SARS-CoV-2 and the risk of Postpartum Depression in expecting mothers. – Part 1

The subject I am going to write about today demands attention and it is so vast, that I cannot write everything I know in one post. So for my readers to have an easier time in reading it, I will divide it into parts.
 
In the first part, I just want to introduce my readers to the idea of Postpartum Depression (PPD) and how it affects mothers. The second part will focus on the increased risk of PPD for mothers who are expecting now during a pandemic and what they can do to minimise their distress.

So now, let us move on to some science. All of you need to know that I have a very close connection with this topic. For my Masters thesis, I researched postpartum health in mothers for almost 2 years. I even did an empirical study on the sexual health of women who had just given birth. Over the course of my reading, PPD seemed to repeatedly stand out as a cause for concern for psychiatrists, psychologists, obstetricians and gynaecologists.
 
Europe is already ahead of India in prenatal and postnatal care. They know that a serious mental health problem can affect new mothers after the birth of their child. But India still hasn’t opened up to discussing this topic yet. In the Indian culture, the birth of a child is seen as the most favourable time for a family. To imagine that a mother may not be experiencing joy at the birth of her baby is unthinkable in a culture like India’s. But it happens, and it happens with a severity that can affect her entire adult life along with her baby’s childhood.
 
So why aren’t we paying more attention to the mother’s mental state of mind during pregnancy and after birth? What is the difference in the global and Indian estimates of PPD? What can mothers do to recognise and protect themselves and their babies from PPD? How does a global pandemic impact the risk of developing PPD in expecting mothers? These are some of the issues I will be addressing in these articles.
 
What is PPD and how common is it in the population?
 
PPD is defined as a “a major depressive episode with peri-partum onset if the mood symptoms occur during pregnancy or within 4 weeks after delivery” (1,2). However, PPD can also occur within 3 months, 6 months or 12 months after childbirth (1). It is characterised by symptoms such as:

• sleep disturbances (not related to waking with the baby),
• irritability,
• anxiety,
• a feeling of being over whelmed,
• an obsessive preoccupation with the health and well being of the baby.

 
In some severe cases, suicidal thoughts and thoughts of harming the baby have also been reported. PPD is very common around the world. Global estimates stand somewhere around 6% to 12% (approximately one in eight) of all new mothers (1). Some studies have shown rise of PPD in fathers as well, but that is a separate topic.
 
The important thing to remember with PPD is that, it is different from the normal “baby blues” or “post-baby mood swings". “Baby blues” are recognised by an onset of low mood and depressive symptoms within a day or two after birth and usually resolves by itself within two weeks after birth. But while baby blues are temporary and go away on their own, PPD can take a while to develop with full capacity and it will not resolve without treatment.
 
What about PPD in India? What do the statistics show for India?
 
When I gave birth to my first baby in Europe, my mother and other family members took pride in the fact that we were from India and that Indian mothers had the best outcomes after birth. It is very normal in India for a new mother to be asked to rest for 2 months after the birth of the baby. She would normally go to her mother’s home and be given daily massages and food in bed. Her only job would be to sleep and take care of her newborn.
 
However, in spite of a robust familial support system for mothers, India’s PPD rates one of the highest in the world. Research from all over India shows that PPD rates range from 19% to 22% in Indian mothers (2). The rates are highest in south and southwestern India. Urban populations have higher rates of PPD than rural populations at almost 24% of births for urban births as compared to 21% for rural births (2).
 
These numbers are quite staggering and frankly, worrying. The same research also shows that often PPD and other mood disorders in women are undiagnosed and untreated. These can have an adverse outcome on the child for at least 10 years after the birth. Mothers who suffer from PPD are less likely to breastfeed their baby and also not seek proper health care. Long term PPD in mothers can affect the cognitive, interpersonal and behavioural development of her child (2).
  
So, how does this current pandemic fit into this picture?
 
One of the risk factors greatly associated with developing PPD was having a negative experience during the pregnancy itself (1,2). For example, having an unplanned pregnancy, financial difficulties, physical assault or death of the baby in utero are some of the causes of PPD later on. The reason this is concerning is because a global pandemic is considered as one of life’s greatest health risks.
 
Mothers all over the world, who are pregnant right now, are facing a great challenge. They are going through an event that will go down in history as one of the biggest epidemic events of this century. And they are expecting a baby in the middle of it all. Some mothers may even suffer job losses or their partners may suffer job losses. Financial stress is one of the key risk factors for developing PPD. My concern as a psychologist specialising in women’s health is that, this pandemic is going to increase those PPD percentages worldwide.
 
Mothers are enduring stressful pregnancies right now and they are worried for their health and their baby’s health. They are worried about getting to the hospital, giving birth and getting home, all without contracting Covid-19. The threat of infection is high and doctors will not have the time to counsel each mother exclusively. It is time that mental health practitioners counsel mothers to prepare for this.

​That’s it from me for today. In the next part of the PPD series, I will discuss the risk factors particularly for Indian mothers. I will also discuss signs and symptoms to look out for and what mothers can do to protect themselves and their babies from the harm of PPD. As usual, all scientific data is available in the articles in the bibliography below.
 
Take care and stay safe!
  
Bibliography:
1. Stewart, D. E., & Vigod, S. (2016). Postpartum Depression. New England Journal of Medicine, 375(22), 2177–2186. https://doi.org/10.1056/NEJMcp1607649
 
2. Upadhyay, R. P., Chowdhury, R., Aslyeh Salehi, Sarkar, K., Singh, S. K., Sinha, B., Pawar, A., Rajalakshmi, A. K., & Kumar, A. (2017). Postpartum depression in India: A systematic review and meta-analysis. Bulletin of the World Health Organization, 95(10), 706-717C. https://doi.org/10.2471/BLT.17.192237