Maternal Mental Health and Wellbeing

Abstract

The aim of this editorial is to raise awareness about maternal mental health and wellbeing. It is, well recognised that during pregnancy, birth and following birth women can be at increased risk of mental health problems. Increase in levels of anxiety and stress commonly occur during pregnancy and following birth, which can stand alone or also be present with other mental health problems.

The aim of this editorial is to raise awareness about maternal mental health and wellbeing. It is, well recognised that during pregnancy, birth and following birth women can be at increased risk of mental health problems. Increase in levels of anxiety and stress commonly occur during pregnancy and following birth, which can stand alone or also be present with other mental health problems.(1)

Mental health relates to a person's emotional, psychological and wellbeing status and can therefore, influence how a pregnant woman and a newly birthed mother feels and functions.

The World Health Organization (WHO) define mental health as "...a state of wellbeing in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community".(2)

Yet, wellbeing is not routinely screened for and many pregnant women and newly birthed mothers at risk are not identified as having a poor state of wellbeing and opportunities to detect anxiety, stress and having problems coping are missed. However, postnatal depression (PND) is routinely being screened for in many countries of the world and some countries also advocate screening for antenatal depression.(3-5)

However, there are some concerns as to how effective the screening for depression approach is in detecting maternal mental health problems(6) as screening is usually undertaken at a single point in time, and therefore has limitations and can only provide a snapshot of a woman's emotional status. Additionally, there has also been concerns that screening women adds to the medicalisation of childbirth and motherhood,(7) and it is important to acknowledge that there is potential stigma attached to screening for postnatal depression.(8,9)

Therefore, would it be more beneficial to assess for wellbeing and enable pregnant women to self-monitor and continue to do so following birth?

The Warwick-Edinburgh Mental Well-Being Scale (WEMWBS)(10) has been used effectively in England to measure wellbeing by pregnant women and new mothers in a study investigating how to build resilience for better mental health.(11) WEMWBS is built around five core concepts those being: satisfying interpersonal relationships; positive functioning; positive affect; hedonic perspective and eudemonic perspective.

There has also been some more recent research undertaken in Australia that indicates that self-monitoring for maternal wellbeing has potential. A visual tool 'Capture My Mood' (CMM) which involves five (C) descriptors (Connected, Confident, Cheerful, Contented and Capable) which aligns with the five core concepts of WEMWBS mentioned above has been specifically designed to enable women to self-monitor their wellbeing during the early postnatal period.(7) The CMM tool has been piloted and further development and research is ongoing to provide a digital online version as many pregnant women and new mothers have mobile phones and access to the internet.

It is interesting to note that a 'Parity of Esteem' concept has been reported.(1) This concept stresses how important it is to assess mental health and gives it similar recognition to physical health problems. Poor maternal physical health following birth can lead to mental health problems and poor mental health can lead to physical health problems, as these are interconnected. For example, when a person is anxious and stressed many physical symptoms will be present such as, muscle tension, dizziness, headaches, palpations, gastric and urinary problems, restlessness, insomnia and increase susceptibility to pain.(12) During pregnancy, raised cortisol levels can increase a woman's likelihood to develop high blood pressure, pre-eclampsia, intrauterine growth restriction, premature birth and also a difficult birth.(13)

Therefore, it is vitally important that the links between mental health and physical health are taken into consideration during pregnancy and postnatally when providing maternity care. It appears that there is clear justification to give equal importance to a woman's mental and physical health status and promote wellbeing during pregnancy and then following birth.

Promoting maternal mental health

Depression is the most prevalent mental health disorder in pregnancy and postpartum, effecting approximately, one fifth of women.(14) Antenatal depression is a major risk factor for postnatal depression, which is generally a continuation of the depression that begins antenatally.(15'18)

In Brazil, the prevalence of antenatal depression is about 20% (19) that is similar to other high income countries, and considering the problems some women of reproductive age have to overcome to access the health care system, antenatal care is vitally important for preventing postnatal depression and promoting women's mental wellbeing.

