Last reviewed 5 August 2015
Perinatal depression is the term given to cover depression that occurs during pregnancy (it can be known as antenatal depression) or once the baby is born (normally referred to as postnatal depression or PND). Liz Hodgman, early years’ consultant and mother, explains that perinatal depression is common.
About 10–15% of women experience ante or postnatal depression. It is quite normal for a mother to be emotional following the birth of her baby. Many mums experience feeling weepy and irritable during this time. It is thought that this is due to the hormonal levels two to four days after birth. The hormones that were high during pregnancy are no longer needed by the body and their levels drop dramatically.
At the same time, the body produces hormones that promote bonding and the production of milk. This can leave mum confused and emotional. She may already be feeling overwhelmed at the responsibility of being a parent. The baby blues can also be a result of problems for the baby, such as feeding difficulties or jaundice. Both can be easily resolved but can cause new parents anxiety. Lack of sleep and exhaustion following the birth can add to these feelings.
These feelings normally pass in a few days without any medical intervention.
What is postnatal depression?
PND normally develops within the first six weeks of giving birth but often is not obvious until the baby is about six months of age. This condition affects women from all ethnic groups. However, teenage mothers are particularly at risk. The symptoms vary from woman to woman and can include difficulty in sleeping, feeling unable to cope or feeling in a low mood.
Puerperal or postnatal psychosis is a far more serious form of PND. It is rarer, affecting around 1 in 1000 women. The mother can have bipolar-like symptoms, ie feel very happy one moment and then very depressed the next. She may experience delusions (believing things are not true or very illogical), for example thinking that her healthy baby is dying or has magical powers. She may experience hallucinations. This may include hearing voices telling her to harm her baby.
This is a serious condition and therefore must be treated as a medical emergency, especially if there is the risk of imminent harm to the woman, baby, partner or others.
Prenatal or antenatal depression
This type of depression occurs during the pregnancy. The symptoms women have include guilt, chronic anxiety, crying, lack of energy, worrying over relationships and their partners leaving them, conflict with their own parents, isolation and fear of asking for help.
It is thought that there are three main causes of prenatal depression: physical, emotional or social.
The woman’s body undergoes significant changes during pregnancy, Mothers-to-be can experience weight gain, swollen breasts, dizziness, nausea, lack of energy, aches and pains … the list goes on. The change in hormone levels (oestrogen and progesterone) increases the need to urinate, causing breasts to swell and morning sickness. However, once the levels are more settled they can create a sense of wellbeing and “blooming”. But not all women produce enough progesterone and this can cause depression.
Emotionally, being pregnant, especially for the first time, involves a complete change of life. This can magnify problems in relationships with partners and even parents. Planning for parenthood can bring back memories of childhood which are not always happy.
If the woman has experienced a miscarriage or stillbirth in a previous pregnancy this can make her more anxious and fearful when next pregnant. This depression can be linked to loss and grief.
Socially, prenatal depression has only recently been recognised, so many generations still have the attitude: “just get on with it”. Families have changed and no longer are there large families with many generations living together. This means that, often, new parents do not get the same support from their family.
Women have more pressure within the work environment and are now expected to juggle being a parent and continuing with their career. Other women may also be facing pregnancy alone and the daunting task of being a lone parent. Other women may be worried about the financial pressures having a child brings, with time off for maternity leave and the cost of all the equipment and resources needed.
The majority of antenatal depression disappears once the baby is born. However, about one-third of mums will go on to have postnatal depression.
What are the symptoms of PND?
A woman may feel in a low mood or sad, she may not be interested in what is going on around her. She may not enjoy things that she previously did and have a lack of energy, feeling tired all the time.
She may experience other symptoms such as sleeping problems, difficulty concentrating, struggling to make decisions, have low self-confidence, poor appetite or comfort eating, feeling agitated or not bothered, guilt or self-blame and in more serious cases thoughts of self-harm or even suicide.
A practitioner might notice the following in a mother, which might signify PND.
Frequently crying for no obvious reason.
Having difficulty bonding with her baby. How is she when she comes to pick her baby up after the session?
Neglecting herself — for example, not washing or changing their clothes. Is she wearing the same outfit every day?
Losing all sense of time — for example, being unaware whether 10 minutes or two hours have passed. She may arrive at the wrong time to collect her child.
