Understanding Postpartum Depression – A Professional Perspective : Mamma Love Series

Mamma Love Series

As part of the Mamma Love Series, I approached Dr. Susan Pawlby, a Developmental Clinical Psychologist, and former Lecturer in the Section of Perinatal Psychiatry at the King’s College, London, UK.  She is also a member of the Multi-Disciplinary Team on the Channi Kumar Mother and Baby Unit at the Bethlem Royal Hospital, South London and Maudsley NHS Trust. Dr. Pawlby is now a visiting Senior Research Fellow at King’s College, London.

She shares below about depression in parents, mothers in particular, from her years of experience working in this field. She also shares what kind of support is offered clinically and how we can support the pregnant and postpartum mammas in our lives.


How is antenatal depression different from postnatal depression and how do they affect the baby? 

A major depressive episode is an illness characterized by low mood and/or loss of interest or pleasure in usual activities, lasting at least 2 weeks, with secondary symptoms being appetite or weight changes, sleep difficulties, psychomotor agitation or retardation, fatigue or loss of energy, diminished ability to think or concentrate, feelings of worthlessness or excessive guilt, and suicidality. The difference between antenatal depression and postnatal depression is only in the timing of the depressive episode, one being during pregnancy and the other after the birth. The symptoms are the same. Antenatal depression may affect the foetus by increasing cortisol, norepinephrine and inflammation which affect the fetal environment and have implications for maternal and infant health. Maternal stress has been associated with poor birth outcomes including preterm birth, infant mortality and low birthweight. Postnatal depression may affect the baby if the mother’s symptoms mean that she finds it difficult to respond to her baby’s physical, emotional and social needs.

How does depression of mothers affect the emotional regulation of babies? 

One of our tasks as mothers is to help our babies regulate their own emotions. When a baby is born their brains are not well-developed. Infants have some limited self-directed regulatory behaviours such as thumb sucking, visual avoidance, and withdrawal but these behaviours have limited effectiveness. When babies have uncontrollable cries, it is up to us, the parents, to help them regulate their bodies and emotions, so that they learn to self-regulate. This is more easily accomplished during the sensitive period when the brain is still flexible. In order to do this a mother needs to notice, monitor and recognize her baby’s emotions and adapt her own emotions according to the situation. If the mother is depressed, her own emotional feelings may overwhelm her and she may not notice her baby’s distress or be able to offer appropriate support.

What kind of intervention is offered to mothers experiencing depression? 

In the UK, we have multidisciplinary teams of perinatal health professionals – psychiatrists, psychologists, nurses, nursery nurses, occupational therapists, social workers – who support women suffering from depression during pregnancy and following the birth, both in the community and in special Mother and Baby Units. They offer different interventions including medication, talking therapies, promoting well-being through support with sleep, nutrition, exercise, and specially tailored interventions promoting the relationship between mother and baby, keeping the whole family in mind.

How many women who experience postpartum depression actually seek treatment? Why do you think many do not come forward for help?

One UK study in 2011 showed that only 43% of people suffering from postpartum depression sought help. Among the reasons given for not seeking help were that

  • it was not serious enough to warrant help from a professional
  • they were too scared to tell someone for fear of the consequences, which included fear that their baby would be taken away by social workers
  • they did not realise until later that they were suffering from postpartum depression
  • they felt that the support they were receiving from family and friends was sufficient;
  • they felt that their partner did not support their seeking treatment, they lacked sufficient information about what to do.

How can healthcare providers pay attention to the mental health of pregnant mammas during routine checkup?

In the UK midwives now routinely ask questions about a woman’s mental health at the first antenatal appointment, as recommended in the NICE guidelines (2014)

How common is PPD in fathers? Why might this happen? 

Research suggests that between 8% and 22% of new fathers suffer from postpartum depression. Men may be reluctant to talk about their symptoms and may self-medicate using alcohol. Men whose partners are suffering from postpartum depression may feel that they have to be strong, but once the partner has recovered, their symptoms may become visible. Look at Mark Williams website to learn more about how fathers experiencing postpartum depression can be supported. 

How can new parents be supported to avoid depression during pregnancy and after? 

More discussion in antenatal classes and in the media about the risk factors of becoming depressed and the importance of seeking help. Awareness of keeping stress levels down in pregnancy and encouraging women to take maternity leave from 36 weeks pregnant rather than from the birth. Reaching out to Governments to recognize the importance of supporting mothers-to-be and fathers-to-be in order to avoid mental health problems in this and the next generation. Seeing parenthood as one of the most important tasks that we do.

Are there any ways by which as a society, we can eradicate the stigma around mental health? 

Promote the slogan that mental health is as important as physical health and that Governments should invest as much in one as the other. 

