‘Never should we blame the mum’

Dr Andrew Mayers, perinatal mental illness expert, in conversation

According to the National Health Service (NHS), PMH problems are those which arise during pregnancy or within the initial year after childbirth. NHS estimates that 27 per cent of new and expectant mums will be impacted by perinatal mental illness, leading to serious consequences. Without treatment, 20 per cent of women with perinatal mental illness tends to have suicidal thoughts or self-harm acts. Currently, the NHS is working on the Long Term Plan with an investment of £2.3bn in mental health, part of it is allocated to PMH.

Frequently, Dr Mayers is invited to Parliament to contribute to campaigns on mental health, particularly issues related to PMH. In this interview, Dr Mayers discusses about different conditions of PMH, the consequences of leaving mothers untreated, his advice for women and their families, and recent advancements in this field. Excerpts:

You have been working in PMH field for 20 years. Have you observed any improvements in support services during this time?

Yeah, there has been. One of the things that we found was that mums weren’t getting the support that they needed in the past. For example, when a mum became unwell, she needed to be in a hospital where she would recover better. But there were very few what we called ‘Mother and Baby Units’ across England, probably about 6 or 7. Through my involvement with the Maternal Mental Health Alliance, I worked alongside some other people, and we campaigned through the government to have more. Now we’ve got mother and baby and it’s across the whole country. That is good.

We’ve also seen improvements in community care. There are more charities and more community groups supporting mums. So, I think it’s better than it was 20 years ago, always more that we could do, but it’s there’s been an enormous improvement.

Based on your experience, what are some common symptoms or indicators of perinatal mental illness that women may experience?

This is not just about the mum or the dad, this is about the entire family

I think we need to look at four main areas and each of those will have different symptoms. Postnatal depression is the most common, affecting about one in 10 mums. Symptoms include low mood, tearfulness, sadness, and a lack of motivation to do those things that normal people want to do. Additionally, other issues such as sleep disturbances, changes in appetite, difficulty concentrating, low self-worth, feelings of guilt, and thoughts of death may also occur. All these things add to those symptoms for a diagnosis of postnatal depression, which is typically diagnosed in the first year or two after the baby has been born.

Postpartum psychosis is a much more serious condition. About one in 1000 mums will experience this which we would call psychotic symptoms or possibly the more manic symptoms of bipolar disorder. What we’re seeing here is a wild fluctuating mood and mums are perhaps not functioning in a way we might normally expect someone to function. She may be experiencing hallucinations, which would be seeing and hearing things that others might not as well as delusions such as believing the baby is not hers or has been replaced with a religious or devil baby. And she truly believes these things. Her behaviours, actions, or her understanding of reality will get out of control and she could potentially be a danger to herself and possibly even to that baby.

Another thing we see is maternal OCD, which means maternal obsessive-compulsive disorder. OCD is something we’ve seen in the general population which is described as neat freaks and needing everything in order. But it is the simplest, not at all. OCD is also intrusive thoughts that a person cannot get out of their head. They invade every part of their thinking day and become obsessions which we can’t get rid of. OCD will be a serious and very distressing condition now when this happens to the mums, the focus of those intrusive thoughts is the safety of their baby which becomes irrationally and disproportionately focused on that baby’s safety. One common thing that happens with a mum at this stage is that she develops this irrational fear that she might hurt the baby, even though she won’t. She goes to extremes to protect the baby, even though there’s no real need to do.

The last condition is birth trauma. It occurs when something very dramatic happens during childbirth that could have potentially threatened the life of both the mother and her baby. For example, the mum thinks she’s going to have a home birth and pregnancy is a difficult but wonderful experience. Then all of a sudden change because the medical staff say “I’m sorry, but there are complications. You cannot have that baby. You need to come into hospital” or “We think it’d be safer for you and the baby if we undergo a caesarean section operation”. Now that can be distressing and traumatic because the mum had the idea that the birth was gonna be different.

She develops this irrational fear that she might hurt the baby, even though she won’t

One in four mums will have some kind of traumatic birth, and many of them will be distressed by that. But about one in 25 of those will then go on to develop post-traumatic stress disorder as anybody else might. In the event of trauma, we need to be able to support her too, with the symptoms of PTSD (Post-traumatic stress disorder).

This reminds me of a story from Vietnam. A young mother, after giving birth, suffered from postnatal depression. She brought her child and committed suicide together. It’s a heart-breaking situation. What are your thoughts on this?

It’s still the case today that the leading cause of death among women of childbearing age is suicide. The biggest factor in suicide is mental health problems. It’s a simple truth and that’s why we need to help mums.

Are you suggesting that every mum will experience perinatal mental health issues?

Not everyone will experience these problems obviously. Let’s look at the figures here. Approximately one in 10 mothers may experience postnatal depression, while maybe one in 1000 mothers suffer from postpartum psychosis. Maternal OCD affects around one in 10 to one in 20 mothers, and a small proportion, probably around 4 per cent of mothers, may experience post-traumatic stress disorder.

However, one thing that all mothers are likely to experience is what we call the baby blues. While evidence suggests it affects around 75 per cent of mothers, I believe it’s experienced by most, if not all, mothers.

And what happens within the first few days after giving birth? Her mood will fluctuate. She’ll start questioning her ability. She should become tearful, and have problems eating problems, sleeping, and the hormone’s changes. This is normal. It doesn’t tend to be too dramatic, but the key thing is, after a few days it will go away so it’s not anything we need to worry about. It’s only after that that we start seeing other problems.

