The Postpartum, and Why She Became Depressed
I met Lynn Lu, a visual artist from Singapore, in November 2015.
Lynn was working on an interactive performance/installation art project inspired by her own recent experience of depression during pregnancy and the postpartum.
Whilst helping Lynn prepare for the project and reflecting on her own experience, we identified many concepts and notions that she did not know at that time, and that could have helped her.
She has allowed me to share these with you.
1. Miscarriage increase the risk of depression in a subsequent pregnancy.
Lynn was devastated after suffering from miscarriages in 2011 and 2012. And then she planned for another pregnancy.
She did not know that women who have suffered a miscarriage are at increased risk of developing anxiety and depression in a subsequent pregnancy, especially if the interval is less than six months.
She became pregnant again in late 2012.
2. Depression and anxiety in pregnancy increase the risk of postpartum depression.
Lynn cried often throughout her pregnancy, and felt anxious about the future.
She did not know that, like her, around 8–12% of pregnant women suffer from significant symptoms of depression and anxiety. Indeed, depression in pregnancy is probably more common than its much more famous relative, “postpartum depression”.
She also did not know that depressive and anxiety symptoms in pregnancy are the most powerful risk factor for postpartum depression, and thus should be treated early.
3. Many pregnant women worry and ruminate.
Lynn was trapped in constantly ruminating about her pregnancy, and because of this she felt desperate and disappointed in herself. For example, she was worried that her baby was not normal and was not growing inside her, or that she would not be a good mother, able to take care of her child.
She did not know that these so called “pregnancy-related” anxiety symptoms are very common, occurring in up to 12% of pregnant women, and that specific scales have been developed to detect and measure their intensity.
4. For many women, labour is excruciatingly painful.
Lynn thought she could avoid pain during labour by reading abut orgasmic birth, practicing hypnobirthing training, and engaging a doula. So many of her friends told her that they had a successful delivery at home without medications. However, she eventually “begged for an epidural” during her labour. And then she felt disappointed in herself for experiencing pain.
She did not know that more than half of women receive epidural analgesia or powerful opioids painkillers during labour.
Indeed, labour rates higher than many other pain conditions, such as back pain, cancer pain, toothache, or arthritic pain; only amputation of a digit and nerve lesions are rated higher.
A quarter of women early in labour, and half of women late in labour, describe their pain as “horrible or excruciating”.
However, some women later recall their experience of paid during labour with a positive emphasis on coping strategies and increased confidence. This does not make labour less painful.
5. Difficult breastfeeding can lead to depression.
Lynn successfully breastfed her daughter for a whole year, but she struggled with a slow flow of milk, horrendously sore breasts, continuous use of a breast pump, painful bleeding nipples, and a terror of mastitis.
She did not know that difficult breastfeeding increases the risk of postpartum depression.
Breastfeeding may protect mothers from cancers and diabetes, and confer children lower infectious morbidity and higher intelligence; however, postpartum depression, with the emotional suffering and the disruption of mother-infant bond, can also negatively affect offspring development, and perhaps more so than formula feeding.
6. It is ok to seek respite from a relentless, inconsolable baby.
Lynn suffered from the relentlessness of caring for an inconsolable baby. She felt lonely, isolated, sad, guilt, helpless and, occasionally, angry.
She did not know that up to 10% of crying bouts are inconsolable, with babies appearing to be in pain even if perfectly healthy; that 25% of babies cry more than 3.5 hours per day; and that the longest crying bouts last up to two hours.
She also did not know that all parents feel guilty and helpless and angry when dealing with an inconsolable baby, so much so that guidelines recommend alternating with a second caregiver and using coping strategies, such as leaving the baby in the cot or another safe place for a few minutes and taking a hot shower with the radio playing.
7. Sometimes you just need help from specialists in perinatal mental health.
Lynn’s depression was not recognised in pregnancy, and then she was prescribed “low intensity” talking therapies for her postpartum depression, based on education and counselling.
While these strategies are effective for minor mental health ailments, they did not help Lynn, who remained depressed at 18 months postpartum.
She did not know that more intense psychological therapies, such as individual cognitive-behavioural therapy or psychological therapy focussed on the relationship between the mother and baby, are effective for depression both in pregnancy and in the postpartum; and that nutritional interventions, such as fish oil, can also be effective.
She also did not know that antidepressants are an available clinical choice both in pregnancy and in the postpartum, albeit with a higher prescribing threshold than outside these periods.
It was amazing to work with Lynn and experiencing how performance art could address an issue that I had only considered as a medical problem until then.
And it is a testimony to her strength-and perhaps to the healing power of art-that Lynn improved with little outside help.
However, from the time she developed depression in pregnancy it took almost three years to get better.
Lynn felt that her daughter became fun, interacting and able to reciprocate her love, when she turned two. She now finds that it is “a profound pleasure and privilege” to be a mother.
However, I wonder if this could have happened sooner, if she had known then what she knows now; if she had asked sooner for the help she needed.