Day 28. Miles covered: 318.5
Few things in our society are mythologised as much as giving birth. From almost the second you fall pregnant and start looking into both the process of giving birth and into parenthood more widely, you become acutely aware that there are Opinions out there on every aspect of maternity. Worse still for those trying to navigate this minefield, there are battlelines drawn between warring factions that imply you need to make choices between what seem impossible dichotomies that will fundamentally define you as a mother and a human being. From natural vs medicated births, breast vs bottle feeding, routines vs attachment parenting, to stay at home vs working parents, literally everything you make a choice about as a parent is seen as a hugely significant life choice that, made wrongly, will scar your children forever.
The big Catch-22 for parents, but particularly women, has become that you can have it all, but you can only do that successfully in the eyes of the world if you are prepared to be it all. You must simultaneously be the parent who is there at home listening to them read, mopping up their every tear and nurturing every aspect of development, and the one who is demonstrating to their sons and daughters that women can be successful and have careers outside the homes. It doesn’t take a genius to figure out that that’s almost impossible. If you’re at work trying to get that next promotion, society thinks you’re neglecting your children. If you’re at home directing potty-training and singing The Wheels on the Bus, society thinks you’re a flaw in the GDP statistics and should be out making a point by earning your keep.
In so many aspects of our lives, women simply cannot win. Every choice we make is questioned, and when it involves children it’s not only questioned but offered up with trowelfuls of guilt.
It’s perhaps not surprising then that Post Natal Depression (PND) amongst women is reasonably common, underdiagnosed and frequently inadequately treated. It’s not that this kind of social pressure can cause PND directly, but it doesn’t help that vulnerable women, at a stressful time in their lives, feel so much pressure to Get It Right. We are fed this stream of mutually exclusive ideals that make us feel our unsuccessful attempts even to get the children out of bed without someone crying are a sign of our personal failure. And worse, a society which insists there are right ways to do things makes it harder for someone already feeling inadequate to ask for help. Like all mental health issues there is a stigma, but that stigma for PND is worse because we feel we are supposed to be like all those other families out there. To be depressed is just another sign of failure and not something struggling mothers (or fathers) want to admit to.
The first thing to say then is that if you feel you are suffering from PND, you should try to ask for help. Fortunately, to some extent, awareness of PND – at least in the immediate aftermath of birth – is reasonably common. Midwives and Health Visitors will ask you questions about how you feel after the birth. They are aware that PND is a risk and go out of their way (in many cases – certainly in our area) to give you opportunities to tell them how you feel. But for most women PND isn’t obvious a few weeks after birth. Their emotions are on such a roller-coaster anyway that it’s not always clear until later that they have a problem, by which time they may feel they ought to be able to cope. By this stage the midwives and the health visitors have usually gone and you’re on your own.
“I didn’t realise until a long time after. So I didn’t seek treatment at all. I felt very low, weepy, lethargic, small tasks felt like wading through treacle.”
Women who need help at this point – despite the fact it’s commonly shared that PND can appear a year or more after giving birth – will need to come forward themselves. If you are struggling and you are reluctant to seek out support, here are two key things to remember:
- You will not be judged as a poor parent because you are depressed. Depression is not a failure to be a good parent, nor a reaction to failing to be a good parent. Depression is totally unrelated to your parenting skills. In fact, coming forward and acknowledging depression, and seeking help, is a good thing to do. That is not a failure; that is a successful recognition of your own state of mind.
- No-one will take your children from you because you are depressed. You must not be afraid to admit to feeling unwell because you fear the loss of your children if you admit to a mental health problem. Many, many mothers have difficulties, for which they receive treatment of one sort or another, and they then carry on happily parenting their children. Even in cases of post-partum psychosis, after treatment, most women are able to resume taking care of their children fully and successfully.
The other thing to say is that PND, like many other mental health disorders, clearly has a physiological cause, and how that impacts you is beyond your control. When you give birth you go through a significant physical and emotional process. For some the actual physicality is harder than others. When everyone around you talks about wonderful, peaceful waterbirths, and you gave birth sobbing in agony as the obstetrician sucked your baby out in an emergency delivery, it’s hard not to feel you failed in some way. But you must not judge yourself or others for the birth you had or did not have. If you have had a traumatic birth, it was not your fault. Going through a trauma puts you at much greater risk of PND however, and some mothers even experience a form of PTSD (post-traumatic stress disorder) from particularly harrowing experiences. Yet even if you have a straightforward birth, or a calm planned caesarian, you are still at the mercy of your hormones, which can go completely bananas in new and creative ways. It’s no surprise that the balance can sometimes go wrong and women can fall ill with PND. When you put the physical aspect of labour together with the changes in hormones and the new, terrifying responsibility of caring for a newborn, you have a potentially toxic mix of physiological and emotional factors that can result in PND.