Journey towards Motherhood; Experiences on Pregnancy & Postpartum : Mamma Love Series

Mamma Love Series

Do you think pregnancy focuses on preparing for motherhood as much as preparing or a baby? 

Ramya, who lives in Bangalore with her toddler shares, “I do not believe pregnancy focuses on preparing for motherhood. Throughout pregnancy, a mom, especially a first time mom, usually thinks a lot about the course of pregnancy, how to get through it & how to keep her growing baby healthy. Then there is of course labour and delivery, which preoccupies many moms-to-be. And finally, one thinks about processes and things for when the baby comes – how do you swaddle, what stroller do you need. There is very little mention – from healthcare providers or more experienced moms’, in literature, depictions in popular culture of what motherhood entails, and the mental fortitude required to deal with it. 

Shilpa, mother of baby Dhruv who is 11 months old, writes, “Contrary to what I thought, not in the least. While I was pregnant, it was all about staying healthy, happy and focusing on having a safe pregnancy. Rest, sleep, nutritious food, supplements, yoga – the days just whizzed by. Coupled with long hours at work, there wasn’t really any time to think of anything else. And no one really spoke about motherhood, at least to me. Other than the usual, “Oh, this is nothing, wait for the baby to arrive!” – no one had much to say, and it never occurred to me that we actually do need to prepare for motherhood.

Can you share with us the emotional and physical ride you went through soon after your baby’s arrival?

Shilpa begins, “Remember how I said that people tend to tell you, “Oh, this is nothing, wait for the baby to arrive!”. At the time I thought, well, it would really help if the same people could actually tell me something useful instead of these unwarranted comments,” she says. “But, what I can tell you now, is that, NO ONE can really tell you anything about how you are likely to feel. Every pregnancy is different, every baby is different AND every mother is different. There is really no ‘one size fits all’ advice – and it would really help if that is what people would tell new mothers.”  She continues, “For me, it was much easier to deal with the physical aspects than the emotional ones. I had a C-section, it was not easy, and it was painful, but with the help of doctors and nurses I found it quite manageable. For someone who really really needs sleep to function, the lack of sleep that comes with a new baby hit me like an express train! Even that I managed to deal with in the best way I could. 

She says none of the physical challenges came close to what was going on in her mind. “The answer to what was going on in my mind is, nothing, and everything,” shares Shilpa.  “A lot of the time I was completely blanked out and functioning like a robot, and when I wasn’t in that mode – I was paranoid and overthinking EVERYTHING baby. Is he sleeping ok, is he being fed enough, is he peeing enough, is his poop the right color, is he breathing while he is asleep (yes, even this!), have I covered him enough and so on. ” She assures, “But, things do settle down eventually and the important thing for you and your immediate family is to acknowledge what you are going through.”

Meanwhile, Ramya speaks of her experience, “I had been waiting to be a mother my whole life. Since I was five years old, I would play pretend with my dolls, and as I got older, I’d imagine scenarios with my future children, and fantasise about life as a mother. I struggled to get and stay pregnant, which added to my deep yearning to be a mother. This pregnancy and my unborn baby were so precious and important to me – it’s not wrong to say that all my hopes were pinned on them. Then my daughter was born, and all my castles went up in smoke.” She says, “I knew it almost immediately – I did not feel all the emotions that everyone says you must, that I was prepared to feel – the overwhelming love, the immediate affection. I felt removed from my baby, I couldn’t bring myself to feel the quantum of love that I expected and wanted. She was low birth weight, and had experienced some in-utero stress. This led her to being diagnosed as a baby high needs. The intensity of her behaviour and emotions were jarring. She would cry for hours on end, and I would be at wits end, unable to comfort her, and not knowing what to do. Our bonding was not immediate, and took lots of time and effort. I felt deep anguish when I saw how easily my husband and father bonded with and loved my daughter, and I struggled to do the same. 

My angst was compounded by the fact that I moved back to my parent’s house after living away from them for more than five years. My father is a doctor, and was very involved in my daughter from the moment of her birth. My mother- in- law and husband’s aunt were also very keen to help and would come over everyday. I am an introvert at heart, fiercely independent, and deeply opinionated. This combination did not bode well for me in my circumstances. I felt like I was drowning under the torrent of constant advice, comments, and suggestions. I felt that I was not getting the support and rest I truly needed, and started feeling resentment towards those around me. The restrictions on eating, going out, and general to-dos, mild though they were, felt unbearable to me. 

About her initial breastfeeding experience, Ramya shares, “Breastfeeding was probably the worst part of the initial days. I struggled to produce sufficient milk, and felt like I was subjected to an inquisition from all the elders at home. It was deeply anxiety inducing. To add to this, my baby was born with a tooth, which rendered breastfeeding traumatic at times. Physically, my recovery was quite quick and relatively easy, given that I had a vaginal birth. However, I had stitches and some digestive issues that left me in constant discomfort for the first couple of months. Coupled with my lack of sleep, I felt like a zombie. 

