My clinical notes for women experiencing stress, anxiety and depression in the postnatal period are littered with the expression ‘I want my life back’. The change from paid work to full-time motherhood can be a joyful experience, where many women report being happy to be at home with their children, but for others it can be a time of emotional upheaval and even mental illness.^{1 2 3}

Having a baby and parenthood can be stressful life events. The moral and social expectations set for mothers about their role and the ‘acceptable feelings’ they should go through can be a burden when they do not match with their own experiences.⁴

Going from a time when they had relatively more freedom to choose what to do in a week, day or hour, to addressing the baby’s needs first can be oppressive. These feelings can be amplified by the fact that many women are having children later and have already made strong headway in their chosen work or career.⁵

Generally, the majority of primary caregivers to babies and young children – single or in a relationship – are women. This entails either being a full-time mother or working paid part or full time in addition to mothering – the latter often a difficult juggling act between competing priorities. In couples where the woman has previously had a busy career, there are common concerns and issues surrounding stay-at-home mothers.

While not the focus of this article, it is the case that pregnancy itself can present potential problems and stressors for women that need to be managed while working. How these are dealt with can also impact the postnatal period. Some mental preparation for the role change and challenges of the postnatal period is also important in the antenatal period.

Many of my clients fit the category of full-time mother previously full-time career woman. One is a 37-year-old environmental scientist who has travelled the globe advising on sustainable agriculture. She adores her baby and loves being at home, but her experience of full-time motherhood – and an impending return to work – is a game of juggling parenthood, a professional life and career development. For those mothers at the beginning of their time at home or for those who choose not to return to paid work, the experience is challenging.

Common themes

All women need to adjust to motherhood. Most will experience some stress, but some go on to develop or exacerbate more serious mental-health issues such as generalised anxiety, obsessive compulsive disorder and mood disorder.^{6 7}

Sleep deprivation and settling baby are naturally an issue. The seemingly relentless nature of caring for an infant can be hard when previously used to having some sense of control in their daily life and attempts to control the situation can sometimes end in greater stress.⁸

Women who are drawn to certain career roles are all after similar ‘payback’ from fulfilling these roles – status, money and the power to achieve. Personal sense of worth flows from these roles. Contrast this with the sudden social and professional isolation that can accompany new parenthood and you can see the vital importance of role adjustment. The current political and economic imperative to get women back to work also contributes to devaluing the role of the primary carer and is often cited by women who stay at home.

Women who describe themselves as high achievers at work can experience varying effects on how they manage their expectations of themselves (for example, breastfeeding), their baby (for example, settling) and their partner and family. It is common for perinatal women feeling anxious and depressed to believe they are not doing a good job, that they have failed as a mother and that other women are much better at mothering. This can become circular as sometimes they are indeed not mothering to their potential when anxious and depressed.

Comparisons with other mothers or families are rarely favourable in women who are anxious or depressed in the postnatal period. At the more worrying end of the spectrum, mothers express the belief that their baby – and often partner – would be better off without them. Some talk about running away and escaping and more concerning is when they consider suicide as a means to escape or cope.^{9 10}

Women can describe also feeling trapped or experiencing grief over the loss of their past life, including financial independence. Most women in Australia have access to some form of maternity leave, but even when they do this money runs out. The majority also report difficulty in asking their partner for money, with some resultant resentment.

If women are not coping or enjoying motherhood, feelings of guilt and shame are experienced – particularly for those who always thought they would love being a mother. Those who have endured fertility problems can feel significant guilt and confusion when they question why they have had their baby or resent their role.¹¹

The need for a social life can become very important to a stay-at-home mother. However, as her friends may not have children themselves, she can feel misunderstood. It is also hard to get babies and children out in the first place, impacting on the ability of a mother to socialise. Additionally, if a mother is very anxious about sleep and routine, fear her baby will not sleep means she stays home. For others, feeling depressed makes it less likely they want to socialise and the pattern continues.

