Pregnancy, Childbirth and Breastfeeding Concerns in Our Culture During COVID-19: Mother’s Mental Health and Wellness

How maternal mental health in pregnancy, childbirth and breastfeeding is shaping up during the coronavirus pandemic here in Saudi Arabia:

Mental health issues are as equally important as physical health. You need treatment for depression just as you would for a bad back. Anxiety can ruin your life just as much as having poor eyesight can. Mental health issues can significantly affect the quality of your life, and has an impact on those around you as well. Mental health issues can affect our physical health either positively or negatively, and I think more and more of us are learning for ourselves how much our mood and attitude can affect us, and are developing a respect and awareness of how we feel to live more fulfilling lives.

Perinatal mood and anxiety disorders affect 1 out of 5 women, yet we do not formally screen for them here in Saudi Arabia. Consider this when I tell you that 1 out of 22 women develop gestational diabetes but we screen all women for this routinely. The prevalence rate for PMAD’s is very high and detection is possible with appropriate screening (Meyer, 2020). PMAD’s are preventable and treatable but we need to do better here. The risks of untreated PMAD’s are well established (see my posts on the economic and social burdens).

Most often what happens is a cursory statement as the woman leaves the hospital “if you’re crying a lot, then be sure to call your doctor” but that may not be the only thing to keep an eye out for, she could be feeling panicky or nervous or irritable or angry and mean and rageful. These are all signs of PMAD’s that persist beyond what are called the baby blues (beyond 2 weeks postpartum), and I’m sure many of you can recall a time in your lives when your mom just started yelling that one time, or burst into tears and nobody knew what to do and everyone pretended it was nothing.

At the postpartum visits most of the questions if not all of them focus on the physical aspects, how’s your bleeding, your stitches, sometimes questions about breastfeeding, mostly with the intention of clearing the woman for intercourse post-birth, and questions on birth control and considerations of future pregnancies. But rarely if never do we ask women how they are feeling. How was the birth for you? How are you doing emotionally? Are you feeling capable and strong? Do you have support? If she does comment that she’s feeling overwhelmed, it most probably brushed off with ” be thankful you are healthy and your baby is healthy”, which only serves to make her feel worse about how she’s feeling, and is not helpful in the least, and clearing a woman physically for sexual activity does not automatically assure she is mentally or emotionally ready as well…

Proper screening for PMAD’s is very important but there are barriers to this, some of which center around doctors lack of time, or uncertainty of whose responsibility it is, or concern about what might happen if they ask her something and she falls apart, worries about professional boundaries or they have never asked before and aren’t sure how to, or how do they refer and to whom. Some doctors at a loss for what to do, may prescribe vitamins or suggest women see a neurologist, which isn’t sufficient. So we mostly skip over this critical issue. Although I’m sure there is an some form of mention somewhere about postnatal depression (hence the cursory note when she’s leaving the hospital) it is not a topic that is adequately addressed in medical training and there seems to be a general assumption that if a woman has an issue we will be able to tell just by looking at her. You can’t. Specific questions should be asked and there are various well-established screening tools available. If any issues are flagged, these women should be referred for further attention from a specialist in mental health, and preferably a specialist in perinatal mental health, not even general women’s health…and there are many options for treatment that women can be connected to, such as support groups or various forms of therapy or medication or a combination of these, or working on establishing social support and enhancing self-care practices.

Women will not ask or start this conversation, because there is a lot of shame and guilt and fear around these feelings, and for her to come out and state that she needs help is rare and often when it is already out of control and requires serious intervention and/or hospitalization, which ends up as more cost for the health system that could have been prevented with a few simple questions and a referral if she has a positive result of the screen. Screening is also an opportunity to educate women and their partners, using the tool to explain the signs and symptoms to look for to them so they know what to watch out for properly. Reassure them of their privacy and confidentiality and then inform them that its very common, everyone gets screened and that there is nothing wrong with her, and that if there is an issue that help is available and – with that help – she will get over this soon.

Childbirth education is also a key factor that is underappreciated in our society and overlooked by the healthcare system. When a woman fully understands the adventure she is embarking upon, and her husband is involved and aware of the changes and they both know the 4-1-1 they will be empowered to ask questions and take action if they face any issues, and seek help and support when they need it, before things get complicated. The mother’s health outcomes and experiences will improve, and overall quality of life and wellbeing enhanced. Isn’t that what we all want, and deserve?

There is a cultural misconception that I would like to take the opportunity to correct here. Many people assume that since we have a strong family oriented society that automatically means mothers are supported and therefore we have little or no incidence of PMAD’s. That is incorrect. In fact many mothers are reporting feeling suffocated by their families constant presence and inappropriate levels of interference and unhelpful advice which leads to conflict and so much guilt because moms then feel unappreciative and pressure to keep up appearances, which in many ways may exacerbate the development of PMAD’s المجاملة و الضغوط الاجتماعية

1 in 7 women develop a PMAD during pregnancy, 1 in 7 within the first three months, 1 in 5 develop a PMAD within the first year after having a baby (Wisner, K, 2013). The physical aspects of recovery from birth, the lack of sleep, the unpredictability, the newness of breastfeeding, the exhaustion, are all factors that pile together to make this a truly challenging time of transition for the mother and the family, and put her, depending on her circumstances, at risk of developing a PMAD. The recommendation is that women should have several screens during the perinatal period. Although there is no formal consensus PSI has developed their own recommendations (Postpartum Support International, 2020). Currently here in Saudi Arabia women are seen after birth once or twice, but again there is no mandate for screening for perinatal mood and anxiety disorders (yet).

