Motherhood’s Little Known Secret

Posted on June 9, 2015


As written for The Ceylon Today [June 2015]

Post Partum Depression [image via The Daily Mail]

Post Partum Depression [image via The Daily Mail]

Pavitra was known among her friends and family as cheery by nature. As an accomplished an optimistic young woman, it was only natural that she was ecstatic at the news of her first pregnancy. It came as quite the surprise then, when following the birth of her first born, this otherwise lively person was transformed into someone neither she nor her loved ones could recognise.

‘’I alternated between wishing I would die and then feeling terrified that something would happen to me, leaving my newborn son without a mother. I was chronically sleep deprived, but when my son finally went to sleep, I lay in bed wide-eyed, jittery and unable to sleep or stay asleep for very long. I would hear him crying for me –even if he was dozing peacefully or out for a walk with his father- and the sound of his wailing haunted me.’’

Postpartum Depression, or PPD, affects approximately 30 per cent of Sri Lankan women. An unfathomable statistic in a society where the mother is glorified, and the ‘journey’ that is motherhood is oft associated with great joy and a sense of fulfilment at the thrill of nurturing a new life.

While these sentiments are more often the norm, some new mothers have good reason to feel depressed. For some, the birthing process in itself is a harrowing experience, and once home the drastic turn their lives have now taken, expectedly a shift to a more meaningful life, is instead a swerve to a road downhill. She is over come with the looming expectations of motherhood, her family isn’t there to assist with the baby, nor is her partner available for the emotional support she so direly craves.

As a result the woman feels overwhelmed, detached and inadequate.

Consultant Community Physician and National Programme Manager for intra natal and newborn care at the Ministry of Health, Dr. Dhammica Rowell, has conducted extensive research on Postpartum Depression in Sri Lanka.

‘’There are three types of psychological conditions we usually identify in post partum women,’’ she says. ‘’The most prevalent –detected in about 50 percent of women- are the postpartum blues, or what we all know as the ‘baby blues.’  This is usually detected within the first few weeks after delivery, but is a transient condition and often wanes off.

Postpartum Depression on the other hand, usually sets in a few weeks after and can last for months depending on its severity, and if not detected early.

The third condition is what we term postpartum psychosis. It is an extreme mental condition and is thankfully very rare, with a prevalence of less than 1 per cent in our women.”

While the symptoms of the baby blues are taken lightly, and the tell-tale signs of postpartum psychosis are glaringly obvious, the manifestations of PPD vary.

According to Dr.Rowell, ‘’If a woman is suffering from the more severe form of the condition, it is naturally much easier to identify. The mother is often withdrawn, and harbours a lot of negative thought. She loses interest in herself and even in her baby. There is  drastic weight loss as a result of a loss of appetite and a lowered self-esteem as a result of a heightening feeling of inadequacy in caring for her new baby.’’

‘’The milder form on the PPD spectrum is more challenging to spot,’’ Dr.Rowell adds. ‘’And this is why awareness of PPD is so important, because the symptoms are more subtle and often sensed solely by the mother herself. She may feel low, irritable, and susceptible to bouts of crying for no fathomable reason. The mother feels that she isn’t her normal self and doesn’t feel that sense of happiness that new mothers usually do.’’

Postpartum depression in itself varies in its severity, and while researchers and psychologists have found it difficult to put a metaphorical finger on what exactly makes one mother more inclined towards it than another, the suspected causes are manyfold.

In Sri Lanka, low familial support is one of the largest contributors to PPD. Women in nuclear families for instance, are more susceptible than those cared for in an extended household. Gender based violence and/or an unsupportive or abusive partner, and even the inevitability of an unplanned pregnancy can abet deterioration in puerperal mental health. Socio-economic factors such as low levels of educational and a lower social standing can also be to blame.

‘’We have also found that women who have undergone normal vaginal deliveries are more prone to PPD than those who underwent a Caesarian delivery. We interpreted this as probably due to the fact that in the case of the latter, a woman is given more attention and care than if she underwent the former.”

