Editors’ note: Today’s post is by Dr. Ja’Nya Jenoch is a health, social, and research data scientist and licensed mental health clinician. Reviewer credits to Chefs Dianndra Roberts and Randy Townsend, who offer the following introduction.
The high-profile trial of Lindsay Clancy, who is accused of fatally strangling her three children, flooded our newsfeeds and algorithms with the term “postpartum psychosis.” As public debate has intensified over what consequences, if any, Clancy should face, a broader question remains for the rest of us: what makes a woman described as “a wonderful mom who loved her kids” commit such a horrible act against her children? Today, Dr. Ja’Nya Jenoch takes us through the history of maternal mental health and explores the complex systems and pressures that shape the experiences of many mothers.
Maternal mental health refers to the psychological well-being of a pregnant or postpartum mother. Although it is usually associated with postpartum depression (PPD), it includes a host of mental health conditions that are on the depression, anxiety, trauma, substance abuse, and psychosis spectrums. In this post, postpartum depression and maternal separation anxiety will be discussed. First, let’s look at how the mental health of perinatal women gained national, medical, and social recognition.
Brief history of Maternal Mental Health
Starting in the early 1980s, a series of events contributed to the growing attention to maternal mental health. Some of these events included the founding of Postpartum Support International in 1987 by Jane Honikman. The goal of this organization was to provide a global place where mothers can turn for support, resources, and information about postpartum health. In 1994, the Diagnostic and Statistical Manual of Mental Disorders — Fourth Edition (DSM-IV) added a specifier for postpartum onset to depression. Since the DSM is considered the “bible” of mental health diagnoses, this specifier was a big step in making postpartum depression an official condition.
Other events, such as the case of Andrea Yates, a mother who struggled with postpartum psychosis and drowned her 5 children in 2001, brought national attention to the devastating impact that pregnancy can have on mothers’ mental health. Celebrity disclosures such as Brooke Shields’ memoir detailing her struggles with PPD and use of medication; Princess Diana’s statement about her mental struggles following the birth of Prince William; and most recently tennis star Serena Williams sharing her birth story and near-fatal delivery have contributed to society’s general knowledge that pregnancy and birth have a big impact on the person whose body becomes a home to another human for almost a year. Although the United States (US) does not have higher maternal mental health rates compared to other industrialized countries, it does stand out in its high maternal mortality rate and lack of national paid maternity leave.
From a global perspective, the World Health Organization recognizes that between 13 to 20 percent of pregnant or postpartum mothers experience a mental disorder. However, the prevalence of postpartum mental illness is complex and impacted by a host of conditions. For example, the Maternal Mental Health Alliance reported that the risk for maternal mental disorders can increase due to Adverse Childhood Experiences (ACEs), race, ethnicity, birth trauma, poverty, and other social and psychological factors.
Researchers Uriel Halbreich and Sandhya Karkum were curious about the global prevalence rates of maternal mental health conditions. To answer their questions, they completed a literature review of 143 studies that explored maternal mental health in 40 countries. Their findings showed that although similar scales were used to measure maternal mental health — the Edinburgh Postnatal Depression Scale (EPDS) and the Beck Depression Inventory (BDI) — prevalence rates varied from almost 0 percent to 60 percent. For studies that were conducted in the US, the prevalence rates for maternal mental disorders ranged from 2 to 36 percent. Globally, countries like Singapore, Austria, Denmark, and Malaysia reported that between 0 and 5.5 percent of mothers experienced a mental health condition after childbirth. Meanwhile, the range for other countries was as follows: France (0 – 73.5%); India (11 – 32.4%); South Africa (7.8 – 36.9%); Australia (4.2 – 62%); Japan (13.6 – 48.9%); Costa Rica (16 – 48%); United Kingdom (2 – 61.5%); China (9 – 17.9%); Chile (4.6 – 50%).
Notably, these studies all occurred before 2006, the year that the article was published. It would be interesting to see results based on more current data. However, the researchers completed a formidable task and laid the groundwork for conducting cross-cultural studies on maternal mental health. They concluded that the cross-cultural variety in measurement, methods, cultural practices, socioeconomics, and biological factors points to the importance of uncovering the key risk factors of maternal mental health conditions. They wanted to show that the 10-15% estimate of postpartum depression did not represent the global presence of these conditions.
Postpartum Depression
When we talk about maternal mental health one of the first topics that most people think of is postpartum depression. According to the DSM-5-TR, postpartum depression can be diagnosed if a mother meets the criteria for Major Depressive Disorder during or within 4 weeks of delivering a baby. The criteria for depression includes 5 symptoms from any of the following: depressed mood, reduced interest in activities, significant weight fluctuation, sleep difficulties, restlessness or inactivity, fatigue, feeling worthless or guilty, difficulty thinking, and recurring thoughts of death. It also includes feelings of sadness, crying, trouble sleeping, lack of appetite, and even suicidal thoughts that can occur after a woman gives birth.
Postpartum depression is a very serious condition which is estimated to occur globally in 6-20% of mothers. Women with pre-existing or prior experience of mental disorders are at increased risk of PPD. The prevailing treatments are therapy and medication. Some mothers may experience what was previously called the “baby blues” for about 2 weeks after childbirth while their hormones recalibrate. Before we knew of the term postpartum depression, the “baby blues” was a phrase used to describe a sadness that manifested in mothers after childbirth. Compared to the baby blues, PPD lasts longer, symptoms are felt more intensely to the point where they impair the mother’s ability to function at home, work, or other areas of life. Over time postpartum depression became more widely accepted as the clinical term used to describe feelings of sadness, crying, trouble sleeping, lack of appetite, and even suicidal thoughts that occurred after a woman gave birth. Since the late 1980s/early 1990s, organizations like Postpartum Support International (PSI), and the Maternal Mental Health Leadership Alliance (MMHLA) have been offering information, support, and resources for mothers and families to navigate the perinatal period.
