As a parent of a premature infant (POPI), you will spend an extraordinary amount of time thinking about your baby. Let’s face it, POPIs have more to worry about. POPIs also have to negotiate the implications of their baby’s under- developed immune system, poor body temperature regulation and highly unpredictable milestone development. On top of all this you’ll also probably worry about the future and wonder whether your child will fully overcome his/her difficult beginnings.
These are perfectly normal, if not necessary thoughts for a POPI to have. Extra attention to your infant will increase your chances of detecting postpartum complications. However; A lot of POPIs feel guilty considering this question. A common attitude is; “Only a selfish person would think about themselves when they’re supposed to be caring for a sick, defenceless child”. As mental health professionals we would say that it is not the selfish POPIs but the smart ones that consider their own needs alongside their child’s. There are no prizes for being a martyr and there is certainly no shame in taking care of yourself. After all, a healthy and well- functioning parent will be able to take better care of a baby than an exhausted and overwhelmed one.
As a POPI, it is important to recognise that you are more likely to develop mental health difficulties than parents of full term infants. This does not necessarily mean that you will, but it does mean that you should make yourself aware of the range of problems that could occur. This article addresses postpartum depression (PPD). It will outline PPD symptoms and list the factors that might contribute to their onset. Strategies for dealing with these issues are also provided.
Postpartum Depression (PPD)
PPD is a mood disorder that effects 14% of fullterm mothers. It can also effect new fathers although the prevalence rate is less clear. PPD is different from the “baby blues” which is a relatively fleeting period of sadness and irritability that affects the vast majority of new mothers. However while the baby blues tend to decrease in intensity approximately two weeks following the birth, PPD is more long-term and can occur anytime within the first year. Due to the increased psychological stress placed on premmie mothers, the rate among these women is higher, estimated to be between 28-70%. A number of factors associated with the premature birth experience have been found to contribute to the higher incidence of PPD among premmie mothers. These factors probably also contribute to a premmie father’s distress although there is less research available to support this assumption.
POPI specific risk factors for PPD
- Child-birth related distress – emergency delivery, a painful labour, high levels of discomfort, fear or anxiety during or after birth
- Negative NICU experience – poor communication from staff, feelings of helplessness and estrangement from the child
- Increased feelings of failure and guilt about not taking their child to term. Although completely untrue, premmie mothers frequently blame themselves and suspect that “they did something wrong”. This feeling of inadequacy can lead to a profound loss of self-esteem
- Sadness over the loss of what they imagined their parental role to be like
- Caring for a child who is restless, difficult to settle or unwell
What is PPD?
PPD is characterized by :
- Changes in Mood
- depressed mood
- depressed mood most of the day,
- every day loss of interest or pleasure in most activities
- Changes in Daily Functioning
- over eating or not eating
- over sleeping or insomnia
- lack of energy and motivation
- disinterest in personal hygiene
- difficulty concentrating and poor memory
- Negative Feelings Toward the Self
- feelings of worthless, failure and guilt
- a sense of helplessness about the future
- suicidal thoughts
- Negative Feelings Toward Others
- social withdrawal
- thoughts about harming your baby
- irrational fears that your partner doesn’t love you
- belief that you are a burden to others
PPD can effect people in different ways. This means that people who suffer from PPD do not necessarily have every single one of these symptoms. Most people however have at least five. You may have noticed that many of the symptoms are also normal “side effects” of having a new born baby. For example, the majority of new mums would experience changes that are listed in the “Daily Functioning” category. A consequence of this overlap is that that the presence of PPD can often be “disguised”. New mums may assume that this is what motherhood is supposed to feel like.
Also, most POPIs report a range of negative thoughts and feelings as they adapt to having a preterm child. Such thoughts are a perfectly normal part of “working through” the adjustment process. Coming to terms with the unique parenting required of a POPI can be
overwhelming and confusing. However, such thoughts should become less frequent and intense as you become more familiar with your circumstances. If negative thoughts persist or get worse over time, they may be suggestive of PPD. Because it will be hard for you to tell what is “normal” from what is not, it is crucial to seek a professional assessment if you suspect PPD.
To assist with the assessment process it will be useful for you to have a record of your symptoms. Partners can also make relevant observations. For example, it would be helpful for your health professional to know how often and to what extent you are feeling worthless. Do you feel worthless all the time or are there times during the day where you feel more positive about yourself? Although you feel depressed most of the time, are there any activities that you still enjoy?