The reported impact of new babies on partner relationships is significant in the perinatal period. The correlation between relationship adjustment and functioning is high, so it can be useful to determine if the anxiety and mood issues are a factor in the relationship issues or if the relationship issues are themselves causative of the mood and anxiety problems. Once entrenched, though, it can be difficult to separate the causes.^{12 13 14}

It is also important to recognise that partners can also suffer postnatal mental health issues – the assessment of which is important for individuals as well as the impact it has on the functioning and wellbeing of the mother and infant.¹⁵

The issue of childcare provision for women working after having a baby is another stressful factor. Choosing a type of childcare and getting a position can be time consuming and difficult, along with the emotions that go with having a child cared for by someone else, including guilt, anxiety and relief.

Can you really have it all?

At some stage, most women dealing with the changes of motherhood might ask: can you really have it all? Given they were told they could as they grew up, why not? The reality of this balancing act is often very difficult and most women will say they have not got it right. Feeling a sense of failure and believing they are not doing well enough at work and at home can be overwhelming.

Some stay-at-home mums never adjust to, or like, the role change, resenting being at home and not wanting to be full-time carer for their baby. While this is worrying in terms of mother-infant attachment, we cannot ignore this as a choice. While the mother needs to be able to validate these feelings in a non-judgemental way, it must be ensured that her baby is getting its attachment needs met and the woman is supported on her return to the workforce. In fact, once she returns to work her perspective on mothering may change.¹⁶

Identification of psychological issues

The mental health of a mother affects greatly that of her baby, older children and partner. All mothers want their family to be happy and healthy. This is not only a motivator for change, but can also put more pressure on a mother to be well.¹⁷

Severe, chronic stress has been shown to deleteriously affect maternal and fetal health, while management of stress in pregnancy has been shown to be efficacious in reducing perinatal stress, anxiety and depression.¹⁸ Evidence in the literature indicates psychological distress, depressive and anxiety symptoms are related to increased risk of adverse outcomes for mother and child during and after pregnancy.¹⁹ In the postnatal period not only the mother suffers, but her relationship with her infant and the infant’s ongoing emotional and cognitive development may also be affected by mental illness.^{20 21}

Some of the important factors affecting the duration of postpartum depression and anxiety include preventative measures and minimising the time taken to recognise and receive adequate treatment.²² Identification of depression and anxiety in the postnatal period can be hard to detect as it is often suffered covertly.

In assessing a woman in the perinatal period, it is important to complete a full psychosocial assessment. If postnatal, an assessment of mother-infant interaction and assessment of risk to mother and baby is also required.²³

A forward-thinking and collaborative approach to management of psychological issues is about identifying women who may be at risk and commencing treatment before birth or as soon as possible once symptoms commence in the postnatal period.²⁴ Obstetricians, midwives, maternal and child health nurses and GPs are in a good position to identify women of concern. Use of screening tools such as the Edinburgh Postnatal Depression Scale (and its antenatal version) is appropriate.²⁵

There is a large amount of literature identifying risk factors and predictors for perinatal mood and anxiety problems. Rarely is a single factor explanatory of a woman’s current mental state. The reality is a combination of many factors – biological, social and psychological. These include personal and family history of mental health issues, personality style, relationship stress and social support.^{26 27 28} If a woman is seen to have a number of risk factors in the antenatal period then this is a good time to refer to help. Much work and preparation can be achieved in the time before the baby is born. Generally speaking, helping in adjustment to the role of mother and managing expectations in pregnancy and the postnatal period is important.

During the perinatal period, women presenting to a psychologist often report no previous history of anxiety or mood disorder.However, many have suffered anxiety at a high level and sometimes depression in the context of her work, relationships or other situations that are stressful that was undiagnosed, untreated or mainly considered – in the case of anxiety – a useful feeling that motivated and helped them achieve. The combination of recovering from the birth, a lack of sleep and the demands of parenthood can mean anxiety is no longer manageable and affects their functioning.^{29 30}

Part of helping a mother involves education about the effects that her mental health can have on her baby and, if it is the case, her other children. However, it is not helpful to make them feel any more guilty than they often already do. Mothers seeking or being referred to help are sorely aware of the impact and it is this that often stops them seeking assistance initially.^{31 32} In those cases where the mother is so unwell – such as in severe depression and psychosis – the insight into the effect on her baby can be lacking, the resultant education should be given clearly, but with her capacity to assimilate this information taken into account.

