Postpartum depression: Worsened by lack of awareness?

The transition into motherhood is often depicted as a joyous occasion. For many women, it comes with its own challenges, including postpartum depression (PPD). According to the World Health Organization (WHO), more than 10% of pregnant and postpartum women worldwide experience depression, with nearly one in five facing mental health issues during or after pregnancy. Ignoring mental health not only harms women's well-being but also affects the infant’s development.

In light of the multifaceted impacts associated with maternal mental health, we investigated the level of awareness about perinatal (before childbirth) depression, postpartum (after childbirth) depression and postpartum blues among individuals in Ladakh. Additionally, we reached out to health specialists in Leh and Kargil to understand their perspectives on the importance of perinatal counselling, risk factors, the importance of social and family support, and their observations regarding awareness levels in Ladakh.

Psychologist at Sonam Norboo Memorial (SNM) Hospital, Leh, Dr. Padma Angmo said that the prevalence rate of postpartum depression is comparable to other parts of the world and is estimated at about one-two cases per 1,000 deliveries. She added, “We say that almost 30-75% females have postpartum blues, which is experienced by most women. Postpartum blues are very common and symptoms include mood swings, crying over small issues, feeling negative, and fear. If that continues and worsens it could include symptoms such as neglect in self-care, disturbance in appetite and sleep patterns, and lack of interest in the baby's care. These are some symptoms of postpartum depression. If the symptoms persist for more than two weeks then one needs professional help. The severity can vary ranging from postpartum depression to postpartum psychosis, which is more severe. In this, there is a possibility that the mother might harm the child, and there are suicidal risks as well.”

Postpartum depression, though often regarded as rare, affects about one in 1,000 mothers. Lack of awareness contributes to its underestimation. Gynaecologist at District Hospital, Kargil, Dr Nasreen Fatima said, “Postpartum depression is something that is rare and so we expect less awareness about it. The multitude of causes includes psychiatric factors such as first pregnancies, lack of family support, abuse, social isolation, sleep disturbances, and anxiety related to parenthood. Personal factors like smoking and immigrant status also play a role, alongside obstetric factors such as high-risk pregnancies, difficult deliveries, instrumental deliveries, and the absence of pain relief. Genetic predispositions, like a personal history of psychiatric disorders, and hormonal imbalances, indicated by elevated neurotransmitters like tryptophan and serotonin, add to the complexity. Awareness efforts should encompass these various contributing elements to facilitate detection and intervention.”

In addition to this, Dr. Padma Angmo highlighted the impact of the childbirth process. She said, “The delivery process itself is stressful along with increased responsibility. Nowadays, most people live in nuclear families and there's no one other than the mother to take care of the child. One of the reasons is that husbands often do not participate in caring for the child. We have cases where we counsel the husbands as well.”

Studies also show that ignoring mental health not only harms women's well-being but also affects infants' development. Untreated mental health conditions in mothers during pregnancy can lead to complications like pre-eclampsia, haemorrhage, and premature birth. Additionally, it may result in low infant birth weight and difficulties in feeding and bonding. Similarly, postpartum depression impacts the child’s development and growth due to the mother’s inability to take care of the child and that she is less likely to breastfeed. She may also experience difficulties in bonding with the baby. A study published in the Eastern Mediterranean Journal by WHO titled, ‘Effects of postpartum depression on women’s mental and physical health four years after childbirth’ concluded that postpartum depression predisposes women to depression later in life along with other mental and physical health problems.

Ladakh-based Paediatrician, Dr. Spalchen Gonbo said, “On a scale of 0 to 5, I would say that awareness is 2 i.e. most women are not aware. This means that we should be spreading awareness more actively and it should start during perinatal check-up. Healthcare workers, especially gynaecologists, play a big role in identifying women at risk of developing postpartum depression or someone experiencing it. As a paediatrician, I always see many patients of postpartum depression as almost all of them develop issues with breastfeeding. Early intervention is crucial. It can hamper establishing breastfeeding. Breastfeeding is not just for nutrition but also for nurturing value. Postpartum depression in mother can hamper a child’s cognitive and emotional well-being and language development.”