Losing all sense of humour and not being able to see the funny side of anything.
Worrying that something is wrong with the baby, regardless of reassurance. She may be constantly making doctors’ appointments and keeping her baby out of the provision.
What will be the impact on the baby or child?
There has been lots of research over the last few years that provides evidence that PND can have a significant, negative impact on a child’s development. This is through the effects of the mother-infant relationship. These children are more likely to experience an insecure mother-child attachment and the resulting insecurities impact on the quality of the child’s social and emotional development from birth into adolescence.
Lack of stimulation, because mum has postnatal depression, can have an impact on the child’s emotional wellbeing. This can be seen clearly in the “still face experiment” by Edward Tronick (first seen in 1975).
Why is it important for practitioners to identify possible PND and respond appropriately?
Practitioners may identify antenatal depression in pregnant women using the provision for an older sibling, as well as PND in mums and dads bringing their younger child to the provision post birth.
Postnatal depression is a temporary condition that can be distressing and frightening but it can be treated and recovered from. However, it is unlikely to go away without treatment and support. Therefore, any family identified with this problem needs to be supported to access treatments that are available. This may include medication, talking therapies (counselling/CBT, etc) or self-help (advice from support groups or internet and family). It is important to remember that PND can have a long-term significant impact on the baby or toddler.
Raising concerns to a parent about possible PND needs to be done sensitively and preferably by a member of the staff team that the family know and work well with.
What can childcare practitioners do to provide appropriate support?
What support is offered will very much depend on how well you know the family and your relationship with them.
Listen. Make time to listen to a mother (or father) if they want to talk. Use active listening techniques and ensure they feel understood and supported. Be non-judgmental, allowing them to talk about their worries and feelings.
Encourage them to seek professional support, making an appointment with their GP.
Encourage them to talk with other new mums and dads. They may gain reassurance hearing that other new parents have some of the same anxieties and concerns that they do.
Encourage them to make some time for themselves, perhaps while the child is in the provision. Suggest doing some exercise each day. This could be just going for a walk with the pram. Research shows that exercise has a positive impact on mental wellbeing.
Encourage them to eat healthy and nutritious meals. A poor diet or missing meals can add to irritability and tiredness.
Ask if they can get any support from families and family around the home with the house keeping.
Where do we refer women to?
There are several sources on information and support online (see links below). Your local NHS will provide a perinatal mental health service and you will need to find out more information on this. How are women referred to them? This is usually by a GP, but this can vary from Trust to Trust. A GP will normally ask a mum if during the last month she has felt down, depressed or hopeless. Has she taken little or no pleasure in things that would normally make her happy? If the mum answers yes she is likely to have PND.
There is a more formal questionnaire that is sometimes used by GPs and health visitors to assess if a mum has PND, which is the Edinburgh Postnatal Depression Scale.
Research to see what services are available locally — there may be a support group or help available through your local children’s centre.
Men and postnatal depression
Postnatal depression is not just experienced by the mum — dads can get PND too. This is sometimes referred to as Paternal Depression. Although the father will not experience the hormonal changes that a women does following birth, he may well feel overwhelmed by the responsibility of the new baby, supporting his partner (especially if she has PND), increased financial responsibility and changes to lifestyle. Sleep deprivation and having to take on a greater role within the home may also impact on the father’s emotional wellbeing.
The symptoms experienced by men are very similar to those that women experience. They may feel despondent, tired and lethargic or even numb. They may feel unable to cope and then guilty that they are not coping. They may feel they are not loving their baby enough. They may experience panic attacks right through to more severe symptoms of considering harming themselves or their baby.
Fathers Reaching Out is a website especially for fathers who are seeking support.
Action plan for a provision
Training — ensure all staff working within the baby rooms are familiar with the symptoms of PND and feel confident to raise concerns with the room leader.
Develop baby room leader’s skills to be able to sensitively raise the issue of possible PND with the mother or father.
Supervision — ensure that PND is a regular focus within supervision meetings with baby room staff.
Research what support is available locally and what the referral pathways are.
Obtain information for parents to access and provide copies in the provisions literature. Include links to support on provisions website and literature.
Have a keyworker ensure that the baby or toddler is given appropriate levels of stimulation and his/her development is monitored closely to reduce possible PND impact.