Finally, she says, “Of course like all things, the lower the lows, the higher the highs. I could watch my daughter sleep for hours on end. Hugging her tiny 2.5 kg body to my chest on those chilly winter afternoons as we did skin to skin, was tranquility epitomised. I always maintain one of life’s greatest joys is holding a sleeping baby, a truth I realised in those early days. When my daughter would smile in her sleep, or yawn, or I’d count her tiny fingers and toes, I truly understood why it was called the miracle of life.”

Mamma Love Series Set 1

In those initial months, what kind of support comforted you most and what caused turbulence? 

“My husband was my biggest support, my rock and my wall”, begins Ramya. “When he was there, I felt completely confident and comfortable. He always let me take the lead and played the perfect complement. He was ever ready to do any physical task, and give me a break. This rejuvenated me and kept me sane. I found his presence to be calm and soothing because he never questioned me, and instilled in me the belief that I was doing my best. I also found immense comfort in my best friend who had a baby 18 days after me. We were able to go through all the trials and tribulations of new motherhood together. Speaking to someone who was feeling all the things that I was feeling, was an immense reassurance. My parents were very supportive and generous. I feel I took them for granted to some extent, but knowing that they were there for relief and my father for medical help and advice was very comforting. The things that caused turbulence was constant critiques and criticism of my choices and parenting style, and people providing anecdotes about the choices that they made with their children. I felt that there was so much pressure and instruction, it left me dizzy, and unable to think out the best choice for me and my baby.”

Meanwhile, Shilpa says space and privacy were what she needed and when given that, she was able to enjoy the initial days and stay comfortable. She adds, “This was essential to recover, bond with and get to know my baby. I didn’t want a long lines of visitors at the hospital or at home, and that was THE factor that caused turbulence in my case. Being in India, a LOT of people tend to visit – out of courtesy, even when you don’t want/ expect that courtesy!  The cardinal rule of “never wake a sleeping baby” was thrown to the winds, and that was incredibly upsetting for me.”

At any point in this journey, have you felt that you were so unprepared for the task in hand?

“Honestly this happens so often that I have lost track,” admits Shilpa. “While most matters appear fairly routine and ‘everyone has gone through it’, when it is your own baby, and when it is you who are completely responsible – even the simplest of tasks can put a lot of pressure on you. At the start, even changing diapers used to stress me out – have I cleaned him properly so that he doesn’t end up with a rash?! After getting through the first few months, I can now probably tell another new mom to hang in there and that it gets better.”

“Yes!” exclaims Ramya.”Many times in the first three months, I’d cry to myself, asking what I had done to my husband’s and my life.” “The physical and mental exertions were nothing close to what I had expected, and I was completely overwhelmed. At the same time I felt like a complete failure, because I thought that since the start of time, billions on billions have undertaken motherhood successfully, why am I finding it so hard. I also felt a great amount of guilt since I knew the majority of people have minimal amounts of help and I had so much. I was perpetually petrified of what life would be like when I moved out on my own.”

Is there anything that you have learnt on this journey that you want to share with other mothers?

Shilpa advices new mothers, “You may have heard a lot of people talk about how they are independent and how they managed to do everything for their baby all by themselves. Now, that’s great. But, if you are in a position to get some help, take it! You will feel much better. While it is beautiful, it is not an easy journey, and every mother needs her rest, as well. You don’t have to feel guilty if you are unable to manage by yourself, taking care of a newborn is no easy task and especially for a new mom who doesn’t sleep nights (or days). Even now, with an 8 month old, I don’t need help with any chores, but I do ask the grandparents to come and just play with the baby. I physically don’t have the amount of energy required to keep my baby entertained for hours and that’s the one thing I ask for even now.”

Ramya puts into words something beautiful for expectant mammas, “I think I would want to share that there are so many narratives, dictats, rules, and expectations. There are so many voices in the background. There is so much stress and tension. Hard as it may seem, block ALL of that out. Remember the only thing that is right is what works for you and your baby. There is no wrong. There are no winners and losers. There is no better and worse. So focus on making yourself happy and content because that’s when you will be able to make the best choices as a parent for your child and family. Learn to trust yourself, that’s how you can be the best mother you can. 

Cut out the competition in toto. It doesn’t matter – epidural or non, vaginal or c-section, breast, bottle or both, co-sleeper or in the crib. These choices literally do not matter at all in the long run in any material way, they have no reflection on you or your child. You aren’t better if they did things one way, nor are you worse. She finally says, “Don’t derive a sense of achievement from your children!  Enjoy each milestone, quietly and peacefully.”