Women’s Experience of Postnatal
Depression
Catherine Dakin
Maureen Tearle
Liz Roberts
ACKNOWLEDGEMENTS
Our heartfelt thanks go to twelve wonderful women who were willing to be interviewed and
supported this research. We were humbled by their remarkable stories of courage and
hope, often in the face of adversity, and their willingness to help others through their
stories is truly inspiring.
To Geoff Bridgman and David Haigh - Thank you for your know how and understanding
approach to our often confused questions.
Thanks to Mind & Body Consultants for the use of their offices and resources.
Thanks to Deirdre Tollestrup and Lesley Young from Family Works, Waitakere for their
input and support.
Thanks also, to Dayspring Trust for the use of their resources and special thanks to
Amanda MacGillycuddy for her enthusiasm, support and endless supply of books.
Also, many thanks to David Orwin and Jenny Harrison for the momentous task of proof
reading this research, and Jo Brailsford for the wonderful transcribing and Sam RB for
creating the demographic charts.
To our families for sorting the chaos while we slip out the door to yet another “research
group” meeting. Thank you.
CONTENTS
2
Acknowledgements ………………………………………………….
2
…………………………………………………………..
4
Introduction ………………………………………………………….
5
…………………………………………………
7
Abstract
Literature Review
Methodology
……………………………………………………….
Demographics …………………………………………………
23
31
Findings ………………………………………………………………. 32
Historical Context ……………………………………………. 32
Social Context
……………………………………………. 46
Recovery Context ……………………………………………. 57
Discussion ……………………………………………………………… 68
Conclusion ……………………………………………………………… 76
Bibliography ……………………………………………………………. 78
Appendix ………………………………………………………………..
Interview Schedule ……………………………………………..
Information Sheet ………………………………………………
Consent Form …………………………………………………..
81
81
82
83
ABSTRACT
3
We embarked on this research in order to gain an understanding of women’s experience
of Postnatal Depression (PND) and undertook to interview twelve women, using a
qualitative Social Theory approach within a Narrative framework.
The purpose of the research is to listen and learn from women’s narratives of PND. We
believe that women hold crucial knowledge about themselves and their experience of
PND which could ultimately benefit us individually, as a community and as a society. We
disagree with the idea that research, or any other source of knowledge outside the women
has a higher level of credibility than that gained from their personal stories and we have
tried to reflect this by drawing on current research, but maintaining a definite focus on the
women’s interpretations and meanings.
We explore women’s knowledge of PND within three main contexts. These are; Historical,
Social and Recovery. Within these contexts we have learn the following:
Expectations and constraints imposed on women by New Zealand society is a
reflection of how childbirth and motherhood is viewed.

Recognising childbirth as a significant transition and acknowledging the
importance of mental and physical health after childbirth.

Increased awareness and appropriate education for women and society as a
whole would enhance early intervention strategies.

Diagnosis and treatment is imperative to recovery.

Being able to talk and challenge the myth of motherhood assists women to feel
confident in their mothering roles and practices.