What are the factors behind this issue you think?

The causes can vary with each condition. Postnatal depression, for example, doesn’t tend to be biological or hormonal, whereas baby blues is and it’s not a formal mental illness. Baby blues are more about the environment and psychology. Mothers who are more likely to develop postnatal depression are often younger, facing financial difficulties, recent life challenges such as bereavement or marriage breakup, or living in poorer areas. Lack of nearby support from one’s own mother, particularly with the first child, and the absence of a supportive partner can also contribute to postnatal depression. By contrast, postpartum psychosis is much more likely to be a biological, and that’s because of the hormonal changes, problems with sleep and other factors.

Is it necessary for every mother to return home with their own mothers to help take care after giving birth, or does it depend on the individual circumstances?

Well, it helps, doesn’t it? Though it’s only one of many factors. I think one of the problems we’ve got, particularly in Western cultures, is that families tend to be further apart than they ever were. By contrast, in other communities, like in Eastern Oriental, and Asian countries, families often stay together more, which can be really important. What the mother’s mother can do is that she brings not only her experience, but also that sort of support and empathy that no one else really can. Not having your mum around doesn’t mean you will develop postnatal depression, but it certainly helps.

What are the potential long-term consequences if perinatal mental illness is left untreated?

One of the most obvious consequences for the mum if she is untreated, is that she is at high risk of suicide. Now, we have more mums were actually dying and occasionally they would potentially harm their own child. But the impact on her can be great. First of all, some mums who have severe mental health problems will not want to have another child. However, for those who choose to become pregnant again, they may face an increased risk due to the fear of experiencing similar problems once more. So that can be bad, but there are wider impacts too. As we know, the most important period in any human being’s life is those first few years of life. Therefore, the impact on the child can be dramatic.

If the mum’s not well, it’s not her fault

They are utterly dependent on their parents, but particularly the bond with mother happens within hours after birth when the mother holds that baby for the first time. That bond begins through eye contact, skin contact, breastfeeding, and that means the child will grow up feeling that the world is a safe place, mother will resolve the crises and be available to support the baby. If the mum’s not well, it’s not her fault, that attachment’s gonna be compromised and she’s gonna find it harder to bond with the baby. Then that bond can be broken. That is not a judgment on the mum, and that never should we blame the mum. Instead, it’s about recognising the need to provide better support for mothers and help them strengthen their bond with their baby. Of course, it also has an impact on the family relationship, including the husband. He might not even understand what he needs to be able to do to help, but it can cause problems. So, this underscores why our work is crucial. It’s not just about aiding the individual who is unwell, it’s also about mitigating the impact on those around them.

In your experience, what are some effective strategies or for supporting women with perinatal mental health challenges?

There’s many things we can do such as therapy and medication. If a mum has postnatal depression, we can look at using things like antidepressants (a type of medicine used to treat clinical depression). We should be very careful with the dose to make sure that they are safe for mums who are breastfeeding. Another thing we can do is we can look at therapy. We will have a psychologist sit down with the mum and start working through her thoughts and helping her change the way she thinks, feels and behaves. Another thing we can do beyond all of that is that we have support groups like charities and general support groups. We can have other mothers helping to support the mothers so that they can use their own experience of what they’ve been through to help them through.

Are there any advancements in the field of perinatal mental health that offer hope for improved outcomes?

I think we mentioned earlier that there’s been some significant developments in the way in which we do support so there’s lots of hope. We’ve got more mother and baby units. We’ve got more charities. We’ve got more interventions that we’ve ever had before. There is a lot more hope I think than there was. However, I think one area that we’re not doing well on. We’ve done very well with postnatal depression, postpartum psychosis, maternal OCD but we still don’t understand enough and don’t have anywhere near enough support for the impact of birth trauma. Now that’s improving because a group of MP’s within the British government have decided to set up an inquiry. And I was part of that inquiry. I was at Parliament on last Monday and was talking to MPs about what I think needs to be done and based on what we’re telling them, they will then report back to the government and say we need to do this. Let’s hope it will work.

What advice would you give to mothers who may be experiencing perinatal mental health concerns, as well as to their partners and family members?

I think for the conditions including postnatal depression, maternal OCD, and potentially birth trauma, the mums should recognise that they’re not functioning the way that they normally do.

I’d always urge the mum to go and talk to the GP

And I would urge them to seek help. One of the problems we get, one of the reasons why mums might be reluctant to tell their midwife, or their GP is the fear of judgment. They are told that they shouldn’t be feeling that way because having a baby’s a wonderful time. So they don’t like to come forward. What people don’t understand is that it’s not the mum’s fault and the mum needs to have the confidence to seek help because she needs that help. The other fear is if she tells her midwife or a health visitor at that she’s got postnatal depression, there’s a risk that the baby will be taken away. But that’s not the right way.

I’d always urge the mum to go and talk to the GP and their GP will know what is available locally to help her. But there are lots of charities out there that do this too, like PANDAS (Pre and Postnatal Depression Advice and Support) and others. Sometimes the mum becomes so unwell, like in postpartum psychosis she doesn’t recognise, and that’s when the family come in. If family members know she just had a baby, they feel her behaviour, mood and anxiety and other things about her being different. Ask her, if she’s okay and don’t just wait for the first answer, which is “I’m fine”. Ask again and keep asking until you’re confident that you know, and if she needs that support, encourage her to go and get that support. If need be, go with the with her to the GP to get that help.

This interview has been edited for brevity and clarity.

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