We also need to stop mythologising the moments after birth and the newborn phase. There is this expectation around birth that there will be an immediate rush of love, that the pain of labour will instantly fade in the glow of what it has produced, and that you will then spend blissful weeks happily breastfeeding your baby in the comfort of your own bed.
It’s not always like that. In fact, if it is like that, you are very lucky. It is absolutely possible that you will feel immediate love for your child and never want to let them go. On the other hand it’s equally possible you will emerge from labour still in pain, shaking with shock, and even slightly conflicted about the tiny person you don’t know yet who has just caused you to have the most undignified, uncomfortable, agonisingly painful day you’ve ever had. It can take days, even weeks to bond with a baby and you should not feel guilty if that’s the case. It’s not uncommon to wonder if you’ve done the right thing by even having a baby. For some, the responsibility will feel suddenly overwhelming and terrifying. Equally if you have a baby who is very sick and put into special care, the early bonding processes of cuddling and feeding are broken. When your baby is in a box, cared for by nurses and you have to ask whether you can pick up your own child, bonding with them is very complex and your emotions can have even more of a rough ride.
It’s also normal to feel absurdly emotional for some time after birth. Crying at anything and everything and even nothing, especially on day 3 or 4, is perfectly normal. The ‘baby blues’ are a common phenomenon and can cause temporary low moods, anxiety and tearfulness.
“I did have a rollercoaster of emotions post-birth and in the first few months of becoming a Mum.
It was a mixture of euphoria, amazement I was eventually a Mummy and he was here, and abject fear of ‘What on earth do I do with him?’, ‘What do I do if he won’t stop crying?’, ‘How on earth am I going to do this?’, ‘I don’t know what I am doing’, ‘Everyone else knows what they’re doing’, ‘Everyone else looks amazing and I look like a fat blimp’.”
This comment from a mother (who did not have PND) shows not only how common it is to feel overwhelmed as a new parent but also how much of an impact this culture of maternal perfection can have. We believe that everyone else knows, that everyone else is better at this than I am, when the reality is we are all struggling – we just don’t talk about it enough. Or when we do, there is too much judgement and too little support.
However, when these feelings are not fleeting but deeply ingrained, when after weeks or months you are still feeling overwhelmed or simply not yourself, then there is a good chance that something more serious is going on.
As the following real-life stories show, there are some aspects of PND that crop up again and again. The effects of the pressure to be the perfect parent, how often women end up having to self-advocate, and how effective treatment can be when you finally get it.
“I had severe anxiety after having H. I felt in shock after he was born. I also felt I had no idea what I was doing. Couldn’t sleep. Felt completely stuck. It took 8 weeks and a severe panic attack that landed me in A&E to seek help. I put such an immense pressure on myself that I couldn’t function any more. I started taking medication which helped. However I had a relapse when he was one. This time I took medication but also did counselling. This was what really changed my life.”
And again here:
“With B I was diagnosed with post natal anxiety at 6 months after the birth. I also have a mildish PTSD from the birth trauma. Again, I told myself that I didn’t have anything, but by 6 months the lack of sleep, lack of help, birth trauma, and a probably quite traumatised husband took its toll and I was unable to sleep, had a huge knot of anxiety sat on my chest like an elephant, had terribly obsessive thoughts, would frantically search every corner of the internet for the answer to my non sleeping child, staying up all night to do so, weeping constantly, frequent panic attacks. So I took myself to the GP who prescribed sertraline as I was breast feeding. The first week was hellish with a huge worsening of symptoms, but then such relief when the meds kicked in.
I never had a problem bonding with the babies thankfully. But heartily believed I was doing things wrong all the time and there was a magic solution somewhere if only I was a better person and could work it out.”