The assessment will also involve questions about prior mood disorders. A previous depressive or psychotic episode increases your risk of developing PPD. Similarly a family history of depressive disorders (e.g. mother, father or siblings) also indicates higher risk. Having this information available will contribute to a more accurate and thorough assessment.
The quickest way to gain an assessment is to make an appointment with your GP. If your GP decides that your symptoms meet the criteria for PPD, you will most likely be offered a course of medication and/or psychotherapy. If you are breastfeeding, it is important to inform your doctor as some mood altering medications can be harmful to the baby.
Psychotherapy usually involves a referral to an allied mental health professional such as a psychologist or social worker. Under the ‘Better Access to Mental Health Care Plan’, you are entitled to a minimum of six and a maximum of twelve Medicare-rebated therapy session. You may be required to pay a small “gap” fee so seek this information in advance. Also, if you want your partner in attendance at therapy, be mindful that this may incur additional cost.
There are a lot of misconceptions about psychotherapy. The vast majority of therapy does
Spotlight on mental health not involve deep analysis or hypnosis. Therapy for PPD is usually an interactive process that focuses on improving your emotional regulation, mood and life skills.
Why PPD should not go undiagnosed
Depressed mothers have been found to be less responsive, affectionate and positive during
interactions with their infant. This doesn’t mean that they are evil or careless, it is just a consequence of the illness. When you are struggling to “keep your head above the water”, there is little energy left over to dedicate to someone else.
Although all infants are vulnerable to the effects of maternal depression, premmie babies are at greater risk due to their decreased responsiveness and extra need for stimulation. Therefore, if mum has to take time out for her own health, it is vital that another caregiver is available to provide the necessary care. Furthermore, a depressed family member can place great strain on the entire family structure. Prompt help-seeking will hopefully reduce the implications of your mood on other members of the household.
Strategies to Prevent PPD
It is better to try and prevent PPD from occurring in the first place rather than wait until full blown symptoms occur. Not all strategies work for everybody and it may take some time to find the right formula for you and your family. In general, prevention requires both an increased awareness of your mental health and improvement of your coping skills.
For Mum Know thyself
As much as possible try and pay close attention to your thoughts and feelings. Don’t make assumptions how you should feel. Don’t try and “block” things out as this usually does not work forever. Instead accept what you are feeling, even if it is negative. Having a bad thought doesn’t make you a bad mother, it just makes you an honest person. Of course there are going to be times when you feel ambivalent about your child, you are going through an extremely hard time. Keep a diary as this can be an excellent way to release negative energy.
Try and detect if there are patterns to your moods. When are your lowest points during the day?
Are there particular triggers that set off the negativity? What helps you feel good? Being mindful of such factors makes it easier to act in a preventative rather than reactionary way. For example, if you know that 4pm-6pm is your most vulnerable time, recruit a family or friend to help you at this time.
Ignore motherhood myths
Society endorses a number of motherhood myths that revolve around the idea of motherhood being an instinctual skill beset with countless joys. The truth is that motherhood is definitely not always wonderful. Some women have trouble admitting this due to the belief that it means that must be strange or defective in some way. It is important for new mothers to reject these myths and have realistic expectations about the motherhood experience.
- Motherhood is a woman’s ultimate fulfillment
- A woman instantly feels love for her baby
- A woman will instinctively know how to mother
- Motherhood is a time of sublime contentment and joy
- A mother is selfish if she expresses her own needs
- If a mother does not bond with her baby straight away, there is something wrong with her and the baby will suffer long term psychological damage
- Mothers must cope with the demands they face and it is not OK to ask for help
- A good mother is full time and totally available to her children
- Motherhood is a difficult but rewarding job that involves long hours with little respite
- A mother may feel love for her baby as soon as it is born, but this ‘falling in love’ is more likely to occur over time as she gets to know her baby. It may take weeks or even months to bond with the baby.
Post partum depression & premature birth
- Motherhood is not merely instinctive.
- A woman has to learn to be a mother and this takes time and practice.
- It is OK for a mother to make mistakes
- A mother must express her own needs and learn to nurture herself to be able to nurture her family. It’s ok to ask for help
- A mother needs to keep alive her own dreams for herself and long term plans for her future
(Myths cited in Bishop, L. (1999). Postnatal depression: families in turmoil. Halstead Press.).
Acknowledge what you are doing right
The list of parenting tasks for a POPI may seem daunting. Until you get the hang of things
you will probably spend a lot of time second guessing yourself, “Am I doing this right, enough, too much?” etc. You will probably berate yourself from time to time about forgetting something or not doing something well enough.
