Perinatal Mental Health and Telehealth Opportunities*

*Trigger Warning: Discussion of Trauma, Abuse, Self-Harm

Birth can be a challenging time for a woman, as it is not only a physical process, but also a deeply personal and emotional experience. Many women as they become mothers struggle with processing their birth experiences and reconciling the event with their expectations, and many may need support in dealing with trauma issues, physical as well as mental and emotional. These experiences can generate strong and overwhelming feelings, among them vulnerability and loss of control or autonomy, or a lack of safety. According to Beck (2004) it’s not necessarily the event itself in so much as how the event was perceived by the woman herself (the mother). 

Previous trauma experiences may also resurface during the transition to motherhood and the perinatal period. Women with a history of sexual violence, physical abuse or abandonment may not register these histories as trauma, but struggle during birth and feel the physiological effects of that. Research has shown that people who have trauma experiences retain implicit memory of them in their brains and in their bodies, and these can be expressed as PTSD: nightmares, being easy to startle, strong flashbacks, and disassociation or ambivalence. Mothers may exhibit an inability to emotionally regulate, feeling numb, inability to sleep, being hyper aroused, hypervigilant or panicked, or manifest gastrointestinal symptoms, headaches or muscle pain. There may be cases where there are issues with substance abuse or self-injury.

There is a need to educate birth professionals and support people on how to handle such issues with care and sensitivity to encourage a positive birth experience, and how to identify and refer mothers to appropriate services such as perinatal mental health support and encourage them towards that. Research on obstetric practice has shown that women with history of trauma will detach during pregnancy, disassociate during vaginal exams, or have flashbacks during c-section deliveries, panic attacks during medical visits, or demonstrate ambivalent behaviour towards the newborn or avoid breastfeeding. Therefore, it is imperative to be attentive towards institutional and individual practices that may traumatise or re-traumatise women during this time, and enhance every opportunity to ensure her trust, her safety, her choice. Fully informed consent and shared decision making are means to educate and empower women towards positive birth experiences and a resilient postpartum.

Some issues mothers may be dealing with during the perinatal period can be mistimed pregnancy (especially during the pandemic), disappointment with the gender of the baby, discovery of a multiple pregnancy when a singleton was preferred, the expectation of the pregnancy, birth, postpartum or breastfeeding experience differing from the reality, the appearance of the baby at birth, having a baby with health issues, the baby’s temperament, disappointment at not falling in love with the baby at first sight, the lack of support from family.

If a woman is suffering from pregnancy complications or is placed on bedrest, this can be challenging on many levels. She may be worried about herself or her baby because of her health issues. She may blame herself or feel guilty for not eating well or preparing better for conception and pregnancy or being healthier in general, or that she may have done something wrong or caused these complications and lose confidence in her own body. She may also struggle with the logistical issues of being unable to work or care for other children she may have, or with financial issues.

If the baby is diagnosed with issues in the womb, this can be upsetting and trigger PTSD, as she struggles with intrusive thoughts and expends much of her emotional energy attempting to avoid them and detach from the pregnancy. She may also avoid discussing the issue or avoid her pregnant peers or feel rage towards them. She may be hypervigilant during pregnancy or experience feelings of guilt or blame herself. She may also be angry with God or struggle with her faith at this challenging time (Cole et al, 2016). If the baby is premature or is placed in the NICU, she may also experience similar issues emotionally.

If the baby is healthy at birth, her experiences in pregnancy may be dismissed or invalidated by those around her, including her medical team, as it is often the focus of the perinatal period, and discount her experiences as the mother. Many people will seek to falsely reassure the mother with platitudes such as: “you were worried about nothing”, “everything worked out in the end”, which only gaslight the deeply complex feelings she may have experienced at the time and needs to process.

It is also very important to consider the perinatal mental health of women who struggle with fertility issues or suffer with a miscarriage or stillbirth. These experiences can lead to complex feelings of shame and grief mixed with relief in some cases when ending a pregnancy. The experience of learning of these issues can also play a role in her response, therefore it is important to consider how she was informed and by whom, and what options she was offered.

There may be a reluctance to share the loss with others or physical pain if undergoing a medical procedure, as well as shame and stigma surrounding the inability to become pregnant or carry a pregnancy to term, or displeasure with her body or herself. If it is a stillbirth, she may not have been informed about the options to meet or hold the baby or manage the experience. These issues may also impact any subsequent pregnancies.

Immediately postpartum, no matter the outcome, the mother (and her partner) will require support. If there has been a loss, there will be a need to manage the death and the grief and pain that is associated with it, and the questions that will be asked by others, and how to handle the baby paraphernalia that is no longer going to be used, and coping with no longer being pregnant, the production of breastmilk and the return of menstruation, the re-engagement in sexual intimacy, the consideration of birth control or when and if there will be another attempt at pregnancy. It is important to honor these feelings and normalise them and support them to work through it at their pace.

Therapy can be a way to heal such trauma and allow for careful processing and release from these traumatic experiences and must be done with the support of a trained professional. In this time of COVID-19, access to such types of therapy is imperative.

Utilizing technology to support mothers and families through an already challenging time added onto that the pressures of birthing and caring for a newborn in a pandemic situation. Telehealth is literally meeting mothers where they are, and increases access and continuity of care in the provision of services, and offers an opportunity to provide perinatal mental health support which is vital in the early postpartum period.

Offering perinatal mental health support through telehealth allows significant flexibility in scheduling and increased intimacy and comfort without the actual physical contact or the necessity of leaving the home with a newborn and attending in a formal setting, which can be intimidating for mothers seeking support. It can also be a means of overcoming the stigma of mental health issues in society, offering privacy and confidentiality. It is also important to consider that there are mothers who have challenges in accessing of using technology, and the role of the partners in this interaction and in the care process.

There are many options for therapy that can be offered (through telehealth services):

• CBT
• IPT
• Mindfulness
• Peer Support
• Psycho-Educational Group Therapy
• Mother-Infant Therapy and Education
• Internal Family Systems Model
• Acceptance and Commitment Therapy
• Emotionally Focused Therapy
• Transcranial Magnetic Stimulation (TMS)
• Behavioural Activation
• Eye Movement Desensitization and Reprocessing (EMDR)
• Dialectical Behavioural Therapy (DBT)
• Tapping
• Yoga and Breathwork

If you are reading this and would like more information or a referral to a perinatal mental health specialist near you please contact me: maternalwellnessksa@gmail.com 💌 or visit postpartumsupportinternational.com

You are not alone. You are not to blame. With help, you will be well. PSI