Even when a diagnosis is made quickly, it’s important to remember that women with PND, like anyone with a mental health disorder, are incredibly vulnerable. They themselves, in the grip of a condition that prevents them perceiving things clearly and rationally, may be unable to self-advocate and even deliberately disguise their feelings.
“My PND was diagnosed really quickly, largely due to the fact that I kept bursting into tears whenever I saw a health professional. I declined any medication because in my misguided way I thought it was best for the baby and no one ever pushed it with me. My overriding feeling throughout it all was that it was now my job to keep this baby safe at all costs and if that meant that I withered away to nothing in the process, then so be it. This was my life now. I was overwhelmed with the sole responsibility for this tiny human. I took everything on myself, refused help, refused to sleep, refused to listen to people when they told me to see the GP, refused to give up breastfeeding even though it wasn’t working. One of my clearest memories is changing my daughter’s nappy with tears dripping onto her little tummy while she smiled and gurgled at me. I just felt so completely despondent all the time and I spent a lot of time gazing blankly into space. The midwife kept me on longer to keep an eye on me but, when I was discharged I think I’d just become better at putting a brave face on. I convinced her I was fine and I was so bright and smiley that she handed me over to the health visitor and I found it easier to keep up the facade with her. Eventually during one of my epic googling sessions I stumbled upon a research project looking at whether online CBT could be effective with PND. I signed up and I think it saved me.
Looking back, I think it was harder for my family and friends than for me because I was numb and they were helpless. More support for families would be good. I think we were all nervous when I decided to have another baby but thankfully I didn’t get it second time round. Maybe because I had better coping strategies. I don’t know. CBT was definitely helpful though.”
These are moving stories, but also show that PND is not just about feeling low after giving birth as it’s sometimes assumed to be. These women are talking about serious feelings of anxiety, about obsessive thinking, about blankness and detachment from the world.
At the most serious end of PND is post-natal psychosis – or indeed antenatal or perinatal psychosis if it occurs before birth. This is an extremely serious condition – rare, but requiring fast, effective treatment. More than 30 years after someone in my own family suffered this, very little has improved in the way it is recognised and treated. When I spoke to Steve Mallen he said that mental health treatment is a hundred years behind physical medicine and when you look at how post-natal mental health is dealt with, it’s not hard to believe that.
One lady who has been through pregnancy and birth related psychosis was brave and kind enough to share her story with me.
“With each child, I experienced really awful perinatal depression and anxiety. Perinatal because it first stretched its suffocating fog across the pregnancies before plunging me into mind-bending, paranoid, irrational terror after my children were born. I’m not sure that ‘depression and anxiety’ adequately describes what happened, in hindsight, I can see that I experienced the kind of depression that bordered on the delusional and psychotic.
I didn’t plan for my baby’s arrival. I wouldn’t allow anyone to mention prams, clothes, baby bedrooms, feeding, or anything that might imply I would be having a real live baby, not because of superstition (I’m the least superstitious person going), but because I KNEW that I would not be getting one. That knowledge, driven by intense fear and feelings of guilt dating back to my past, drove me to the hospital multiple evenings each month, inventing excuses to have the baby’s heartbeat listened to, even reaching the point where I didn’t know I was inventing them any longer, because the only time I felt safe was when the monitor was actually on my baby. I must have wasted literally hours of NHS time.
My GP and obstetrician knew all this but did nothing about seeking mental health care for me.
I spent hours multiple times a week googling stillbirth, baby loss and all things that could go wrong, then waking my husband up in the middle of the night screaming hysterically. I made him drive me the hour long trip to hospital all of those times. He was bewildered, frustrated, at times angry with me, and scared. The midwives were harassed, fed up with me and often nasty. I finally agreed to order baby equipment from the computer at my hospital bedside, the week before I was due to be induced. I made my husband take delivery of it and put it all in the back room covered by a sheet and refused to look at it or allow him to build it.
I couldn’t cope with breastfeeding. A lot of that was a fairly standard tongue tie/jaundice/dehydration cycle mixed with bad advice but it was also about getting put on antidepressants which were not compatible with breastfeeding, and it was also about me having absolutely no self belief at all and truly believing in my heart that I was a sick, diseased individual who couldn’t possibly sustain a baby.
