We Wear the Masks
We wear the mask that grins and lies,
It hides our cheeks and shades our eyes,—
This debt we pay to human guile;
With torn and bleeding hearts we smile,
And mouth with myriad subtleties.
Paul Lawrence Dunbar
Pregnancy is often a very hopeful time for expecting parents. They may spend time dreaming of what life will be like with a newborn, who will become a child and flourish into an adult that will tend to and grow the family line. The expectant couple may prepare themselves financially for their child, purchase a larger home, create a savings account, and reassess their career paths and goals. All of this is in hope for a happy family life once their baby arrives.
As a midwife, it is not uncommon to walk into a patient room for a postpartum visit with a large smile and the word congratulations on my lips. The look in the woman’s eyes often guides the intonation of the next words out of my mouth. “How are things going?” Most of the time she smiles in a manner that warms her entire face, she is aglow in new baby bliss. But there are occasions where the smile only reaches her lips, or tears ensue.
While all of a new parent's hopes and dreams may come to fruition, some postpartum families may find themselves struggling with unexpected emotions, behaviors, and attitudes that reduce the feelings of happiness we often imagine connected with the birth of a baby. It is important to address these changes without shame or concern for loss of status or face to avoid the individual and generational pain that can be experienced when depression is left untreated.
Know the Facts
Perinatal depression is one of the most common perinatal complications, affecting 1 out of 7 women. It is a depression that may begin during pregnancy or in the first 12 months after delivery, which is also known as postpartum depression. Perinatal depression can include major and minor depressive episodes that can include feelings of “extreme sadness, indifference and or/anxiety.” While it is treatable, perinatal depression carries risks for both mothers and babies.
Unfortunately, stigma, family and social expectation can inhibit women from seeking the help that they need during this very vulnerable time. It is our job as potential mothers and fathers, family and community members, health care providers and religious leaders, friends and coworkers to be aware of perinatal depression, encourage agency for ourselves, and offer support and assistance in any way we can.
Who’s At Risk
While pregnancy can often be a time of happiness and hope for women, it can also be a time of increased anxiety and depression. The hormonal, physical, and emotional challenges faced in pregnancy can instigate or increase feelings of sadness and despair. Expecting a child can also create financial, social, and relationship challenges that can create an environment of insecurity and increase the risk for perinatal depression.
Any pregnant woman is at risk for perinatal depression, but some have an increased risk.
Women with pre-existing anxiety or depression or other mood disorders are at increased risk for perinatal depression. If possible, women with a preexisting mental disorder should start planning for their emotional well-being prior to pregnancy or after receiving confirmation of a pregnancy. If on medication, it is important to discuss the safety profile of those medications during pregnancy. Some women think they must stop mental health medications prior to pregnancy, but that is untrue. There is actually more risk associated with untreated mental health needs than taking appropriate medication.
Increase in stressful life events during pregnancy can also increase risk of perinatal depression. This can include the loss of loved ones, marital and family problems, moving or change in employment. It is important for women to be supported by their family and friends during and after pregnancy, since a lack of social support can create feelings of loneliness and helplessness can deepen depression and anxiety (Hutchens & Kearney, 2020).
In addition, unexpected complications during pregnancy can take a toll on maternal mental health. With improved fetal monitoring and testing, we often know more about congenital defects or illnesses that affect the health of the baby. Sometimes a mother finds out during the pregnancy that her child will have Downs Syndrome which can be linked to heart defects, or require long term assistance from a caregiver. She may be told that her child has a cleft palate or a club foot, both conditions that can be medically managed, but can be challenging due to need for procedures, the risks associated with those procedures, as well as the financial and time burden they may place on the family. If she has other children she has to care for already perhaps she wonders how she will be able to manage it all. These types of stressors and the need for additional medical treatments for the newborn can be an impetus for depression and anxiety.
Most pregnancies end with a healthy delivery for both mother and baby, however some pregnancies end with a fetal demise and about half of all fetal demise occur with a pregnancy that was uncomplicated. In this case, parents who were expecting a healthy baby learn quite quickly that they will not take their baby home. This shock is accompanied by sadness, grief and can compound into depression that can be deep and long lasting. Many hospitals have grief and bereavement programs to help parents cope and manage this type of loss.
Other risk factors include unintended pregnancy, low income, lack of education and tobacco use. These factors have been consistently found in women who have postpartum depression but researchers are still trying to figure out more about the correlation.
Look for Signs and Symptoms
By some statistics, about 50% of women will experience the “baby blues,” which is a mild depression that can occur in the first few days or weeks in the postpartum period. This time frame can be punctuated with crying spells, mood swings, anxiety, and changes in sleeping patterns.
Women suffering from perinatal depression may experience more intense feelings of sadness, anxiety, irritability, and depression. They may be lethargic or experience insomnia or sleep most of the day, experience loss of appetite, and seem joyless. One way to differentiate from baby blues in the postpartum period, is to note that the symptoms last longer and may occur anytime during the first year after birth. Perinatal depression may affect her ability to function and can worsen without medical attention.
Look out for symptoms like anger, irritability, crying often, outbursts, and/or panic attacks. Pay attention if the new mom expresses feelings of worthlessness or guilt, worries that she may hurt the baby or herself, or won’t let the baby out of her sight. Most of us have heard of pregnancy brain, which is a reference to increased forgetfulness in pregnancy, but pay attention if the new mom is having a hard time focusing, remembering, or making decisions. A typical sign of depression can also be a lack of joy in activities that were normally enjoyable.
