The World Health Organisation states that there is no health without mental health. The physical aspect of pregnancy and postpartum recovery has received lots of attention, but  little attention has been paid to a woman's mental health, despite the evidence that depression is the most common complication of pregnancy. Maternal mental health day, marked in May, was created to increase awareness and reduce the stigma surrounding mental ill health.

 

What is understood by maternal mental health?

Maternal mental health is understood as the mental wellbeing of mothers as they go through pregnancy and the first year postpartum. We usually refer to this period as the perinatal period. Research and experience show that this when mothers are most vulnerable to mental health issues. Perinatal mental health incorporates the emotional well-being of the mother, the father and the infant, as all are deeply effected in this time.

The changes that occur during pregnancy and the postpartum are psychological, social, environmental and physical. All together, these factors increase a woman's susceptibility to mental health problems. The most common maternal mental health issues are depressive and anxiety disorders, including obsessional compulsive disorder and general anxiety disorder.

Meanwhile, around 80% of women may experience postpartum blues.  This is a brief period, usually starting 3-4 days after birth and lasting approximately ten days, where the woman experiences mood swings, sadness and bursting into tears easily, irritability and feeling anxious at times. Normally, there is no need for treatment. However, if the condition does not subside, then a depressive disorder is considered.

There are also other psychiatric complications which can occur in this period such as post-traumatic stress disorder (usually after a traumatic birth or complications during pregnancy and delivery) and postpartum psychosis, which is a rare disorder.  

Are mothers sufficiently supported during pregnancy and after giving birth?

During pregnancy and the postpartum period women have frequent contact with health professionals, such as obstetricians, midwives, general practitioners and paediatricians. This provides a window of opportunity for detecting and treating any emotional stress. The mother's main concern is usually the wellbeing of the child, but the changes she goes through can affect her not only physically but also emotionally. Support during this period is crucial.

Partners, family members, and friends are usually a mother's first line of support. When this is not sufficient, or not available, there are services to offer support. However, for support services to be useful, disorders or stressors need to be detected as early as possible. We know that this is not always the case and that there are mothers with difficulties which remain undetected and untreated. Unfortunately, reaching out for support carries a stigma. A woman might feel uncomfortable about reaching out for professional support or even about reaching out to family and friends.

That is why we feel it is so important to educate people and raise awareness of the changes, experiences and difficulties a woman may face in the transition to motherhood, a time which is popularly associated with joy and happiness. As professionals, we do not only want to reach out to the mothers, but also to those who are in close contact with her, such as her partner, family members and other professionals.

There is also increasing research into paternal mental health issues. We need to remember to also support the father in this vulnerable time, especially when the mother is psychologically distressed.  

 

Is there enough screening in place to ensure that warning signs do not go unnoticed? 

So far, there are no formal screening procedures in the obstetric services. However, midwives ask basic questions regarding the women's psychological wellbeing when she registers to give birth. These questions deal with any history of depression and whether she is under any psychiatric treatment. In Malta, there is only one perinatal mental health service that runs once a week. However, a lot of support is given through other services such as the Parent Craft service, Breastfeeding Clinic, bereavement midwife and discharge liaison service at Mater Dei Hospital.

Internally, research shows that over 75% of women are not diagnosed and do not receive adequate treatment and support. No research has been done in Malta on such statistics, however, we try our best to advocate for early identification and treatment so that we can decrease the negative impact of mental disorders on the mother, the father and the infant.  

 

Would you say there has been an increase in the number of mothers being referred for support and treatment?

Literature in Malta shows that, due to our close communities, mothers are able to receive increased support through the community. Within the perinatal mental health service, we have seen an increase in the number of cases which are referred for support and treatment. This can be interpreted as the result of increased awareness among health professionals working closely with mothers.

Risk factors for mothers not being able to cope well during this time include a history of mental health issues, history of antenatal depression or anxiety, problems in the relationship or marriage, lack of support, financial difficulties, history of traumas, isolation, stressful life events and poverty.  When these risk factors are identified, the services tackle these issues through referrals to the appropriate services.

It is important to remember that, when a mother feels that she is finding it hard to cope or not coping at all, the services are available and very willing to help. Such difficulties in coping are known to affect not just the mother, but also on a family level, including the father's wellbeing, the child's emotional, cognitive and physical development, the couple's relationship, as well as the attachment between the parents and the child.  

 

What is the way forward?

A perinatal mental health strategy is needed to screen women, both during pregnancy and postpartum, for risk factors and to detect emotional disorders. Early detection is crucial to minimise the distress caused by emotional difficulties during this period.

Health services in Malta generally do not consider the father's mental health difficulties and increased distress. Including these factors within the services would not only help the father within this period, but also the mother and the child. Afully inclusive practice that can address the family system as a whole is still needed. 

 

Who does one turn to for help?

Support is one of the best treatments for emotional distress and it does not always have to be professional. A supportive family structure is crucial in helping the mother through her distress. Sometimes professional support is needed and there is no shame in that. Reaching out to a trusted health professional, such as your family doctor, who you are comfortable with, can be a start. Your doctor can then refer you to the appropriate services.

Since the mother is usually in close contact with midwives and their obstetricians, turning to them for support and guidance is also an option. Further to this, there is a specialised service within the Antenatal Outpatients Clinic at Mater Dei Hospital. The Perinatal Mental Health Service includes psychiatrists and psychologists and social workers who are available to provide support.

Dr Ethel Felice is a consultant psychiatrist and expert in perinatal mental health. She forms part of The Association for Child and Adolescent Mental Health - ACAMH Malta. The association held a maternal mental conference in May in which President Marie-Louise Coleiro Preca called for stronger synergies between civil society and national authorities to implement policies to safeguard early detection and treatment of maternity-related mental illness.