I allowed my newborn (at the time breastfed) daughter to go into hospital with jaundice with my husband while I stayed at home and cycled between crying and staring blankly into space. I couldn’t cope with the constant doctors’ appointments, was exhausted to a level I’ve never experienced before or since, and felt too ashamed of myself to be her mother at the hospital. As a result she was undergoing tests in hospital at only weeks old without me. It breaks me up to this day. But at the time what I mostly felt was relief that I wasn’t there.
After my son was born things got really interesting. I spent two months of his life, starting from day 2-3, psychotically depressed, with strange obsessions and ideas about watching certain TV programmes or listening to certain pieces of music repeatedly. I was sleep deprived, wandering about crying in front of my daughter, in a panic about breastfeeding again, re-traumatised from the first time round without realising it, and once again felt like a shameful, useless human being. Eventually, my husband having failed to notice it was time to trigger the actions I had outlined in my ‘relapse prevention plan’, I had to beg him to seek help for me after I just couldn’t bear to get out of bed to look after my baby son one morning. I spent time crying, howling like an animal for hours on end, rocking back and forward and generally not functioning. I couldn’t eat or drink ,and the GP warned me I would have to be admitted for rehydration if I didn’t start taking fluids. Literally this was the worst period of my entire life. The whole time I felt like nothing but the most worthless piece of shit imaginable. I had a beautiful baby son there and I was failing him every minute, every hour, every day, every night. I DID love him and I knew deep down that I did, but I felt a huge emotional block whenever I actually tried to FEEL it. The only thing I did feel, clear and sharp, when I looked at him was terror.
So – that’s where the guilt, loss and shame comes from. And do you know what? I’m one of the lucky ones. Because I retained enough insight after my kids were born to seek help. I didn’t have to be detained under the Mental Health Act (though if they’d needed to, I hope they would have done it). I did respond to time, and treatment, and medicine. I did have local perinatal mental health services available to me. I did use them. I did feel love for my kids again – massive, indescribable, life changing love that has never stopped. I am a good mum. We had a great time on maternity leave after I was better. And, at just under and just over a year respectively after having my two kids, I went back to work well, and happy, and took back my place in a ‘normal’ life.”
There are two things that really strike me after reading that incredibly raw and personal account. One is that it is appalling that with so many warning signs this woman was not given help at a much earlier stage in her first pregnancy. The hostile attitude of the people in the hospital is indicative of how intolerant we are of the mentally ill before they have a ‘label’ – and sometimes even afterwards. Clearly someone who returns repeatedly for that level of reassurance is not well, but she was viewed as a problem, not as someone who needed help. That attitude needs to change.
The second thing is what depths of depression it is possible to come back from with the right treatment. Even after hitting what feels like rock bottom, it is possible for people to recover if they are given medication, or therapy, or both. If you are suffering from PND, believe that there is light at the end of the tunnel. It can get better. It will not last forever. Hang in there.
The problem is making sure everyone does get the right treatment – or at least the best treatment. Another friend told me how having been diagnosed with PND she was placed on a waiting list for CBT (mentioned elsewhere in this post, CBT refers to cognitive behaviour therapy, and is a kind of therapy that focuses on altering the thinking patterns of sufferers to help them cope with difficult feelings) which took months to offer her a place. When she eventually went, it was not private or targeted but a group session in which she was the only person with PND. Other patients had a variety of issues like alcoholism or bereavement. But for reasons of economy in an over-stretched system, they were all put in together regardless of their specific difficulties. This is exactly what is wrong with mental health provision in this country. It’s badly organised, badly funded, badly targeted and therefore less effective than it ought to be.
Post-natal depression can strike anyone after giving birth, and depression and anxiety can become problems even during pregnancy. I’m sorry we haven’t given more time to men here, because they too can suffer from it in the aftermath of becoming fathers, particularly if they’ve watched their partners suffer traumatic births. But there are some things you can do to increase the chances of getting treatment early on and to recognise what is happening to you. All these are suggestions from one of the above women who shared her story.
- If you have a history of depression either in yourself or in your family, get this put in your pre-natal notes and bring it up with your midwives and doctor. If you are at risk of developing PND or psychosis you should be given access to support via the perinatal mental health team. This NHS guide sets out what you can do to make sure you get the support you need.
- Find a way to monitor your emotional state during pregnancy to help you and those close to you highlight any potential problems. With everything going on during pregnancy it’s sometimes hard to remember how long you’ve been feeling a particular way. Keeping a mood diary or chart or simply recording how you feel on a scale of 1-10 each day can help you monitor your wellbeing.
