Editorial - Mixed feelings

AIMS Journal, 2023, Vol 35, No 4

By Alex Smith

Welcome to the December issue of the AIMS journal, which this quarter has the theme of perinatal emotional and mental well being.

That the experience of early parenthood is likely to include ‘mixed feelings’, is an understatement, and by all accounts, it has always been that way.¹ In 1984 I had my fourth baby and my first dog at around about the same time. Nestling my newborn under my coat, and with three other small children in tow, I walked along to the post office to buy the dog licence - (we didn’t need one for the baby). The post office lady, who was older than me, leant forward to admire the baby and gave me some motherly advice. She told me not to be surprised if I woke up every morning for the next six months wondering what I had done; wondering whether I had made a huge mistake; and more tired than ever before with the additional responsibility. She said that this was absolutely normal. Then she said that I would wake up one day soon afterwards feeling as if the dog had always been part of our family and wondering how we could ever live without him - (I assume she thought I would take the baby in my stride). This was when I learned that post-dog depression was a thing, and this was the point when I started to reconfigure the idea of postnatal depression as being more than the temporary chemical imbalance I imagined it to be.² Might a period of altered mood be common after any big life change?

Some years later I was standing in the hall reading an article. I was standing because if I sat down to read in those days, a dog and four children tried to sit on top of me. The article was written by a woman who had experienced a period of severe depression after having her baby daughter. She wrote about her feelings and her sadness with such poignancy that tears rolled down my cheeks and onto the paper. The article was entitled, My Experience of Postnatal Expression, and in that lay her point; she felt that her feelings were probably normal in the circumstances and that she had a right to express them without the label of mental illness. She believed that if society ‘listened’ to what women and new parents were expressing in their altered mood, we could learn to ‘do birth’ and the transition to parenthood differently. In this way, her mood was a ‘signal’ that the birth and new parenting environments were not meeting her needs - it had a purpose. More recently I read another interesting article.³ Exploring cross-cultural literature the author, an anthropologist, also proposed an evolutionary explanation for postpartum depression as ‘having a purpose’. Whilst thought-provoking, it was a challenging read on many levels.

The idea of postnatal expression further developed the way I was learning to understand the experience of postnatal depression. It stirred within me a sense of political and feminist disquiet. Much has been written about the way in which the medical model of birth views the woman as a ‘defective machine’,⁴ as inherently ‘faulty’⁵ Women supposedly cannot ‘do pregnancy’ without medical surveillance, with those labelled as high risk in pregnancy carrying feelings of shock, fear, frustration, grief, isolation and loneliness, anger, sadness, and guilt that spill beyond the birth.⁶ Women supposedly cannot ‘do labour and birth’ without a high chance of medical intervention being required or imposed, with increasing rates of intervention and poor care, both associated with increasing experiences of postnatal distress;^7,8,9 and quite possibly women will not ‘do breastfeeding’ in the way or to the extent that they had expected, with 80% of women stopping breastfeeding before they would have hoped,¹⁰ often experiencing a deep sense of grief when they do.¹¹ Yet when they express their very reasonable feelings about all of this, plus their feelings of isolation, loss of identity, loss of income, loss of sleep, insecure housing and more¹² - for a little bit longer than is considered normal - they are diagnosed as having a mood disorder. How disorderly of them!

The discomfort we feel (as a society) about the expression of ‘the wrong’ feelings is echoed throughout history and is particularly (but not solely) targeted at women. Hysterectomy was performed as a treatment for the common diagnosis of hysteria in the 18th, 19th and early 20th centuries; ‘wayward’ girls were sent for punishing stints in asylums or homes, well into living memory; frontal lobotomy for treating ‘mental illness’ in the 1940s and 1950s (and beyond), was predominantly used on women;¹³ and the equally controversial use of Electroconvulsive Therapy (ECT) to treat depression is still being used on twice as many women as men without addressing the social issues behind why more women than men appear to have depression.¹⁴ It is described by one researcher as being “part of the over-medicalisation of human distress”.^15,16 This controversy is also found in the pathologising of extended grief, where psychologists and psychiatrists argue as to whether human emotions should be classified as illness, with one specialist saying that “grief warrants strong social support and compassionate connection, not medicalisation”. ¹⁷ What the woman who wrote about postnatal expression was saying is exactly the same - that what she needed was strong social support and compassionate connection, not medicalisation, and study after study finds that this is true for other new mothers too.¹⁸