Supporting pregnant women to build and maintain resilience and develop coping strategies to promote health and wellbeing is an important aspect of maternity care. Being resilient will help pregnant women to develop some coping strategies, manage anxiety and stress, reduce fear associated with childbirth and help them to maintain health and wellbeing through the transition to motherhood.(11)

It is, therefore, very important to consider promoting wellbeing and ways to maintain wellbeing such as 'the five ways to wellbeing'(20) and also by providing continuity of care.(21)

The impact of a mother's mental health status upon an infant's physical, emotional and psychological development is well recognised and also needs to be taken into consideration when providing maternity care.(22)

In summary

It is important to assess a woman's wellbeing during the prenatal and postnatal period and self-monitoring may be beneficial and tools such as 'capture my mood' may help her to recognise that she is at risk and seek health professional help or disclose her concerns to a family member or friend and contact a helpline. It is also important to consider promoting wellbeing and ways to maintain wellbeing, learning ways to develop coping strategies to manage anxiety and stress and building supportive networks. Continuity of care and community support groups can help pregnant women and new mothers to have confidence to disclose any mental health problems and build resilience and prevent social isolation. Raising awareness of the parity of esteem concept and that mental health needs to be given the same consideration that physical health has will help mothers to remain resilient and stay well.

PhD, RN, FAAN, FEANS, FRCN Mary Steen

Professor of Midwifery at the School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Adelaide, Australia

Profa Dra Adriana Amorim Francisco

Departamento de Enfermagem na Saúde da Mulher, Escola Paulista de Enfermagem, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brasil

https://orcid.org/0000-0003-4705-6987

DOI:http://dx.doi.org/10.1590/1982-0194201900049

References

1. Steen M, Steen S. Striving for better maternal mental health. Pract Midwife. 2014;17(3):11-4.

2. World Health Organization (WHO). Mental health: strengthening our response [Internet]. Geneve: WHO; 2016. [cited 2019 May 13]. Available from: who.int/mediacentre/factsheets/fs220/en/

3. Perinatal Mental Health National Action Plan 2008-2010 [Internet]. [cited 2019 May 13]. Available from: Beyondblue.org.au/docs/default-source/8.-perinatal-documents/bw0125-report-beyondblues-perinatalmental-health-(nap)-full-report.pdf?sfvrsn=2

4. National Institute for Health and Care Excelence (NICE). Antenatal and postnatal mental health: clinical management and service guidance (clinical guideline CG192). London: NICE; 2014. [cited 2019 May 13]. Available from: nice.org.uk/guidance/indevelopment/gid-cgwave0598

5. s O'Connor E, Rossom RC, Henninger M, Groom HC, Burda BU. Primary Care Screening for and Treatment of Depression in Pregnant and Postpartum Women: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2016;315(4):388-406.

6. Austin MP, Middleton PF, Highet NJ. Australian mental health reform for perinatal care. Med J Aust. 2011;195(3):112-3.

7. Brealey SD, Hewitt C, Green JM, Morrell J, Gilbody S. Screening for postnatal depression - is it acceptable to women and healthcare professionals? A systematic review and meta-synthesis. J Reprod Infant Psychol. 2010;28(4):328-44.

8. McKellar L, Steen M, Lorensuhewa N. Capture my mood: a feasibility study to develop a visual scale for women to self-monitor their mental wellbeing following birth. Evid Based Midwifery. 2017;15(2):54-9.

9. Steen M, Jones A. Maternal mental health: stigma and shame. Pract Midwife. 2013;16(6):5.

10. Tennant R, Hiller L, Fishwick R, Platt S, Joseph S, Weich S, et al. The Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS): development and UK validation. Health Qual Life Outcomes. 2007;5(1):63.

11. Steen M, Robinson M, Robertson S, Raine G. Pre- and post-survey fi ndings from the Mind 'Building resilience programme for better mental health: pregnant women and new mothers'. Evid Based Midwifery. 2015;13(3):92-9.

12. Wood L. Psychologi cal interventions in anxiety and depression. In: Smith G, editors. Psychological interventions in mental health nursing. United Kingdom: Open University Press/McGraw Hill Education Maidenhead; 2012.

13. Steen M, Green B. ( Mental Health during pregnancy and parenthood. In: Mental health: Across the Lifespan. Steen M, Thomas M, editors. London, UK: Taylor & Francis; 2016.

14. Limlomwongse N, Liabsuetrakul T. Cohort study of depressive moods in Thai women during late pregnancy and 6-8 weeks of postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Arch Women Ment Health. 2006 May;9(3):131-8.

15. Alami KM, Kadri N , Berrada S. Prevalence and psychosocial correlates of depressed mood during pregnancy and after childbirth in a Moroccan sample. Arch Women Ment Health. 2006;9(6):343-6.