Healthcare workers and community health workers at primary health centres and sub-centres acknowledge the limited awareness about maternal mental health. Many reported that they have had rare encounters of perinatal depression at their centres or during home-based new born care (HBNC) and home-based care for young children (HBYC) visits.

Community Health Officer (CHO) at Health and Wellness Centre, Nyemo, Sonam Putit said, “Although we do spread awareness on mental health, I have never received any training specific to maternal mental health or perinatal depression. We make HBNC visits on the 3rd, 7th, 14th, 21st, 28th, and 42nd days after delivery. If it’s a hospital delivery, we do not make the visit on the 3rd day because usually, the mother and the child are still at the hospital. Accredited Social Health Activists (ASHA) conduct regular HBYC visits to check how the baby is doing. They also talk about reduced breast-milk flow, particularly for those who undergo a C-section delivery, and we tell them not to stress about it. Also, we check for jaundice symptoms in the baby. I have so far not encountered any severe case of postpartum depression. Maybe they are not speaking about it. Though we ask mothers about problems they are facing, we do not specifically ask about perinatal depression. Our role is to provide awareness in the community and we celebrate important days related to health and spread awareness among people. However, not everyone in rural areas participates in awareness programmes as they are often busy with their house and field work.”

It is important to de-stigmatise the act of seeking help while also fostering a supportive environment for individuals facing perinatal mental health challenges. Gynaecologist at SNM Hospital, Leh, Dr. Shamima Haq said, “There are many challenges the female body undergoes during pregnancy. A disturbance in any direction could possibly result in mental health issues associated with pregnancy. Exposure to high levels of maternal stress during pregnancy can potentially have adverse impacts on the mother’s mental and physical health and the baby’s development. Awareness about postpartum depression and depression during pregnancy is very low in Ladakh. Moreover, there are stigmas associated with seeking help for mental health issues. Depression during pregnancy is the most common psychiatric morbidity affecting more than 13% of pregnant women. It is also observed among adolescents, women from inner city areas, and women with a history of depression. That said, depression during pregnancy is less common than postpartum depression. Postpartum depression is different from postpartum baby blues—mild transient dysphoria occurring in the first week after delivery that is seen in 50-80% of new mothers. Hormonal imbalances during pregnancy possibly cause postpartum depression. Family support is very important, including from the partner/husband, which will allow the mother to take frequent breaks while caring for the new born.”

Dr. Padma Angmo further explained that in other parts of the world, they plan for pregnancy and discuss all the issues beforehand. “This includes financial security and increased responsibility. Both partners must undergo counselling and discuss all issues. Throughout the pregnancy, both partners must participate equally in counselling and check-ups. It is very helpful when the husband accompanies the wife for counselling and yoga sessions. This trend does not exist in Ladakh. Here the pregnant women visit the hospital alone. The concept of planned pregnancy is still new to Ladakh. What I have seen is that due to unplanned pregnancy, Ladakhi women are not able to adjust to the timing and responsibility. Thus, when they come for delivery, they experience fear and increased stress. A little bit of counselling from the gynaecologist will help pregnant women prepare for the delivery.”

Managing postpartum depression

Dr. Nasreen Fatima highlighted some essential steps to manage postpartum depression. She emphasised the importance of early recognition and intervention.

She said, “Managing postpartum depression involves several critical steps. Perinatal counselling is important to help expectant mothers recognise and address symptoms early on. Community health workers such as ASHA and CHO play a vital role in providing valuable support and guidance, especially in areas with limited access to healthcare. Family support is vital to provide emotional and practical support, which is crucial for the mother’s well-being. Also, encouraging mothers to rest well and eat nutritious foods rich in vitamin B9 and B12, supports their health and baby’s development. Others include symptomatic treatment, mild sedation may be needed in a few cases, providing nursing care and support with breastfeeding fosters bonding and ensures mother and child thrive.”