- If you have risk factors for depression, make a plan for what will happen before during or after birth if you become unwell. When you are in a good place, make notes on what helps you when you are in a bad place so that others around you know what to do. You may get to a point where you cannot self-advocate – you need to empower people to be able to make the right choices for you if you cannot make them yourself. Try to ensure your loved ones feel confident about knowing your mental health themselves so they know when they need to step in and can also tell you of their concerns. Help on doing this can be found online, including the WRAP plan here.
What then do mothers (and fathers) need to happen to ‘fix’ this in terms of society’s treatment of PND? In my view, all of the following:
- We need more money put into research and therefore better research done into the specific causes (and therefore the risk factors) of PND and post partum psychosis.
- Those risk factors need to be specifically and effectively communicated through community midwives and frontline ante-natal services to all pregnant women, and ideally their partners so that at-risk women can identify themselves and be identified by those managing their care.
- Much more specific and targeted information about the symptoms of PND needs to be given to mothers and their partners if possible, and not just in the immediate aftermath of birth.
- At-risk women should be supportively monitored by health visiting staff for longer periods, and all women and their partners should be made aware of whom they can contact if they are concerned about their emotional wellbeing.
- A study in 2010 suggested that properly trained health visitors can make a significant difference in lowering rates of PND in new mothers. However not all health visitors are trained fully in mental health support and their numbers are in decline. We need better recruitment, retention and training of health visitors to provide successful support for those struggling with PND – and hopefully prevent its further development.
- Treatment for PND and psychosis needs to be better researched and more specifically targeted. Where some women will benefit from medical treatments, others will be better off with talking therapies and approaches like CBT. Both of these should be options and available soon after referral, not after weeks and months in situations where the mental state of vulnerable women can easily go downhill. Ideally therapies should be offered to individuals or in sensibly structured groups of women with PND who might conceivably understand how they all feel, not in groups comprised of people with different types of depressive or anxiety disorders.
- We ourselves need to be more open about the way we talk about PND. It should be considered another potential physiological symptom of the perinatal state and something women can talk about like they do their episiotomy stitches or their awful haemorrhoids. None of those things are pleasant, but it is ridiculous that women should feel PND is a sign of weakness. We don’t consider how many haemorrhoids we end up with as a sign of our rectal insufficiency – why should our mental health be any different? We need to get away from the stigma that attaches to PND and especially psychosis – we still treat people like the stereotypes of the ‘mad’ in centuries past in a way that is completely unacceptable.
- We need a radical overhaul in attitudes of employers to women with children both during their maternity leave and on their return to work. That’s a big feminist topic perhaps for another day, but the additional pressure put on mothers – and to some extent fathers – with children to look after is not helpful.
- Finally we need to stop judging women (and parents in general) for their parenting choices where they do not directly effect us or our children (which is most of the time). I make the caveat that if someone’s inability to look after their child puts that child (or somehow your child) at risk of harm, clearly they need help, but the vast majority of choices that people gripe about have next to no impact on anyone bar their own sense of propriety. I’m probably as guilty of this (certainly internally) as the next person, but if we all made an effort to stop doing it then it might help. And certainly the media and society as a whole could do with talking much less about things like what women look like after giving birth and whether they are going back to work or not. We need to stop perpetuating these myths of what motherhood looks like and instead promote a greater sense of realism.
Maybe all this is impossible. It will take money invested in mental health services for a start, which seems like something nobody wants to do. As I have said elsewhere on here however, it’s economically shortsighted not to do it. Women who come out of childbirth with healthy minds and bodies are in a much better position to go back to work and juggle (as they inevitably have to) childcare and work. They will be more successful and contribute more to the economy (if we must address it in those terms) from positions of mental stability. Their longterm health will be improved with earlier, better treatment, saving the NHS money in the longterm. The partners of those suffering PND equally undergo stress and emotional turmoil at this time, putting themselves and their jobs at risk and storing up possible physical and mental health problems of their own. Most importantly the impact of mental illness on children when it’s at its worse can be devastating. Through better treatment, the impact of PND on children can be minimised and lessen the chances of them developing their own mental health issues as they grow up.
Someone needs to do something about all of this, through a combination of money, research and re-organisation. It would be madness not to.