Pregnancy is a very important phase in a woman's life and so is the postpartum period, not only for the woman but also for the developing fetus and when the baby grows into an adult. These are critical periods where a lot can be done to improve the wellbeing of the mothers and babies. This conversation, between Dr Prabha Chandra, perinatal psychiatrist at NIMHANS, and Dr Latha Venkatram, obstetrician, throws light on the relevance of mental health and mental wellbeing in women's lives when they are pregnant and in the postpartum period.
Prabha Chandra: As an obstetrician, what do you think is the relevance of mental health in a pregnant woman's life?
Latha Venkatram: It's very important, not only for the woman but for the growing fetus and even after the baby is born, when it grows up as an individual. It's very important that maternal mental health is looked after if you have to have a mentally healthy baby when it's growing within the womb, and also when it grows as an individual. Many times, mental health issues are not recognized and addressed. I would say women don't report their mental health issues easily and the obstetricians also don't recognize mental health problems easily, because of their busy clinics and also lack of their awarenesss. So it does take a toll, not only on the lady but the fetus as well.
Low birth weight, prematurity are important outcomes during pregnancy, if the mother is under a lot of stress or if she has other psychological or psychiatric problems. Low birth weight not only means that the baby doesnt grow properly inside the womb, but it has long-term implications. Like you rightly said, it can become diabetic, hypertensive and also have cardiac problems earlier in life as an individual. And also, the mental health aspects, i.e. attention deficit hyperactive disorder, depression, behavioral problems, schizophrenia, (the chances of) all these are increased.
PC: Yes, I think the one place where we need to put our attention, our focus and our money into, is the mental health of mothers in pregnancy and in early postpartum period.
LV: Very much.
PC: As an obstetrician, what are the kind of issues that mothers come with, what are the kind of mental health issues?
LV: Many times, they don't recognize that they have a mental health issue. That's the biggest problem. So the obstetrician should get himself or herself trained to recognize mental health issues. I also bring in patient awareness. As part of health education, we should impart knowledge: when they have to report, what they have to report, and what is not normal phenomena for pregnancy.
Pregnancy actually is a very normal thing for every woman. I would say every woman is designed to get pregnant and most of the time, deliver normally. But it has become quite stressful of late, and is perceived as stressful, I would say. So the attitude towards pregnancy is very important and (there should be a) healthy attitude towards pregnancy, they don't have to unnecessarily worry.
There is a lot of information available for women, but not all information is the right information. So I think it's important that they get the right information and they discuss with the doctor so that they relieve their stresses.
The other thing is multitasking, they want to be achievers. At least during pregnancy, I think they should de-stress themselves and change their lifestyle a bit. Nuclear families have added to the stress. And also non-availability of mental health practitioners and professionals (and obstetricians also), that's one of the biggest challenges. I'm very glad that we are having this conversation, because I think it is high time mental healthcare professionals and obstetricians came together and start combined clinics. That would help a lot of women.
On the role of family members and husband
PC: Can you give tips to women who are pregnant, or the family members on how we can enhance the wellbeing of the mothers in pregnancy? I mean we know that they worry a lot, we know there is a lot of information available, but sometimes, focus becomes more on the negative rather than the positive. What do you tell the mothers who come to you for obstetric care, what should they do to feel better?
LV: I think lot of reassurance (is needed) from a doctor and also from the family members – mother, mother-in-law -- that pregnancy is something natural for every woman and most of the time, they won't have complications during pregnancy. That has to come from both the healthcare professionals as well as family members. De-stressing is very very important. As I said, lifestyle changes are required, to cut down extra activities and not pack in too much. Also one should not become very target-oriented. De-stressing in the form of hobbies is helpful; also there is lot of creativity during pregnancy. I think they should enjoy that as a mother. Also, do yoga, it has a profound effect (on the mother). There have been important studies that we have also contributed to, on yoga and pregnancy. It not only de-stresses but all the complications are also reduced. The chances of normal delivery and also problems during labor come down, if one is less stressed.
PC: So what do you think husbands can do? Because they are often in the periphery, they don't know what's going on, they attribute everything to hormones. So how can he feel useful, in terms of enhancing the mother's mental health at that time?
LV: Being supportive, understanding, and also knowing that there could be mood fluctuations during pregnancy. And also reporting any serious concerns that he has about her mental or physical health, I think that's important. Being supportive throughout pregnancy and also through the labor would go a long way. Of course postpartum also they would need support. Postpartum problems can be quite special, quite challenging because you have to cope with the small baby, the new addition (and also his own exhaustion). There can be so many social issues (which trouble a lot during the postpartum period), also lot of restrictions on diet, sleeplessness, all these add on to the problems.