Additionally, in the age of social media and online pretences, women are often prone to self-doubt and worthlessness by being privy to the sometimes exaggerated feelings of rapture that other mothers portray which heavily discount the reality of the experience. The fatigue and anxiety involved for instance, or even the occasional bouts of frustration – all of which are completely normal. The shift to parenthood calls for a readjustment of priorities and a considerable alteration in identity which some women (and even men) aren’t counselled into preparing for, hence the grapple with emotions after a birth.

Considering the fact that the tendency for the average Sri Lankan woman to succumb to PPD is higher than her Western counterparts, is the country equipped to detect and treat this psychological condition?

‘’Yes,’’ Dr. Rowell is confident. ‘’Right now, every mother in our country admitted to a government clinic, is at the time of discharge, examined by a medical officer and has her physical as well as mental state assessed. Our field midwives have been educated on the symptoms of PPD, and on their home visits (at least two every ten days) know to look out for its tell-tale signs and refer the mother to the Ministry of Health if they feel that she is susceptible. Also, one month from the time of discharge, every mother has been instructed to visit a post natal clinic for a follow up. Here they will be administered with an instrument to measure for PPD – the Edinburgh Post Natal Depression Scale, and treatment will be prescribed accordingly.’’

There are many things that can ease a depressive woman out of PPD, but first and foremost it involves the acceptance of her condition, ideally at an early stage. Treatment then progresses to counselling.

“Counselling involves the inclusion of her spouse and family as well, elaborates Dr. Rowell. “They need to be educated as well, and their active support encouraged. In most cases where this has been achieved, the condition won’t be allowed to progress to a more severe stage, and psychiatry will not have to be resorted to.”

In the past there has been the odd instance of maternal suicide and infanticide as a result of PPD gone unchecked, but Dr. Rowell is reassuring. “The rate of suicide in the country has drastically come down over the years, and this includes maternal suicide and infanticide. And it is most certainly not increasing. This degree of mental illness falls under the remit of postpartum psychosis, and while it is extremely rare to come across these instances, it is unfortunate that it sometimes does happen. These cases are not easy to deal with. The mother has to be monitored at all times and has to be treated with medication.”

While there already is a ‘game plan’ laid out with confidence for the detection and treatment of PPD, its prevention is not as easy. What makes deterence so hard to thwart is that it requires taking well-embedded societal malaises head-on.

‘’In  government hospitals, women are encouraged to visit ante-natal clinics where the mothers are educated on different aspects of their pregnancy. Again, we encourage their spouses and extended families to attend as well as it isn’t enough that just the woman is informed.”

The clinics subsequently become opportunities for peer education, when these issues are discussed among others outside of the clinics as well.”

Significant triggers such as alcoholism, abuse and poverty, whether intertwined with or independent of the other require long term policy measures. An attitude of respect towards women and as a result the prevention of gender based violence for instance, is the product of a stable home. Education for children living below the poverty line needs to be facilitated, the national poverty threshold in itself needs to be lowered, and family planning programmes need to be established.

However, the state of awareness of PPD in the country is improving, although this can most certainly be bettered further. Many are unaware of its existence let along its prevalence, and the social stigma attached to a mental illness prevents most women from voicing out their suffering.

While it may be considered normal to be overwhelmed at first with the physical, mental, and emotion baggage that comes with having a baby, it is important to be able distinguish between ‘just baby blues’ and PPD. Postpartum Depression is real, and this melancholia is often suffered silently for fear of shame or being deemed inadequate as a mother. If these women aren’t encouraged to come forward and have their struggles validated, the delay or even absence of treatment can affect not just the mother, but potentially the health of her baby as well.

The rose-tinted glasses through which we view motherhood calls for a replacement with a new lens – one which accommodates and is accepting of a broader view of maternal feelings, making allowances for realities without impinging on the wonderful experiences that makes one a mother.

Pavitra is now a happy mother of three children, and has completely overcome her joust with PPD. “Thankfully I never needed medication,” she says, “But I did need my husband’s help and understanding of what I was going through.”

“If you are a new mother, you’re probably over-worked and exhausted, but that should not make you feel hopeless, depressed, afraid or resentful of your baby. Most importantly, you shouldn’t be afraid of reaching out for help.”