen antautua rukoilematta ja maailmalle
puoleksi hyvästi jättämättä. Puheluni Jumalan kanssa kelpaa minulle
hyväksi unilääkkeeksi. Muuta en kaipaa saadakseni hyvää unta, ja
sitten suljen silmäni turvallisesti tyytyen sanomaan jäähyväiset
auringolle, jos minun on nukuttava ylösnousemukseen asti.

Sitä menetelmää, jota minun olisi noudatettava tuomitessani,

käytän usein keskinäisissä asioissa ja sovitan siihen geometrisen
suhteen, jonka vuoksi, koettaessani olla toisille tasapuolinen, olen
puolueellinen itseäni kohtaan ja liioittelen noudattaessani sääntöä:
mitä tahdot ihmisten sinulle tekevän, tee se myöskin heille. En
syntynyt perittyihin rikkauksiin, eikä tähteni lie ennustanut minulle
varallisuutta. Tai jos olisikin niin ollut, niin sieluni vapaus ja mieleni
suoruus olisivat tehneet tyhjiksi kohtaloni määräykset. Sillä minusta
ahneus ei niin paljon tunnu paheelta kuin surkuteltavalta hulluudelta.
Se, että pidämme itseämme saviastioina tai uskomme olevamme
vainajia, ei ole niin naurettavaa eikä niin monta astetta aivastusyrtin
vaikutuksen ulkopuolella kuin tämä. Ihmisten teoreettiset mielipiteet
ja väittämät eivät ole niin järkeä vailla kuin heidän käytäntönsä
johtopäätökset. Jotkut ovat väittäneet, että lumi on mustaa, että maa
liikkuu ja että sielu on ilmaa, tulta, vettä; mutta kaikki tämä on
filosofiaa eikä siinä ole suorastaan hulluutta, kun sitävastoin
vähänkin ajatellen tajuamme, kuinka hupsua ja nurinkurista on himo
maanalaiseen jumalaan, kultaan.

Minun täytyy tunnustaa olevani siinä merkityksessä ateisti. En voi

suostuttaa itseäni kunnioittamaan sitä, mitä maailma palvelee. Mitä
hyvänsä sen vaikutus saaneekin aikaan ruumiissani, ei sillä ole
mitään tekemistä eikä vaikutusta sen ulkopuolella. Koko Intian
hinnasta en pitäisi mielessäni alhaista aietta tai suunnittelisi tekoa,
jonka vuoksi minua voitaisiin nimittää heittiöksi. Pelkästään tämän
takia rakastan ja kunnioitan omaa sieluani, ja minulta puuttuu toinen
pari käsivarsia syleilläkseni itseäni. Aristoteles on liian ankara, hän
kun ei myönnä meidän voivan olla todellisesti anteliaita ilman
rikkautta, onnettaren suopeaa kättä. Jos tämä on totta, niin
tunnustan olevani laupias vain anteliaissa aikeissani ja runsaissa
toivotuksissani. Mutta jos lesken ropo ei ollut vain kummastusta
herättävä teko, vaan mitä ylevimmän uhraavaisuuden osoitus, silloin
köyhätkin ihmiset saattavat rakentaa sairaaloita eivätkä rikkaat
yksinään kykene pystyttämään temppeleitä.

Minä noudatan omaa menettelytapaani, jota muut eivät käytä: otan

huomioon omat pienet tilaisuuteni hyvää tehdäkseni, supistan omia
välttämättömiä tarpeitani anteliaisuuden osoituksiin ja tyydytän
toisten puutetta silloin, kun itsekin enimmin kaipaan. Sillä rehellinen
sotajuoni on yllättää itsensä ja niin järjestää hyveiden ilmauksia, että
silloin, kun niitä puuttuu yhdessä kohdassa, ne voisivat saada
korvauksen toisessa. En toivo saavani Perun rikkauksia, vaan tyydyn
kohtuulliseen toimeentuloon ja kykyyn voida tehdä sitä hyvää, johon
Jumala on antanut minulle taipumuksia. Se, jolla on kyllin
voidakseen olla antelias, on rikas, ja vaikeaapa on olla niin köyhä,
ettei jalo mieli keksi keinoja toteuttaakseen hyvää tahtoansa. Joka
köyhää armahtaa, lainaa Herralle; siinä on lyhykäisesti enemmän
kaunopuheisuutta kuin saarnakokoelmassa. Ja jos todellakin lukija
ymmärtäisi tuollaiset lauseet niin vakavalta kannalta kuin ne on
lausuttu, emme tarvitsisi laveita opetuksia, vaan olisimme rehellisiä
pienen otteen kuultuamme.