The most dangerous form of postpartum depression is called postpartum psychosis. This rare, serious mental illness affects 1 in 1,000 women in the postpartum period. According to the Mayo Clinic, the symptoms of psychosis include:
- Confusion and disorientation
- Obsessive thoughts about baby
- Hallucinations and delusions
- Sleep disturbances
- Excessive energy and agitation
- Attempts to harm self or baby
Impacts for Men, Too
Approximately 8-10% of men may experience postpartum depression. Partners of women who have perinatal depression are more at risk to experience depression themselves. However, the change in sleeping patterns due to the new baby’s needs, as well as fatigue and loss of attention can be contributing factors as well. Other risk factors include poverty, history of preexisting anxiety or depression, marital discord, hormonal changes, and unintended pregnancy.
Signs of a father experiencing postpartum depression can include symptoms similar to what mothers experience. Additional symptoms may include: withholding of feelings, significant weight loss or gain, repeated thoughts of death, and recurrent suicidal ideation. These signs may be most prevalent between 3-6 months postpartum, but can occur anytime up to a year postpartum.
“So, verily, with every difficulty, there is relief
Verily, with every difficulty there is relief.”
(Surah Ash-Shahr, 94:5-6)
The good news for parents that may suffer from perinatal depression is that there is treatment available. Sometimes people feel ashamed of the thoughts and feelings they are experiencing and to save face will not share their struggle with family or a health care provider. It is important to shake the concerns of seeming weak, ungrateful or “lacking faith” and seek help. Children raised by parents who experience untreated postpartum depression are at higher risk for emotional problems of their own. They may have difficulty eating and sleeping, cry excessively, and have language delays.
The type of treatment individuals receive and the time it takes to recover will vary depending on the severity of the depression and its causations. If depression is caused by an underlying illness, that will need to be addressed. Seeing a therapist is the first line of treatment in depression. It is important to find a therapist that creates a sense of safety, respects individuals’ values and beliefs, and will use evidence based treatment through this difficult time.
Treatments can vary from talk therapy alone or combining care with antidepressants or anti-anxiety medications, or a combination of those. Light therapy and brain stimulation therapy can also help some recover from depression. Depressed individuals need protected sleep, family support, time for themselves, good nutrition, and connection with other new parents to begin to heal. Those suffering from postpartum psychosis will require anti-psychotic medications and will likely spend time hospitalized until they are stable.
It Takes a Village
“And for those who fear Allah, He always prepares a way out, and He provides for him from sources he never could imagine. And if anyone puts his trust in Allah, sufficient is Allah for him. For Allah will surely accomplish His purpose: verily, for all things has Allah appointed a due proportion.”
Surah At-Talaq, 65:2-3
It can be difficult for the one who is experiencing perinatal depression to recognize it and name it. Often their partners or family and friends will note the signs and symptoms. Maybe they will notice that their friend is just not acting like herself. Perhaps a grandparent may note that their child, the new parent, is sleeping all day long and losing weight too fast. It is imperative for the witnesses of depression to bring it up and encourage their friend or family member to speak to their health care provider about how they are feeling and any changes that have been noted.
In addition, family and friends can make ruqyah for their loved ones, pray and implore Allah on their behalf. Encourage them to seek comfort in Allah, and do not dismiss medicinal and therapeutic care that can save their life and the life of their baby.
If you know someone is suffering from depression here are some emergency resources:
Call 911 if you are concerned they may hurt themselves, their baby or someone else.
SAMHSA’s National Helpline, 1-800-662-HELP (4357), (also known as the Treatment Referral Routing Service) or TTY: 1-800-487-4889 is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for individuals and family members facing mental and/or substance use disorders. This service provides referrals to local treatment facilities, support groups, and community-based organizations. Callers can also order free publications and other information (SAMSHSA’s website).
In the U.S., call the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255) or use their webchat on suicidepreventionlifeline.org/chat.
Contact the Crisis Text Line 24 hours a day, 7 days a week, by texting HELLO to 741741.
Additional References H3 Header
American College of Obstetricians and Gynecologists. (2018). Screening for perinatal depression. Retrieved from https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/11/screening-for-perinatal-depression
Dunbar, P. (1926). We wear the mask. The complete poems of paul laurence dunbar (). New York: Dodd, Mead and Company.
Hutchens, B. F., & Kearney, J. (2020). Risk factors for postpartum depression: An umbrella review. Journal of Midwifery & Women's Health, 65(1), 96-108. doi:10.1111/jmwh.13067
National Institute of Mental Health.Perinatal depression. Retrieved from https://www.nimh.nih.gov/health/publications/perinatal-depression
Melissa Fleming is a Muslim wife, mother of four, daughter, sister and auntie. She is a certified nurse-midwife and lactation consultant in Maryland and has had the pleasure of attending to women and their babies in both birth center and hospital settings.She is a founding board member and health services director for Faith Families of African-Descent Meeting for Marriage & Parenting Support (FFAMM, INC.), a service organization focused on helping Africans of the diaspora connect with the African continent through travel and service. She has been working on increasing maternal/child and women’s health care in The Gambia through this collaboration. You can learn more about this project here: FFAMM Projects. Melissa is active in her local community with service and youth groups.