Maternal Mental Health and Wellbeing

The aim of this editorial is to raise awareness about maternal mental health and wellbeing. It is, well recognised that during pregnancy, birth and following birth women can be at increased risk of mental health problems. Increase in levels of anxiety and stress commonly occur during pregnancy and following birth, which can stand alone or also be present with other mental health problems.¹

Mental health relates to a person´s emotional, psychological and wellbeing status and can therefore, influence how a pregnant woman and a newly birthed mother feels and functions.

The World Health Organization (WHO) define mental health as “…a state of wellbeing in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community”.²

Yet, wellbeing is not routinely screened for and many pregnant women and newly birthed mothers at risk are not identified as having a poor state of wellbeing and opportunities to detect anxiety, stress and having problems coping are missed. However, postnatal depression (PND) is routinely being screened for in many countries of the world and some countries also advocate screening for antenatal depression.³-⁵

However, there are some concerns as to how effective the screening for depression approach is in detecting maternal mental health problems⁶as screening is usually undertaken at a single point in time, and therefore has limitations and can only provide a snapshot of a woman’s emotional status. Additionally, there has also been concerns that screening women adds to the medicalisation of childbirth and motherhood,⁷ and it is important to acknowledge that there is potential stigma attached to screening for postnatal depression.⁸,⁹

Therefore, would it be more beneficial to assess for wellbeing and enable pregnant women to self-monitor and continue to do so following birth?

The Warwick-Edinburgh Mental Well-Being Scale (WEMWBS)¹⁰ has been used effectively in England to measure wellbeing by pregnant women and new mothers in a study investigating how to build resilience for better mental health.¹¹ WEMWBS is built around five core concepts those being: satisfying interpersonal relationships; positive functioning; positive affect; hedonic perspective and eudemonic perspective.

There has also been some more recent research undertaken in Australia that indicates that self-monitoring for maternal wellbeing has potential. A visual tool ´Capture My Mood´ (CMM) which involves five (C) descriptors (Connected, Confident, Cheerful, Contented and Capable) which aligns with the five core concepts of WEMWBS mentioned above has been specifically designed to enable women to self-monitor their wellbeing during the early postnatal period.⁷ The CMM tool has been piloted and further development and research is ongoing to provide a digital online version as many pregnant women and new mothers have mobile phones and access to the internet.

It is interesting to note that a ‘Parity of Esteem’ concept has been reported.¹ This concept stresses how important it is to assess mental health and gives it similar recognition to physical health problems. Poor maternal physical health following birth can lead to mental health problems and poor mental health can lead to physical health problems, as these are interconnected. For example, when a person is anxious and stressed many physical symptoms will be present such as, muscle tension, dizziness, headaches, palpations, gastric and urinary problems, restlessness, insomnia and increase susceptibility to pain.¹² During pregnancy, raised cortisol levels can increase a woman’s likelihood to develop high blood pressure, pre-eclampsia, intrauterine growth restriction, premature birth and also a difficult birth.¹³

Therefore, it is vitally important that the links between mental health and physical health are taken into consideration during pregnancy and postnatally when providing maternity care. It appears that there is clear justification to give equal importance to a woman´s mental and physical health status and promote wellbeing during pregnancy and then following birth.

Promoting maternal mental health

Depression is the most prevalent mental health disorder in pregnancy and postpartum, effecting approximately, one fifth of women.¹⁴ Antenatal depression is a major risk factor for postnatal depression, which is generally a continuation of the depression that begins antenatally.¹⁵-¹⁸

In Brazil, the prevalence of antenatal depression is about 20 that is similar to other high income countries, and considering the problems some women of reproductive age have to overcome to access the health care system, antenatal care is vitally important for preventing postnatal depression and promoting women’s mental wellbeing.

Supporting pregnant women to build and maintain resilience and develop coping strategies to promote health and wellbeing is an important aspect of maternity care. Being resilient will help pregnant women to develop some coping strategies, manage anxiety and stress, reduce fear associated with childbirth and help them to maintain health and wellbeing through the transition to motherhood.¹¹

It is, therefore, very important to consider promoting wellbeing and ways to maintain wellbeing such as ‘the five ways to wellbeing’²⁰ and also by providing continuity of care.²¹

The impact of a mother´s mental health status upon an infant’s physical, emotional and psychological development is well recognised and also needs to be taken into consideration when providing maternity care.²²

In summary

It is important to assess a woman’s wellbeing during the prenatal and postnatal period and self-monitoring may be beneficial and tools such as ´capture my mood´ may help her to recognise that she is at risk and seek health professional help or disclose her concerns to a family member or friend and contact a helpline. It is also important to consider promoting wellbeing and ways to maintain wellbeing, learning ways to develop coping strategies to manage anxiety and stress and building supportive networks. Continuity of care and community support groups can help pregnant women and new mothers to have confidence to disclose any mental health problems and build resilience and prevent social isolation. Raising awareness of the parity of esteem concept and that mental health needs to be given the same consideration that physical health has will help mothers to remain resilient and stay well.