Responsive, competent professionals and healthcare services benefit women with
PND.
INTRODUCTION
4
Greetings…
We are three mature, women students, who through our own experience of motherhood
and postnatal depression, recognise the ‘journey’ a new mother enters has to be
experienced in order to completely understand what it is like to be a mother in the
changing context of today’s society.
Our ‘co-research’ focuses on twelve New Zealand women who have experienced
postnatal depression and have courageously come forward to share their stories. Coresearch came from the ideas of David Epston (2001) and presented itself as an
alternative way of conducting qualitative social theory research, women who have
experienced postnatal depression have an opportunity to share and draw on their own
histories, traditions and processes and to give us insight to the real story. It is also seen
by us as a step towards reconciling with women, who because of stigma associated with
postnatal depression, may have felt disenfranchised from their families and/or
communities. Through our witnessing of the narratives, our hope and our reason for
embarking on this research is to firstly, listen and learn from our consultant’s testimonies,
while also providing an opportunity to privilege their meanings and interpretations as they
give voice to their remarkable stories.
We are aware, however, that in the process of
quoting from women’s narratives for this research, we will be removing quotes from the
original context in which they were said, for this reason we have tried to keep the quotes
reasonably long in the hope of holding true to their intended meaning.
An Overview of PND
Postnatal Depression(PND) can be traced back to fourth century BC and the Greek
physician Hippocrates, who described it as a mental disturbance following childbirth and
believed it to be a disturbance caused by the stoppage of the normal secretion of milk,
which was then directed to the brain instead of to the breast (Slee, 2002). The first
recognized scientific study of postnatal depression came from Esquirol in 1845 and Marce
in 1858 (Cox, 1986), both studies were in France and concentrated on women admitted to
psychiatric institutions. (Thurtle, 1995).
Today, Postnatal Depression is accepted as a unique illness though not represented as a
specific disorder in the (DSM-IV) Diagnostic and Statistical Manual of Mental Disorders
(American Psychiatric Association, 2000). As with most mental illnesses what causes the
5
onset of Postnatal Depression is still a matter for debate, but is generally described or
coded using DSM-IV as a ‘mood disorder’ occurring in women in the first year after the
birth of a child. Ten to 20 percent of New Zealand women will develop postnatal
depression in the months after the birth of a baby, it may also start during pregnancy and,
if untreated, continue and perhaps get worse after the baby is born (Mental Health
Foundation of New Zealand, 2002).
The term ‘postnatal depression’ can be very misleading because patients can present with
anxiety or obsessional thoughts rather than depression. It is also often used to cover a
variety of affective disturbances in the period after childbirth (Buist,1996). The illness
should be differentiated from the baby blues, which can affect up to 70 per cent of women
post-delivery, and the much rarer postpartum psychosis, which affects 0.1 to 0.2 per cent
of women post-delivery (Aiken, 2000. p 131).
LITERATURE REVIEW
Organic Theory: (Biological factors)
Postnatal Depression (PND) is a medical condition,
and the result of biochemical change which influence
the
neurotransmitters
in
the
brain.
Hormonal
6
imbalances are a strong contributing factor (Dr Malcolm George, cited in Aiken, 2000).
Following birth, abrupt changes in progesterone and estrogen levels and changes in the
pituitary gland can alter the physiological endocrine system. The thyroid gland being
depleted may also be a factor in PND, (Harris, 1993. Cited in Milgrom, Martin, Negri,
1999; Dr Hamilton, cited in Gruen,1990). However, there is no conclusive evidence as to
the cause of PND, or why some people suffer and others don’t (Aiken, 2000).
Common symptoms are the feelings of being abnormal, being lost, emotionally vulnerable,
isolated and alone, ashamed and sad, guilt because of lack of bonding with the baby, and
relationship issues (Aiken, 2000). Pitt (1968) states that it is an ‘atypical’ depression and
is distinguished from other types of depression, in that the mother may start off the day
feeling ambivalent, but the depression will worsen throughout the day (Cited in Aiken,
2000).
Onset & Duration
PND has a gradual or acute onset usually within the first year following childbirth, but
normally within the first six months. The severity is mild to severe, and the duration is from
3 months to 2 years, but sometime longer. However, even when women do consult a
healthcare professional, half still remain untreated (Hearn et al., 1998).
Signs and Symptoms
 Low or depressed mood, crying a lot, feeling sad
 Not enjoying anything
 Confused thoughts
 Lack of concentration
 Being irritable, intolerant
 Having difficulty making decisions
 Self-blame and/ or guilt
 Feelings of inadequacy and not coping
 Emotional labiality, feeling numb and having no feelings
 Getting very anxious, on guard and hypersensitive
 Irrational’ fears
 Disturbed sleep, having nightmares
 Exhaustion
7
 Lack of energy and loss of motivation
 Appetite disturbance
 Feelings of hopelessness and/or worthlessness
 Suicidal ideation
Biopsychosocial Theories
An individual’s biological makeup may predispose them to PND. This may be
compounded by the sudden change in hormones following childbirth, and the extreme life
changes that having a child brings, for which they may be ill prepared. There may also be
deep-seated roots resulting from adverse life experiences (1 George, cited in Aiken, 2000).
There may be little or no warning of the onset of PND, and often arrives with little or no
warning and there is often little understanding of the illness. It can place a severe strain on
the mother’s support system and relationships, and there may be lack of support and
understanding which can exacerbate the condition.
Lack of closeness and other
relationship factors are predictive factors for depression in women regardless of
pregnancy (Aiken, 2000).
A number of factors can affect adversely the mother’s sense of identity and increase
feelings of hopelessness; lack of understanding of the process of childbirth and
motherhood; lack of warning of the nature of the care and time needed for the baby, and
ill-preparedness for the change in lifestyle can cause serious affects on the identity of the
mother. Strained marital relationships can result from the stress of the PND and the
partner’s lack of understanding of its seriousness can result in marital breakdown. Other
influences are grief over loss of lifestyle and major change and transition to motherhood,
loss of control over ones physical state, loss of sleep, and sometimes relational loss
(Ball,1994).
The biopsychosocial model of PND looks to ‘vulnerability factors’ and argues that some
women are more susceptible to developing PND than others. These vulnerabilities can
include certain personality traits, psychiatric disorders and negative life events. (Milgrom,
et al, 1999).
Dr Malcolm George – Department of Physiology, St Bartholomew & Royal London Hospital Medical
School.
1
8
Risk and Vulnerability Factors
 Loss of own mother and/or poor relationship with mother
 Difficult childbirth and complications with birth and /or pregnancy
 Relationship issues/conflicts and poor social networks
 Stressful life events in the last 3 months of pregnancy
 Disturbed early life and/or history of abuse
 Neo-natal illness
 Personality and Cognitive Style
 High medical anxiety over pregnancy or birth
 Personal or Family history of Depression or other Mental illness
 Negative life events, for example miscarriage, still-birth, death of parent;
 Poor marital relationships or partnership. (Milgrom, et al, 1999).
Woman with low levels of emotional support are also more susceptible as are those who
have experienced isolation from close family or extended whanau support. (Aiken, 2000;
Milgrom, 1999 et al; Fettling & Tune, 2005; Harvey, 1999). New mothers are particularly
susceptible if they have experience of mental illness, a history of childhood or current
abuse, low support level, stressful life events; traumatic childbirth; changes in hormone
levels to which the mother maybe especially sensitive, and finding care and responsibility
of the baby difficult and overwhelming. (Fettling & Tune, 2005). In addition, low self
esteem, childcare stress, single marital status, unplanned/unwanted pregnancy and infant
temperament, were also reported as risk factors (Beck,2001).
Personality Traits
There may be a high anxiety level in the mother, and possible high expectations,
especially for the first child. For some mothers being used to an ordered life, and not
being prepared adequately for the lack of order that a new baby brings. The need to
control and being unable to control the circumstances around childbirth can result in a
“learned helplessness”. Previous experiences that influence the coping process, along
with the individual coping behaviour where anxiety may be an antecedent factor as a
reaction to stress. (Ball, 1994).
Detection & Diagnosis
9
Being seen by health professionals several times, and the signs and symptoms or a
particular pattern is observed for at least 2 weeks. (Fettling & Tune, 2005).
The DSM-IV ‘postpartum onset’ specifies major depression is four weeks postpartum
(Milgrom, et al,1999).
Awareness ante-natally of the “baby blues”, PND, and education; leaflets to the new
mothers. The PHC team (GP’s), Midwives and Public Health nurses, Plunket nurses, the
six week check on baby.
Prevention
Maternal Mental Health (MMH) in New Zealand help women who have long term
experience of mental illness, or mental illness within their families, during their pregnancy
as a preventative measure. They can help women to obtain counselling, group therapy,
medication, or regular visits by the MMH team. They also network with other agencies.
Examples of these in Auckland include Mind and Body Consultants Peer Support Service,
Dayspring Trust and Community Mental Health teams to support the women in pregnancy
and following the birth of the child up to eight months to a year postnatal. After this they
refer the women to other agencies for continued support if there is still an ongoing
problem with PND.
Early intervention can be a significant factor to preventing the syndrome of PND becoming
such a crisis. Although it does not seem possible to avoid PND, it is possible to give
information and teach about the symptoms, to offer prenatal assessments of risk factors,
and to reinforce early intervention so that families can ask for help. (Gruen, 1990).
Recurrence
If there is full recovery it is less likely to develop again, than if pregnancy occurs again
before full recovery. There is higher risk if there has been previous PND. If the treatment
has not been completed, (or not treated at all), depression is likely to continue into the
next pregnancy or even get worse. (Fettling & Tune, 2005).
Prenatal Factors
Women who are depressed postpartum may also have been depressed during pregnancy
(Watson et al., 1984). Those with recurrent or long lasting issues may be a more
vulnerable group than women who only have depressive symptoms postpartum and they
10
would therefore be an important group to identify and support during pregnancy and the
postpartum period (Green & Murray, 1994, cited in Rubertsson et al.,2004).
With the unsuccessful coping of stress experienced in childbirth and surrounding
circumstances, in order to gain control of the situation various behaviours are evident.
These are anticipatory action; attack and avoidance, which can cause denial, apathy and
inaction and are part of the symptoms of depression that characterise PND. This is a
reactive depression, resulting from lack of control over life, and the absence of warm,
confiding relationships when most vulnerable (Ball, 1994).
Exploring the Impact of Pregnancy and Childbirth
Our memories of birth are held in every cell of our bodies and can affect our whole mental,
emotional, physical, sexual and spiritual well -being. The quality of birth can affect the
quality of life, which in turn shapes the quality of society as a whole.. Valins (1993:53)
Corrie & Tubridy (2005:157) write “Even a normal pregnancy is a state of dislodgement
from a woman’s former self and previous ways of thinking, feeling and behaving”. There is
no doubt that pregnancy and childbirth are significant and often are not acknowledged as
a pivotal experience. For all women who have been through this process, life will never
be the same, even if ideally all of their expectations are met.
Birth is an important and pivotal event in women’s lives. In all societies there are childbirth
beliefs and practices. According to Fitzgerald et al (1998:para), these beliefs and practices
have a direct impact on mental health and the sense of well-being among new mothers
and their families.
Giving birth is a universal human biological process. What it means to give birth varies
from one cultural group to another. There is diversity in apparent sameness. In some
cases women control the context, in others they must respond to a context that is not of
their own making. Prior experience and the cultural knowledge (beliefs, practices,
expectations) they bring to it influence how women perceive and respond to that context
(Fitzgerald et al, 1998:118-119).
11
Valins (1993:54) states that birth itself is a ‘metaphor’ for all creative processes. The
quality of birth not only affects the future health of the child but also of the mother. As
Valins (Ibid: 53) suggests, the quality of birth experience has consequences for wider
society, both in an actual and a symbolic way.
Aiken (2000) describes childbirth as a key experience. She suggests that even in normal
circumstances new mothers are more vulnerable to stress, anxiety and emotional
upheaval. The way in which women are treated both during and after the birth, may have
further impact on their emotional fragility. A difficult birth including medical complications
will therefore add to the potential for depression. However as Corry & Tubridy (2005: 155)
point out, in some circumstances “even in the face of extraordinary trauma or prenatal
history, a mother’s emotional reaction against all odds, is not one of depression” and to
contrast this with the mother who is totally prepared and supported, with the ideal context
in place, who finds herself in the grip of PND.
It is clear that there are many variables in the experience of pregnancy and childbirth and
this is mirrored in the experience of PND. Is PND a reasonable response to the huge
changes and adjustments that motherhood brings?
The grieving for the old you who has permanently disappeared can be profound: the you
who was in control of her energy, body, sleep, time, social life, work identity and a
rewarding sexual and emotional relationship with the child’s father (Ibid: 158).
Welburn supports the idea that issues of identity are crucial to our response to the
experience of birth and motherhood. She suggests, “The way we experience birth affects
the way we experience ourselves as women and as mothers (Welburn, 1980:44)”.
Welburn (Ibid: 46) refers to childbirth as created by western society, as an alienating
experience. This she suggests is due to the lack of understanding by health professionals
and the ‘medicalisation’ of childbirth. Medical science, Welburn (Ibid: 47) contends, still
often the domain of men, has claimed childbirth as its own and has not been attentive
enough to those parts of the experience which are important to women, such as the
emotional experience of the birth and the mother /child relationship.
12
Motherhood
In his book ”Motherhood and Mental Health,” Ian Brockington suggests “Childbirth is more
complex than any other human situation because it is a period of rapid biological, social
and emotional transition, and exposes the mother to the full gamut of psychological
complications, as well as some which result from somatic changes and medical illness”
(Brockington, 1996. p 612).
Those things previously taken for granted, particularly since the advent of “Feminism,” as
a normal part of an adult woman’s life, are no longer – the active social life, personal
freedom, time to yourself, space and privacy. With the reality of motherhood, comes the
realisation that your life has changed forever. Keeping this in mind, we ask, is it any
surprise that mothers may be led to the notion that ‘depression is a realistic response to
motherhood’ (Nicolson, 2000).
It is well known from clinical observation that mother’s experiencing depression are not
likely to seek professional assistance (Cox, et al., 1982) A study of postnatal depressed
women showed that almost all the women 97% realised something was wrong, however
less than 20% reported their symptoms to a healthcare provider. Of this sample, only
32% believed they were suffering from postnatal depression (Whitton, et al. 1996). To
disclose feelings of stress or an inability to cope to others, when these feelings are
believed to be ‘unnatural’, is to experience them as stigmatising. Such a disclosure can
feel like an expression of personal failure as a woman and as a mother, which reinforces
the view that if other people knew about these unmotherly, unfeminine feelings, they
would react with disapproval and rejection. Anticipating a reaction of this kind is a potent
incentive for remaining silent (Brown, et al,. 1994. p 161). The social stigma attached to
the image of a mother who cannot cope with the needs of her infant contributes to the
reluctance of many to admit they are unwell and/or unable to cope (Thio, et al,. 2006).
Fatherhood
PND is a form of depression that is seen as ‘feminised’, because of the association with
women and childbirth, however it can affect men as well, and research has identified male
partners (George, cited in Aiken, 2000). When a woman experiences PND, her partner’s
world can also be turned upside down, often with severe consequences for him and/or
their relationship.
A significant number of men will become depressed themselves.
13
Possible causes include fears of becoming a father, by rigid and unrealized expectations
of themselves, by unmet needs from their own childhoods or by other stresses (Fettling,
Tune, 2005. p 8).
Cultural Factors
Reference has been made to an Auckland study that found Maori ethnicity to be a risk
factor for PND (Webster et al, 1994), however, comparative studies within multiethnic
societies have generally found little difference between ethnic groups (National Health &
Medical Research Council, 2000). Reviewers of relevant international literature2
concluded that there is little support for the notion that PND is largely the product of
Western societies.
While risk factors of PND are fairly similar across cultures, the
meaning and significance of particular values may vary. Researchers of PND symptoms
among Pacific women in Auckland, concluded that Pacific women are likely to be at a high
risk of PND but suggested that risk factors identified in Western populations might not
apply to them, and that retention of elements of traditional Pacific identity, family and
cultural supports, affordable childcare, and antenatal education serve as important
protective factors (Abbott et al, 2005).
As part of alleviating risk factors for PND, It is also useful to enquire about specific family
or cultural rituals which would usually be expected to take place (round the birth of a baby)
and discuss the value of these for the client and family/whanau. This can be particularly
important for women (and their families/whanau) who have migrated (Hunt, 2006).
Professional Perspective Theories
For many women PND goes largely untreated according to a recent 3survey in NZ. This
survey was a postal survey of women in the community who were four months
postpartum. They were assessed with the Edinburgh Postnatal Depression Scale
(EPDS).4 Of the 225 responses 36 women (16%), score above the threshold for the
symptoms of PND, and only nine of them were in treatment. Of a further 31 women
(13.8%), who scored just below the threshold region for PND, none of them were in
treatment. The prevalence rate of PND in NZ is slightly higher than the world-wide
2
National Health and Medical Research Council (2000); Kumar, (1994); Affonoso, et al (2000).
Thio, Browne, Coverdale, Argle. (2006). Social Psychiatry & Psychiatric Epidemiology; Vol. 41 Issue 10,
p814-818, 5p. Retrieved 27/11/07
4
EPDS – Edinburgh Postnatal Depression Scale, a 10 item questionnaire developed by Professor John Cox.
UK 1987, and used world wide for the screening of new mothers.
3
14
average, at a rate of 1 in 3 women. 5Argyle believes that the higher rate of PND in NZ is
related to many factors, including financial pressure, adjusting to one income, stress on
working mothers, and older mothers adjusting to becoming housebound after being
successful career women.
According to Clements, women had difficulty in admitting they needed help, mothers’ in
our society like to put on a brave face and try to present a coping image to the world.
(MacIntyre, 2007). This is also partly due to the fear of being labeled mentally ill, and the
consequences of not being seen as a “good” mother. According to Argyle, the loss of
general practitioners doing obstetrics means they are less aware of mental health
changes in patients. Tthere is also a weakness in the health system in the lack of
coordination between obstetricians, midwives and GP’s, and the lack of routine screening
for PND. This screening is routine in countries such as Australia and United States.
(MacIntyre). The NZ research recommends routine screening for PND in mothers
throughout the first year of their child’s life, says Judi Clements. 6
PND is the main cause of maternal suicide after childbirth in the UK. (Pitt, 1968, cited in
Aiken, 2000). it also causes measurable cognitive problems for children of depressed
mother. But if the illness is diagnosed early, treatment reduces the suffering and
damaging effects on the family, especially the child. (Dr Lyn Murray, cited in Aiken, 2000).
Five Groups of Psychiatric Post Partum disorders (Professor Ian Brokington, cited
Aiken, 2000). It has been our observation from the research that women diagnosed with
PND may have also suffered from symptoms from the following categories:
Stress Reactions: Resulting from a history of PTSD (Post Traumatic Stress
Disorder), and phobia’s.
Anxiety disorders: Including specific anxiety syndrome, acute anxiety for the
well-being of the baby and phobia.
Depression: Recurrent postpartum melancholia, accompanied by feelings of
worthlessness and hopelessness.
5
6
Argyle – Director of mental health services at Auckland District Health Board.
Judi Clements – Chief Executive Mental Health Foundation, NZ.
15
Disorders of the mother/infant relationship: Leading to the rejection of the
child, lack of bonding, even hostility.
Puerperal Psychosis: An acute atypical psychosis which affects 0.1 – 0.2% of
mothers in the first 3 weeks of childbirth.
Post Traumatic Stress
I did not die in childbirth, At least not for good.
I did not die in childbirth, but I also did not live (Marion Cohen, 1979)
Post traumatic stress disorder (PTSD) is a term which refers to the emotional reaction to
harrowing experiences (Aiken, 2000). PTSD was first recognised as a distinct diagnostic
disorder in DSM –111(American Psychiatric Association 1980). However it has not been
until just recently that trauma, as a result of a difficult birth, has been widely accepted
(Bailham & Joseph, 2003). Evidence suggests that it is not uncommon for women with
PTSD to also present with postnatal depression (Ballard et al., 1995. cited in Bailham et
al., 2003).
When PTSD happens after childbirth it is termed “Birth Trauma”. One text estimates that
7% of Women suffer it after birth, although it may never be diagnosed as this because the
symptoms may overlap with those of PND (Welford, 1998).
The experience of trauma during childbirth is subjective and it is particularly the perception
of threat to oneself or the baby that causes the PTSD response. Common responses
include fear, helplessness, humiliation, or horror. Women with PTSD, like women with
PND describe an overwhelming sense of a loss of control, which PTSD sufferers are
unable to process or consequently integrate in to their experience.
There are a number of other similarities between PTSD and PND and it seems that
women can be affected by both diagnoses simultaneously, which can complicate the
recovery process. These include but are not limited to weepiness, lack of concentration,
anxiety, sleep problems, guilt, depression, lack of bonding with the baby, feelings of selfharm, feeling emotionally numb, irritability and isolating oneself from others (Hartill et al
2000:14).
16
One of the major points of difference for those with PTSD is the overriding need to deal
with the birth experience above anything else. Women with PTSD will re- experience the
birth event including dreams and emotions. They will exhibit extreme hyper-arousal and
hyper-vigilance.
Treatment of Postnatal Depression
There are several options for treatment, and usually a combination of approaches is used.
These include support groups, counselling, therapy groups, medication, hospitalization,
ECT treatment (for severe cases when medication is ineffective.)
(Fettling & Tune, 2005; Milgrom et al, 1999; Aiken, 2000).
Anti-depressant drugs have been a main stay of treatment in the majority of cases, but
drugs merely remove the symptoms of the problem, they do not attend to the individual
circumstances and personality traits which also play a significant role in depression.
However they do provide and impetus to overcome the depression, by helping to
overcome the lack of motivation and despair that stops mothers from actively seeking to
get better. There is also a real need to assess the role as ‘mother’, and to learn coping
mechanism to adapt to the motherhood and family life in a positive approach (Harvey,
1999).
Counselling
For counselling, women are generally referred to psychiatrists, psychologists or
specialized counsellors in PND. These can include ‘talk therapies’, this includes strategies
for coping with day to day difficulties of living with PND; to reduce anxiety, and to build
self-esteem and confidence. CBT is used by the Maternal Mental Health providers and
counselling in group work, to challenge negative thought patterns.
In the case of relationship difficulties which contribute to the development of PND, or the
PND contributes toward developing relationship issues, couples counselling can be
useful. Sometimes existing relationship issues are exacerbated, as PND causes an
enormous strain on all couples. (Aiken, 2000; Milgrom et al, 1999; Fettling & Tune, 2005).
Therapy Groups: These groups are closed, with a set number of people per session, and
provide strategies for coping with PND, and to modify expectations.
17
Abuse and trauma counselling by ACC Counsellors, is also provided for women who have
had PTSD7 or background abuse issues. (Aiken, 2000; Milgrom et al, 1999; Fettling &
Tune, 2005).
Psychotherapy is used to understand and resolve underlying psychological factors which
have contributed to the development of PND, aiming to get to the root of the problem and
help make the depression less likely to return with the next baby.
A growing body of studies shows that psychotherapy or counselling maybe all that is
needed to help a woman to climb out of depression and with the combination of drug
therapy this is highly affective. (Aiken, 2000; Milgrom et al, 1999; Fettling & Tune, 2005;
Harvey, 1999).
Medication Antidepressants are used to correct chemical imbalances in the brain; these
usually take 2–3 weeks to take affect and are used for six months to two years generally.
Tranquilizers to assist in reducing extreme anxiety are sometimes used.
Hormone replacement is occasionally used to correct hormonal imbalance. In the case of
Thyroid depletion, medication will be used to correct this. Some drugs are for anti-anxiety,
as anxiety is often one of the main symptoms; however these can cause severe side
effects, but as tolerance develops to the medications, the side effects subside. Mood
stabilizers for severe depression in manic states can also be used, but can cause toxicity
if the right dose is not reached. All drugs need to be taken continuously to maintain effect.
(Aiken, 2000; Milgrom et al, 1999; Fettling & Tune, 2005; Harvey, 1999).
Hospitalisation
New Zealand has only one mother and baby unit at Christchurch Hospital.
Special units are provided in some countries with specialized PND care, these may be
within Obstetric or Psychiatric units. This is for women who need to have the drug therapy
and psychotherapy monitored more closely; for women who have intimated suicidal
ideation or when the depression has not responded to any treatments, in which case ECT
maybe recommended. A hospital stay in itself can be traumatic, but it will only be for as
long as it is needed to bring the depression, mania or paranoia under control.( Aiken,
2000; Milgrom et al, 1999; Fettling & Tune, 2005; Harvey, 1999).
7
PTSD – Post Traumatic Stress Disorder
18
Complementary Approaches / Alternative treatments
These are often preferred in the place of conventional treatment, particularly if women are
breastfeeding, and can be used in a self-help way, off the shelf as supplements or from a
complementary
therapist.
The
treatments
include
Homeopathy;
Hydrotherapy;
Acupuncture; Aromatherapy; Massage; Yoga; Meditations; Nutritional Therapy; Essential
Oils and Herbal remedies, and they can be used in conjunction with conventional or
therapist led treatment. They are also affective if used in conjunction with counselling or
psychotherapy and can be taken with all classes of anti-depressants except for 8MAOI’s.
(Harvey, 1999).
Recovery Themes ( As related to interviews).
Professional help: Medication; Own Doctor; Formal diagnosis; Support groups
and Mental Health Services; Counselling and Therapy; Effectiveness of help.
Strategies/what helped: Keeping busy; getting out of the house; visiting family
and friends; freedom.
Support: Relationships are crucial; understanding is crucial; spiritual factors; if
lack of support symptoms last longer.
Stigma: Labeling and mental health; family ostracizing; if talked about easier to
handle; wanting their stories out there; for others to know what it is like; to help
others.
Professional help and diagnosis can be significant and medications can make a real
difference to women’s lives. However, some women refuse medication and may find
alternatives to get through without it, this takes determination and could be a long haul.
Counselling and psychotherapy are very important in the recovery process in order to
make meaning of the whole journey. For some hospitalization is necessary for treatment
and intervention at crucial stages of the illness. ( Aiken, 2000; Milgrom et al, 1999; Fettling
& Tune, 2005; Harvey, 1999).
Recovery is a journey for most women for whom there is often a turning point or pivotal
change in the process, whereby they reach a certain stage in the depression, and then
manage to move away from it. (Frame, 2007). It is a journey of acceptance, by others and
8
MAOI (Monaomine Oxidase Inhibitors, used for Anti-Anxiety.
19
by oneself. Accepting the illness and accepting help, that it is okay to need help is very
significant, as is seeing the depression as separate to who they are as a person.
Often the turning point involved a crisis, with an admission to a psychiatric unit, with family
insisting that help be sought. With some, it was a conscious decision made by each
woman to work on her own recovering experience. (Pedan, 2006). In making the decision
to choose to work on recovery, a decision to choose life rather than to die is also a turning
point for many (Frame, 2007).
The response of the father, family and friends to the mother’s depression often affects
how the recovery progresses. It is greatly aided if the family acknowledges and
recognizes the depression as a legitimate concern (Gruen,1990). The support,
understanding, and non-judgmental attitude of partner, husband and family can greatly
lesson the guilt and hasten recovery. However fathers and partners have their own
emotional difficulties when the mother suffers from PND. They may feel frightened and
helpless when they see their partners so disabled. While some may respond with the
support and validation which is so vital to recovery, others are bewildered, betrayed and
angry at the unexpected situation, which is very different from what was anticipated with
the birth of a new baby (Gruen,1990).
Professional help and diagnosis made a difference for some and counselling therapy.
The turning point was often related to receiving the necessary skills and support to
facilitate recovery, with there being a fit between the woman and the professional. (Pedan,
2006).
Personal Strategies play a big part in the recovery process, for instance getting out of
the house, planning their day to meet with friends, and joining with others in a supportive
setting. The need for space and freedom is significant, and the need to keep occupied,
particularly with activities away from the home.
Social and Emotional support
This is probably the most significant factor in recovery, particularly by the closest person
to the woman, usually her partner, if this is a missing factor it is very difficult for women to
move on. (George, cited in Aiken, 2000). Even if all practical support is being given, if the
20
emotional support is not adequate, this is not sufficient for women. Emotional support by
the partner may be the most significant factor in the recovery process. For those who did
not have this, recovery may be slow. (George, cited in Aiken, 2000).
Positive influences from people were identified for the women who had involvement in
relationships that were positive and supportive. (Pedan, 2006). This was a very important
component of recovery; for some women who did not have such positive relationships,
recovery was a long drawn out process, and depression dogged them continually from
thereon. Some woman described limiting relationships with their parents. Others had been
in unhappy marital relationships which had ended subsequently.
Recovery Strategies

Working out strategies with the partner or person closest, in order to get enough
sleep; to get away for a break and to have time out and space.