PC: So the husband or a family member can be quite supportive at that time. We often tell husbands to take on some of the care and not be just a working dad, or if he has to forego a couple of hours of sleep at night, that's okay because that enhances the mother's mental health.
LV: That's true
On pregnancy and pre-existing mental illness
PC: Some women have pre-existing mental health problems, it may be a serious mental health problem or it may have been postpartum depression in the previous episode, anxiety, or personality issues. How can an obstetrician encourage women to talk about it, and what all should women tell, because women often do not report some of these things because they think they have come for the pregnancy and why is it important to talk about your previous mental health issues. So what's your advice to women?
LV: It is important for women with pre-existing mental health conditions to see mental healthcare professionals. Also if they are under a lot of stress, it is better to get themselves assessed by a counselor. There are a lot of taboos about seeing mental health professionals, I think that should go because we are risking our progeny. I think it's very important to give our best.
PC: Yes that's right. In fact a lot of mothers, like you mentioned, may stop medication during pregnancy abruptly, because they worry about the impact of medication on pregnancy and I think, mothers need to know that untreated depression and untreated anxiety may be even more harmful than medications. And the fact is that there are safe medications available, relatively safer medicines.
LV: Also the fact that you will be putting them on the lowest dose possible. Whatever is safest for the pregnancy among the medications available. So I dont think they should fear taking the medications.
PC: They also discuss it very openly with the obstetrician about what is going on, and their apprehensions and fears. Because if the condition is not very severe, we can go without medication and focus on psychotherapy or other forms of counseling. But sometimes, just because they fear they might be put on medication, they dont reveal their problems.
On postpartum and wellbeing of mother
PC: A little bit about the postpartum period, a fairly vulnerable period. In fact, it has been known that for mental health problems, it's probably the highest risk in a woman's life. And given the huge cultural issues in India, many of them related to rituals and gender..
LV: Absolutely. If they had a female child and they were expecting a male child, I think that's one of the biggest causes of depression for a woman.
PC: Yes, in fact, simple things like saying 'your child is not very fair' or 'the child is too thin'; in a vulnerable woman, comments like this can trigger off a huge reaction. We have seen mothers feeling quite low, becoming depressed, thinking that they have displeased the family, or not met the expectations of the family. What do you think is the family's role in the postpartum period, because often mothers are with their in-laws or their parents.
LV: It's very important to provide proper nutrition. There are lots of taboos about postpartum on diet, restricting water, restricting nutritious food, going out, etc. That also adds on to the mental health problems. The other thing is how to support this woman, who in turn would be supporting the baby; breastfeeding is affected. In fact bonding, breastfeeding, all these get affected if the lady is under a lot of stress or has depression or any other health issues. So family should support the woman. Also, little things like rituals should be let go a little. Whatever is meaningful is okay, but they should not be putting the woman through stress, it should be enjoyable. Whatever is acceptable to the woman, enjoyable to her should be encouraged. And of course, the husband's role is very big. I know he is usually stuck between the in-laws and his wife but I think its very important for him to cope properly during this period.
PC: In fact, a lot of family members, if the woman has a mental health problem they might feel having a baby will cure it all or will make a difference but I think preparation for motherhood in any woman is important. It doesnt happen suddenly, you can't become a mother like that. In fact I have mothers who often feel apprehensive because they say I am not bonding with the baby the way I ought to, I cant feel the way I should. And sometimes normalizing it, that it's okay not to feel great love towards the baby because you are tired, you are exhausted, the baby's small, difficult to manage, sometimes cranky, so it's okay to not feel like a supermom and to let the feelings develop as they go on.
LV: The expectations of the woman and the family can be quite high and I think you have to come to reality and also the doctors should promote the wellbeing by reassuring them.
PC: A lot of family members with mothers with depression or anxiety or even minor mental health problems would say 'You ought to be happy, you have such a lovely baby. Why are you feeling sad? Why are you crying?'. And I think more than that the family members need to be alert that this is a vulnerable period, look out for signs that she might be having a relapse if she has a previous condition or if she is more tearful, or more distant from the baby, or can't sleep very well.
LV: Whether she is looking after herself, this should be reported to the obstetrician or the pediatrician, because they would be seeing her more often. And we should be aware of these symptoms and refer them on to you (a psychiatrist).
And also, in a busy postnatal or antenatal clinic, we might not be able to give her solace and do justice for the complaints that they come up with. So I think it's important to have a specialized perinatal clinic, I think the time has come for that.