However, it is common knowledge that what you think effects how you feel. Basically, if youthink negatively, you are going to feel negative. A simple way to improve your mood is to consciously focus on what you are doing right. We bet there are many things that you are doing perfectly everyday that you are not even acknowledging. In fact, if you stopped and really thought about it, you’d probably find that the good far outweighs the bad. Be fair on yourself and judge your parenting skills in a non-biased way.
Some people find it easier than others to “look on the bright side”. People might tell you to
“focus on what you do have rather than what you don’t”. However this might be easier said than done for POPIs who are exhausted and facing an uncertain future. Perhaps for these parents, the best advice would be to retain perspective. Acknowledge your difficulties but also remind yourself that things have to eventually improve. Remember, a short-term struggle often results in long-term gain.
Research indicates that a sense of feeling supported helps protect against PPD. Therefore, it is your responsibility to ensure that you are getting the support that you need. The majority of partners, family and friends want to be useful but they often don’t know how.
They are relying on your lead.
Don’t be shy about asking for what you want and don’t be afraid to change your mind. You may need different forms of support at different times. support at different times. For example, at times you might feel the need to talk while on other occasions you’d rather be alone.
Maintain outside interests
There is no need to put your entire life on hold for your baby. It is important that you don’t loose connection with the non-mother part of your identity. Take time out to do the things that you enjoy. Think about the things you used to like doing before you had the baby and try to reintroduce them back into your life. Take time to spoil yourself, you deserve it.
Exercise and relaxation
Exercise might be the last thing you feel like doing as a new mum. However, research shows that even a short, low-impact walk can be enough to activate the “feel good” endorphins in your body. Getting out of the house will also give you a mental break. However, remember to follow your Doctor’s recommendations about physical exertion if you are still recovering from the birth.
Relaxation strategies such as yoga and meditationare can reduce anxiety in both your body and mind. If attending a formal class is not possible, hire/buy a meditative DVD and try it when the baby is sleeping. Playing relaxing music or audio such as ocean or rainforest sounds might also help to de-stress you and the baby.
Minimise other stressors
This is an obvious but often overlooked coping strategy. If you already feel stressed, don’t allow more stress into your life. Tell work that you are completely unavailable. Tell your partner that you can’t get his great aunt’s birthday gift. Now is the time to look after yourself, other people should understand this if you are honest with them.
For partners, friends and family
Don’t ignore the “white elephant” In the mental health field, the white elephant
phenomenon refers to those occasions when there is an obvious need to address a difficult issue, but nobody has the courage to bring it up. The issue might get so big and so obvious (like a white elephant) but still family members would rather pretend it is not there. Don’t let your suspicion of PPD become a white elephant.
Post partum depression & premature birth
You know what the symptoms are (they have been provided in this article), so ask your partner if he/she is experiencing any.
Approach the topic in a caring and non-judgmental way but don’t skirt around the issue. For example, “I’ve been noticing that you seem really down a lot lately, how are you feeling about things/yourself/the baby/motherhood?” If your partner is uncomfortable expressing vulnerable emotions, rating scales can be a good way to gauge her mood, “On a scale of 1-10, how agitated/tired/sad do you feel?”
Follow up by encouraging professional help and accompany her/him to appointments. If an assessment for PPD is necessary, the person doing the assessment might benefit from another person’s perspective of your partner’s symptoms. In particular take note of his/her moods and eating habits. Inform your partner that you are doing this as you don’t want to come across as “dobbing” when you see the Doctor/Psychologist.
Encourage honest talk
Many couples fall into the trap of idealizing the parental experience because society tells us that this is supposed to be a wonderful experience. People who experience feelings contrary to this can fear stigma and judgment in admitting the truth. Encourage your partner’s honesty by being honest with them. Tell her what you are struggling with and invite her to do the same.
Some POPIs can be deeply affected by the NICU experience. They might dream about it or find their thoughts returning to that time. Life and death situations usually have a profound on people. Don’t be afraid to think about this time, it might be difficult and distressing but it cannot hurt you. It is just a memory and it needs to be integrated into your life history like other memories. Discuss what it was like for each of you. Give yourselves the opportunity to understand each other’s perspective.
If one of you seems extremely distressed by NICU related thoughts and feelings it may represent an unresolved trauma reaction. For example, if you have nightmares or vivid flashbacks (memories that seem “too real”, like you are actually back there again) or develop an excessive fear of hospitals.
In such cases a professional consultation is immediately necessary.
