Content warning: please be aware that this Article mentions self-harm and suicide, which some people may find distressing.

Childbirth and new motherhood carry an expectation of joy and happiness, but it’s also a time of great emotional upheaval.

As new parents face adjustments to their lifestyle and relationships, significant mental health problems can develop. This can potentially disrupt the care of the newborn and challenge established family dynamics.

What is Perinatal Mental Illness?

Perinatal mental illness is defined by The Royal College of Psychiatrists (2021) as mental health problems that complicate pregnancy as well as the postnatal period.

It’s a definition that also embraces mental health problems that were present before the onset of pregnancy (RC Psych 2021).

Perinatal mental illness may include:

• Depression
• Anxiety
• Post-traumatic stress disorder (PTSD)
• Bipolar affective disorder
• Borderline personality disorder (BPD)
• Postnatal psychosis
• Eating disorders.

(NSW Health 2021; RC Psych 2021)

Overall, in Australia, perinatal mental illness affects up to 1 in 5 expecting or new mothers and 1 in 10 expecting or new fathers (SANE 2022).

These numbers are quite significant as mental illness can have major impacts on both the pregnant person and their family’s lives. Some of the adverse effects of mental illness include poor self-care, compromised caregiving and increased morbidity from other causes.

Alarmingly, suicide is the third leading cause of maternal death in Australia (AIHW 2022).

Mental illness can also affect the infant through malnutrition, poor physical and cognitive development and increased risk of illness.

Recognising Risk Factors

Missed or undermanaged mental health problems can have lasting negative effects on maternal self-esteem, partner and family relationships, and the mental and social wellbeing of the child (Stein & Pearson et al., as cited in RC Psych 2021).

The question is: how can perinatal mental illness be recognised so that effective help can be offered early?

Identified risk factors for perinatal mental illness include:

• Personal or family history of mental illness
• Fear regarding childbirth
• Difficult or complex pregnancy
• Birth trauma
• Premature or sick baby
• Challenges with feeding or settling
• Sleep deprivation
• Pre-existing physical illness
• Low socioeconomic status
• Lack of social support
• Financial stress
• Relationship stress
• History of abuse or domestic violence
• Unplanned or unwanted pregnancy
• Age (adolescent or advanced maternal age)
• Single marital status
• Prior pregnancy terminations or losses
• Anaemia
• Gestational diabetes
• Stopping or altering medication due to pregnancy e.g. antidepressants.

(PANDA 2022; Raisanen et al. 2014; Biaggi et al. 2016; Mama Academy 2022)

Signs and Symptoms of Perinatal Mental Illness

Signs and symptoms of perinatal depression and anxiety can be mild, moderate or severe and may include:

• Panic attacks (palpitations, shortness of breath, shaking)
• Persistent, generalised worry, often focused on fears for the health, wellbeing or safety of the baby
• Development of obsessive or compulsive thoughts and/or behaviours
• Abrupt mood swings
• Feeling constantly sad and/or crying for no obvious reason
• Being nervous or panicky
• Feeling constantly tired and lacking energy
• Decreased interest in things that normally bring joy
• Sleeping too much or not sleeping very well
• Losing interest in intimacy
• Withdrawing from friends and family
• Being easily annoyed or irritated
• Feeling angry
• Finding it difficult to focus, concentrate or remember
• Engaging in more risk-taking behaviour
• Having thoughts of harming yourself or your baby.

(PANDA 2018)

Perinatal Depression or ‘the Baby Blues’?

It's important to differentiate perinatal depression from ‘the baby blues’. It is not uncommon for birthing parents to experience what is called ‘the baby blues’ a few days following the birth of their child, but this experience is different from perinatal depression (Pregnancy, Birth and Baby 2022a).

Although similar symptoms present, these usually resolve within a few days with understanding, acknowledgement and support. Therefore, ‘the baby blues’ is not considered a mental health concern that requires treatment unless it lasts for longer than two weeks, which may suggest perinatal depression (Pregnancy, Birth and Baby 2022a).

Postnatal Psychosis

Postnatal psychosis affects 1 to 2 people out of every 1,000 following childbirth. It usually occurs in the first 1-2 weeks following birth but can occur up to 12 weeks postpartum (PANDA 2017; Pregnancy, Birth and Baby 2022b).

Postnatal psychosis is a very serious condition that not only puts the parent at risk but also the baby (Pregnancy, Birth and Baby 2022b).