16. Andersson L, Sundström-Poromaa I, Wulff M, Aström M, Bixo M. Depression and anxiety during pregnancy and six months postpartum: a follow-up study. Acta Obstet Gynecol Scand. 2006;85(8):937-44.

17. Ryan D, Milis L, Misri N. Depression during pregnancy. Can Fam Physician. 2005;51:1087-93.

18. Heron J, O'Connor TG, Evans J, Golding J, Glover V; ALSPAC Study Team. The course of anxiety and depression through pregnancy and the postpartum in a community sample. J Affect Disord. 2004;80(1):65-73.

19. Pereira PK, Lovisi GM. Prevalence of gestacional depression and associated factors. Rev Psiq Clin. 2008;35(4):144-53.

20. New Economic Foundati on. Five ways to wellbeing [Internet].London: New Economic Foundation; 2008. [cited 2019 May 13]. Available from: neweconomics.org/projects/entry/five-ways-to-well-being

21. Care Quality Commission (CQC). National fi nd i ngs from the 2013 survey of women's experiences of maternity care. London: CQC; 2013.

22. Steen M, Jones A, Woodsworth B. Anxiety, bonding and attachment during pregnancy, the transition to parenthood and psychotherapy. Br J Midwifery. 2013;21(12):768-74.

El objetivo de este editorial es crear conciencia sobre la salud mental y el bienestar materno. Es bien sabido que, durante el embarazo, el parto y después del parto, las mujeres tienen mayor riesgo de tener problemas de salud mental. Durante la gestación y después del parto es común que aumenten los niveles de ansiedad y estrés, que puede suceder de forma aislada o presentarse junto con otros problemas de salud mental.(1)

La salud mental está relacionada con el estado emocional, psicológico y de bienestar de una persona y, por lo tanto, puede afectar los sentimientos y la forma de actuar de una mujer embarazada o en período de puerperio.

La Organización Mundial de la Salud (OMS) define la salud mental como "...un estado de bienestar en el cual el individuo es consciente de sus propias capacidades, puede afrontar las tensiones normales de la vida, puede trabajar de forma productiva y fructífera y es capaz de hacer una contribución a su comunidad".(2)

Pero el bienestar no se evalúa de forma rutinaria y muchas mujeres embarazadas o en período de puerperio en situación de riesgo no son identifi cadas como personas con un mal estado de bienestar y se pierde la oportunidad de detectar cuadros de ansiedad, estrés y problemas para lidiar con situaciones. Sin embargo, la depresión posparto (DPP) se evalúa rutinariamente en muchos países del mundo y algunos países también son partidarios de examinar la depresión preparto.(3-5)

Por otro lado, existen ciertas dudas sobre la eficacia de la estrategia de evaluación de depresión para detectar problemas de salud mental materna(6) ya que la evaluación normalmente se realiza en un momento específico y, por lo tanto, es limitada y solo ofrece un panorama del estado emocional de la mujer. Además, también existe la preocupación de que esta evaluación a mujeres colabora con la medicalización del parto y de la maternidad,(7) y es importante reconocer que existe un posible estigma asociado a la detección de depresión posparto.(8,9)

Por lo tanto, ¿no sería mejor evaluar el bienestar y permitir que las mujeres embarazadas se autobserven y continúen haciéndolo después del parto?

La escala de bienestar mental de Warwick-Edinburgh (WEMWBS, por sus siglas en inglés)(10) se ha utilizado con eficacia por mujeres embarazadas y nuevas madres en Inglaterra para medir su bienestar en un estudio que investiga cómo adquirir capacidad de adaptación para tener mejor salud mental.(11) La escala WEMWBS está basada en cinco conceptos principales, a saber: la satisfacción de las relaciones interpersonales, el funcionamiento positivo, el afecto positivo, la perspectiva hedónica y la perspectiva eudaimónica.

En Australia, recientemente se llevó a cabo un estudio que indica que la autobservación para el bienestar materno tiene potencial. Para que las mujeres puedan autoevaluar su bienestar durante el período de posparto temprano, fue creada una herramienta visual específica llamada "Capture My Mood" (registro de estado de ánimo), que incluye cinco descriptores (conectada, segura, animada, contenta y capaz), que están alineados con los cinco conceptos principales de la escala WEMWBS antes mencionados.(7) Esta herramienta ya se puso a prueba y se están realizando más estudios para desarrollar una versión digital ya que muchas mujeres embarazadas y nuevas madres tienen celular y navegan en internet.