Support from partner, family and friends; Support groups with peers.

Treatment and Therapy as individuals, with partners or in groups. (Frame, 2007)

Relaxation techniques

Eating well at regular intervals, (Harvey, 1999)

Asking for help, especially profession help

If not coping, don’t be afraid to admit it

Avoid intoxicants

Write down feelings in journal

If angry or have violent feelings that are frightening, share with a trustworthy
person

Attend mother/ child groups

Don’t compare self with others

Don’t strive too hard, or have too high expectations

Respect your own needs (Aiken, 2000).
If women are able to share their experiences with other women, this assists in the healing
process, and if they are able to assist others in the journey of recovery, this will also help
their own progress. (de Valda, 2003; Frame, 2007).
21
Barriers to Recovery
Many sufferers attribute the symptoms which can be very frightening, to exhaustion and
therefore overlook the significance of them. Others may focus on the symptoms and
attempt to get relief through medication or finding a physical cause for their illness
(Gruen,1990).
Because it is an emotionally vulnerable time following childbirth, some women may be
reluctant to acknowledge they are suffering from symptoms of depression; as such an
admission would intensify their feelings of guilt and inadequacy. Therefore they may do
their best to ignore the symptoms or minimise them (Gruen,1990).
In some instances the barrier to recovery was the lack of understanding from the medical
profession, they do not always recognise the problem, even after the new parent seeks
help. For some of the women at the time period when they had the illness there was a
general lack of knowledge as to the cause and the seriousness of the nature of the illness.
The GP may say that it is only a temporary adjustment and not serious or minimise the
symptoms that the women is having. This leads her feeling more confused and
overwhelmed, hopeless and guilty for feeling the way she is, as it is hard for her to
describe what she is experiencing or why she feels so bad. (Gruen, 1990).
METHODOLOGY
How it began
As women we are aware of the enormous pressures placed upon us by society in terms of
our role as mothers. We have been encouraged by recent texts in which women share
their motherhood experiences and we have noticed how important it is to have childbirth
and motherhood experiences validated. Our own discussions and research have
reinforced the premise that women’s stories are still largely absent from current literature
22
on PND. We believe that this research is relevant and contemporary considering the
current advertising campaign by Like Minds.
Aim
Our aim was to conduct ‘co-research’ using the ideas of David Epston (2001) which
provided an alternative approach to qualitative social theory research. Our inspiration
came from wanting to honour women’s stories, something that seems to be largely absent
and lacking in current literature.
We also sort to utilize other concepts of Narrative
Therapy by:

Giving voice to mothers stories

Privileging the meanings and interpretations of women’s stories

Learning from our consultants knowledge and experiences

Wanting to reveal the subjugated or alternative story
What we were trying to achieve
We were trying to learn more about PND and its effects on women, their partners and
their children.
We wanted to learn more about outside contributing factors, which may have surrounded
the experience of PND.
We were wondering if the experience of PND had implications for wider society and were
looking for ways in which we could give women a voice to discuss PND, without
experiencing stigmatisation.
We were hoping to provide a rationale for more effective service provision.
Theoretical Perspectives
Rationale for Interviews
In order to research the experiences of women who have had Postnatal Depression, a
decision was made to interview twelve women who self-identified as having had PND. The
decision to research through individual interviews was based on a desire to offer women
the opportunity to share their stories in a safe, respectful and confidential environment.
23
With this in mind, individual interviews seemed more appropriate than a focus group or
group interview.
The skills necessary to conduct an effective interview included:
 prior knowledge of the research subject
 listening skills
 empathy and attentiveness to potential stress/distress of interviewee
 flexibility (ability to ask appropriate questions and to deviate from schedule as
appropriate)
 maturity (age and experience)
 non-judgmental attitude
 respect
 congruence
 warmth and compassion
 ability to build rapport quickly
 ability to contain emotional content and bring safe conclusion to the interview
Ideology of Motherhood & Feminist Theory
We explored the ‘ideology of motherhood’ from a feminist perspective and in this process
we hoped to contribute to the “reframing of motherhood’ and encompass a wider cultural
context that incorporated the feminist ideology of ‘the personal is political’ (Hainisch,
1970).9
The Power of Narrative
Story telling is an ancient art form, an integral part of human existence and the
most enduring form of communicating and reflecting upon experience, both real
and imagined…
(Grainger cited Crawford, Brown, & Crawford 2004:1)
Crawford et al (2004:2) state “Stories are a transformative force in people’s lives,
provoking self-reflection and change, and are profoundly human…but more than merely
describe experience, stories build or construct (experience)”. It was this idea that narrative
Carol Hainisch (1970) first said in print “the personal is political” early in the Feminist movement. Cited in
Mansbridge, J. (1995) “What is the Feminist Movement?”
9
24
could transform and give agency to people’s experiences that led us to approach our
research through the lens of metaphor and story.
It was the wondering around whether the telling of the story within the safety of the
interview could enable our consultants to reframe their experience of not only PND, but
also childbirth and mothering. Holmes (cited Ibid: 3) suggests that the sharing of stories
can lead to “the assignment of positive meaning to what appear to be very negative
situations”.
Bruner (1986 cited White & Epston1990: 3) states, “Story as a model has a remarkable
dual aspect-it is both linear and instantaneous”. With this in mind we also hoped to gain
an understanding of the different ‘layers of narrative’, within the research relationship.
Narrative Therapy
Narrative Therapists share a passionate engagement with issues of justice and ethics
states Bird (2000) and this is based on a compassionate connection with and
acknowledgment of the people we work with, underpinning everything is this relationship.
“A living engagement with ethics, writes Bird (cited Ibid), moves us outside of compliance
with the traditional professional position which then engages us with linguistic strategies
that internalise lived experiences”. Within this relationship theoretical ideas and practices
are, according to Bird (2000), “discovered and re-discovered, supported and challenged,
confirmed and changed within this environment”. It is our sincere hope that the outcomes
of our research will promote issues of ethics and justice.
We understand as narrative therapy students that acknowledging context is vital to
understanding experience. We note as well the fluidity of context and our inability to
restrict experience to the three main areas that we have highlighted (historical, social, and
recovery). It is our belief that all contexts, like experience are subjective and not able to be
contained or constrained by theory, models or frameworks. “Interpretive frameworks”
(Goffman 1974 cited Ibid: 5) Analogies are how we make sense of events.
Co-Research
The term ‘co-research’ has evolved within feminist and qualitative research contexts. It
refers to the notion that knowledge can be ‘co-produced’ within the research relationship.
25
It therefore does not assume expert knowledge on the part of the researcher but
emphasises the expert knowledge of those that are participating in the research. The
language of co-research also highlights the shift in emphasis from power and knowledge
lying with the researcher only and according to Epston (2004:32), further enables a sense
of ‘joint exploration’. Terms such as ‘co-research’, and ‘consultant’ help to construct this
more collaborative research approach. Epston (Ibid: 31) also suggests that co-research is
unlike traditional research in that it does not claim to be objective; rather its ‘value’ is in the
contributions of both the researcher and the research consultant.
Where language and naming are power, silence is oppression, is violence
(Adrienne Rich, 1972 cited Belenky et al:23)
We observed also that this approach made women’s ways of knowing central and
therefore powerful. As Gilligan (1982 cited Belenky et al, 1986:preface) observes, this
enables the emergence of considerable wisdom and acknowledgment of the power of
women’s voices in expanding our conceptions of human development. Belenky et al
(1986:19) suggest that voice is metaphor and that this applies to many aspects of
women’s experience. They (Ibid: 23) propose the idea that being given voice enables
women to be influential.
Hermeneutics
The term Hermeneutics came into use in the seventeenth century within the context of
biblical studies (Crotty, 1998:87). Hermeneutics is defined as a method for making sense
of text and illuminating or exploring hidden or indirect meanings. Hermeneutics also
grounds these meanings within the context ie the history and culture of the individual and
the community and produces a ‘sharing of meaning’.
This interpretation and understanding of text has been one of the historical influences on
the development of the brand of social enquiry known as “Interpretivism” (Crotty 1998:
para: 87).
Social Research
The form of research known as Interpretivism (Weber), focuses social enquiry on
‘understanding rather than on explanation’ (Crotty, 1998:67). According to Crotty (Ibid)
values and meaning are the processes by which we make sense of the world. All meaning
26
writes Berger (1985 cited Ibid: 58) is socially constructed. This way of viewing research
and meaning heavily influenced Epston’s development of both narrative therapy and the
ideas of co-research.
Limitations of process
 The small sample size of women represented, limits the experiences open for research
 Cultural differences were not addressed within the sample group
 The questions, although deliberately open in nature, are none the less specific and
directional and therefore may have failed to elicit accurate or honest responses.
 Because each member of the research group has personal experience with PND or
similar, there is some tensions around staying objective as researchers throughout the
interview process.
Inevitably, the interviewer will ‘hear’ through the lens of their own
experiences and discourses.
This means that themes outside of the interviewers
experience may not be picked up.
interviews.
Hence the importance of transcribing and re-reading
However, there may still be questions that are not asked or information not
asked for because of the interviewer bias.
Research Consultants
There were twelve women, drawn from the general public, gathered through snowballing
techniques.
There were Invitations to participate through special interest groups, for
example through consumer led mental health services.
Those who identified as having
experienced PND and indicated an interest in taking part in the research were given an
information sheet (see appendix) to consider. Consultants were given a week to consider
whether or not they wished to take part, and were assured of their right to withdraw their
consent at any time before publication.
We wish to acknowledge the following key qualities that we observed in this unique group
of women. They:
Exhibited amazing courage in sharing their stories
Wanted to make a contribution by sharing their experiences
Were creative, resourceful and adaptable
Were intelligent and knowledgeable
Retained a sense of humour
Challenged the Myth of Motherhood
Valued relationship
27
All developed their own agency
Demographics: (see following graphs)
Age of consultants
Ethnic identities
Number of children
Marital status
Educational Qualifications
Self-identified severity of Post-Natal Depression on a scale of 1 to 10
Process
The tools used in this research were an interview schedule and questionnaire, an
interviewer, and a digital recording device.
The interviews took place between July and September 2007, in an environment chosen
by the interviewee, so as to be both comfortable and convenient.
The interviews took approximately one hour each.
Each member of the research group conducted four interviews and these interviews were
then transcribed.
The specific questions used in the interview had not been given to participants beforehand
but the information sheet (see appendix) had outlined the topics.
The questions in the interview schedule (see appendix) were designed to elicit information
in three broad categories:
Historical context (pregnancy, birth trauma, previous mental health),
Social context (relationships and emotional support, stigma issues)
Recovery context (treatment, diagnosis, services offered)
There were three general questions relating to these areas and a final question which
asked women to look back at the experience and to articulate what they would have liked
28
to have been different, and what they may identify as not yet resolved.
Further probes
were asked within each of these categories.
Ethical Issues (see previous comments re narrative therapy)
This research process involved gaining ethics approval from the Unitec Ethics Committee
by way of a written application (see appendix).
The application was approved without difficulty.
Information sheets and consent forms were sent out to the participants prior to interviews.
The information sheet explained the background to the research and the procedure, and
outlined the parameters of confidentiality.
It was made clear who would be reading the
research and who would be either hearing the tapes or reading the transcripts.
As a precautionary measure, reference was made to the provision of a counselor, should
the interview process cause undue distress.
The greatest ethical issue was concerning safety for the interviewee.
It was recognized
that this process could cause distress, particularly if the experience of PND was recent or
unresolved.
Because of this concern, the decision was made to only interview women
whose experience had occurred five years or more previously.
In the interests of confidentiality, women were invited to use pseudonyms for themselves
and/or their children.
Consent forms (see appendix), that included a clause about confidentiality, were signed
by both researcher and co-researcher.
29
HISTORICAL CONTEXT FINDINGS
The Historical context (see Appendix - Questionnaire) explored issues for women during
their pregnancy and birth. This included how they felt during their pregnancy and whether
they felt prepared emotionally and physically for their baby’s arrival. We were interested to
discover if women, on reflection of the pregnancy and the context surrounding it, felt that
this had an overall impact on their experience of PND. We wanted to give women an
opportunity to share their birth stories and in hearing to acknowledge the complexities, the
joys and disappointments of this important rite of passage for women. We wondered
whether our consultants were given opportunities to de-brief after the birth and if they, in
hindsight, would have found that useful. Women were asked if they had been aware of the
symptoms/expressions of PND and if they knew of any history of PND or Mental Illness in
their own, or their family history. It seemed important to ask if our consultants had been
formally diagnosed with PND or were self-diagnosed, after the event and to wonder if this
had been helpful in terms of their recovery. We were curious to know how long the PND
lasted and what was still there for them around pregnancy and birth and other situational
stressors.
30
The experience of pregnancy
Fitzgerald et al (1998:101) state that complications during pregnancy can also affect the
perceptions of the quality of the birth process and can affect women’s mental and physical
health.
Only two out of twelve of our research consultants recalled feeling depressed or very
unwell during their pregnancy. Six out of the twelve reported a smooth, easy or idyllic
pregnancy in which they were looking forward to the birth, feeling excited about the
prospect of being a mother and during which they were physically and emotionally well.
…we planned to have Ben and conceived straight away, so I was terribly excited.
Huge joy and the pregnancy, it was pretty okay, not too much morning sickness or
anything…It was a pretty smooth pregnancy.
However several described situational stressors during the course of their pregnancy,
which they felt, may have contributed to having PND.
But towards the end of my pregnancy with our youngest, my relationship with my
husband was strained… You know, there was tension there. The about a week
before Bella was born, I had a car accident, 50 yards/50 metres from our
house…that was shock to the system”. . I was taking our middle one down to
kindergarten, I had taken our car down the road to pick up another child, backed
out of their drive, and was just turning around to turn down Grey Street, just down
the road from us, and there were road works resealing the road, and I didn’t see
the gas company van coming hurtling down the hill, when I had just come out far
enough and he hit me in the front, and that was a shock to the system. So that
meant no car. Mum came up from Gisborne to be with us, she was coming up
anyway. That didn’t help, and the fact that the other two had been early, Kate, four
weeks early, and Fleur a couple of weeks early, and Bella five days late. It was a
complete opposite. So she was due on the 5th November, and she arrived on the
10th. I had woken up about 4 o’clock in cracking good labour. I had the accident
one Monday, been to see the specialist on Wednesday. Everything appeared ok.
Went into labour on the following Monday morning.
31
Relationship difficulties also appeared to be an important issue for women in their
pregnancy. It was this lack of emotional support that created the potential for feelings of
isolation during the birth itself.
Expectations of the Birth
Expectations of the birth experience by the mother appeared to have had an important
impact on the overall experience and consequent development of PND. Disappointment
or difficulty around the birth led some women to doubt their own capabilities subsequently
as a mother.
One woman described the physical process of the birth as frightening and expressed her
sense of being quite unprepared for the ‘intensity’ of the experience.
…I personally found the whole labour, having the baby thing, really... unpleasant,
sounds kind of naïve and silly. It was a real shock to my body and me. It just really
took my breath away, so to speak.
Many talked about feelings of panic, anxiety and a loss of control during the birth and
several stated that they felt that they had failed in terms of their own and others
expectations. Some of the feelings of failure appeared to be the result of comparisons with
other women’s birth experiences and their own previous experiences, if this was a second
or subsequent pregnancy.
First time mother’s stated that they thought that childbirth was a natural process and had
been told that complications were rare. One first time Mother describes her sense of
shock at not having a “normal birth”.
It was quite a shock, having a Caesar, it was a shock, because everybody goes
and tells us in the ante-natal classes that everybody has normal births, and hardly
anyone has ‘Caesars’, so I’d been a perfectly healthy and fit person, you don’t
expect a Caesar.
32
Feelings of inadequacy in terms of their own performance appeared to be linked to the
circumstances surrounding the birth and to the individual’s cultural expectations.
But then there was all my thinking that went along, that there were thousands of
women and hundreds of millions of women all over the world that were having
babies and why can’t I do it? I just thought hundreds and thousands of women
have done this before how bad can it be? Then she was born at 7 in the morning
and at 10pm that night she was still crying, she just wouldn’t settle. I had gone
from having lots of time to sleeping and myself whenever I wanted. That was to be
her pattern, she wouldn’t settle. I got worn out. Tired really easily. I wasn’t coping,
wasn’t coping at all.
Medical Procedures and Birth Complications
Feelings of failure often seemed to be directly proportionate to the number of
complications experienced during the birth and also the amount and type of medical
intervention that occurred. Medical intervention that was performed without adequate
communication left some of our participants feeling violated and frightened.
There were about 11 doctors in the room at the time-it was pretty full on and the
guy who came in to do the episiotomy and the forceps, I remember freaking out
because he walked in, in white gumboots and a white plastic apron and I
remember, cos I was on the bed, I couldn’t move, because they had thrown me
back and had the bed up and the stirrups- very dramatic, stirrups and everything,
and thinking he’s from the freezing works. Cos he looked like he was and I
actually said that, “You look like you’re from the freezing works”. It was
completely unexpected that a doctor would walk in, in gumboots and an apron to
deliver a child, a baby.
Because he was overdue, I was supposed to be going in for an induction at 8.00 in
the morning, on Monday morning I actually went into labour at 5 o’clock on the
morning I was due to go in for induction so I was really pleased about that, cos it
was quite a stressful kind of time because I didn’t know who was doing that and
what doctor – male or female, that was out of my control. And then it was a 27
hour labour. I started off at Waitakere and it was about midnight I was transferred
33
to National Women’s in an ambulance. It was about 17 hours into the labour
before the anaesthetist arrived to give me an epidural, because they’d decided I
needed an epidural to speed up the contractions.
It was quite a shock, having a Caesar, it was a shock, because everybody goes
and tells us in the Ante-natal classes that everybody has normal births, and hardly
anyone has Caesars, so I’d been a perfectly healthy and fit person, you don’t
expect a Caesar. But I personally think it’s the chemicals in your brain that are
changing, and the hormones that are changing, not so much the trauma, but that
does, trigger depression, but then it changes the chemicals in your brain, which is
what has happened to me a few times in my life, you know.
All our research consultants noted the lack of accurate information surrounding
pregnancy, birth and PND. Many saw their experience of PND as the result of a number of
factors, a complex intertwining of situational stressors including lack of support networks,
previous and current losses, perceptions and expectations of the birth experience, and the
levels of anxiety that occurred during pregnancy, birth and early motherhood.
It was just a cause and effect of a whole lot of things that hit me. Whether
subconsciously and I haven’t thought of this before and having a tubal ligation,
subconsciously meant that I knew I couldn’t have any more children.
The effects of a difficult birth can become cumulative adding to the stress of new
motherhood and affecting the bonding process. Separation of the baby from the
mother added to feelings of disappointment around the birth.
And the pregnancy went just normally, only a couple of weeks overdue, but what
happened was, that when I went into labour it was very, very difficult, it was a
whole day and at the end I was so exhausted I was falling asleep with the
contractions, you know, and when I finally had the baby…I just didn’t want to
know, and then after the few days when they bring the baby to you, I just wasn’t
interested at all.
Yeah, like I didn’t get to hold him immediately. I didn’t get him directly on my
skin…I missed all that. I really wanted that skin-to-skin contact and then let the
34
placenta, you know, the whole bit. I didn’t get to have that…and he was dressed
and they’d wrapped him, so I didn’t really get to have that initial contact.
Birth Trauma
Four out of twelve women used the word ‘traumatic’ to describe their birth experience.
This was often related to the degree of medical intervention and a sense of loss of control
and fear for their own or the baby’s safety.
Women consistently felt overpowered by both the birth process and the intervention that
often occurred without explanation. Fear and helplessness were common responses to
this lack of consultation.
But, I think that had a lot to do with it, just the …feeling helpless and these
people doing things around me, I didn’t feel, I didn’t know what was going on,
to be honest, …
Well, I got in there at midnight and she was born at 1 o’clock the next day,
and I just felt completely not in control, and the pain was excruciating…
I think if I could have walked around and perhaps…yeah. They gave me
Pethidine too, a shot in my leg, and then they couldn’t find an anesthetist,
because then they thought they might give me a Caesar, but they couldn’t find
one, …and so all these things were happening.
Yes, I was terrified, with my first baby I um, was powerless, was x-rayed, had a
trial labour, had an epidural which only half worked; but he was born two weeks
later, after a rather lengthy, scary induction, and people coming and going…
I’m just reflecting… well it was a traumatic experience. Yeah, it was quite a
horrendous experience actually. Yeah, antenatal classes don’t prepare you for
that.
…there was fears, terrible fears, of going to bed and not sleeping, fears of going
out and confronting people and coming home, and looking after your house and
stuff, of course, you stopped your job as well don’t you, to have a baby, that’s
another thing, that’s a big change, yes that’s a change, but it didn’t seem to worry
35
me, because it came on when I came out of that hospital. And I know I didn’t like
that hospital that could have been a trigger, because the hospital scared me.
I think they did (explain), they said they needed to do some tests but they didn’t
really explain what tests they were doing or what they meant and I wasn’t just quite
coherent enough to ask the right questions.
Post – Birth Complications
Some of our research consultants described difficulties with post-birth complications and
sick and unsettled babies. These added difficulties appeared to leave mothers feeling
anxious about their own and their baby’s health and inadequate in terms of mothering.
I had to go to physio for my stitches because I lost, I hemorrhaged too after having
him, so I got stitches that became infected, I was unable to have a bowel
movement for 11 days, so there was a lot of pressure and the stitches stared to
come apart and they wondered if I was going to have to be re-stitched, which
fortunately I didn’t …
Lack of opportunity to debrief following the birth
All of our research consultants expressed feelings of isolation and a lack of ability to
communicate with others about the birth experience. None of our consultants had been
offered a chance to de-brief after a difficult birth experience. Mothers also found it difficult
to talk to friends or family members about the emotional consequences of birth.
No, because everyone, I don’t know, maybe they talked about how many stitches
they had, or the physical stuff, or I remember, Christine, she had a baby a month
before John, and she had to have a [procedure] done, you know we talked about
that, but not you know the way we felt”
Personality type
In terms of personality styles many of our research consultants described themselves as
being forward planners with a need to know what was going to happen and with
considerable expectations around their own performance particularly around the birth
experience and the role of motherhood.
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…And I’m very much like that. I very much hope that in my life – I like to know in
advance – and I like to know how things are so I was the person who read the 600
pregnancy books and spoke to 600 other people and studied and was on line, and
newsletter boards, and because I wanted to know…
And when you feel desperately unhappy and out of control, you um, you want to
go back to something you feel good at and to me that was working and I
enjoyed that. I thought ‘why did I ever want to have a baby, it must have been
the stupidest thing I ever decided to do, that’s what I thought.
Out of control, and yeah, that overwhelming feeling of responsibility and not