For some new parents, especially those with complex lives and those with increasingly worrying symptoms (see the next article in this journal), the timely support of some specialist help may be welcomed and can even be life-saving. Thank goodness that these days there should be no shame in admitting to feeling mentally and emotionally out of sorts. But shame exists, not for the struggling parent but for a society that finds so many struggling. It is a shame that the social structures, cultural traditions and rituals that once ‘held’ people during times of transition or incapacity have largely broken down; broken down because we didn’t and still don’t value them as we should.¹⁹ As a consequence, some parents have to be diagnosed with an illness by a doctor in order to get the time and support they need to adapt to their new role. It is also a very real shame that strategies known to reduce the incidence and severity of mental and emotional unhappiness both before and after a birth (including: continuity of carer;²⁰ labour and birth care that supports the physiological process;²¹ and home visits from people who listen and care;²²) are ignored in favour of increased but under-resourced medical surveillance and treatment,²³often with long waits to see an NHS specialist²⁴ and with limited evidence regarding the effectiveness and safety of antidepressants.²⁵ If the expression of postpartum distress is indeed a signal, a fire alarm if you like, then is it not the fire - the lack of strong social support and compassionate connection in maternity care and in life in general - that we should be addressing?

This December issue of the AIMS journal looks at the range of emotional and mental health challenges that people may encounter as they become parents. Using the weather as a metaphor, I start by outlining the different manifestations of the changeable and occasionally tempestuous feelings experienced during the postnatal period, and this is followed by Katharine Handel’s three Christmas wishes that, if granted, would transform the perinatal experience for everyone. While most episodes of postnatal emotional and mental health concerns are mild, a few are not. Lizzy Lister shares a powerful and heartbreaking glimpse into the experience of postnatal illness in the form of a short story, and, given the terrible toll that postnatal depression or on-going symptoms of trauma can take, Mary Nolan puts forward a strong case for offering support to would-be parents before they become pregnant. AIMS quite often hears from people who are considering giving birth without the presence of a midwife or doctor, and one of the reasons they sometimes give is the belief that being in control in this way will protect their mental health.²⁶ While mental health is not her focus, Mariamni Plested’s research study, in which she interviewed ten women who gave birth without a health professional in attendance, makes for a very interesting read. It is noteworthy that, “the experience and sensation of birth was described by all participants in a wholly positive way”. Sadly, this is not what we often hear about hospitalised birth, and especially not when labour has been induced. From listening to women we understand that the experience of induction can be particularly challenging to postnatal emotional and mental well being. With the rate of induction on the rise, Jo Dagustun’s account of nearly having an induction asks the question, “how many of us are induced just before a healthy straightforward spontaneous onset would have anyway occurred”. To round off the themed section of this issue, we have an interview with Dr. Rebecca Moore about her organisation, Make Birth Better.

Moving away from a direct focus on perinatal mental wellbeing, but still intrinsically relevant, Charlotte Edun reports on the recent King’s Fund event, ‘Putting a spotlight on women’s health’, where she spoke on behalf of AIMS. Next we have Jo Dagustun who describes one shocking incident of censorship where she could only conclude that the Maternity Services do not want to listen. This is followed by Jude Field and Jenny Cunningham who want to let you know about an exciting new major project which they are undertaking to identify the top 10 priorities for midwifery and maternity research, based upon the perspectives voiced by midwives, student midwives, maternity support workers, and women and pregnant people. AIMS is very pleased to be involved in this project. For all of you birth activists, the AIMS Campaigns team runs through the recent updates to the NICE guideline on Intrapartum Care, and as ever, we conclude with the AIMS Campaigns team telling us what they have been up to in the last three months.

We are very grateful to all the volunteers who help in the production of our Journal: our authors, peer reviewers, proofreaders, website uploaders and, of course, our readers and supporters. This edition especially benefited from the help of Nadia Higson, Debbie Chippington Derrick, Kath Revell, Anne Glover, Joanne Maylin, Danielle Gilmour and Josey Smith.

We really hope you will enjoy this issue. In March the theme will be about making a complaint. If you have had an experience of maternity care that has led to you making a complaint or feeling very let down, or if you would like to contribute to this issue in some way, please contact me at: alex.smith@aims.org.uk

1 Sparks R (2013) Sadness and Support:A Short History of Postpartum Depression https://medicine.uiowa.edu/bioethics/sites/medicine.uiowa.edu.bioethics/files/wysiwyg_uploads/2013%20Rysavy%20essay.pdf