Provide practical help
It’s vital the POPIs feel supported. Offer help where you can; with the baby’s care, household duties, running errands etc. Even if he/she repeatedly refuses help, keep asking to make it clear that you are not just making a token gesture. Be honest about not being sure how to help; “I really want to help but am not really sure how. Could you tell me how I could best help you out?”
Partners might formulate a roster to ensure that the work-load is shared. Friends/family might like to commit to helping at a regular time interval that suits them. This will assist POPIs in their daily planning and give them a break to look forward to.
Increase pleasant activities
Take time out to plan enjoyable things to do together. If your partner is resistant to going out then think of things that you can do together in the home that is not parenting. You may need to stretch your memory back to your youth for ideas; board games, complete a puzzle together, sort through your photos, cook a meal together, watch a movie, listen to music together.
Take care of yourself
Partners of PPD suffers need to be extremely mindful of their own mental health. The experience of premature labour can be highly stressful for fathers who find their attention divided between worrying about their partner and their child. Many fathers of premmie babies also face the increased pressure of having to provide stability to the family unit. Feeling like they have to be the one to “hold it all together” can be emotionally and physically exhausting. Premmie fathers are also likely to find their domestic responsibilities increasing when the baby comes home. They may also face additional pressure to provide financial support and maintain an adequate level of functioning at work. Adjustment effects the whole family, don’t neglect your own needs.
Women who are not diagnosed can struggle on for years attempting to manage an unrecognised condition.
(Information in this article was kindly provided by Merran Watt on behalf on Monash IVF Counselling Services)
Many women do not seek help for many reasons:
- They may not realize they have a problem that can respond to help, thinking this is just the way it is with a baby
- The stigma associated with mental health problems may stop many women even giving voice to their feelings
- Many women hide behind masks, not even sharing their feelings with close friends
- Some women think they are the problem
- Health professionals are not always able to diagnose perinatal mood disorders
(Gidget Foundation 2009)
How dads can help
Dads can play an important part too, click here for further information
(Good Beginnings Australia)
Support Services for PPD
If you require assistance after hours please call one of the following services
- Maternal and Child Health Line: Ph: 132 229
- Parentline: 132 289
- Lifeline: 131 114
- Lifeline Suicide Helpline Ph. 1300 651 251
- Mensline: 1300 789 978
POST AND ANTENATAL DEPRESSION ASSOCIATION (PANDA)
Provides excellent information, telephone support and support groups.
Ph: 1300 726 306 PANDA’s telephone helpline is open from 9.30am – 4.30pm, Monday to Friday
Black Dog Institute
National Depression Initiative is committed to the prevention and early
intervention and research of depression, anxiety and related disorders.
Phone: 1300 22 4636
Good Beginnings Australia
CARER SERVICES ARAFEMI
Association of Relatives and Friends of the Emotionally and Mentally ill.
Telephone Support: (03) 9889 1777
Interactive on-line exercises aimed to improve mood and negative thought processes.
Designed by Australia National University
Centre for Mental Health Research:
postpartumprogress.comPostpartum depression help and hope from thousands of moms who’ve been there. We understand & we can help.
Below is a 5 day blog they wrote on different mums experience’s with PPD
Day 1 http://postpartumprogress.com/7-postpartum-depression-survivors-share-their-stories-of-having-more-children
Not Just About the Wee
Yuz an LLTF mum has had two premature babies both born at 36wks. She is a PND/PPD/PPA survivor having been admitted to (as she says) the nuthouse following her daughters birth in 2009. This is her ongoing story & journey of both enduring & enjoying motherhood.
www.notjustaboutwee.com/ - Yuz’s Blog
A Mum’s Story
Robbie is home and so is the black dog………
When I first became pregnant I imagined everything going perfectly, I would be glowing during the pregnancy, work up to 36 weeks and then have the baby right around my due date. It would of course be a natural birth with no complications and I would be presented this beautiful baby straight out of an Anne Geddes calendar. We would be in hospital a couple of days and then all go home as a happy little family. What a lovely dream, I can hear the angels singing……
Now lets get back to reality and what really happened! There was no glowing there was 16 weeks of morning sickness, there was a large still unexplained bleed at 12 weeks, there was severe indigestion, the flu and the development of a staph infection on my face which made me look like the elephant man’s sister. There was no glow of pregnancy, just the look of pity from other people on how bad my face and skin was.