being able to get out of it and I think…
First child, being very much in the high powered role, well she is a very highlystrung individual – a get up and go sort of person. Likes to be in control of
everything, and to have this little baby screaming. And also she had an
undiagnosed breech.
Yes, it’s just getting that right balance, because I don’t like, I like to be in control. I
don’t like that feeling of whoozy. And learning to live well, eat well. Because I do
punish myself, I can over eat and then I had to work out how to lose it all so …
Loss of control
Women who identified with needing to be in control found the sense that they were no
longer in control a difficult adjustment. The flexibility required to be a mother and the not
knowing what was going to happen either during the birth or in the early months of
motherhood created high levels of anxiety for these women.
…It was after that first month it hit me and I thought I cant handle this I’m used to
controlling everything and I haven’t got control here and I don’t know what I am
doing and it just spiralled completely, so quick out of control.
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One woman describes her need to control her environment as a direct response to
feelings of things being out of her control.
All of a sudden I became inward & withdrawn, and obsessive silly thoughts and
then one of my early warning signs still now, which was then, is an obsessiveness
about house work, because at that time that was the only thing I felt I had control
over. And that still happens now. I know when I’m becoming unwell it is when I
become obsessive about housework.
I think that for a lot of mothers if they are quite used to having control, and then
they end up with this baby and it’s squawking and you have no idea …
Some women mentioned that having a high self-esteem created a buffer for the
experience of PND. Those whose sense of identity was secure found that they moved on
to recover more quickly from their experience of PND.
Yes, I’m ok, I know who I am, and I’m confident. Well, most of the time. I know
there are times when we get into situations when we aren’t confident, but by and
large, I am fairly confident. As I have gotten older I have gotten more confident.
History of Mental Illness
Seven out of the eleven women recognised a personal or family history of mental illness.
One didn’t know, but said she could not therefore rule it out. Various diagnoses were
recognised including, depression, bi-polar disorder, alcoholism and drug abuse, suicide
and a family history of PND, amongst sisters, mothers and daughters. Two out of eleven
revealed, on reflection, that depression had been a part of their life before the pregnancy
and that the birth was another potential trigger for this. One said that she was depressed
during the pregnancy.
No, but depression in the family history. PND, they told me to expect the baby
blues and things like that, but mine went on, and they were wondering if it was
because I was unable to have a bowel motion, and then all the things that were
tried for that to be able to happen. And then not sleeping and having a new baby
and things like that.
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Yeah. Because I believe I was depressed my whole life I just didn’t know it,
because even as a child I felt different, so I just kind of didn’t know it. Drugs and
alcohol were my way of dealing with my internal world and the world.
I think it just triggered everything off, I think I might have been always depressed,
but the baby blues or PND, triggered it off, into something more severe, because
looking back I think, I have always been depressed.
Lack of Information
All of our consultants felt that there was a considerable lack of honest information about
the birth experience and the symptoms of PND. It seemed that even antenatal classes
focussed on the normal experience and did little to prepare women for the complications
that may arise. They also provided little or no information on the signs and symptoms of
PND. Paradoxically there was an acknowledgement from some that it was impossible to
take in everything that would totally prepare you for the life changing experience of birth
and motherhood.
Well you don’t take it in – it’s that whole “well I won’t have a colic baby” and they
actually don’t do a lot to tell you about it. I can remember that there are all sorts of
things that are not that well educated or conveyed to prospective mothers – I mean
I wouldn’t want to scare a new mother into thinking “oh shit I’m going to get post
natal depression” but I do think that some decent education…
… that was the antenatal class. It was the pregnancy pack. You know, it’s like
“your baby’s fine but how are you”? You know, that pamphlet. I remember looking
through it & thinking, “gosh, it’s pretty scary” sort of stuff, but I didn’t think it was …
We actually had somebody at antenatal classes. A lady talked about it then.
Although interestingly enough, I didn’t actually identify that with myself.
Hospital care often fell short of the mark in terms of supporting mothers after the birth and
also in providing resources to help women on their return home. Some remarked that they
felt their had been a lack of supports generally for their emotional struggles and there was
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a question around how much emphasis and resources the health system places on
healing physical injury over psychological distress
…but just the National Women’s again, the hospital was insanely busy, the room
was filled with every different culture imaginable. That is how it felt like to me.
Visiting hours were horrendous, babies screaming everywhere. It wasn’t until
10pm that night, that a nurse came and said, when I was standing there holding
Nat, and I was balling my eyes out, and she asked what was going on, and I said
she couldn’t’ sleep, so she said take her down to the sleep room. Nobody showed
me how to feed her or how to do anything. If that had been in that little pack that
they send out, if that had some information, about here are some resources in your
community that can help you, should you find yourself struggling.
Yes, yes, but I wasn’t getting the help I needed. It wasn’t available. Society just
doesn’t have the support that when you’re suffering, like I had, you can not get the
home help for depression or post natal depression. If you break your foot you can
get help, if your mind is so distressed that you’re exhausted and unable to get up
and do anything, no, there is no help. Which is very wrong, I have spoken to a
number of Social Workers and they have found this to be a real issue in this
Society, a desperate issue.
Awareness of Symptoms and Expressions of PND
Women described varying levels of knowledge about PND. Ten out of the twelve said that
they did not know what it was and it was only in hindsight that they recognised the
symptoms or expressions of PND.
But yeah, it was something I did not understand, and I did not know what was
happening, instead of being your normal self, you became inward, totally inward,
and couldn’t sleep, at night, and you needed to, because you had a baby, a baby.
And during the day, you just cried all the time, and you don’t know why you are
crying, and all that, and it just went on from there, and it got worse, and worse, and
worse. I was just, I couldn’t sleep, I’d go to bed, I’d freeze emotionally, and try and
make myself go to sleep, and I couldn’t, and you needed to, but it made it worse
by saying “ I got to go to sleep”, and you couldn’t.
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Only one of the women recalled being given some information from antenatal classes
about PND. Another woman was able to make connections between her own experience
and that of her Grandmothers years’ previously.
Her (grandmother) youngest child when she committed suicide was I think 3 or
4yrs old and they lived out on a farm and she had no contact with other people,
they were quite wealthy – so she had everything she needed and she was quite
pretty, she had four children, but mum said she was just very unhappy, she was
always sleeping always crying and was very quiet she didn’t spend time with them.
When I listen to all of that, I say that’s what she had – that’s how I felt.
For all of the consultants the symptoms of PND were confusing and created feelings of
failure and/or despair especially if they ‘compared’ the way they felt with other mothers
without PND. It seemed that often women’s feeling’s and affect were not seen as PND but
as their own difficulty in adjusting to motherhood. This appeared to reinforce women’s
sense of inadequacy.
…Manic behaviour, but finding it hard and not enjoying this, because there were a
couple of close friends who’d always be happy and I’d say to them: “How can you
be happy? You’re always really enjoying this, and I’d say I can’t stand it. I’ve been
up all night. I resent having to be up in the night, I’m really not enjoying this and if
I’d known I wouldn’t have had children. So as well as the mania, I was starting to
make these complaints and people that I speak to now, they say: “well, when we
look back we thought it was odd how much you hated parenthood.
Feelings of guilt, resentment, isolation, and inadequacy were common themes that
women identified with as underlying their symptoms.
…I think I was burying that feeling of resentment by keeping busy. That’s another warning
sign; busyness.
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Soon after I got home. It was like I had no energy and I was asking little Jo to get
the nappy and she was sort of running round. I didn’t.. And he was no help, my
husband. The only thing I really did for Jeff was breast feed him and bath him.
For most, the realisation that how they were feeling was more than an adjustment to
parenthood was not immediate and often occurred as women found that activities that
they would have once enjoyed, were now lacking that joy.
I remember one afternoon, when she wasn’t very old, and things felt so, so dark.
Like my world felt so dark, like a darkness I had never experienced before, and
was sitting on the lounge floor, and I just started crying and my Gran was really
concerned. She was just asking, “What’s the matter darling? Come here”. And
then I went for a picnic in Cornwall Park with my family, and I just realised that
nothing was feeling right, and thought this would normally be an occasion that I
would be really enjoying, and I would normally be a part of, and I realised that
things were definitely not right.
Along with the expressions of the illness, all of our consultants remarked on the lack of
understanding of what was happening to them both physically and mentally. One woman
described her symptoms as equivalent to being in a strait jacket.
It felt like a strait jacket, like something put over your head, and suddenly you felt
like you are all clouded in, all these feelings come, and you’re clouded in, and
sinking.
You don’t have any motivation, you lose it, you loose everything, you want to curl
up and hibernate, like a bear, but you have to keep going.”
Diagnosis
Ten out of twelve women were formally diagnosed with PND. All of the women who were
diagnosed stated that this was helpful in gaining understanding about what was
happening to them. For most it legitimised their concerns and helped to alleviate feelings
of inadequacy. The relief for women that they were not going crazy was enormous, as
was the sense that there was an end to how they were feeling.
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Yeah, cos I wasn’t mad. But then, it’s kinda that double-edged sword thing. It
was actually quite a relief to go to maternal mental health services to be actually
clinically diagnosed because then I knew it is real. Just not me coping with my
normal ongoing depression, being caught up with other things too. Identifying it,
was a huge relief I think the identification of something makes you feel so much
better because I know there is a reason – and it brings clarity; it makes you feel
better instantly. To know there is actually something wrong, and it’s not going to be
a state I’m in for the rest of my life.
For those that were formally diagnosed there was a lot of variance in the time frame of
diagnosis. The earliest diagnosis occurred prior to hospital discharge and the latest oneyear after the birth. Professionals responsible for the diagnoses included gynaecologists,
GP’S, Plunket nurses and PAFT workers.
All of the women were prescribed some medication in relation to the PND and all
described benefits from taking medication. It is unclear as to whether the diagnosis
impacted directly on recovery by alleviating the sense of self-responsibility for the PND or
whether taking medication caused the better outcome
It was massive. That was the biggest (to be) diagnosed and medication and I’d
have to say that two weeks into taking that medication I actually felt the best I’d felt
since I was 17.
For some of the women the path to diagnosis was difficult and made more difficult by the
lack of understanding by friends and family.
Yeah. So there wasn’t a clinical diagnosis until that 1-year mark, when I got
pregnant again, with (daughter)…I got pregnant with (daughter), I could not get out
of bed, I couldn’t stand it when 1st child cried – I’d just leave … I can’t stand this,
and I remember driving to a friends house and I could hardly keep awake. I don’t
know if you’ve ever been in that situation - just so extremely fatigued. Yeah, and
there was no reason for it because I’d had good nights sleep – and it would hurt to
put one-foot in front of the other. It would hurt to get dressed, you know, I was so,
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so tired, and I remember I was practically falling asleep at the wheel. Went
through a red light at corner of dominion and Balmoral – pretty big intersection –
and so I was pregnant and had son in the back seat and I rang Mum and said
Mum I need some help. I remember her comment, she said: Don’t look at me, I
can’t do anything.” And I thought: Oh, Christ! So I went to the Doctor, burst into
tears and said I can’t do this anymore and she referred me to maternal mental
health, who took me straight away.
SOCIAL CONTEXT FINDINGS
What we have learned
When we co-researched the social context surrounding the experience of the women, we
were hoping to gain a deeper sense of the emotions and feelings that were around during
this time and explore the impact of PND on them, their partners and/or extended family.
What became apparent very quickly was all of the women’s conversations reflected not
only the impact of PND on their lives, but also coping with the transition into motherhood
and the range of emotions experienced during this time. The following headings relate to
the questions asked in relation to the social context and are supported by quotes from the
women:
The effects of Postnatal Depression on self and relationships
All of the women were receptive and amenable to discussing the social effects of PND on
themselves, their partners and family relationships. It seems, now looking back, they are
able to see things differently to how things were, using metaphors such as ‘hazy’ and
‘blurry’ to describe what ‘seeing’ was like at the time. They seemed to have a clearer
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picture of their experience and were better able to comprehend what happened in terms of
their relationships and the emotional effects of PND over this time.
…to think of it with PND, I don’t think you can see things clearly for what they are
and you can be just so sensitive that you can take things completely the wrong
way because you’re in such a different state of mind and you think people are
picking on you, or just being mean, or you view it as just not being supportive, but I
guess looking back, it's probably that they are actually being supportive, but
because you’re so fragile, nothing seems supportive.
Everything was very blurry - disassociate, couldn’t become close to anyone or
anything. I didn’t have the energy to be involved with anyone.
A number of women were aware of the effects of PND on their husbands, the emotional
stress and strain and how this manifested itself in different ways and at different times with
the women feeling either supported or unsupported, and the toll it took on their
relationships.
It was often noted that at the time the stress and/or changes to the
relationship were often related to the transition of having a child as opposed to the effects
of PND and this came from both partners.
…the change from when we had been; a very intimate, loving couple to; I can’t
even stand you giving me a hug – just don’t touch me. … yeah, it’s a big stress
because you don’t have any extra energy or emotion or anything to give to your
partner. You’re on pure survival mode to just get through the day. Massive stress,
and also there’s nothing for the husbands. They don’t know what to do, where to
go. They’ve gained a baby and lost a wife, so it puts them in a different place.
Well I got quite a bit of support but it got…it wore him (partner) down, because he
was doing um, he’s a tradesman and worked very hard, and he came home and
had all this um pressure put on him… he lost a lot of weight, he started smoking,
and then because I wasn’t a loving wife physically as well, you know, I think it just
got too much for him and he moved out.
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He was supportive, as much as he knew how to be… one time I’d been away for
three weeks at my parents place and he phoned me at their house and I said to
him, I can’t come home, I’m not ready yet, you know, and he just burst into tears..
and I remember thinking ‘Oh, flip, you’re not handling this either and I think
because I was so much in my own world, me and this baby, I really didn’t think
about how it was affecting him.
We were both so involved in caring for him (baby), and it’s so nightmarish with a
colic baby, the evenings were the worst we just did what we had to do to get by
really.
My husband was reasonably unsupportive, he didn’t understand and he felt that
his role was to be at work and to be called home because I wasn’t coping wasn’t
fun for him at all and he couldn’t understand why I wasn’t coping because he
thought I could just go on and on having children and fulfill his need to procreate
and all that sort of rubbish. It was difficult, I felt very isolated.
The effect of Postnatal Depression on bonding with your baby
Difficulty bonding or connecting with their baby was experienced in different ways by ten
of the women and seemed to be for many a very heartfelt and bewildering experience.
Often this was brought up first in conversations with mothers when they began talking
about the effects of PND on their relationships and many were able to describe the
experience in very real terms as the following extracts portray:
I remember vividly bathing her and bathing your baby is a nice thing to do and I
remember looking at her and just feeling nothing and it took me a very long time to
bond with her, I used to wonder if I would ever bond with her. I felt – I didn’t hate
her or resent her, I really genuinely felt nothing…. and it’s a scary thought to think
that you would raise a child and feel that way.
I definitely didn’t bond to 1st child. I resented him. He’d taken over my life, I mean
my husband and I.
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I just used to routinely give her a bath, and sometimes I didn’t really have fun with
her, because I felt so horrible inside, um, so I just felt I was on auto-pilot.
I didn’t have anything to give her and she was a burden to me, she was work, she
wasn’t a joy…
When I had my daughter and was on medication and was so well looked after and
was enjoying everything, it was very different, but I still hadn’t connected to son
and I just thought; Oh … I can’t really connect.
Ten women found they didn’t know how to feel towards their newborn baby or what was
expected of them in terms of bonding with their babies. There was also a connection with
breastfeeding and bonding, this came through with five women noting the experience of
not being able to breastfeed had impacted on them developing a bond or relationship with
their child and two women were sure that when/if they stopped breastfeeding so too would
the bonding with their baby.
…and I kept on thinking what if I don’t have that instinct - and I remember after my
son was born looking down at him and thinking ‘oh my God what have I done?’
This was going through my head and he was next to my bed and they left me and
everyone disappeared and I remember thinking, I wonder if I can touch him – I
mean I never had anything to do with babies so I was lying looking at him thinking,
I wonder if I am suppose to touch him and where is this love that I’m suppose to
feel and when do you bond, what’s this bonding. It was weird.
…and of course I didn’t build up that close relationship with (baby), he was just
something that needed to be looked after, like the cat. I didn’t mistreat him, but I
didn’t have that bonding.
I was just, I think I got a bit fanatical about trying to do all the housework, do the
washing, rather than trying to interact with my baby.
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As a baby, you looked after it, but you didn’t feel that intense …like I do with my
grandson now, that intense love for him, because you couldn’t feel emotion, it
couldn’t come through properly.
I remember thinking at the time, if I wasn’t breastfeeding that kid, I wouldn’t have
anything to do with her.
Who noticed how you were feeling or did they?
The question we asked related to whether the women thought people around them
including family, friends and/or healthcare providers, noticed or understood how they were
feeling at the time they were experiencing PND. Two women described how they were
able to cover up, or hide how they were really feeling, wanting to give the impression that
they were coping. Often the women felt they couldn’t say anything, either because they
didn’t feel comfortable to speak out about PND, or because they themselves didn’t
understand what was happening. It was noted in hindsight how others may have noticed
something, particularly family, but didn’t say anything or didn’t understand what was
happening.
No, because you didn’t like to show it, you didn’t like to show what was wrong….I
told them, my mother, but she didn’t understand it at all, no, and then it’s only
years later that she said, my grandmother may have had depression, her mother
may have had things like that, but I didn’t understand that until years later, yeah.
No, no-one said anything. Even my husband didn’t and it’s hard; I mean a lot of
people, even my closest friends said I would never have known. But once again, I
had learned from my earlier experience with depression to put on that happy face.
…my doctor was a man, and I didn’t like talking to men about stuff like that. Even
like talking to the nuns the first time, I didn’t know they knew about periods and
babies and things. I was sort of the type of person not to… I’d hold it in.
Before I had my oldest son, I said to my midwife, beware because I have a history
of depression and I am really worried I may get PND, but because I’m a person
that doesn’t like failure, I put on this really good façade that I was coping.
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…they were probably told, but he is the sort that would say, ‘just snap out of it, you
don’t need to be like that’. Well, I didn’t want to be like that, did I!
That’s when my husband came home and said I need to sit down with him, he
phoned the doctor and said we will go and see him together. If he had not taken
me to the doctor then, I would have definitely done something stupid.
…he came in and he didn’t know what to do with me. He’d never seen this. Like if
you watch TV and someone has a flip out? It was just like that, I guess. He didn’t
know what to do.
I remember one afternoon, when she wasn’t very old, and things felt so, so dark.
Like my world felt so dark, like a darkness I had never experienced before, and I
was sitting on the lounge floor, and I just started crying and my Gran was really
concerned. She was just asking, What’s the matter darling? Come here.
Emotions; how did this impact on your experience of PND?
All of the women were able to openly describe various emotional responses to the effects
of PND. The emotions varied with some more intense than others, but the following were
commonly expressed by the women at some time; anxiety and obsessive thoughts, guilt,
crying, anger and resentment, suicidal ideation, isolation, feeling withdrawn or lonely.
Strong feelings were noticeably still present as the women described the depression,
often feeling disconnected and unsupported either from their partner, immediate family
members, or healthcare professionals during the times when they felt they had needed to
feel connected or have support most and there was still raw emotion round this.
The emotional complexities saw many of the women unable to talk about their feelings
during the depression, lost in the struggle to know what was happening to them or where
to look for support, often not receiving the assistance they needed from their partners,
family and health professionals, or if they did, it was at a stage where things had become
so bad there was no alternative but to act. Often partners or family members were also
lost in knowing what to do, or who to turn to for help, enforcing the silence of PND.
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…because I felt so depressed and so frightened and lonely, I just couldn’t seem to
reach out to them, I just didn’t want to know, I just wanted to stay at home, and if I
went out, I just went to the shops, did what I had to do, and then went home, you
know.