If the above symptoms last beyond 3 weeks, then mothers and family members should consider the possibility of PPD. If a mother is not caring for herself, her baby, or other family members, and generally seems like she is “checked out,” that is a sign to get her help. Forgetting things, intense anxiety, guilt, loss of interest in things that used to be fun, and a general blank expression while going through life can all be signs that a woman who has recently given birth may need some help. Family and friends can offer a lot of support — childcare, housework, meals, and other errands to ease the burden on new mothers.
Cognitive behavior therapy (CBT) is the predominant psychotherapeutic treatment modality. It helps mothers to recognize errors in thinking that impact mood and behavior. Once faulty thought patterns are identified, CBT clinicians provide training on how to reduce these thoughts to alleviate symptoms.
Maternal Separation Anxiety
Although PPD is the most popular mental health condition associated with maternal mental health, there is also a condition called maternal separation anxiety that was researched in the late 1980s/early 1990s. It never received as much attention as PPD. I came across it while doing graduate research on maternity leave. During this time period, the United States was debating its first and only national maternity leave policy and what would eventually become the Family and Medical Leave Act (FMLA). Researchers, legal scholars, policymakers, and others were debating many aspects of maternity leave policy. One researcher — Ellen Hock — and her team at the Ohio State University were concerned about the psychological impact of mothers’ return to work. They were particularly concerned with how mothers experienced separation when they had to return to work and send their infants to daycare.
After conducting a series of experiments, Hock and her colleagues coined the term maternal separation anxiety (MSA). It was defined as “an unpleasant emotional state tied to the separation experience: it may be evidenced by expressions of worry, sadness, or guilt” (Hock, McBride, & Gnezda, 1989, p. 794). Maternal separation anxiety takes into account anxiety that may be experienced by the mother after childbirth, while separation anxiety — a DSM diagnosis — had traditionally focused on the child’s experience with separation. However, in 2013, the designation of separation anxiety as a childhood onset disorder was removed from the DSM-5.
Specifically, Hock and her team wondered if working mothers may feel sad and anxious about being separated from their newborn children when they returned to work at the end of maternity leave. Their work was based on decades of research on attachment that was carried out by John Bowlby in the 1960s. John Bowlby, a British psychiatrist, developed Attachment Theory. The theory grew out of years of observing and studying children who were separated from parents for brief and long periods of time or children who were homeless. Bowlby viewed the early years when a child spends almost all of their time with their mother as critical in human development. He felt that this period of attachment was to prevent harm and promote mental health (Bowlby, 1973). This was such an important topic that Bowlby wrote three volumes on attachment, separation, and loss.
One of the interesting findings by Hock and associates was that working mothers had less separation anxiety about returning to work if they preferred to return to work and were able to return when they wanted to. Working mothers experienced more separation anxiety if they preferred to stay at home but had to return to work before they wanted to. The studies conducted by Hock and colleagues led them to develop the Maternal Separation Anxiety Scale (MSAS), a 35-item scale that measured 3 factors: separation anxiety, perception of separation effects on the child, and employment-related separation concerns. Four years after the MSAS was developed, the FMLA was signed into law and working mothers received some recognition of their need to balance home and work life.
Although Hock and colleagues focused on mothers’ experience with separation anxiety, research on paternal separation anxiety was conducted in the early 1990s as well. Researchers found that fathers experienced separation anxiety; however, compared to mothers, who had more employment concerns, fathers were slightly more concerned about their child. Current perspectives are that the term parental separation anxiety is more fitting to describe anxiety that is experienced by both mothers and fathers.
After the 1990s, research on MSA dwindled to non-existence; however, my brief time learning about it has left an impact on me and my memory of it is jogged when I hear the term maternal mental health. MSA was a promising mental health condition that could be measured by a valid questionnaire; however, it never gained traction. Perhaps Hock and colleagues were ahead of their time as they were exploring complex processes at a time when life was seen and experienced on simpler terms. Maternity leave and the separation that it brings between working mothers and their newborn infants, and between worker and employer are still hot topics in society, even 33 years after a national family leave law was passed.
Maternal mental health is an equally complex topic, and there are a myriad of related topics and research mysteries waiting to be solved. However, Hock and colleagues at least got the idea into our consciousness that when women give birth and bring forth new life, and are compelled to return to the workplace before they are ready to return, they may experience high levels of psychological instability due to this change. They brought to our awareness that maternal mental health may not just rest solely in women’s minds but may be connected to social conditions such as working, relationships, and possibly other underexplored social, economic, and historical conditions.
Conclusion
When we think of maternal mental health, PPD is not the only condition that mothers experience after childbirth. There has been prolific research about MSA, a condition that is related to anxiety and experienced by working women when separating from their infants to return to work. If we situate maternal mental health outside of the mother and consider social factors that may impact her wellbeing, then returning to work can be one catalyst for poor mental health. Recognizing that mothers exist in complex systems that impact their full self is important to understanding maternal mental health. When we look at maternal mental health through this lens then we can expand our understanding of the experiences of all mothers and start to explore factors that can shape a critical time in human development — the months and years after childbirth.
In my forthcoming book, Unequal Before Birth, I used a sociocultural historical lens to examine maternity leave in the United States. A small group of working mothers shared valuable insights into their experiences with maternity leave and mental health. From those insights, I made recommendations at the end of the book of how the entire social community- partners, family members, coworkers, neighbors, employers, policymakers, and governments can collaborate to create the shift that we need to reduce the conditions that can negatively impact a mother’s mental well-being after delivering a child.