Work around self-care, realistic expectations and acceptance versus change is helpful in managing feelings of being overwhelmed and/or trapped or isolated. Getting partners and other family members involved can make a significant difference.^{33 34} Encouraging socialising – and for some more formal connections such as mothers’ groups and playgroups – can open up the social world significantly. Activation with physical exercise and involvement in community is encouraged. Addressing longstanding issues that have become more obvious in the perinatal period is valuable when reflecting on current feelings and resulting behaviour.

Referral to antenatal and postnatal support groups on parental adjustment is useful. Groups that offer support to mothers in the postnatal period if they are suffering from emotional issues and mental illness, such as PANDSI, are remarkably helpful. Numerous websites give good information and support to mothers experiencing perinatal distress (for example, the PANDA and beyondblue websites).

Therapeutic approaches

A supportive and flexible therapeutic environment is paramount to successfully working with a woman in the perinatal period. Many women will not openly disclose they are having difficulty for fear of the stigma, a desire to remain in complete control, worry about asking others for help and concern they will be seen as unfit to care for their baby.^{35 36}

Cognitive-behavioural therapy (CBT) interventions have been shown to have positive effects in the antenatal and postpartum period with the relationship between thoughts, feelings and behaviour being the focus.^{37 38} Treatment using mindfulness-based cognitive therapy ^{39 40 41} as well as acceptance and commitment therapy ^{42 43 44} in the perinatal period is also extremely useful. Women appreciate the opportunity to learn about being present with their baby and their life more widely and about values-based choices in their role as a mother, partner and in work. They learn about what they need to accept and what they can change and they learn to take action while managing their thoughts by defusion.

The use of schema therapy⁴⁵ – an approach that combines aspects of cognitive, behavioural, psychodynamic and attachment models – can help women at any stage of their life identify and address specific schemas, coping styles and modes that have developed since childhood. This can offer great insight for a woman in terms of her interaction with her baby as well as her patterns of thoughts and actions. A woman’s upbringing and relationships with family, particularly her mother, is very important at this time.9 Furthermore, a history of abuse has great impact on her parenting and benefits from being addressed.

Interpersonal psychotherapy (IPT)⁴⁶ has long been used in the assessment and treatment of perinatal depression. The focus on relationships and communication, role transitions and interpersonal disputes is especially helpful when a woman experiences much change in role and relationships. Grief and loss are also addressed and this is particularl appropriate for addressing loss of a baby, miscarriage and babies with special needs or requiring time in the NICU, for example.

The requirement for assessment and treatment for trauma in the perinatal period is becoming increasingly recognised.⁴⁷ Many women (and sometimes their partner) experience aspects of the pregnancy and birth and the immediate period after the birth as traumatic. The birth of a baby compromised with a medical condition or born at a stage that requires NICU is also traumatic often for reasons of helplessness and horror for their baby and the treatment they need to receive.

Pharmacologic treatment of mental illness in the perinatal period is also an essential part of treatment success, particularly at the more serious end of disorder. Specialised knowledge is required of psychiatrists, specialist perinatal mental health services and primary care physicians in providing this assessment and advice in addition to psychological assistance. Working in conjunction with a psychologist or counsellor who offers psychological intervention is highly desirable.^{48 49 50}

Conclusions

The birth of a baby to a woman who is leading a productive, paid working life will open up a world of new experiences. While many of these are described as wonderful by full-time mothers, there are also some that cause severe stress and at times anxiety and depression. Identification and help as early as possible for women having these experiences is essential for their mental wellbeing and the wellbeing of their baby, partner and family.

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