Also, cultivating mindfulness practices such as yoga, meditation, and deep breathing techniques equips mothers with powerful tools to manage stress and alleviate anxiety. By challenging negative self-talk and embracing positive coping mechanisms, women can cultivate resilience and emotional well-being. Dr Shamima Haq explained, “New mothers can be encouraged to get adequate sleep, eat healthy food, exercise regularly and stay active, and consult a therapist or healthcare provider for expert guidance. Anxiety and depression are medical problems that need support and care, yet there is still a stigma attached to them. Women must be willing to talk about their experiences and ask for assistance to eliminate the stigma. They also need to find ways of identifying healthy means of expressing and processing feelings such as writing a journal or speaking with a trusted friend or relative. It is important to set reasonable expectations as a new mother. In addition, mothers must try yoga, meditation and deep breathing to relieve anxiety. They should be helped to recognise and combat negative self-talk or thoughts with help of therapy.”

She added, “Risk factors also include history of depression, anxiety, lack of support, stressful life events and medical difficulties during or after pregnancy. Social support is needed to assist new mothers and medical professionals to screen and treat postpartum mental health issues. Maternal mental health can flourish in an environment that is accepting and encouraging.”

Further, Dr Padma Angmo said, “The role of the gynaecologist starts from the pregnancy itself. At SNM Hospital, Female Multipurpose Health Worker (FMPHW) and nurses teach each new mother how to breast feed. This includes what to do if the baby is not accepting the feed, how to change diapers, how to hold the baby etc. However, this is not the responsibility of the mother alone. It is also very important for her to take care of herself. There have been several cases where women are burnt out, exhausted and tired. Counselling needs to be provided to the new mother in each trimester, which will definitely help her to overcome fear during delivery. Though we provide some counselling it is not as effective as we have a shortage of manpower and high workload.”

Postpartum depression is a critical issue that affects mothers worldwide, with significant implications for the well-being of the mother and child. Raising awareness about postpartum depression is crucial. It requires concerted efforts from healthcare providers, communities, and policymakers to de-stigmatise mental health issues, provide adequate support systems, and promote early intervention. By fostering a culture of understanding and support, we can empower mothers to seek help without fear or judgment and embark on the journey of motherhood with confidence and resilience.

By Tsering Dolkar and Rinchen Angmo Chumikchan

Rinchen Angmo Chumikchan is a journalist based in Leh

We also spoke to various women about their personal experiences, including early signs and symptoms they noticed, how it impacted their daily lives and relationships, as well as any specific triggers or factors that contributed to postpartum depression. Additionally, we also asked them about improvements they would like to see in the awareness and support surrounding postpartum depression. These are some responses (all names have been changed)

Stanzin Angmo: Postpartum depression can be triggered by various factors, in my case it was lack of social or family support as I was outside Ladakh at that time. This led to sleep deprivation, anxiety and difficulties in adapting to the demands of motherhood and being a new mother. I feel it's often a complex interplay of these factors that contributed to the development of postpartum depression in me. Early signs of postpartum depression included persistent sadness, irritability, changes in sleep or appetite, and difficulty in bonding with the baby. It impacted my daily life as I was experiencing fatigue, having difficulty concentrating, and there were changes in my appetite or sleep patterns, and recurrent suicidal thoughts. I had started talking less and all I wanted to do was to return home and be with my family. I didn’t care about the challenges of travelling alone with a three-month-old child for several long hours. I would like people especially mothers, mothers-in-law and husbands to know, to read and to become aware about women’s life after giving birth (postpartum) and

mental health challenges faced by new mothers. Understanding the signs and symptoms, such as persistent sadness, anxiety, and changes in behaviour, helps in early identification.

We must encourage open communication about postpartum mental health. New mothers must seek help without stigma. New mothers shouldn’t be judged, no mother harms her baby intentionally. Mothers must be encouraged to do what they feel is best for the baby and learn to ignore unsolicited advice from random people. I feel seeking professional help is crucial for support and guidance. In my case I knew what to do to overcome postpartum depression so I didn’t seek any professional help. I wish all the new mothers strength and they should remember that this too shall pass.

Rigzin Dolkar: Well, I still don’t know if I should call it depression. But I was surely not feeling good. It was a difficult and different phase from my previous postpartum period. I was in constant fear, feeling that I would die, something wrong would happen to me, my children, my loved ones and so on. The moment I would feel fear I would get immersed into it. For instance, if I felt something was going to happen to me. I would have no control over my thoughts and I would start imagining all sorts of scenarios. And I would become very scared. I lost confidence to do daily tasks such as driving, going out etc. All I would do was sit at home assuring myself that I would save myself and the baby by not stepping out.