That sort of precipitated the depression, it’s like all those things in my childhood
that made me vulnerable and defenseless and emotional were still there, it just
took the PND to sort of compound them..
There are things I could have, or would have done better, or different, but I can’t
change it. What I would have liked to have done, is to know myself, being ok to be
able to talk to people, to be able to express myself. Because I didn’t know, I
thought everyone thought like me. You’d only talk about the physical stuff, not the
mental or the emotional stuff.
…the person (lead carer) I got was quite shocking. I would sit and bawl my eyes
out in front of her and she just didn’t seem to think it was a problem, or.. so I
suppose I was quite depressed and I think anyone with half a brain could have
seen it.
…they have been through all this, they could have been through depression as
well, it was never recognised, it was never accepted, they were stigmatized, put on
the outer, and they just want to curl up and die. Do you know what I mean,
because I could have done that, myself.
Definite feelings of anxiety and obsessive behaviour were expressed by six women, with
one describing the emotional anxiety as sometimes feeling like panic attacks and another
women described obsessive behaviour being a part of feeling manic. The anxiety was
intense and usually accompanied by worry over a raft of things; the baby, housework,
going out, not sleeping, not being a good mother, not bonding etc; The more anxiety and
worry took hold, the more intense the feelings became…
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…and I was incredibly nervous about the second one and I was like quite anxious
about it. Thinking: I don’t know how to do it.
I became very serious, would worry about the most silly things – loads of anxiety,
very insecure and continuously feel like a failure all the way through.
I was very unwell, high anxiety, high everything…
I was still feeling extremely lonely, extremely afraid, really anxious…
I was still really anxious over everything, and I couldn’t really sleep, not during the
day.
The anxiety…Yeah, it just really took a hold of me. It was frightening.
…obsessive silly thoughts and then one of my early warning signs still now, which
was then, is an obsessiveness about house work, because at that time that was
the only thing I felt I had control over.
I think the anxiety was terrible and the fact that it had a physical hold on me…it
was a really scary time…I felt so horrible inside, I was just on autopilot, doing the
things I had to do”.
Four women expressed feelings of guilt and it would often appear as a backdrop to other
emotions. It was a difficult emotion to talk about because ‘society expectations’ weighed
heavily on mothers and revealing feelings of guilt was not something you spoke of.
I’ve got so much, I look at my husband and my son and we are all healthy, we
have got everything we need. I couldn’t have asked for any more – but I still don’t
cope and then I get embarrassed and I get that guilt trip.
The biggest thing that comes from being able to talk to other people that are
experiencing it is being able to sit down and say; ‘God, this is really hard’ and
really have a moan without feeling guilty.
Eight women mentioned irrepressible crying…
…and I couldn’t stop crying – I cried for days and I had a big screaming fit at my
partner’s parents – they were staying with us and … I just completely nutted out.
…and I can’t stop crying.
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I look back now, and I’m so angry – cause I used to go and cry, every visit with
her.
I just started crying and my Gran was really concerned.
…and during the day, you just cried all the time, and you don’t know why you are
crying.
I remember crying and looking at my son…
I went to the Doctor, burst into tears and said I can’t do this anymore and she
referred me to maternal mental health.
Five women experienced feeling angry or resentful about their situation.
Anger and
resentment are emotions that are not always easy to discuss, particularly for mothers, but
looking back it seemed there was more awareness now of its influence and in some cases
realising it’s still around and wanting to do something about it.
I’d like to do an anger management course, because I think too, that like you can
go through PND, but I think you can end up angry at the other end as well, like, I’m
angry that I got it; I’m angry that it wasn’t picked up early when I was bloody
pregnant because here’s this pregnant women just falling to pieces….
…. She (mother) hasn’t helped me she’s left me and I was just angry and angry
with my son all the time.
…I had been feeling very angry, and she set me up on a course…
When I knew that I was really on a fine line. I knew then that things, something
needed to happen, because I was getting really angry…
…and I think I was burying that feeling of resentment by keeping busy. That’s
another warning sign; busyness.
Half the women interviewed experienced suicidal ideation, one having attempted suicide.
Two had a family history of suicide which they connected with PND, and one woman had
contemplated suicide before PND. Even though the women were feeling very low, on the
whole they believed that although it was something they had considered, sometimes just
as a passing thought, they would not have gone through with it because of the
child/children.
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‘Definitely my work and my husband and if I did not have my son I think I would
have committed suicide long ago.
But I also think as a mother, that you can’t really go there, because I’ve got a child
to protect now.
…and also because I thought that suicide was cruel to the children.
Except for the suicide question, because I wasn’t going to kill myself because I’d
just had a baby and I didn’t want to hurt them.
…and I went to a doctor in Christchurch and he gave me sleeping pills, which
didn’t help, and so I proceeded to take the whole lot one night because I couldn’t
decide what to ...
…because you do actually feel suicidal, I’m afraid you do, and it’s nothing to do
with killing babies, or hurting your baby, its just yourself, you just want to stop the
unusual emotional turmoil, inside..
Six women expressed at times feeling either, isolated, withdrawn or lonely during the
PND. These feelings were also closely associated with low self esteem and it brings an
awareness of how depression can substantially alter (sometimes quickly) the way we think
about ourselves and our situation.
Absolutely isolated
I just felt completely alone, quite isolated
All of a sudden I became inward & withdrawn
Fairly isolated….I just wanted to stay at home, and if I went out, I just went to the
shops, did what I had to do, and then went home, you know.
Did PND impact of your sense of identity as a mother?
For all of the women we interviewed ‘motherhood’ had either not been what they expected
or prepared for, or they had not known what to expect. Any expectations or preconceived
ideas would, according to research, be heavily influenced by the ideology of motherhood,
or the ‘myth of motherhood.’ It is not surprising therefore that the women we interviewed
felt bewildered and confused by the binary between the myth and reality of their
experience. As the following extracts show:
I was so excited, I was only concentrating on the day of the actual birth and I
thought I was prepared for the after… if someone had told me it’s not like what you
see on Television, those Johnson and Johnson ads everything all so lovely. I won’t
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be skipping down the road with my child laughing – if I knew those things, if
someone had told me, they sleep when they want to, they wake up when they
want to.
I would have had a different experience.
Getting home, trying to
breastfeed and it doesn’t want to work… I felt cheated.
I actually believed I was a crap mother… that you’re suppose to be really happy
and just glowing and ‘the new baby’ and all that sort of stuff, and really it’s just not
like that at all…. and your own expectations of yourself - If you have really high
standards of how you are going to be with your child… then?
motherhood is a whole different field. We don’t know where we are going – it’s a
step in the dark for many, many women, and that puts them on the back foot I feel,
they don’t really know what to ask.
‘Most of the time I was thinking – I’m not coping and everybody around me is
coping, and that made me feel worse. What is wrong with me, why am I such a
loser? Why aren’t I doing this right?
Yeah, well I just felt as a woman I wasn’t good enough because somebody left me
and all those sort of things, I wasn’t good enough, I wasn’t pretty enough I wasn’t a
good mother, I wasn’t sexy enough.
it just seemed like hours and hours and hours, of being trapped and not knowing
what I was doing and um, just feeling really scared and overwhelmed and that
responsibility of having a baby; it was pretty scary, and I felt quite desperate at
times.
These extracts typify the feelings, emotions and confusion surrounding the belief in the
ideology that sees women as natural mothers, immediately able to care for their babies
and ultimately fulfilled in their role of selfless carer and nurturer (Woollett & Marshall,
2000). From the depths of depression it can be difficult to contemplate tackling all these
emotions and feeling (Harvey, 1999).
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RECOVERY CONTEXT FINDINGS
What we have learned
In some instances the barrier to recovery was the lack of understanding from the medical
profession, they do not always recognise the problem, even after the new parent seeks
help. For the women twenty to thirty years ago when they had the illness there was a
general lack of knowledge as to the causes and the seriousness of the nature of the
illness. Even today the GP may say that it is only a temporary adjustment and not serious,
or minimize the symptoms that the women is having. This leads her feeling more confused
and overwhelmed, hopeless and guilty for feeling the way she is, as it is hard for her to
describe what she is experiencing or why she feels so bad. (Gruen, 2000).
Another barrier is the stigma which can be experienced and can be either through the
women’s direct family members, or the public or the health profession.
Key factors in the recovery journey
55
As we co-researched with our consultants we explored with them the key aspects of their
recovery which was aptly described as a life journey or process beginning with their
pregnancy and continuing on for the rest of their lives. For most the recovery process
began once their illness was recognised by professionals, this becoming the turning point
for them However when asked how long the illness lasted for, there was not a cut off point
where they could say it was definitely gone, but for the majority depression continued to
follow them at different points throughout their life. However the critical point of the illness
with treatment was addressed and the majority of the women were able to carry on their
lives normally and care for their infants and families.
Following are some of the women’s comments regarding this journey and what made a
difference for them:
A lot of it I think is to with your life’s journey, and what’s happening externally around
you and where you are and where you’re at. For me a big part of that recovery would
be me would be meeting my second husband and getting that security….you just
lose all your trust, and in my friends. You look at everyone sideways. So I guess it’s
… and going through that journey of, I don’t know, finding me too, it’s taking a long
time.
Recovery for me is probably a life-long journey
Being treated kindly and not judged aided recovery. Think that there is more
awareness now than 32 years ago.
I was in a position of having to find full time work, and just get on with life, and do it,
and although I was still pushing away issues and things that could have made me
depressed, I became so busy, that I was able to cope a lot better.
I had to find ways of doing it myself, you try to calm yourself down, you try to
understand why you are like that, and counting sheep by the thousand, and doing
things to make me feel normal, but you don’t feel normal at the time, you just, feel
like you are, like they say, in a big dark hole, that you think you are in, and you can’t
climb out of it, you think, ‘why aren’t you happy and feeling good about yourself, and
there is something there stopping you from doing that, but you don’t know what, and
56
that went on for probably six months to a year, it was only after a year that you felt
you were starting to come right again
Yes, it’s just getting that right balance, because I don’t like, I like to be in control. I
don’t like that feeling of woozy. And learning to live well, eat well. Because I do
punish myself, I can over eat and then I had to work out how to lose it all so…
Yes, taking care of myself and exercise.
The hormones must have just started correcting themselves, for about a year. So,
the first six months, was diabolical, and just day by day, and by a year, it takes a
good year, to, for perhaps the hormones to settle down, and come right, you see, but
even then, you are always scared after that, that it will come back. Because you
think, well what brought it on, why did it come?
Emotional support from family and friends
Support from close family was crucial for all the women, for the three out of the twelve that
did not receive close family emotional support they took a lot longer to recover. The
women each commented on the level of support they received as being vital to their
recovery.
Do you think you had sufficient emotional support?
Um, I think my husband tried.
Yeah, he tried, but he didn’t really know what to do with me. He was pretty good with
my daughter. And my parents were an hour and half drive away and I used to drive
there, and I stayed there. Yeah, they were quite supportive.
Sharing with others
Being able to share with others family, friends and support networks is crucial particularly
speaking with someone who has been through it.
The women expressed their desire for others to know about the illness, to reduce the
stigma of it, they want the story out there; for there to be more information for the public
and for pregnant mothers to be; the more they can talk about it the freer they feel. Being
able to share their experience of PND with other women who have experienced it already
is something the women identified would have been helpful and to have some form of
57
peer support. Sharing with others is a wonderful aid to recovery, as the women
commented:
It helped so much talking to somebody. It makes you feel, ‘look I’m not a nutter, its
not the end of the world’.
I didn’t realize how much I needed people. It is really important to have that sort of
time with other women that understand.
There is an end to it, it’s not going to last forever and there is help out there, you just
have to ask for it if you want to get better.
Increased awareness of PND and ability to recognise it in daughters
Counselling would have been helpful to deal with loss and ensuing grief
Depression was on going. Took medication again when baby 2 years old and again
in the last couple of years, however thinks that there has been resolution. Maybe
different types of resolution or maybe on-going?
The biggest thing that comes from being able to talk to other people that are
experiencing it. Being able to sit down and say God, this is really hard and really
have a moan without feeling guilty.
I think it is the responsibility of every woman who has experienced PND to share her
story with her family- mothers to daughters. Its something that hasn’t gone on in the
past and it needs to.
…that there are all sorts of things that are not that well educated or conveyed to
prospective mothers – I mean I wouldn’t want to scare a new mother into thinking oh
shit I’m going to get post natal depression but I do think that some decent education
around that would be helpful. I think a lot of woman suffer through what I suffered
with my first child and feel guilty for feeling that way. You’re surrounded by other
mothers who may be even feeling like that but don’t share it.
That would have been absolutely brilliant; (to share with), somebody who gets it.
Someone who’s been there, who’s done it, who could maybe come and sit and have
a cup of coffee, you know, to break up that day, break that day up and just help with
58
being understanding of things.
Yeah, peer support would have been absolutely
brilliant!
I’ve been able to speak to other people and just one day last week, I spoke to a lady
who said to me, that she felt like she had PND, and 3 years later she was still coping
with it, so it was really good to say to her, ‘l know how you feel’ and I can say that
and truly mean it.
Support from outside the home, the wider community would have been useful, as the
following comments intimated:
More external supports as well, because not everybody in the family can support
and do those things that can be an unrealistic expectation.
Just the emotional support; or to maybe come and have a coffee or to, you know, to
know you’re not losing your mind. Yeah, that emotional kind of, practical kind of
help, you know, breaks the day up and especially with a baby that didn’t sleep much.
You know how they talk about in India, and in other parts of the world, where they
say it takes a village to raise a baby. It’s such a lovely thing, but our village is so
spread out and fragmented, and it is really hard for people to get together and
communicate with each other I feel.
Effectiveness of services offered
We asked the woman as to how effective the services and treatment they received was
for them, and what was most preferred? For the ten out of the twelve that were diagnosed
and consequently treated they found the treatment affective and within two to three
months they were starting to feel on top of things again. All 12 women received some form
of drug medication for their illness, and 2 of the women received counselling. Three
women were offered Karitane services with ‘Time out’ facilities which were very helpful,
and one woman received hospital treatment. Other services used were Barnadoes, Anger
change courses, Plunket and Maternal Mental Health, and Counselling services. For the
few that took longer to be diagnosed, it was a longer process. Thirty years ago the illness
was not recognised as PND, as the following comments show, with serious repercussions:
59
And the Doctors and nurses put it down to the ‘baby blues’. You have them a few
days and then it all clears up, but in my case it did not clear up and it just went on
and on and on…
I mean the fact that PND wasn’t really recognised, as a valid condition…My
marriage was lost, my mental health was almost lost, and it’s just had enormous
repercussions for the whole of my life, as well as my son’s life. You see that is 30
years of my life that has been lost, thirty years of adult life have been lost, because I
haven’t been able to um, like if the facilities had of been available then when I had
the PND, I could have worked through so much, and cleared the path.
Diagnosis of PND made a difference
The actual process of diagnosis was an important facet of recovery, to know that they
were not going crazy, they were not ‘mad’.
Professional help and diagnosis made a difference for ten out of the twelve women. The
turning point was often related to receiving the necessary skills and support to facilitate
recovering, with there being a fit between the woman and the professional. (Pedan, 2006).
Did you feel that having that (diagnosis) made a difference to your recovery?
Yes a big difference.
Because most of time I was thinking I’m not coping and
everybody around me is coping and that was making me feel worse. What is wrong
with me, why am I such a loser? Why aren’t I doing this right?
When they said you have PND this is what it is – was they explained it to me I
thought well I’m not crazy. They explained having my son must have triggered it and
it comes out in different forms and stays for different periods.
Identifying it was a huge relief, identification of something makes you feel so much
better because you know there is a reason… and it brings clarity; it makes you feel
better instantly
Well, I think I was really well treated.
I was really lucky as I had a woman
obstetrician who was really aware of what was going on, and she got onto it pretty
smartly. I remember her coming in and asking me whether I had depression or not,
and I said I was fine, fine, with tears streaming down my face!
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It took 9 months the first time to be treated, and then come off it. Then when she
was 2, I went back on the medication. As I said, I can’t remember how long it took
me to get off it then, but probably about six months.
Well, somebody recognising that I had a problem, getting on to it and getting
medication. The rest was up to me
‘It was helpful to know what it was’.
Well somebody recognising that I had a problem, getting on to it, and getting
medication. The rest of it was up to me.
It’s an acceptance, it’s a big part, which is very much what I talk with my clients
about too, is once you accept this, and you’re ok to take your medication and you’re
using it for my benefit rather than having to be on it, you’ll find your day to day is
moving forward a lot easier and your knowledge about it.
It was more of an acceptance, yeah, total acceptance once I’d had the diagnosis.
And being on medication I just felt better. I didn’t have any more of my obsessive
thoughts. I didn’t have anything near my worrying and anxiety. And I guess that’s
why I don’t want to come off it, even though I’ve been on it for six years now. This is
the best six years that I’ve felt.
Well I think I was really well treated. I was really lucky as I had a woman obstetrician
who was really aware of what was going on and she got on to it pretty smartly. I
remember her coming in and asking me whether I had depression or not and I said I
was fine, fine, with tears streaming down my face.
Another woman commented:
I started counselling and pretty much my journey of self discovery and recovery
really started…the counselling was helpful. Getting on medication was helpful, I’ve
grown so much and I’ve learned so much Another said, I don’t know what it did, it
must have lifted my feelings, my spirits. It must have evened out the massive
hormone imbalance in my body.
Other Services
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For other services that the woman received they appeared to be largely ambivalent as to
as to the helpfulness of them. Stigma; including ‘own’ and ‘others’ perceptions of mental
illness; this affected thoughts about using mental health services and what sort of help
was sort after. For three out of the twelve women, attending PND group support was
helpful, for the remainder they were ambivalent to group therapy or it was not offered to
them.
The sense of wanting to do it independently and not to be reliant on services also had
bearing on the woman’s choices, as one woman commented:
Yeah and I think that I was just used to dealing with my own stuff, with pushing it
down and all of that and I was told by a member of the family that ‘You don’t want to
be on those pills. You want to… get off those as fast as possible’, so it just added to
that whole, ‘Oh there’s something wrong with me’. Because I already thought there’s
something really, really wrong with me. Fundamentally there was something wrong.
‘Fear’ of going crazy. Am I going to go, or am I going to stay? I didn’t know if I was
ever going to come back from that. That was incredibly frightening.
I wish there was an alternative to hospital setting that’s not clinical a place of respite
not 36 hours of respite its not enough 3 weeks respite yes.
It’s a pity that either you have to be ridiculously unwell in hospital or just struggle on.
I think that the peer support service for people with mental illness could work really
effectively targeting PND, having someone come and visit you in the home or get
you in the car with the baby and baby seat and take you to the park or take you to, I
mean even things like supermarket shopping became Mt Everest, you just don’t
have the strength to carry that kind of task out.
There was the MMH psychiatrist and the option of going to the PND group.
Getting the right balance Yes, it’s just getting the right balance because I don’t
like…I like to be in control. I don’t like that feeling of woozy. And learning to live well,
eat well…now I know I have to take them (medication).
Support Group-sounded really heavy!
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Personal Strategies
Play is a big part in the recovery process, for instance getting out of the house, planning
their day to meet with friends, and joining with others in a supportive setting. The need for
space and freedom is significant, and the need to keep occupied, particularly with
activities away from the home. Attending courses, support groups, getting back to work,
putting the children into daycare were some of the strategies the women used.
One woman commented the following:
A big part of my recovery was throwing myself into something that gave me identity,
and that’s been all of my studies.
Giving yourself something to look forward to, I had to do that, I had to eat, because
you had to get through to the end of the week, so you had to give yourself, I’m going
to go and visit a friend, or I’m going to go shopping, or I’m going to go to the park
with the baby. You had to give yourself something to look forward to, each day to
give you that momentum, to you get on with the day, sort of thing.
…until you could get through a whole week, if you didn’t need it every day, perhaps,
you could say, ‘Oh well, every second day, I needed something to look forward
