Perinatal depression (a term used to collectivity describe the experience of depression throughout conception, pregnancy, after childbirth or within the first year of a baby’s life)  often begins antenatally but may go undiagnosed until the postnatal period.

It is a common disorder, affecting one in five new mothers, one in 10 fathers and 100,000 Australians each year.

On the frontline of this mental health crisis are midwives who support women through the often-tumultuous experience of pregnancy, childbirth and motherhood.

The best treatment for perinatal depression and anxiety, according to psychiatrist Professor Bryanne Barnett, is a system that facilitates continuity of care.

“I cannot stress enough that a well-trained, well-supported midwife who provides care in a system that ensures continuity of care, is the best treatment we can offer.

“This is universally recommended nationally, internationally and in the usual obstetric and midwifery textbooks,” Prof. Barnett said.

Antenatal Midwife Coordinator of Mater Hospital Sydney, Sarah Tooke, said a fragmented system of care, especially in the private maternity sector, is counterproductive to early diagnosis and care.

“A collaborative and holistic care model between obstetricians, midwives, social workers, psychologists, lactation consultants and discharge planning teams is critical to be able to provide support for emotional well-being in the perinatal period,” said Ms Tooke.

While pregnant women who plan to give birth in the public hospital system receive mental health support, the private system lags behind, according to Ms Tooke.

The Mater Hospital Sydney is one of just a few private hospitals Australia-wide offering a ‘Pre-admission Midwife Appointment Program,’ incorporating the Gidget Foundation’s Emotional Well-Being Program.

The Gidget Foundation, a not-for-profit organisation providing support for perinatal depression and anxiety, created the program based on a study at a private hospital highlighting the importance of antenatal depression screening for all women, including those who choose private obstetric care.

The program, supported by leading psychiatrists, obstetricians and midwives, provides a one-on-one appointment with a specially trained midwife to discuss emotional well-being in the private hospital system.

“The implementation of a team of midwives to provide emotional well-being screening enables the provision of holistic, multidisciplinary care to patients.

“It offers support from pregnancy, the birth of their baby and into the postnatal period and encourages each area of the maternity team to communicate to provide optimal and transparent patient care.

“This collaborative model between obstetricians, midwives, social workers, psychologists, lactation and discharge planning teams is critical to provide emotional well-being support in the perinatal period,” said Ms Tooke.

Despite the support offered in the public hospital system, pregnant women still fall through the cracks, according to Secretary for The Australian College of Midwives, Christine Bowles, a practising midwife at Redland Hospital.

In the public system, the Edinburgh postnatal depression scale is used to screen women at 16 and 36 weeks, and those identified usually have a history of depression and anxiety, said Ms Bowles.

“If positively screened to have been thinking of self-harm, this is an urgent referral, and we address the issue on the spot before they leave the appointment and make a safety plan with a social worker.”

In a less urgent scenario, a woman who scores positively on the Edinburgh postnatal depression scale may receive one phone call from the mental health team with no follow up deemed necessary at that point, explained Ms Bowles.

As a result, if perinatal depression and anxiety develop during routine visits with a GP,  these women may go undiagnosed until the last month of their pregnancy, said Ms Bowles.

Similarly, if a woman is high-risk and under obstetric care, she may miss the 36-week appointment with a midwife. As a result, perinatal depression might not be picked up until six weeks postpartum making the difficult transition into motherhood harder, said Ms Bowles.

“Perinatal depression must be dealt with holistically, as there are many aspects to consider, not just psychologically, but the environmental, physical, financial, emotional and support factors.

“One solution is that all women have one-to-one continuity of care with a known midwife throughout the entire pregnancy and postnatal period where a strong relationship is built and appropriate referral and follow up possible.

“There is a multitude of evidence to demonstrate the importance of this model of care and how it improves maternal and neonatal physical and psychological morbidity and mortality rates,” said Ms Bowles.

Caring for the carer: the importance of midwife support.

In providing a service that protects the emotional well-being of patients, it’s also important to consider the service provider.

“Midwives and health professionals need support and regular supervision to practice professionally, and to practice self-care, as it can be draining providing a service of this kind,” said Ms Tooke.

Prof Barnett agreed, saying it’s crucial that midwives receive not only online training in perinatal depression and anxiety but also face-to-face sessions and ongoing workshops to discuss issues that have arisen and any concerns they are facing.

“Self-care is essential, but, as with their patients, staff will only attend to this if encouraged and supported. We need to remember that they are usually women and many have suffered some of the problems we are expecting them to manage for others.

