Maternal Mental Health in Saudi Arabia

I have been reading and researching a great deal on the issue of maternal health care in Saudi Arabia and what I have noted is that mental health services for “mothers” are seriously inadequate at this time and not given the priority attention required, and I hope to be a catalyst to change that for the better. I believe that it is a public health issue, and one of common sense. When our mothers mental health and well-being is optimal, they will be able to show up more fully in their own lives, and better be able to take on the role of motherhood, the ability to care for their children and their families, and this will positively impact the Saudi society.

Currently, young women here enter into motherhood mostly unaware or unprepared for the experience of marital relationships, pregnancy, childbirth, breastfeeding, infant care, and child-rearing, and the responsibilities and burdens they entail. This is a result of a combination of social norms, cultural and religious beliefs, a paucity of education and awareness around the health and social impact of these issues, and attention to given by policy-makers historically.

There are patchy individual efforts at awareness and education, such as the Amani Birth movement that offers courses on childbirth in various cities, and Al-Bidaya Center in Jeddah that supports maternal wellness specifically in breastfeeding awareness and lactation support, and several programs offered by private hospitals on labor and delivery in the form of short courses. There are multiple physiotherapists and fitness experts who work on promoting physical strength for pregnancy and childbirth (labor and delivery) as well as recovery in the postpartum period. There are various social media accounts that motivate mothers and inspire them to be better parents. But there is a marked gap in addressing the issue of mental wellness and the women’s ability to develop resilience in the face of the drastic shift that is the transition to motherhood. I have to date only been able to identify one or two therapists who specialize in maternal mental health in Saudi Arabia.

Let me paint a picture: a young woman is newly married, and is eager to build a home and a family to meet the expectations of those around her. She has grown up expecting to be a mother, and she is soon pregnant. Understanding the changes occurring in her body is only one aspect that she was unprepared for, she learns day by day, from seeing what is happening to herself firsthand, to gleaning slivers of information from her busy doctor, to googling from her mobile phone, to worried comments to the women around her, who take the opportunity to share their own experiences overshadowing her and almost certainly not providing her with a clear answer to her unspoken questions. She attends her medical appointments and in her excitement starts to shop for baby items. She feels overwhelmed at times worrying about the labor and delivery, but isn’t encouraged to be proactive and learn more about the experience, and may even be advised against it that she may become afraid and it’s better to take it as it comes.

On the day, she is shocked by the great pains she hadn’t expected, as she was briefly told labor pain was only slightly worse than period pain, and quickly realizes she had seriously underestimated this. And as the labor progresses and delivery becomes imminent, the fight or flight instinct takes over and she struggles against the pain instead of working with it, most often causing the labor to be prolonged or stalled. The doctors take it in stride, assuming control and intervening to speed up the labor and process the delivery so they can move on to the next patient, sidestepping the issue that they failed to support the birthing woman in the most fundamental way; the easier way. They did not work to support her learning and entering into the experience fully aware and prepared, to enable her to handle the pain and feel more empowered and in control, to view the labor and delivery as a positive experience and live it as such. The woman, being by this time exhausted and having suffered for hours, is beyond comprehension of what is occurring. Myriad doctors and nurses circle, each tasked with some element, the baby is delivered, she is cleaned up and the ordeal is considered to be over.

What typically occurs at the point is that the mother, having suffered unduly and is extremely exhausted, and may not be capable or interested to hold the baby skin-to-skin or attempt to breastfeed, instead the baby is taken to the nursery and she is taken to her room to rest and sleep. Hours later visitors descend, and she is prepped for that, while the feeding of the baby is not given priority. She may even decline to do so because visitors are present and it is not convenient. Baby is given formula instead until the mother is ready. The baby is dressed and displayed, and passed from hand to hand, the new addition to the family, to carry his fathers’ name, while the mother looks on from a distance, feeling confused as to the feelings swirling in her, not being able to put her finger on what they are, and becoming preoccupied with so many people talking to her and asking her questions. By now she is in fresh pain as the uterus begins to contract, given mild painkillers and mostly ignored. Once the baby has received a stamp of approval and the paperwork is in order, they go home. Of course this is usually to her mother’s house, where she is expected to stay for the first 40 days to aid in her recovery.