Jo tämäkin syy vaikuttaa, etten voi nähdä kerjäläistä

huojentamatta hänen hätäänsä kukkarostani tai hänen sielunsa
taakkaa rukouksillani. Näennäiset ja satunnaiset eroavaisuudet
meidän välillämme eivät saata minua unohtamaan meissä
molemmissa olevaa yhteistä ja koskematonta. Ryysyisen puvun ja
viheliäisen ulkoasun alla, raajarikkoisen ja vajavaisen ruumiin
suojassa asuu sielu, joka on samaa sukua kuin omammekin,
Jumalasta kotoisin niinkuin meidänkin ja yhtä hyvin pelastettavaksi
aiottu. Kansantalousmiehen työskennellessään saadakseen aikaan
yhteiskunnan, jossa ei köyhyyttä olisi, poistavat tilaisuuden harjoittaa
armeliaisuutta eivätkä ymmärrä kristityn yhteiskunta-ajatusta,
unohtaen myös Kristuksen ennustuksen.

Mutta on toinenkin laupeuden puoli, joka on edellisen perustus ja

kulmakivi, nimittäin rakkaus Jumalaan, jonka nojassa voimme
rakastaa lähimmäistäkin. Sillä se minusta on oikeata laupeutta, että
rakastamme Jumalaa hänen itsensä vuoksi ja lähimmäistämme
Jumalan vuoksi. Kaikki, mikä on todella rakastettavaa, on Jumalaa
tai tavallaan osa hänestä, joka heijastaa ja kuvastaa häntä. Eikä ole
ihmeellistä, että rakkautemme kiintyy näkymättömään, sillä kaikki,
mitä todella rakastamme, on näkymätöntä. Se, mitä hellimme
aistimiemme vaikutelman takia, ei ansaitse niin puhdasta nimitystä.
Niinpä siis ihailemme hyvettä, vaikka emme aistimillamme voi sitä
havaita. Samoin ei se puoli, mitä ylevissä ystävissämme
rakastamme, ole käsin tavoiteltavissa, vaan se on jotakin sisäistä,
jota emme voi syleillä. Jumala, joka on itse hyvyys, ei voi rakastaa
muuta kuin sitä, mikä on hänestä. Hän rakastaa meissäkin sitä, mikä
on niin sanoaksemme häntä itseänsä ja hänen Pyhän Henkensä
vaikutusta. Jos tarkastamme todellisuuden mukaisesti vanhempain,
vaimon ja lasten rakkautta, niin se kaikki on tyhjää kuvitelmaa ja
unennäköä, vailla todellisuutta, totuutta ja pysyväisyyttä. Sillä vaikka
aluksi meidän ja vanhempien välillä on voimakas yhdysside, niin
kuinka helposti se katkeaakaan! Me kiinnymme vieraaseen naiseen
ja unohdamme vaimon takia oman äitimme ja sen kohdun, jossa
sikisimme, muistaen vain sitä, jossa oma kuvamme on sikiävä. Kun
tämä nainen lahjoittaa meille lapsia, ei rakkautemme enää pysy yhtä
korkealla, vaan laskee, siirtyen seuraamaan uutta sukupolvea, jossa
taas rakkaudella ei ole vakaata asuinsijaa. Kun lapset varttuvat,
toivovat he meidän jo lähtevän tieltä pois tai kiintyen johonkin
naiseen käyttävät laillista keinoa rakastaa vierasta ihmistä enemmän
kuin meitä. Näin ollen kuvittelen ihmisen joutuvan elävältä
haudatuksi ja näkevän hautansa omissa jälkeläisissään.

Niinpä siis lopettaakseni sanon, ettei auringon alla (tai niinkuin

Kopernikus tahtoisi sanoa: yllä) ole mitään onnellisuutta, eikä ole
perätön Salomon niin usein toistettu viisas lauselma: kaikki on
turhuutta ja hengen vaivaa. Ei ole mitään onnellisuutta siinä, mitä
maailma ihailee. Kun Aristoteles ponnistelee kumotakseen Platon
aatteita, joutuu hän itse samanlaiseen kumottavaan aatteeseen, sillä
hänen esittämänsä summum bonum, korkein hyvä, on vain
mielikuva, eikä ole olemassakaan sellaista, mitä hän pitää
onnellisuutena.

Se, missä Jumala itse on onnellinen ja enkelit autuaita ja minkä

puutteessa paholaiset ovat onnettomia, sitä vain uskallan nimittää
onnellisuudeksi. Mikä hyvänsä siihen johtaa, ansaitsee myös tuon
nimen, mutta sensijaan mikä muu hyvänsä, mitä maailma nimittää
onnellisuudeksi, on minusta vain kuin Pliniuksen tai Boccacion tai
Malizspinin juttuja, haavekuva tai harhanäky, jossa ei ole muuta
onnellisuutta kuin sen nimi. Siunaa minua, oi Herra, tässä elämässä
vain omantunnon rauhalla, tunteitteni hallinnalla, omalla ja
kalleimpien ystävieni rakkaudella, niin olen onnellinen Caesarin
kadehdittavaksi. Nämä ovat perin vaatimattoman kunnianhimoni
nöyrät toiveet, ja niihin sisältyy kaikki, mitä maan päällä uskallan
onnellisuudeksi nimittää. Siinä en tahdo panna mitään rajoja Sinun
kädellesi tai kaitselmuksellesi. Määrää kohtaloni oman
hyväksinäkemisesi viisauden mukaan. Tapahtukoon Sinun tahtosi,
vaikka se merkitsisi minun tuhoani.
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