“To describe my mother would be to write about a hurricane in its perfect power. Or the climbing, falling colours of a rainbow.” – Maya Angelou, American poet and civil rights activist
Being a mother is not easy. It reminds me of the hurricane of emotions in her life. As a psychiatrist, I try to convert that hurricane into a rainbow of emotions.
Why this hurricane? During pregnancy and postpartum period (six to eight weeks after the birth of a baby), most women experience a range of overwhelming emotions — excitement, happiness, fulfilment. Many also experience anxiety, frustration, confusion or sadness. The postpartum period makes new mothers vulnerable to various psychiatric disorders like postpartum blues, puerperal psychosis or postpartum depression.
I remember seeing a mother about a year ago. She was admitted to a general hospital just four weeks after her delivery. She had become fearful that her in-laws were against her and her child, that the family would harm her and take away her baby. She became aggressive and violent and tried to beat her brother-in-law. Due to her behaviour, her husband sent her back to her maternal home where, too, she behaved aggressively, shouting continuously, and was admitted to hospital.
She was suspicious about the hospital staff too, so my intervention was sought. I tried to explain her condition to her maternal family and her husband. The latter abandoned her; he did not understand the illness. But her maternal family continued the treatment. She improved and after three months her husband and his family accepted her. Now she is better and has assimilated with her in-laws and the family. This was postpartum psychosis (PP).
A 26-year-old mother was brought to my OPD by her husband and her father. She had delivered a baby 10 days earlier. Initially she was excited about the baby but in three or four days, her behaviour changed dramatically. She would not sleep at night, would sit idle, and did not care for the baby even if it was crying. She would not get up from the bed and was disinterested in meeting any family member. She would say she won’t be able to do anything, and was incapable of raising a child. She was slow to react to my questions. Tears rolled down her cheek but she showed no emotions. She had a blank gaze.
This young mother had postpartum depression (PPD). According to her father, she used to be very talkative and cheerful. She had been extremely happy about her pregnancy and had prepared a lot for the baby. Her father was dismayed at the drastic change in her.
Many such perinatal mental illnesses are under-diagnosed and undertreated and go on to have great societal ramifications. There are often reports about mothers harming, throwing or even killing their newborns. Sometimes this is followed by the mother trying to take her own life.
According to scientific studies, infanticide and suicide are observed in 4% and 5%, respectively, of women suffering from PPD. Enquiring about suicidal and infanticidal thoughts is crucial during assessment of women suffering from PPD.
PPD is seen in 1 or 2 out of 1,000 childbearing women within the first two or four weeks after delivery. The onset of PPD can be sudden. It is seen as early as two or three days after delivery. The patient can be suspicious or more talkative, with inflated self-worth or showing bizarre behaviour. There can be mood swings, confused thinking and gross disorganisation. There can be a dramatic change from her previous functioning. Postpartum depression is observed in 10-13% of new mothers and maternity blues is seen in 50-75% of postpartum women.
In rural India, PPD was seen in 11% of mothers. In adolescent mothers, it is around 26%.
Postpartum psychiatric illness is seen more commonly (81%) in mothers below 25 years of age. A family history of mental illness was present in 25% of cases.
The third important illness is postpartum blues (PPB). PPB is characterised by frequent crying episodes, irritability, confusion and anxiety. However, elation might also be observed in the first few days after childbirth.
PPB is more commonly seen in Western countries because of the lack of strong familial support and bonding. It can be as high as between 40% and 85%. The symptoms arise within the first 10 days and peak around three to five days. Generally symptoms of PPB do not interfere with the social and occupational functioning of women. PPB is self-limiting with no need for active intervention beyond social support and reassurance from family members. It can be attributed to changes in hormonal levels of women, compounded by the stress following delivery. However, PPB persisting for more than two weeks may make women vulnerable to more severe mood disorders.
Postpartum illnesses are caused by marked changes in the female hormones progesterone and oestrogen. After delivery, there is a drop in these hormones. Drop in oestrogen markedly affects the neurochemicals in the brain, serotonin and dopamine, causing mood changes and psychotic symptoms.
Pregnancy and motherhood come with a lot of psychosocial changes. The woman has to adjust to her body image, her relationship with her husband and family members, and her responsibilities.
Risk factors associated with the development of postpartum disorders are:
* first pregnancy
* unmarried mother
* Caesarean sections
* unplanned pregnancy
* perinatal or natal complication
* history of psychotic illness
* history of anxiety and depression
* family history of psychiatric illness, especially mother and sister having postpartum disorders
* previous episode of postpartum disorders
* stressful life events, especially during pregnancy and near delivery
* unsupportive spouse
* history of sexual abuse
The prognosis of postpartum disorders is generally good if diagnosed early and treated adequately. Between 75% and 86% of women experiencing these disorders remained symptom-free.
The relapse rate in subsequent pregnancies can be as high as 40%. Women who sought help within a month of delivery had more favourable outcomes and were less likely to suffer long-term disability as compared to women with late-onset postpartum disorders.
Untreated postpartum illness has an adverse effect on the mother-child interaction and attachment. There is a high rate of untreated and unrecognised postpartum mental illness. It has adverse societal as well as mother-child ramifications but it is easily treatable, with favourable outcomes. Early diagnosis is the key.
All doctors, especially obstetricians and gynaecologists, should routinely check the psychological status of the mother. Society too should play its part and not ignore the slightest emotional or behavioural changes in the mother in this period.
Dr Shailesh Umate is a consultant psychiatrist, sexologist and addiction specialist, whose mission is spreading awareness about mental health and well-being