While her birth experience was not ideal, when she asks about it she is told to count her blessings, as she and the baby are fine, and she feels unsure but doesn’t know what to say, and says nothing further. Her husband, the father, moves in and out of the picture intermittently, unsure himself of how or what his role is in these circumstances, as this is all new to both of them, and doesn’t feel comfortable to ask. So he exists on the periphery and rarely spends any time with his wife and new baby exclusively without the presence of wider family. She is still in pain, and astounded at how no one ever told her this would be the case, struggling with breastfeeding, frustrated and teary and overwhelmed with the lack of sleep and constant need to check on the baby for every breath while desperately wanting to sleep, missing the glorious sleep she used to sleep, feeling resentment towards the man who doesn’t have to be sat in bed in pain and who can go about his life normally while hers has ground to an excruciating halt.

They grow distant, and he has little opportunity to experience this golden time, and she is following what seems to be the norm and feeling out of her depth. She feels detached from the experience, and longs to go out and be free with her friends as she used to, and hands over the baby to either a servant or a nursery or her mother as soon as she is able.

In the postpartum period there is a general requirement for a check-up at six weeks, however the issue of mental health and well-being isn’t prioritized or given much attention, beyond a cursory inquiry if at all, and often merely a non-verbal assessment by the doctor and a checked box on a form. There are wonderful doctors who do take the time to ask about their patients, how the mother is coping and how she is feeling, but these are few and it is a purely individual effort. No in-depth assessment of mental health is required at any stage during pregnancy or postpartum. Most often, the woman will begin to have strong feelings a few days after the birth, but this is not taken into consideration and she does not approach the health care provider unless she is physically unwell with the myriad complications that can arise after delivery.

Others still may suffer the experiences of the inability to get pregnant, and endure the hardships of fertility testing and treatment, facing fear and disappointment and anger and resentment and jealousy over and over again, wanting this with increasing desperation and if it doesn’t happen may cause their relationships to suffer, or lead to divorce because their expectations weren’t properly managed. Other women may also feel the joy of becoming pregnant only to have their hopes dashed a few weeks later with an unfortunate miscarriage. This may happen many times. She feels like a failure and suffers terribly in silence, unsure of what is wrong with her or why this has to happen to her or what to do to deal with the feelings she is feeling. She is told that it will get better soon, and for lack of other options, just keeps it to herself. Others may go through the experience of pregnancy only to be faced with other difficulties such as birth deformities, disabilities or stillbirth. The horrors of what they must endure are rarely handled beyond the physical aspects, very little of which is explained to them as parents, merely managed in the purest clinical form by the doctors.

The impact of the addition of a new baby to the family is understated and under-supported. The effects on the family dynamic are great, but unaddressed. The toll it takes on the couple’s relationship is major, but misunderstood and mismanaged. The demands of childcare, from feeding to changing to sleeping to bathing to teaching and raising’ the responsibilities are unclear and unbalanced in most cases, and lead to strife and struggle in the family. The expenses associated with a growing family may also be a source of conflict.

If the mother is employed this adds another layer of challenge to the mix. The length of the maternity leave is 70 days, within which she is expected to make a full recovery, bounce back, establish breastfeeding and arrange for childcare, and return to take on the full load of work that they had kindly kept away from her during her time off. The working hours are between 6-9 hours long depending on the sector she works in, and the cursory breastfeeding hour isn’t practical for her at this stage of breastfeeding, so she may introduce formula or be pumping in impractical means. This places her under a great deal of stress, anxiety and guilt, and may lead to depression or anger. She had no idea it was going to be this hard, and she is doing it, but feels lost and confused.

Why is motherhood so hard anyway? Isn’t there any way we can make it easier? Plainly put, supporting mothers in the transition to motherhood and throughout is smart policy. Offering strong support services throughout the system in multiple key points in the motherhood journey is imperative to ensure the well-being of our mothers, and their ability to enjoy the beautiful experience of motherhood as it surely can be. When a mother is well and coping with strength and support, she can give more to her children and her family as well as to society and the workplace. Without this support she suffers mental issues, social challenges, domestic strife, work struggles, and poorly parents her children. It is a public health issue of the first order, and is a fundamental need in society to improve everyone’s wellness as a result. The economic impact must be tremendous but I believe at this stage it has not been studied. These are pieces of the puzzle that we have not realized are missing yet.

*I have written an article detailing all previous efforts in this area, and suggesting ways forward to work on improving maternal mental health in Saudi Arabia.