One of the most common complications of pregnancy, debilitating Post-Partum Depression (PPD), which often sends new mothers into a downward spiral of despair, is highly treatable and avoidable.
Figures available from abroad indicate that some 10 to 15 percent of women will be afflicted by PPD in the first year after giving birth. Local experts agree that these figures are also representative of the South African population. A recent study carried out by the PPD Support Group also showed that depression can begin before the baby is born. Fifty percent of the women in the study were depressed during pregnancy and in no cases was it picked up.
Yet despite the considerable number of cases, the condition generally remains undiagnosed and untreated, with mothers dragging themselves through each day without any end in sight!
The condition is generally glossed over in childbirth preparation classes and pregnancy guidebooks, and is not routinely screened for in post-partum check-ups. During the check-ups, the focus is very much on the mother’s physical health rather than her emotional wellbeing. Dr Frans Korb, a local expert, says it is important that the medical profession do not overlook this very common problem with the new mother’s health. Failure to do so means that the new mother is left to struggle alone with her feelings.
However, studies show that the women who do speak out often battle to find a practitioner who takes their complaint seriously. This often stems from ignorance on the part of the medical practitioner or lack of time or unwillingness to ask more probing questions.
Depressed mothers are often weepy, anxious and easily upset, exhausted but unable to sleep. They may have physical symptoms typical of anxiety as well, such as racing heart, rapid breathing, tremors, dizziness, and even panic attacks. They worry obsessively about their baby’s health, while feeling guilty about their own insufficient love and inadequacy as caretakers. Some fear they will harm their baby, although few do. Many are too ashamed to talk about their symptoms, except the physical ones.
Susan, a PPD sufferer in Cape Town, describes the psychological trauma of the disorder: “I go from day to day clutching onto straws. I still haven’t regained my former self - I used to be a teacher but I can’t do that anymore. I feel like I am going to land up begging on the streets. The only thing that still gives me any joy is my baby.”
Three categories of PPD are generally acknowledged.
Postpartum blues: a weepy, irritable, episode lasting several days, is estimated to affect about 70 percent of women during the first week after delivery; it goes away on its own and rarely requires more than a few days of rest and support.
Postpartum psychosis: at the other end of the spectrum, it progresses quickly from irritability to irrationality. Symptoms include mental confusion, increased activity, hallucinations and even threatening behaviour towards the infant. This condition, which affects about one in a thousand women, most often in the first four weeks after delivery, requires immediate medical attention and usually hospitalisation.
Postpartum depression: lies somewhere in between post partum blues and psychosis. Characterised by crying, irritability, apathy, anxiety, lack of appetite, inability to sleep and highly impaired concentration and decision-making, it typically begins in the first three months after birth. Experts say if symptoms of PDD persist for more than two weeks professional help should be sought.
Experts such as Dr Korb agree that early treatment is the key; while the worst symptoms may ease over time, some doctors believe that untreated depression leaves women and their children vulnerable to future depression.
Experts also warn that mothers with PPD have a higher proportion of babies with health problems, including failure to thrive. Studies have shown that if the mother is treated, the babies recover too.
Depressed mothers often torture themselves as to why the birth of their child, an ostensibly happy occasion, could lead to such despair. Researchers have speculated that an unplanned pregnancy, a difficult pregnancy, complications during delivery and giving birth to twins or triplets make a woman more prone to PDD. Unfortunately studies have not borne out these theories.
Instead, researchers now suspect that the illness may be triggered by the hormonal shifts occurring after delivery and which are greatly exacerbated by the stress of a major life change. They say it is likely that with some women, the precipitous drop in oestrogen and progesterone after birth disrupts the normal functioning of neurotransmitters in the brain.
Though physiology is involved, treatment with psychotherapy may be all that is required for women with mild symptoms. Counseling often includes the spouse and sometimes an evaluation of the mother-infant interaction.
The mother is helped to develop coping skills and to resolve any interpersonal conflicts, such as the level of her husband’s involvement with the child. This is often a source of conflict, given the traditional approach adopted by many South African fathers whereby the wife takes care of the children’s needs.
For new mothers with more severe symptom, the treatment usually entails a combination of psychotherapy and anti-depressants. Mothers who opt for medication usually start feeling at least marginally better after a month or so, but they should expect to stay on medication for up to a year after their symptoms disappear.
Women who choose to stop breast-feeding may be able to use oestrogen therapy as an alternative to anti-depressants. The use of oestrogen patches, while still experimental, has produced very positive results.
But experts agree that the most important aspect of the problem is the need to educate patients and doctors. Patients should be taught to recognise the symptoms and doctors to ask about the new mother’s well being.
Liz Mills, head of the Post Natal Depression Support Association of South Africa (PNDSA), says she is “concerned that so many women who are so well-educated don’t know enough facts about PPD.” She says that women need to be better educated both physically and emotionally when it comes to childbirth. “It is important that, in preparing for having a baby, the mother makes detailed plans for support after the pregnancy.”
Women at particularly high risk are those who were depressed after a first child, or those having a personal or family history of depression.
Some pilot studies done abroad show that doctors can achieve a very high rate of prevention by administering anti-depressants to high-risk women immediately after delivery. Further studies are necessary to confirm these findings, so for now, the watchwords are education for mothers-to-be, and medical practitioners asking those probing questions!