I wanted to seek help but I wasn’t sure to share what I was going through. I also had many questions about being judged. I used to wonder if this was normal. All these thoughts kept me isolated, anxious and stressed. Eventually, it affected my breast feeding too. I was very worried! I would have panic attacks, which slowly increased. That is when I decided to see a doctor.

There were no specific factors or triggers. Everything was going well. I love cooking and I was enjoying it. I was happily raising our son and our second child was also well planned. Nothing was sudden or unexpected. The only thing was that I tested positive for COVID-19 while going for delivery. I was admitted in AIIMS Trauma Centre for delivery and I was kept isolated. No one from my family was allowed to visit me. When it comes to a baby, you plan a lot of things and if things do not go as per plan, it is upsetting. I was shocked and upset. We were four pregnant women in that ward. The moment we entered the trauma centre was very unexpected and scary! The hospital was full of patients who had COVID-19. People would be screaming in the night and it was very scary. This was one of the scariest moments in my life and I still cannot express what I felt then. I still cannot get out of it. It keeps running through my mind…the helpless faces and people screaming…I thought it was hell…it was scary and that is probably why I was scared of dying. I stayed in the hospital for five days. I delivered my daughter without anyone by my side.

Kunzes Angmo: I have a history of mental illness. In my case, I had a C-section because my baby was overdue. I think I didn’t take as much rest as I needed to recover fully after childbirth. I returned to work immediately and started managing multiple tasks, including chores and caring for the baby without seeking help. This probably contributed to my burnout, which eventually manifested as postpartum depression. While I do not recall the exact details of the first few months, I distinctly remember feeling exhausted and frequently breaking down. By six months, I noticed myself becoming very irritable and angry. I was discussing the possibility of suicide with my husband and asking him to take care of the baby. I believe, there is a significant lack of awareness about postpartum depression among individuals in Ladakh. I myself didn’t know what was happening with me. Therefore, initiatives and programmes on maternal mental health are needed. Family support is crucial for women undergoing postpartum depression. Instead of making assumptions or speaking negatively behind her back, directly asking a mother about her feelings can provide her with the support and care she needs. Furthermore, it's important to de-stigmatise the act of seeking help, which can be achieved through increased awareness.

Diskit Dolma: The lack of support from my in-laws and husband during the postpartum period was deeply distressing for me. I still struggle to express the feeling of frustration I had felt. I found myself shouldering the responsibilities of the mother and father for my baby as they were not providing me with the support I needed. During this phase, everyone must be around the mother, who is enduring sleepless nights, pain, loneliness, breastfeeding, laundry, exhaustion, and anxiety. As a society, it's crucial for us to acknowledge that every woman deserves love and care. She should be treated with kindness and compassion. There were moments when I would break down as their insensitivity added to my struggles. After that, I realised that a wife can never be a daughter to the in-laws. The birth of your baby is supposed to be a cherished experience, but I couldn't fully enjoy it due to the lack of support. Thankfully, my parents stepped in to help. Despite the overwhelming responsibilities—changing diapers, laundry, breastfeeding, and sleepless nights—I had to stand strong. We need to raise awareness about postpartum depression and the challenges new mothers face and also sensitise husbands and in-laws. A healthy mind is crucial for a healthy body and a healthy baby. Motherhood encompasses numerous challenges: balancing work, maintaining relationships, adjusting to hormonal changes, grappling with postpartum body changes, and battling anxieties and guilt. Some days I would thrive, while on others I would struggle to survive. It's essential to acknowledge the mental health issues new mothers often face, including frustration, mood swings, and anxiety. Unfortunately, my husband and in-laws failed to understand, instead choosing to complain. To all new mothers, I urge you not to lose yourselves in the process. Take care of yourselves and build a support system. And remember, despite the challenges you face, you are stronger than you realise.

Postpartum depression: Worsened by lack of awareness?

Leave a Reply Cancel reply