Often, symptoms develop quite quickly and include:

• Sudden extreme mood swings
• Aggressive and/or violent behaviour
• Agitation
• Irrational or delusional thoughts
• Hallucinations
• Paranoid or strange beliefs
• Unusual or inappropriate responses to the baby
• Disordered and/or nonsensical thoughts and conversations
• Thoughts or plans to harm the self and/or the baby.

(Pregnancy, Birth and Baby 2022b)

Early detection is essential, and people with postnatal psychosis will most likely need to be admitted to hospital. Treatments might include medication, electroconvulsive therapy and/or psychological therapy (Pregnancy, Birth and Baby 2022b).

Most people experience a full recovery with both treatment and support (Pregnancy, Birth and Baby 2022b).

Screening for Perinatal Mental Illness

As Milgrom and Gemmill (2014) suggest, perinatal mental illness is often underdiagnosed and in the absence of active identification strategies, most patients will neither seek nor receive help.

Using a screening tool to identify those at risk of mental health issues during pregnancy should, as Biaggi et al. (2016) suggest, be a universal practice to promote the long-term wellbeing of parents and babies.

In practice, this means that midwives need to embrace this additional level of screening during routine maternity care.

Treatment for Perinatal Mental Illness

As with all mental health conditions, treatment will vary according to the individual and their experience.

Most guidelines recommend that all primary care practitioners, from midwives to general practitioners, ask about mental illness when seeing new parents.

Some of the treatment options for perinatal mental illness include medication management, counselling and referrals to other health professionals such as psychiatrists, psychologists, social workers and support groups.

Some general strategies that can be implemented by individuals include:

• Seeking company when feeling low in mood
• Sharing experiences with others feeling the same way
• Joining a support group
• Talking to a trusted family member or friend
• Prioritising rest
• Looking after their own health
• Eating well and doing some gentle exercise
• Limiting alcohol and other drugs
• Being gentle on themself and remembering that recovery can take time.

(Beyond Blue 2020)

Barriers to Treatment

There may also be potential barriers to the successful treatment of perinatal mental illness. These can include:

• Unavailability of resources
• Patient or family reluctance for treatment
• Cultural barriers
• Financial constraints
• Denial of mental health issues by the patient
• Physician attitudes
• Patients may be reluctant to take antidepressant medication if they are pregnant or breastfeeding, which then can decrease adherence to treatment and increase the risk of relapse.

(Ford et al. 2017)

What Can Midwives do to Help?

Midwives are uniquely placed to identify those who are at risk of experiencing perinatal mental illness to ensure that these people and their families get the care they need at the earliest opportunity.

The wider role of all midwives in improving maternal mental health includes:

• Raising awareness
• Ensuring that pregnant patients and their partners know about how to maintain and enhance their psychological wellbeing
• Helping patients recognise the signs of emerging mental health problems and signposting or referring them for further help
• Reducing the stigma and discrimination associated with poor mental health
• Providing sensitive and supportive antenatal care and promoting emotional wellbeing
• Supporting and enabling patients to maintain and enhance their emotional wellbeing and reduce their vulnerability to mental illness
• Building strong, trusting relationships with patients, thereby increasing the likelihood that they can identify any problems
• Identifying risk factors and being sensitive to any indicators that mental health may be deteriorating.

(RCM 2017)

Midwives and birthing assistants also have a valuable role to play by fostering emotional and practical support for a pregnant patient’s partner, as well as encouraging patients to broaden their social networks through antenatal and postnatal activities (RCM 2017).

A New Approach is Needed

Perinatal depression is a topic that certainly needs much more discussion. It’s true to say that specialist mental health midwives are now playing a crucial role in effective perinatal mental health care, but not every patient has access to this level of care.

Continued discrepancies between the resources given to male and female perinatal mental health also suggest that future public health campaigns could be usefully targeted more towards men.

Even without the services of specialist mental health midwives, most researchers seem to agree that more needs to be done within existing health services to improve knowledge of mental illness among expecting parents.

Antenatal classes, online resources, child and family health nurses and general practitioners could all use their brief but precious contact time to enquire about the mental health of both parents.

Education is key here, as there clearly remains considerable scope for raising awareness about perinatal mental health.

Seeking Help for Perinatal Mental Illness

If you or someone you know is seeking help for perinatal anxiety or depression in Australia, PANDA is an organisation that supports parents and families during this time. They also offer a National Perinatal Mental Health Helpline, which is Australia’s only helpline relating to perinatal anxiety and depression. This helpline is staffed Monday to Saturday on 1300 726 306.