Es interesante observar que se ha mencionado el concepto de "igualdad de condiciones".(1) Este concepto destaca lo importante que es evaluar la salud mental y le da un reconocimiento similar que a los problemas de salud física. Malas condiciones de salud física después del parto pueden derivar en problemas de salud mental y malas condiciones de salud mental pueden derivar en problemas de salud física, ya que están interconectadas. Por ejemplo, cuando una persona tiene ansiedad o está estresada, aparecen varios síntomas físicos, como tensión muscular, mareos, dolores de cabeza, palpitaciones, problemas gástricos y urinarios, agitación, insomnio y aumento de susceptibilidad al dolor.(12) Durante el embarazo, los niveles de cortisol altos pueden aumentar la posibilidad de que la mujer tenga presión arterial alta, preeclampsia, restricción del crecimiento intrauterino, parto prematuro e, inclusive, un parto complicado.(13)

Por lo tanto, es de vital importancia tener en cuenta la relación entre salud mental y salud física durante el embarazo y el posparto a la hora de brindar atención materna. Aparentemente, los fundamentos para dar la misma importancia al estado de salud mental y física de una mujer y promover el bienestar durante el embarazo y después del parto son evidentes.

Cómo promover la salud mental materna

La depresión es el trastorno de salud mental más frecuente durante la gestación y el posparto y afecta aproximadamente a un quinto de las mujeres.(14) La depresión preparto es un factor de riesgo importante para la depresión posparto, que generalmente es la continuación de la depresión que comienza antes del nacimiento.(15-18)

En Brasil, la prevalencia de depresión preparto es en torno de 20% (19), parecida a otros países de ingresos altos, y considerando los problemas que algunas mujeres en edad reproductiva tienen que enfrentar para acceder al sistema sanitario, la atención prenatal es de vital importancia para prevenir la depresión posparto y promover el bienestar mental de la mujer.

Un aspecto importante de la atención materna es apoyar a las mujeres embarazadas a adquirir capacidad de adaptación y desarrollar estrategias para lidiar con situaciones para promover la salud y el bienestar. Tener capacidad de adaptación ayudará a las mujeres gestantes a desarrollar algunas estrategias para lidiar con situaciones, administrar la ansiedad y el estrés, reducir el miedo asociado con el parto y ayudarlas a mantener la salud y el bienestar en la transición hacia la maternidad.(11)

Por lo tanto, es muy importante que se considere promover el bienestar y de qué forma mantenerlo, como los "cinco caminos hacia el bienestar"(20) y también mediante la continuidad en la atención.(21)

El impacto que el estado de salud mental de una madre causa sobre el desarrollo físico, emocional y psicológico de un niño es bien sabido y debe tenerse en cuenta al ofrecer atención materna.(22)

Conclusión

Es importante evaluar el bienestar de la mujer durante el período prenatal y posparto. La autobservación puede ser beneficiosa y herramientas como "Capture My Mood" pueden ayudarla a reconocer si está en riesgo y buscar ayuda médica profesional o contar sus preocupaciones a algún familiar o amigo y entrar en contacto con una línea de asistencia. También es importante que se considere promover el bienestar y de qué forma mantenerlo, aprender a desarrollar estrategias para lidiar con situaciones y administrar la ansiedad y el estrés y construir redes de apoyo. La continuidad de la asistencia y los grupos de apoyo comunitarios pueden ayudar a las mujeres embarazadas y nuevas madres a ganar confianza para contar cualquier problema de salud mental y adquirir capacidad de adaptación y prevenir el aislamiento social. Crear conciencia del concepto de igualdad de condiciones y de que la salud mental necesita recibir la misma consideración que la salud física ayudará a las madres a adaptarse y a estar bien.

PhD, RN, FAAN, FEANS, FRCN Mary Steen

Profesora de Obstetricia en School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Adelaide, Australia

Profa Dra Adriana Amorim Francisco

Departamento de Enfermería en Salud de la Mujer, Escola Paulista de Enfermagem, Universidade Federal de Sao Paulo, Sao Paulo, SP, Brasil

https://orcid.org/0000-0003-4705-6987

DOI:http://dx.doi.org/10.1590/1982-0194201900049

Referencias

1.Steen M, Steen S. Striving for better maternal mental health. Pract Midwife. 2014;17(3):11-4.