These illnesses have a significant potential to make the motherhood experience a very different reality that what we grow up expecting and from what is portrayed on social media. Anywhere from feeling overwhelmed, sad, angry and irritable all the time all the way to feeling like they wish they wouldn’t wake up tomorrow or that they don’t want to be mothers anymore to actual self-harm or suicide, because they feel confused, out of sorts and alone and desperate, and they feel because of this overwhelm, that this is how its going to be for the rest of their life. Something isn’t right. Motherhood is the hardest job there is, and most women enter into it unprepared and suffer as a result and the system barely supports them through the physical aspects and completely sidelines the mental and emotional aspects.

At the moment, we are living through a pandemic, and there has been a great deal of discussion in professional circles on the impact of COVID-19 on mental health issues. Now in the current circumstances of the coronavirus, with the lockdowns and restrictions, pregnant women are understandably anxious and worried, even more so than they usually would be. Many women may be panicking about their impending birth, that they may contract the virus or give it to their baby, or that the hospital staff will be too busy to pay attention to them. They may worry if they will be able to have their partner with them or not, or have to birth alone, or if the baby will be taken away or separated from her or what kind of support they will have after delivery and when they go home. Many women began to consider homebirth as an option.

The regulations and recommended practices that have been issued for COVID-19 vary widely and could depend on multiple factors like the health status of the pregnant woman (birthing mother) or the baby, or the staffing at the time or the prevalence of COVID-19 in the area or the hospital itself, and even depending on the group of physicians evaluating and deciding on these recommended practices. I have had confirmed that many OB’s are promoting induction, shortening the 2nd stage of labor, instrumental delivery, performing episiotomy, not allowing skin to skin, isolating the baby, limiting breastfeeding, which are procedures and interventions that are all at odds with much of the international recommendations, and while the consideration is now on speeding things up and getting women in and out of hospital quickly and reducing transmission of COVID-19, there is a major concern here that by closing one door we are opening another one, one with a much deeper and longer lasting impact, which is a pandemic of postpartum mental health issues such as depression or PTSD, so there MUST be a balance. I’ve written an article in Al-Watan newspaper about this https://www.alwatan.com.sa/article/1046062.

Birth isn’t an illness or an emergency, for most women it is a natural state of being, and when interrupted or disrupted, even with good intentions, the damage can be significant to the mother and baby, and the entire family. The international recommendations ensure that the birthing mother feels safe, cared for, autonomous, to be given the space and time to deliver her baby, to share the decision-making with her care provider, to be allowed to room in with the baby, and breastfeed, even if she is COVID+. It seems a bit ridiculous and overzealous to isolate them from each other immediately after birth only to send them home together the next day. Limiting breastfeeding is immensely harmful to both mother and baby. Interruptions in the normal flow of hormones at birth can be devastating to the chances of success at breastfeeding and increase the risk of developing PMAD’s.

Many of the decisions that are being made here are extreme and in the interest of the health care providers and hospitals, leaving the preferences and needs of the mother aside and seen as irrelevant. Just because the aftereffects aren’t seen in hospital does not mean they are not vital to mother’s health and wellbeing, and that of her baby by default.

So the theory is: if we educate women about these issues + increase the awareness of the health care providers + encourage them to implement practices in antenatal and peripartum care that honor and care for the mental health impact as well as the physical impact + we pay attention and screen for mental health issues consistently = we can prevent their onset….and if they do appear + we flag + treat them = we promote mothers’ well-being by enhancing their abilities to navigate this challenging time + take on their motherhood role more fully = in turn reflect on their relationships with their children and their families + in their abilities to work and contribute to society.

I see the pandemic as a critical point where we must promote the profile of the issue of maternal mental health. I have deep concerns about how women are being managed in the health care system when pregnant or birthing their babies in general too. I encourage the medical professionals to see all women as birthing mothers, not as “gravida 1, 2, 3, x, y, z”, and to acknowledge the fact that birth is a life-changing experience that can either be affirming a woman’s strength and power, or disappointing, devastating, and even traumatizing.

The medical profession is well placed to support this endeavor, especially with the increase in the role of midwives and the potential for homebirth as well. A healthy and well mother is an indicator of a strong society. It’s a big ask, but our mothers are more than worth it.

References:

Wisner KL, Sit DKY, McShea MC, et al. Onset Timing, Thoughts of Self-harm, and Diagnoses in Postpartum Women With Screen-Positive Depression Findings. JAMA Psychiatry. 2013;70(5):490–498.

Postpartum Support International (2020) COVID-19 Resources. https://www.postpartum.net/psi-blog/psi-covid-19-resources/

Gunyon-Meyer, B. (2020) Perinatal Mood and Anxiety Disorders. International Childbirth Education Association.

Saudi Society of Maternal-Fetal Medicine (SSMFM) (2020) Pregnancy and COVID-19 Guidelines.

Zedan, H. (2020) Pregnancy and Coronavirus (Arabic) Al-Watan Newspaper. https://www.alwatan.com.sa/article/1046062