Why is Perinatal Mental Health So Misunderstood?

Aug 6

Perinatal mental health is an umbrella term covering a wide range of reactions and symptoms occurring during pregnancy, postnatally and up to one year following birth. In recent years, perinatal mental health has been brought firmly into the spotlight by researchers, health professionals, woman, birthing people, partners and families. Despite this, we are still playing catch up as a result of women’s health having received much less attention than men’s health for a very long time. Better late than never.

Why Awareness Matters

We know that increased research, education and funding can have a massive impact. Postnatal depression (PND) is a really good example of this. While not yet a perfect system, it has become commonplace in many countries to routinely ask about mood and depression during postnatal health visits. This, in turn, creates increased awareness and provides more opportunities for help.

All Roads Lead to Postnatal Depression

Let’s do a thought experiment - what comes to your mind when you hear perinatal mental health? I’m going to make a confident guess that PND has popped into your mind. And, you wouldn’t be alone - society really fuels this message.

The narrow focus on PND can unintentionally, colour the lens through which professionals, woman, birthing people, partners and families view their suffering and experiences. There is an expectation that if someone is struggling, it must be their mood. And commonly, people are asked about characteristics of PND rather than mental health more broadly.

Put Simply:

Not all emotional shifts postnatally are linked to a mental health condition.
Not all emotional shifts should be “treated”.
Not all mental health struggles are PND.
Not all mental health difficulties look the same for everyone.
Not all mental health conditions start postnatally.
Not all mental health problems need the same approach.
Not all people struggling with their mental health appear to be suffering.
Not all people struggling emotionally are unable to engage in life.
Not all mental health problems involve one distinct symptom.

Function Does Not Mean Coping

Function does not mean coping. There is a widespread belief that if someone looks like they are okay, then they are okay. However, what we see on the surface tells us not much at all about someone’s internal world or their levels of distress. Society has conjured up an image of what it looks like to be depressed, to be anxious and to have obsessive compulsive difficulties. These assumptions shape whether people will seek care, and if they do, the care they will receive. Distress is not always obvious. We should apply the same curiosity to emotional well-being as we do to physical health problems, regardless of how someone might appear.

What Does Perinatal Mental Health Really Look Like?

Mental health within the perinatal period looks different for different people. And spoiler alert, it’s not just PND. You don’t have to be depressed to be struggling. There is a wide range of reactions, symptoms and experiences, which can vary in intensity. You may see experiences described as antenatal anxiety, postnatal depression, tokophobia, obsessive compulsive disorder (OCD), birth trauma, post-traumatic stress disorder (PTSD), grief and adjustment difficulties. People may also experience bipolar disorder or postpartum psychosis (PPP).

Some common thoughts are listed below:

I can't stop worrying.
I didn’t expect it to be like this.
I'm terrified by the thoughts in my head.
It’s on me to make sure nothing bad happens.
I might get my baby taken away.
I don't even know who I am anymore.
My thoughts just never stop.
Every time I walk past the hospital I panic.
Everything feels overwhelming.
Something terrible is going to happen.
I’m not sleeping at all.
I’m failing.
I have no energy.
I can’t cope.

A note on postpartum psychosis (PPP) which is less common and requires urgent medical assessment. Partners and family members are often the first to notice that something has become very different. Someone experiencing PPP may experience confusion, intense shifts in mood, unusually high energy or difficulty sleeping.

PPP typically involves unusual experiences including hearing voices, seeing or sensing things that others do not, becoming suspicious, feeling unsafe or developing strong beliefs that are not shared by others. They may also find it difficult to know what is real and make sense of what is happening around them. These symptoms can fluctuate over the course of a day.

Matrescence, Systems and Natural Reactions

Psychological symptoms are often best understood within the wider context of a person’s life, including both their current circumstances and past experiences. Becoming a parent is one of life's biggest transitions. The concept of matrescence helps us to understand natural emotional shifts in response to changes in identity, relationships and daily life. Matrescence is something to understand and acknowledge, it is not something to treat or to get rid off. Unexpected events during the perinatal period, such as loss or physical health complications, can also impact emotional wellbeing.

While many emotional changes are a natural part of becoming a parent, the systems surrounding families can either ease or amplify those experiences. Inconsistent care, delays in accessing specialist services and limited support can make an already difficult period even more challenging.

Neurodivergence and Perinatal Mental Health

Neurodivergent people can experience the perinatal period in many different ways, and may be at greater risk of anxiety, depression, overwhelm and burnout. What can make this especially challenging is that services often assume neurotypical needs, and the right adjustments can be difficult to access.

Antenatal Comes Before Postnatal

While training, I carried out my research within the area of antenatal mental health. This, alongside my experience of working with people in the perinatal period, has highlighted that very often there are early warning signs for mental health challenges before birth. Pregnancy can also provide a unique window of opportunity for many to receive education, care and support. This is important because knowing what to look out for can help us get ahead of difficulties, and reduce the likelihood of things worsening after birth.

The Importance of Careful Assessment

Individual experiences or symptoms don’t tell us a whole lot about what is going on for someone. And, some symptoms or experiences may fall into multiple categories (e.g. anxiety can be a feature of obsessive compulsive difficulties, antenatal anxiety, fear of birth, birth trauma, bipolar, adjustment and matrescence). We know that perinatal difficulties may arise for many different reasons which include biological, psychological and social factors. Mental health assessments carried out by qualified professionals are often necessary in order to develop an understanding of the pattern of symptoms, how they developed and how they affect thinking, feeling, physiology and behaviour. This helps to identify natural transitions and where specialist mental health care is needed.

Let’s say you go to A&E for a physical problem - you would be triaged, assessed, discharged or transferred to an appropriate ward for ongoing care. This system is essential so people get the right kind of treatment, at the right time, from the right kind of processional. I mean, that’s the aim anyway. So, if you had a broken hip, you wouldn't expect to be treated on a cardiac ward. And, if you had appendicitis, you would not expect to be assessed as having indigestion and sent home with a few packets of Rennies.

Getting Help

Knowing what to look for, where to turn, and what to do is important. This is true for mental health professionals, women, birthing people, partners and families alike. Getting help may look like talking to the people around you about what you are experiencing. Different people may need different kinds of help, involving one or several layers of support. This may include psychological therapy, medication, support groups and in-patient care. There is a really solid research base showing that perinatal mental health difficulties can be understood and treated. While PPP requires urgent emergency care, it is also very treatable and typically involves a mental health team approach as well as medication.

Shame and Stigma

A large proportion of women, birthing people or partners who are experiencing psychological distress do not get help. This is unsettling. As well as the issues mentioned above, shame and stigma can be a massive barrier to seeking help. The social media explosion portraying ideal, and unrealistic pictures of early parenthood really doesn’t help. People can be terrified of being separated from their children or being perceived as a bad mother. Another factor is way the Western world has evolved where there are societal and cultural expectations that parents should cope, get by and do so with very little, or no support. This completely goes against our biological motivations as humans to recover with support and in community.

Summary

In summary, we still have a lot to learn about perinatal mental health to ensure people get the right care, when they need it. While PND is common, it does not explain all psychological experiences. There are are also many natural and understandable reactions during this period which are to be understood rather than treated. Experiences of distress during the perinatal period are wide ranging and they are not always obvious to others. They may, or may not impact someone’s ability to get by day-to-day. There are a lot of effective approaches that can really help, and an assessment is often needed to make sure you get the right kind of support. PPP requires a different approach and requires an urgent mental health assessment. Reaching out for help can be scary, but you, your partner or your family are certainly not alone and support is available.