“When listening to stresses and concerns, including trauma, loss and grief experiences, midwives share that burden and can burn out, worn down by vicarious trauma,” said Prof Barnett.

Signs of perinatal depression and anxiety

As midwives are aware, no two pregnancies or mothers are alike, said Lsyn Psychologist Breanna Jayne Sade, so understanding the patient as an individual is beneficial.

“What might be considered normal for one patient might be abnormal for another, so monitoring the individual’s character and mood and making resources available to them is important,” said Ms Sade.

“Often people with perinatal depression feel tired, emotional, have difficulty sleeping, lack motivation and have appetite changes.

“It is important to be mindful to not dismiss these as regular symptoms of pregnancy or childbirth as they also may indicate a depressed mood, ” said Ms Sade.

Symptoms requiring further investigation and treatment:

• Recurring negative thoughts
• Thoughts of inadequacy
• Thoughts about suicide or self-harm
• Withdrawal from family and friends
• Loss of interest in social activities or things one would typically enjoy
• Being unable to cope with a daily routine
• A sad mood that does not go away

Often the symptoms indicating perinatal depression and anxiety are not appropriately addressed, said Prof Barnett.

“There is a notion that we should identify and manage only the most severe indications of stress and depression because the system would otherwise be overwhelmed with referrals to specialist mental health services.

“This is a mistake, as many stressed, anxious, mildly depressed women would be adequately helped by support, suggestions and encouragement from their midwife in a situation of continuity of that carer,” said Prof Barnett.

Perinatal depression: a personal account

Rebecca Thornhill-Robinson experienced perinatal depression following a traumatic birth experience. She said after an extended recovery period, returning home wasn’t the joyful experience she expected.

“I wasn’t sleeping at all, and I felt like I was in a fog. A happy fog, but fog all the same. I wasn’t sleeping for more than 20-minute blocks at a time, and it was taking a toll on me.

“It wasn’t our new baby that was keeping me awake; it was my trauma. Every time I slept, I would go back to the moment on the operating table, and I would wake up screaming, thinking I was about to die.”

When her daughter was two weeks old, Ms Thornhill-Robinson contacted the hospital for support and a midwife arranged an appointment with a Gidget House psychologist.

“I immediately felt welcomed and safe,” said Ms Thornhill-Robinson of the experience. 

“In the first stages of my recovery, my husband and I would visit Gidget House as a family. This was a huge factor in helping me get well.

“Today, I am feeling great. Motherhood is as I thought it would be, and I feel so lucky to have had the help and support to get back on track.

“I believe any professional help would have supported my family and me back on the path to wellness, but I do feel lucky to of come in contact with Gidget House for perinatal support,” said Ms Thornhill-Robinson.

Risks of undiagnosed perinatal depression

Where the mother is depressed, risks to the foetus include no, or limited, maternal attendance for formal antenatal care and untreated maternal disorders (such as hypertension, diabetes, thyroid problems, alcohol and other drug use), that adversely affect foetal development, said Prof. Barnett.

“Postpartum, the depressed mother may not manage to breastfeed, soothe or care for her infant in various ways, such as attending her doctor for sickness in herself or the baby, or for routine checks and vaccinations.”

Untreated perinatal depression and anxiety have many, far-reaching consequences for the woman, her partner, the new baby and society in general, according to Gidget House Clinical Psychologist Christine Barnes, so a preventative program is crucial for the well-being of any new parent.

“Our midwives increase awareness of perinatal depression and anxiety and have a thorough understanding of the condition.

“They know the effects of untreated perinatal depression and anxiety, and it’s potentially devastating toll,” said Ms Barnes.

Medication in treating perinatal depression and anxiety: is it safe?

It is not possible to conduct randomised, double-blind, controlled trials of medication during pregnancy, said Prof Barnett, so there is a dependence on repeated, inconclusive studies that are often contradictory.

“As far as possible we avoid using antidepressants during all stages of pregnancy, but if the woman is or becomes seriously ill, medication can be a lifesaver for mother and baby.

“We have a short list of medications that are commonly used and are considered acceptably safe. No medication is prescribed without prior discussion and consent obtained from the mother.

“Interestingly, women are often taking other, non-psychotropic, medications and complementary medicines but are not anxious about those!

“For many women, psychotherapy is adequate treatment for their anxiety and depressive symptoms,” said Prof Barnett.

Perinatal depression and anxiety are diagnosable, common and do not discriminate, said Ms Tooke.

“The good news is perinatal depression and anxiety are treatable.

“Prevention is always better than cure, so early detection of these conditions are vital,” said Ms Tooke.