2. World Health Organization (WHO). Mental health: strengthening our response [Internet]. Geneve: WHO; 2016. [cited 2019 May 13]. Available from: who.int/mediacentre/factsheets/fs220/en/

3. Perinatal Mental Health National Action Plan 2008-2010 [Internet]. [cited 2019 May 13]. Available from: Beyondblue.org.au/docs/default-source/8.-perinatal-documents/bw0125-report-beyondblues-perinatalmental-health-(nap)-full-report.pdf?sfvrsn=2

4. National Institute for Health and Care Excelence (NICE). Antenatal and postnatal mental health: clinical management and service guidance (clinical guideline CG192). London: NICE; 2014. [cited 2019 May 13]. Available from: nice.org.uk/guidance/indevelopment/gid-cgwave0598

5. s O'Connor E, Rossom RC, Henninger M, Groom HC, Burda BU. Primary Care Screening for and Treatment of Depression in Pregnant and Postpartum Women: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2016;315(4):388-406.

6. Austin MP, Middleton PF, Highet NJ. Australian mental health reform for perinatal care. Med J Aust. 2011;195(3):112-3.

7. Brealey SD, Hewitt C, Green JM, Morrell J, Gilbody S. Screening for postnatal depression - is it acceptable to women and healthcare professionals? A systematic review and meta-synthesis. J Reprod Infant Psychol. 2010;28(4):328-44.

8. McKellar L, Steen M, Lorensuhewa N. Capture my mood: a feasibility study to develop a visual scale for women to self-monitor their mental wellbeing following birth. Evid Based Midwifery. 2017;15(2):54-9.

9. Steen M, Jones A. Maternal mental health: stigma and shame. Pract Midwife. 2013;16(6):5.

10. Tennant R, Hiller L, Fishwick R, Platt S, Joseph S, Weich S, et al. The Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS): development and UK validation. Health Qual Life Outcomes. 2007;5(1):63.

11. Steen M, Robinson M, Robertson S, Raine G. Pre- and post-survey f¡ ndings from the Mind 'Building resilience programme for better mental health: pregnant women and new mothers'. Evid Based Midwifery. 2015;13(3):92-9.

12. Wood L. Psychological interventions in anxiety and depression. In: Smith G, editors. Psychological interventions in mental health nursing. United Kingdom: Open University Press/McGraw Hill Education Maidenhead; 2012.

13. Steen M, Green B. ( Mental Health during pregnancy and parenthood. In: Mental health: Across the Lifespan. Steen M, Thomas M, editors. London, UK: Taylor & Francis; 2016.

14. Limlomwongse N, Liabsuetrakul T. Cohort study of depressive moods in Thai women during late pregnancy and 6-8 weeks of postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Arch Women Ment Health. 2006 May;9(3):131-8.

15. Alami KM, Kadri N, Berrada S. Prevalence and psychosocial correlates of depressed mood during pregnancy and after childbirth in a Moroccan sample. Arch Women Ment Health. 2006;9(6):343-6.

16. Andersson L, Sundström-Poromaa I, Wulff M, Aström M, Bixo M. Depression and anxiety during pregnancy and six months postpartum: a follow-up study. Acta Obstet Gynecol Scand. 2006;85(8):937-44.

17. Ryan D, Milis L, Misri N. Depression during pregnancy. Can Fam Physician. 2005;51:1087-93.

18. Heron J, O'Connor TG, Evans J, Golding J, Glover V; ALSPAC Study Team. The course of anxiety and depression through pregnancy and the postpartum in a community sample. J Affect Disord. 2004;80(1):65-73.

19. Pereira PK, Lovisi GM. Prevalence of gestacional depression and associated factors. Rev Psiq Clin. 2008;35(4):144-53.

20. New Economic Foundation. Five ways to wellbeing [Internet].London: New Economic Foundation; 2008. [cited 2019 May 13]. Available from: neweconomics.org/projects/entry/five-ways-to-well-being

21. Care Quality Commission (CQC). National fi ndings from the 2013 survey of women's experiences of maternity care. London: CQC; 2013.

22. Steen M, Jones A, Woodsworth B. Anxiety, bonding and attachment during pregnancy, the transition to parenthood and psychotherapy. Br J Midwifery. 2013;21(12):768-74.