Naturally I was surrounded by women having the perfect pregnancy, looking fantastic, putting on minimal weight (I managed to put on a good 20+ kilos) and as they say they were glowing! My pregnancy went from bad to worse as I developed severe pre-eclampsia which progressed further into HELLP syndrome. My condition was picked up quite late and when I was finally put in hospital things moved very very quickly and there was no messing about, my blood pressure was extremely high, my liver, kidneys and central nervous system were shutting down and I was close to having a fit so this baby had to come out NOW.
Once I was loaded off the ambulance I was prepped and it was straight into the operating theatre, my husband Michael and I naively asked whether Michael could be there for the birth but were told I was too sick and that they needed to give me a general anaesthetic and a caesarean was to be performed so there would be no spectators!
I vaguely remember waking up and Michael telling me that we had a boy whom we named Robbie but the next few days were very hazy. I spent close to two weeks in hospital and wasn’t well enough to see Robbie until 36 hours after his birth when a nurse and Michael managed to get me and all the equipment I was attached to into a wheelchair and down to NICU where I saw him for 10 minutes.
Robbie had a bumpy start and despite being born at 32 weeks was only 1334g. He needed to be ventilated, he needed the lights and had a sepsis infection. The first couple of days looked grim but Robbie turned it all around and kept making milestone after milestone. We ended up having a very good run through NICU and SCN with no major setbacks and were home in 5.5 weeks.
So there we were HOME (and all alone) – one happy family, mummy, daddy and Robbie – but it wasn’t all beer and skittles. I went straight into lock down and didn’t leave the house how could I possibly risk having some snotty nosed kid come near my precious baby.
This naturally gave me plenty of time to think and ponder and stew, which led to the black dog creeping in the back door and making himself nice and cosy in our new family. The guilt also kicked in and the thoughts of “ you shouldn’t be feeling this way, you took home a baby so many people don’t get that” “ you only spend 5.5 weeks in hospital not months and months like so many others” “Robbie may have some issues but he is doing so much better than so many other babies”.
So I kept asking myself “why why are you so sad, why do things look so bleak”. Then there was the resentfulness, I didn’t feel like I bonded with Robbie straight away, I didn’t even feel like I had given birth realistically I missed the whole thing and woke up a few days later. I would hear and read other people’s birth stories and hear them complain about how hard or awful it was thus led me to have pangs of jealousy – they didn’t know how lucky they were. I wanted that, I wanted to feel the contractions, I wanted to hold my baby after birth, and I wanted to give him his first feed. I could feel the sadness creeping into my everyday life and I really wasn’t interested in anything anymore.
I started to think about the time Robbie and I were in hospital more and more and kept reliving every moment. I guess part of it was dealing with my own mortality as the doctors said I came close to saying “goodnight” permanently and also the fact that Robbie had a battle to stay with us as well. I kept thinking back to this moment when I was in hospital and thought to myself “right this is what happened to you, there is nothing you can do to change it so deal with it” – where was that strong person now???
Luckily for me I had a good health nurse Raelene that could see I was not doing so well and recommended that I go and see a counsellor. I got a “mental health” plan from my GP to go and see a psychologist, by getting this mental health plan I was able to have six sessions free of charge through Medicare which made it much more accessible. He also put me on some anti depressants to give me a kick start.
So off I went to meet Dr Tony – such a lovely man and very patient. I think I spent the first three sessions just crying and saying “I know I should be happy to have a baby but I feel so sad”. I went on to see him once a week for several weeks and he said I was suffering both from post natal depression and post traumatic shock syndrome. Hearing this was a bit of an eye opener as I always associated post traumatic shock with war veterans not people like me, he said I had suffered a major trauma with everything that happened and I was having a completely normal reaction.
It’s always nice to hear that you are normal, we are constantly bombarded by what a mother should be and what a mother should feel, this creates an enormous amount of pressure. You hear these mothers saying “I love being with my children every minute I can’t bear to be apart from them” – Liars Liars, you cannot tell me that every mother doesn’t have times when they would give anything to be by themselves having a glass of wine and getting a massage. It is these sorts of statements and the way women are often competitive with each other that create these motherhood myths.
So things were starting to look up I had Dr Tony on my side, the happy pills had kicked in and I was starting to be more confident in myself as a mother. I was lucky enough to have a supportive husband that put up with me and we managed to get through things together and the black dog moved out of our family.
I learnt a lot of things about myself and treat life very differently to how I did before Robbie came along (things don’t stress me as much now).
It didn’t happen overnight and now two years later I still struggle with things that happened. I still haven’t managed to write the letter of complaint and disappointment to the OB that completely stuffed up my care and put both my life and my baby’s life in danger, it is still too hard and painful. However I know one day I will do it whether or not I post it is another thing.