to’…so yes, you had to strive to, strive to find something to give you that little bit of
buoyancy and coming back home, probably too. I didn’t seem to like coming back
home, I had to be out a lot, rather than home.
Personal faith was also a helpful factor for six out of the twelve women, being able to
meditate or to pray was a strengthening factor, as the following comment says:
I decided to keep my brain totally active by reading, the Readers Digest, and when
I could, ‘praying’, always my mind full of prayers.
What could have been more helpful?
The provision of information or lack of was a crucial factor. These are some of their
comments as to what would have helped them:
To know myself, be okay to talk to people, to be able to express myself
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That I would have had information at the time, (would have been helpful) I think
information about all sorts of things, and perhaps that if I had known what resources
were available, I think things could have been very different. At felt like at one point,
I wanted someone to come in and show me how to be a mum, and show me how to
cope. And I think that right at the point when I started to have lack of sleep, (the
baby) wasn’t sleeping, and if I knew who to call, and how to get around it.
Sometimes, even when you say to someone I’m not coping, they don’t hear you.
I just keep going back to ‘information is power’ and if there is some way that women
can be reached prior to the crisis, and you know that I’m not saying that we would
eliminate postnatal depression, but we could certainly could help women a lot
sooner, than what the message is getting out there, and its really neat that all those
things about depression coming out. In fact, what I’d like to see is some ads on TV
in relation to postnatal depression, because there is lots about bipolar, and that sort
of thing.
It would be really cool, the basic housewife could see that postnatal
depression doesn’t mean that you can’t get out of the bed in the morning, you want
to kill yourself instantly, that actually, it can be a lot more subtle that that.
(Being) more aware of the signs and symptoms.
What’s still there? In terms of what might be still there for you, after that
experience, what would be the main thing that sticks out for you?
For all of the women it still affected their lives in varying degrees, not as a critical or
acute depression as it was postnatally, but still an ongoing chronic depression that
hit from time to time, for some an ongoing issue. Life circumstances and turning
points such as Menopause had an affect with many of them. The women expressed
an inner awareness of their vulnerability to depression; they felt more in tune to
being susceptible and awareness that they could relapse.
For 3 of the women they felt that the Professional medical teams let them down; did
not understand what was wrong with them and did not treat them accordingly. One
woman expressed that the main thing that affected her was:
I think being let down by the professionals.
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Other women had the following comments to say:
But, because I’ve had it through Menopause (depression), I know now it must be
hormonal, because it triggered off, as soon as I started my Menopause, which I
didn’t know you could get depression for that, but I got terrible depression then,
through Menopause. So, something triggered that off as well, the changing in the
chemicals.
Actually, I don’t think it actually got better…for me. It was the start of a chemical
imbalance. Hence that is why I am on antidepressants today. And when I have tried
to come off them it has been disastrous. So I have been on them since that time.
Others were grateful for the help they received:
Just that I’ve had it. I mean I don’t feel guilty about it. I know that it is an illness and
I’m very grateful for the help that I’ve had
I think I was able to get over it fairly quickly. I was able to get over it and get back,
which as you have probable realised I don’t get down very often or I try and hide
things. Just get on with life. Life is for living.
I think I was quite fortunate in the chain of events as horrible as it was to go through
it, I can definitely see how people were in the right place at the right time for me, it
could have been worse.
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DISCUSSION
Historical Factors
It was apparent within this research that women’s expectations of the pregnancy and birth,
had an impact on their subsequent emotions and ability to cope with motherhood and this
was considered to be in part a contributing factor to the development of PND. Many talked
about not being prepared for the intensity of the physical experience and the change to
their lifestyle, despite ‘thinking’ that they were. Those whose expectations of the birth and
pregnancy were far from the reality of the experience, found it difficult to resolve this
binary. The literature provides us with evidence that pregnancy and childbirth are huge
challenges and this has certainly been reinforced through our conversations with the
research consultants.
Expectations of the birth and motherhood appeared to be related to both the individual’s
own ideals and the cultural or societal beliefs and constraints. As the literature pointed out
childbirth and our beliefs around it are culturally located. Women often questioned why
they seemed to be the ‘only ones’ who weren’t coping with the challenge of mothering.
This was evidence to us of the isolating effects of silence around such issues, particularly
66
due to the increasing individualism that western society encourages and the absence of
extended family networks. As suggested in the literature women are being silenced in
terms of pregnancy, birth and motherhood narratives.
The ‘silence metaphor’ was also noticeable in the lack of opportunity to de-brief or talk
about the birth soon after, which in a number of cases profoundly affected the women’s
ability to ‘integrate’ the experience. It felt to us as researchers that the inherent value of
women’s stories was still largely unrecognised as an important and necessary tool for
healing and a necessary way of passing on what they had learned to others. As
suggested within the theoretical approaches the potential for shared experience in the
form of narrative to reframe situations from negative to positive was evidenced by our
women’s responses to the process. All found it to be rewarding in terms of having the
ability to reflect on and reframe the experience.
Those who identified as having the type of personality that needed to be ‘in control’
seemed to struggle more with feelings of failure both in terms of the birth and difficulties
around mothering. The ability to be flexible appeared to be incredibly beneficial at this
time, as did identifying as having a high ‘self-esteem’. Lack of preparation for the
challenges as noted by Aitken (2000), will exacerbate women’s difficulties in adjusting to
motherhood. There was a definite wondering for us around whether anyone can be totally
prepared for the process of birth and the changes that parenthood brings. This appeared
to be a common and prominent theme with our consultants as well, who consistently
wished they had been more prepared.
Issues of loss and grief although not always recognised as such, seemed to reflect these
enormous changes. Corry & Tubridy (2005) discuss the losses that motherhood brings
and as depression is a normal part of the grief narrative we believe it is a very appropriate
response to the challenges and uncertainties of motherhood. Although PND is seen an
extreme reaction to motherhood (Ball, 1994), our stories suggest that in terms of our
current cultural context, PND may be a reasonable response and an important coping
mechanism and may need to be re- named as such.
Mothers who felt that they were well supported emotionally and practically by their partner
throughout the process maintained the importance of this to recovery and to re-claiming
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what had seemed to be lost in terms of identity and immediate relationships. Aitken (2000)
provides evidence that suggests that an emotionally close relationship with the partner
acts as a protective factor for the mother and conversely relationship difficulties are one of
the key predictive factors for PND. Our research suggested also that a strong relationship
was important in alleviating feelings of inadequacy and guilt as mothers struggled to find
their feet in their new role.
Those that identified with having a ‘traumatic birth’ found their inability to cope was made
more complex by the need to deal with their issues around the birth before they could fully
enter the role of mother. The recurrent theme around issues of trauma was an
overwhelming ‘loss of control’ and this often involved medical procedures during which
women felt overlooked, frightened and/or humiliated. ‘Loss of control’ was also a common
theme that occurred around the challenges of motherhood and there was a sense for us
as researchers that PND for our consultants was a way of re-gaining this control and/or
restoring equilibrium. High levels of anxiety in these women often reflected this loss of
control and we observed a connection between this and personality type, along with birth
trauma. Ball (1994) supports this observation with his suggestion that anxiety interferes
with the ability to take in information and creates more potential for self-blame.
It was interesting to note that for many of the women there was a combination of stressors
that appeared to have an impact on the development of PND. The stressors rarely
happened in isolation. These included stress in the last few months of pregnancy such as,
financial difficulties, being physically or emotionally unwell, tension within relationships
particularly with the partner, previous or current experiences of grief or loss, and/or a
traumatic or difficult birth.
There is a question around whether some women are more susceptible to developing
PND due to aspects of their personality, history of mental illness and/or negative life
events (Milgrom et al, 1999). A number of women noted that they connected postnatal
depression with a difficult birth experience, medical complications and/or problems with an
unwell baby. Within the narratives of this research it was clear that a variety of causative
factors were revealed (see previous comments) and the implication for us is that it is a
unique combination of these factors that leads to PND.
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These findings appear to support the bio-psychosocial theory of PND, however they do
not totally explain it. It seems that there are still discrepancies and as Corry and Tubridy
(2005) remind us, some women will have all of the potential stressors and still do not
develop PND.
Therefore it is unclear as to whether it is possible to predict which women may suffer from
PND by observing these factors. And would we want to be able to absolutely predict who
might, if the outcomes of having PND are not always negative? Many women revealed the
enormous changes that PND created in their lives and remarked upon the journey of selfdiscovery and growth that has been produced. We wonder if these changes would have
occurred anyway within another context and if so, it causes us to question again the
notion of PND as merely biochemical illness.
The lack of information provided to our consultants about PND was glaringly obvious with
ten out of the twelve not knowing what it was or how it might be expressed. We found this
to be disturbing in terms of long-term effects not only on the women and their families, but
also on society as a whole. We wondered whether this was an indication of the stigma
attached to mental illness generally or whether this was related to deficits in the health
professions and/or was reflective again of the ‘silence metaphor’.
The importance of diagnosis for most (ten out of the twelve) seemed very conclusive
within our findings. For most, the receiving of a diagnosis lifted the burden of guilt that
somehow they had been to blame for the way they were feeling. Diagnosis seemed
especially helpful for family and friends who had been feeling helpless and who lacked
understanding of the changes in their loved one. We want to suggest that it is not totally
clear whether diagnosis can also limit the potential for growth and recovery and create
discrimination due to the constraints of labeling and several of our consultants
acknowledged the ‘double-edged sword’ of diagnosis. There was a wondering as well if it
had been diagnosis alone that had been helpful or the medication that followed closely
after. From a social research perspective it is interesting to note the variety of meanings
attributed to the experience of PND and to acknowledge diagnosis as another socially
constructed lens through which to view PND.
Social and emotional factors
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As the women look back on their journey with PND it is evident they are more in-tune and
aware of the behaviour of PND, particularly how it affected and impacted on their
emotions and relationships, and most importantly the part it played in determining whether
they saw themselves as living up to the expectations of motherhood; were they ‘good
mothers’, able to meet their child’s every need and happily place others needs above their
own, while coping with profound exhaustion? Or were they ‘bad mothers’, failing to have
the perfect baby, the perfectly clean house, just wanting the baby to go away, to stop
crying all the time? It is clear they were at the mercy of PND, it sapped their energy giving
them no way to fight back, they couldn’t control their thoughts, it clouded their thinking and
kept them in a cycle of feeling anxious, worried and concerned.
The emotional
rollercoaster ride left them weary and drained with nothing to give to those closest to
them, and no where to go, creating a feeling of being unsupported and isolated,
withdrawing more and more into themselves and convinced by PND that they were the
only mother feeling this way.
The total absence of positive experience as the women describe their emotional and
relational journey through PND is very apparent. We already know from research that this
is part of the aetiology of PND, however it begs the question; why do women think there is
something wrong with them, rather than something wrong with the circumstance of their
lives, and why are we so strongly influenced by the pervasive ideology of motherhood as it
is within this context where unrealistic demands are placed upon us, oppression occurs
and discrimination of our practices takes place. The ‘good mother’ behaviour is validated
only in relation to how successful we are in our role as mothers. In terms of PND, those
women most vulnerable are at risk trying to attain the dominant ideology of motherhood
which still remains deeply central to our feminine identity.
The dominant discourse
becomes the ideal and assumes that we have not met the expectations of good motherly
behaviour if we have not coped with the demands placed upon us.
Is it little wonder that women struggling with PND are reluctant to come forward and speak
out about the effects of PND, the stigma and isolation. From the emotional rawness of
their experience we do not hear any evidence of resistance to PND or the ideology of
motherhood. It is only now when they have claimed agency and have adjusted to the
context of their lives as mothers they are at last able to challenge PND and the myth of
motherhood. Not surprisingly, all the women were unanimous in their agreement to want
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to tell their story and most believed this was a step towards self healing and an
opportunity to inform other women so they do not have to experience the same. Through
their narratives, we see they have gained a perspective, they are silent no longer. They
have come to the realization that they are not alone and from this vantage point have
gained strength to express openly the importance of caring for their emotional and
physical health, before, during and after childbirth; they have come to an awareness of the
significance of having and maintaining good partner relationships and creating sound,
effective social support.
They want to establish awareness and education of PND,
particularly for new mothers, and to have responsive, competent health professionals;
these are seen as crucial elements to the emotional wellbeing for them as mothers.
It is interesting to note that many of the factors mentioned by the women also reflect
current qualitative research as protective factors for PND.10 Perhaps this suggests we may
be heading in the right direction to creating an alternative experience of motherhood for
many women. However, there is still more to be done, beginning with moving to change
society’s attitude towards the myth of motherhood, bringing it more in line with the reality
of mothering and parenting in today’s social and cultural context. Early intervention of
PND and an integrated approach should also be recognised as an essential move to
creating a positive experience of motherhood for all women. Along with this there needs
to be more relevant qualitative research of PND that incorporates knowledge ascertained
from women themselves and focuses attention on the relational and social context of
women with PND.
What is it that underpins recovery?
The women’s experience of recovery is often described as a journey starting with a
turning point usually with the diagnosis of the PND. With medical intervention, support and
other factors of relevance such as recognising the need to get help, and even the
conscious decision by woman themselves to work on their own recovery and creating their
own personal strategies to help themselves; these situations and decisions were critical in
the turning point onto the road to recovery.
Professional support and the identification along with explanations as to what is
happening to them is very important, for the woman who did not have this support from
Professional help, their recovery was much slower and longer. Involvement with people
10
See literature Review (Abbott et al, 2005). (George,cited in Aitken, 1996).
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who are positive influences on the women is identified as a pivotal ingredient for recovery,
particularly partner and family. Sharing with other woman, the power of the narrative is
also a crucial element, and being able to share without discrimination or fear of stigma
which is a real barrier to recovery.
Our question is as researchers ‘is it possible to prevent PND?’ Are there protective factors
that can be put into place in the aid to prevention? At first we decided that it would not be
possible because of the variableness of the woman’s situations and circumstances, with
their historical factors, social and cultural identity all being crucial elements in the journey
to recovery. However we discussed that if women and their families were sufficiently
educated pre-natally; if they had adequate emotional support in place; professional
support at the time of birth along with the emotional support these factors alone could
have a huge bearing on the prevention of PND. Doctor Malcolm George (Aiken, 2000)
says that male partners may be a crucial element to helping to prevent PND occurring,
and a crucial element for the path of recovery, or the absence of it. Some overseas clinics
run sessions for depressed mothers and their partners, so that he becomes a part of the
solution, and not a forgotten part of the problem. What we have noticed from the
discussions with the woman we researched is that the ones who had good emotional
support from their partners and family made a faster recovery than the ones for whom it
was absent.
How easy is it to recognise the illness? For these things to be put into place the women
themselves often need to be the ones to recognise that they may be vulnerable to PND, or
for their GP’s to recognise there may be a need for additional support. Ante natal
detection is an important factor with specific focus on the emotional state of the parent to
be, and a history gained of any type of depression or other traumatic factors and
emotional aspects, which are very important but rarely investigated. (Aiken, 2000).
What we have noticed is that the woman realised their own vulnerability and state of
unwellness, but this was not recognised by medical staff or taken seriously. This is now
beginning to be changed due to increased public awareness and the presence of Maternal
Mental Health aiding in the detection and being there for woman today with PND.
This research shows that if many of these woman had received appropriate warning and
education as to the subtleties of PND, the awareness of it as an illness, the awareness
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from the Medical profession of the seriousness of its nature and treated accordingly, there
may have been a lot less trauma involved for them. Our range of woman and ages varies
from young women to older women who had children up to thirty years ago, yet all of their
responses have been the same or very similar, ‘if only we had known more about it, if only
there had been more information, if only the Medical profession could have recognised it
and treated it earlier’. For others it was the Social dimension that was most significant, ‘ if
only there had been the support for them, or extended whanau to help out in the wider
community, if only the immediate family could have been more informed and therefore
more understanding, this would have made a huge impact for them. The vulnerability of
the women and risk factors needed to be taken more into account by the Medical
profession, screening in NZ would be helpful as it is now done automatically in other
countries. Huge numbers of women go undetected, and suffer in silence in many cases.
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CONCLUSION
“It is a subject on which nothing final can be known, so long as those who alone
can really know it; women themselves, have but given little testimony, and that
little, mostly suborned.”
John Stuart Mill, 19th Century British Philosopher
The power of narrative has not been entirely harnessed as a healing tool within therapy
and it is with this in mind that we sought to explore the experience of PND through the
lens of story and metaphor. The overwhelming response by our research consultants was
that having had an opportunity to share their narrative, to be heard within the telling and
within the hearing they were able to reflect, to heal and to give hope to others. In being
able to talk about it, women gained agency to challenge the myth of motherhood and this
supported them to feel confident in their mothering roles and practices.
Story and narrative are essential ways in which women pass on information about the
often hidden complexities of birth and mothering. The loss of extended family for women
has created deficits in terms of acquiring information and receiving adequate emotional
support throughout pregnancy, birth and motherhood.
The constraints imposed on
women by New Zealand society are a reflection of how childbirth and motherhood is
viewed. With this in mind, is it any surprise that mothers may be led to the notion that
‘depression is a realistic response to motherhood’ (Nicolson, 2000).
74
We have observed the importance of attending to mental and physical health both during
and after childbirth, and we believe that support, care and acknowledgement of
motherhood as a major transition, is vital. Support and information seems to be largely
the role of health or voluntary services and often lack the resources to provide adequate
care and information. There needs to be enhanced strategies and more resources
available for early intervention.
A greater awareness and appropriate education for
women and wider society in terms of gaining knowledge of preventive measures,
protective factors, areas of vulnerability and risk factors, and a more realistic interpretation
of the realities of mothering.
We believe that recognition of the need for help by women and their families with
subsequent diagnosis and treatment is imperative to recovery.
Diagnosis signals the
beginning of the journey of recovery. Good partner relationships and social support are
crucial to the ongoing wellbeing of mothers, along with having responsive and competent
healthcare professionals and services to benefit those women in need of support and
more extensive care.
Finally, we consider an integrated approach and wide-ranging publication of research,
which focuses attention on the relational and social context of women with PND, may
contribute to improving their chances of experiencing motherhood as a positive happy
event, giving infant and partner relationships a better chance to flourish.
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Fettling, L., & Tune, B. (2005). Kitchen Table Conversations. Melbourne Australia; IP.
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Affonso, S., De, A.,Horowitz, J., Myaberry, L.(2000). An international study exploring levels of
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Beck, C. (2001). Predictors of postpartum depression: An update. Nursing Research. No 50 p 275285.
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(2002). Mental Health Foundation of New Zealand. Auckland. NZ. – sourced 11.10.07
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Feminist Movement? Edited by Myra Marx Ferre. UK.
Interview Schedule
Women’s experience of Post Natal Depression
If you feel comfortable about it, would you be able to give me some background as to
what was happening for you at the time PND was around?
Probes: Historical Context (Pregnancy/birth trauma/previous mental health)