Referências

• ¹
  Steen M, Steen S. Striving for better maternal mental health. Pract Midwife. 2014;17(3):11–4.
• ²
  World Health Organization (WHO). Mental health: strengthening our response [Internet]. Genève: WHO; 2016. [cited 2019 May 13]. Available from: who.int/mediacentre/factsheets/fs220/en/
  » who.int/mediacentre/factsheets/fs220/en/
• ³
  Perinatal Mental Health National Action Plan 2008-2010 [Internet]. [cited 2019 May 13]. Available from: Beyondblue.org.au/docs/default-source/8.-perinatal-documents/bw0125-report-beyondblues-perinatal-mental-health-(nap)-full-report.pdf?sfvrsn=2
  » Beyondblue.org.au/docs/default-source/8.-perinatal-documents/bw0125-report-beyondblues-perinatal-mental-health-(nap)-full-report.pdf?sfvrsn=2
• ⁴
  National Institute for Health and Care Excelence (NICE). Antenatal and postnatal mental health: clinical management and service guidance (clinical guideline CG192). London: NICE; 2014. [cited 2019 May 13]. Available from: nice.org.uk/guidance/indevelopment/gid-cgwave0598
  » nice.org.uk/guidance/indevelopment/gid-cgwave0598
• ⁵
  s O’Connor E, Rossom RC, Henninger M, Groom HC, Burda BU. Primary Care Screening for and Treatment of Depression in Pregnant and Postpartum Women: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2016;315(4):388–406.
• ⁶
  Austin MP, Middleton PF, Highet NJ. Australian mental health reform for perinatal care. Med J Aust. 2011;195(3):112–3.
• ⁷
  Brealey SD, Hewitt C, Green JM, Morrell J, Gilbody S. Screening for postnatal depression – is it acceptable to women and healthcare professionals? A systematic review and meta-synthesis. J Reprod Infant Psychol. 2010;28(4):328–44.
• ⁸
  McKellar L, Steen M, Lorensuhewa N. Capture my mood: a feasibility study to develop a visual scale for women to self-monitor their mental wellbeing following birth. Evid Based Midwifery. 2017;15(2):54–9.
• ⁹
  Steen M, Jones A. Maternal mental health: stigma and shame. Pract Midwife. 2013;16(6):5.
• ¹⁰
  Tennant R, Hiller L, Fishwick R, Platt S, Joseph S, Weich S, et al. The Warwick-Edinburgh Mental Well-being Scale (WEMWBS): development and UK validation. Health Qual Life Outcomes. 2007;5(1):63.
• ¹¹
  Steen M, Robinson M, Robertson S, Raine G. Pre- and post-survey findings from the Mind ‘Building resilience programme for better mental health: pregnant women and new mothers’. Evid Based Midwifery. 2015;13(3):92–9.
• ¹²
  Wood L. Psychological interventions in anxiety and depression. In: Smith G, editors. Psychological interventions in mental health nursing. United Kingdom: Open University Press/McGraw Hill Education Maidenhead; 2012.
• ¹³
  Steen M, Green B. (Mental Health during pregnancy and parenthood. In: Mental health: Across the Lifespan. Steen M, Thomas M, editors. London, UK: Taylor & Francis; 2016.
• ¹⁴
  Limlomwongse N, Liabsuetrakul T. Cohort study of depressive moods in Thai women during late pregnancy and 6-8 weeks of postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Arch Women Ment Health. 2006 May;9(3):131–8.
• ¹⁵
  Alami KM, Kadri N, Berrada S. Prevalence and psychosocial correlates of depressed mood during pregnancy and after childbirth in a Moroccan sample. Arch Women Ment Health. 2006;9(6):343–6.
• ¹⁶
  Andersson L, Sundström-Poromaa I, Wulff M, Aström M, Bixo M. Depression and anxiety during pregnancy and six months postpartum: a follow-up study. Acta Obstet Gynecol Scand. 2006;85(8):937–44.
• ¹⁷
  Ryan D, Milis L, Misri N. Depression during pregnancy. Can Fam Physician. 2005;51:1087–93.
• ¹⁸
  Heron J, O’Connor TG, Evans J, Golding J, Glover V; ALSPAC Study Team. The course of anxiety and depression through pregnancy and the postpartum in a community sample. J Affect Disord. 2004;80(1):65–73.
• ¹⁹
  Pereira PK, Lovisi GM. Prevalence of gestacional depression and associated factors. Rev Psiq Clín. 2008;35(4):144–53.
• ²⁰
  New Economic Foundation. Five ways to wellbeing [Internet].London: New Economic Foundation; 2008. [cited 2019 May 13]. Available from: neweconomics.org/projects/entry/five-ways-to-well-being
  » neweconomics.org/projects/entry/five-ways-to-well-being
• ²¹
  Care Quality Commission (CQC). National findings from the 2013 survey of women’s experiences of maternity care. London: CQC; 2013.
• ²²
  Steen M, Jones A, Woodsworth B. Anxiety, bonding and attachment during pregnancy, the transition to parenthood and psychotherapy. Br J Midwifery. 2013;21(12):768–74.

Publication Dates

• Publication in this collection
  12 Aug 2019
• Date of issue
  Jul-Aug 2019