How were you during your pregnancy? Did you feel emotionally and physically
prepared for the baby’s arrival?
Birth/Trauma: Were you given an opportunity to talk about your birth experience?
If “No” Looking back, could that have been something you would have found
useful?
Were you aware of the symptoms associated with PND?
Were you aware of any PND in your family history?
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


Were you formally diagnosed with PND? Did this impact on your recovery?
How long did the PND last?
What’s still there?
How would you describe the effects of PND on yourself, your family and other
relationships?
Probes: Social Context (Relationships emotional support)




Who noticed how you were feeling?
Did you feel you had sufficient emotional support? How did this impact on you
experience of PND?
Did PND impact on your sense of identity as a women/mother/person? And if so,
how?
How much connection/bond did you have with your baby?
What conclusions have you reached about your experience with PND?
Probes: Recovery (Treatment/Diagnosis)



What were the key factors in your recovery?
What services did you find useful/helpful?
Was there a preferred treatment or did you deal with PND yourself?
Looking back at your experience, what would you like to have been different? What’s
still there?
Age ________ Ethnic Identity ________________________No. of children _____
Marital Status ___________________Education____________________________
Severity of PND on scale of 1-10 _________
THE EXPERIENCES OF WOMEN WHO HAVE
HAD POST-NATAL DEPRESSION
Greetings
We are three, Bachelor of Social Practice students at Unitec. Part of our degree programme
involves a research paper on the subject of our choice. The research topic that we have chosen
looks at women’s experiences of post-natal depression (PND) and their stories. We are hoping
through this research to raise awareness of post-natal depression and to give women an opportunity
to share their own perceptions of PND We have the approval of the Unitec Ethics Research
Committee (UREC) to undertake this research.
How it began
As women we are aware of the enormous pressures placed upon us by society in terms of
our role as mothers. We have been encouraged by recent texts in which women share their
motherhood experiences and we have noticed how important it is to have childbirth and
80
motherhood experiences validated. Our own discussions and research have reinforced the
premise that women’s stories are still largely absent from current literature on PND. We
believe that this research is relevant and contemporary considering the current advertising
campaign by Like Minds.
What we are doing
•
We are trying to learn more about PND and its effects on women, their partners and
their children.
•
We want to learn more about outside contributing factors, which may have
surrounded your experience of PND.
•
We are wondering if the experience of PND has implications for wider society and
are looking for ways in which we can give women a voice to discuss PND, without
experiencing stigmatisation.
•
We are hoping to provide a rationale for more effective service provision.
What it will mean for you?
•
We would like to interview you and hear about your experience of PND.
•
We would like you to be able to share your experience in a way that is comfortable
for you.
•
For that reason this will not be a formal interview but an informal conversation.
•
We are looking for areas of commonality, difference and recurrent themes,
acknowledging as well the ‘uniqueness’ of your experience.
We are also keen to hear about what was helpful in your recovery:
•
What services you found helpful?
•
What could have been improved?
•
What other supports you used?
•
The effect on your relationships?
•
Any issues you had around stigma, marginalisation and/or shame?
We will need approximately 1 hour of your time for the interview. We will arrange to meet
you at a place and time of your convenience to conduct this conversation. The session will
be taped and transcribed. In the unlikely event of you becoming distressed during or
following the interview, we can arrange for you to access the appropriate supports.
What will we do with this….
By taking part in this research we hope that sharing your experiences in a supportive
environment will enrich you and will provide much needed information to help those
working with women to improve on their practices in the future. You will be given the
opportunity to view the transcript and change it if you wish. We can also make available to
you a copy of the final report in electronic form.
Consent
If you agree to participate, you will sign a consent form. This does not stop you from
changing your mind at a later time and asking to withdraw from this project. You can with
draw at any time following the interview up to the time when the data is analysed. This can
be done by sending us a letter or email, to one of the following addresses:
81
Maureen Tearle
Maureen.tearle@ihug.co.nz
43 Parrs Cross Rd
Henderson.
Ph. (09) 8378960
Liz Roberts
j_eroberts@xtra.co.nz
125 Konini Rd
Titirangi
Ph. (09)8171551
Catherine Dakin
catherinedakin@ihug.co.nz
5 Rawhiti Rd
Onehunga.
Ph.(09) 5256211
At any time if you have any concerns about the research project, you can contact our
supervisors:
Geoff Bridgman
David Haigh
Confidentiality
Your name and any information that may identify you will be kept completely confidential.
All information collected from you will be stored on a password-protected file and the only
people who will have access to your information is yourself, the three researchers and our
supervisors.
Thankyou!
Consent Form
THE EXPERIENCES
DEPRESSION
OF
WOMEN
WHO
HAVE
HAD
POSTNATAL
Your participation will help us to obtain information for a research project looking at the
experiences of women who have had post-natal depression.
I have had the research project explained to me and I have read and understood the
information sheet given.
82
I understand that my participation is voluntary and I may withdraw my consent at any time,
up to when the information has been analysed.
I understand that my participation will be confidential and no direct identifiable
information about me will be accessible to persons other than the researchers and their
supervisors. I further understand that the research data will be stored securely on password
protected computer file at Unitec for a period of five years.
I understand that my discussion with the researcher will be taped and transcribed.
I understand that I can have access to the finished research document.
I am aware that I may contact the Research Supervisors, Geoff Bridgman, (09) 815 4321
ext.5071 or David Haigh (09) 379 5538, if I have any enquiries about the project.
I have had time to consider everything and I give my consent to be part of this research
project.
Participant Signature:……………………………..
Project Researcher:……………………………….
Date:…………………………
Date:…………………………..
This study has been approved by the Unitec Research Ethics Committee from ( ) to (
). If you have any complaints or reservations about the ethical conduct of this
research, you may contact the Committee through the UREC Secretariat (09) 815
4321 ext.7254. Any issues you raise will be treated in confidence and investigated fully
and you will be informed of the outcome.
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