Challenges of New Motherhood and Postpartum Depression

There is nothing easy about having a newborn baby! Being a new mom is hard, no matter how “easy” others around you (or those you might see on the internet) make it look.

What are some reasons that new motherhood can be so challenging?

1. Recovery from childbirth. The physical recovery from having a baby can take several months and it’s normal for new mothers to experience all of the following symptoms after giving birth: pain, vaginal bleeding, sore nipples, breast engorgement, gas, and constipation. Keep in mind that women who deliver by c-section also need to recover from having a major abdominal surgery.
   
2. Newborn babies do not sleep for long stretches at a time. Despite common belief, babies do not usually sleep through the night until they are at least six months old because they need to wake up frequently to feed. Moms who encounter breastfeeding challenges, such as “triple feeding” or exclusively pumping, often get even less sleep. In addition, many women do not sleep well during their 3rd trimesters of pregnancy, so they’ve already been sleep deprived for months before entering into the postpartum period.
3. Breastfeeding can be challenging. According to a recent study of over 500 new mothers from Italy, 70% experienced at least one major breastfeeding challenge during the first two postpartum months. These problems included difficulty with latching, pain while breastfeeding, concern about not having enough milk, overwhelming fatigue, engorgement, and/or mastitis. Breastfeeding problems can be a source of stress if mothers do not have access to good lactation support.
   
4. Many of today’s new moms lack a “village” of helpers, thus do not have enough postpartum support. In the past, new mothers were often able to count on their family members (i.e. mothers, sisters, aunts, and cousins) to come and help with new babies so that they would be able to recover and rest. Nowadays, many women live away from their families of origin when they have babies. Even if they live close to their families, it’s not unusual for family members to work outside of their homes, prohibiting them from being able to help out for large chunks of time.
   
5. It’s not unusual to have unrealistic expectations for the realities of postpartum life and what it’s like to be a new mom. There is such an emphasis on planning for babies’ needs while pregnant, i.e. setting up a nursery and purchasing baby equipment and supplies ahead of time, that mothers’ needs are not often anticipated or considered to be important.
   
6. The postpartum hormonal shifts that all new moms experience can be associated with mood changes. “Baby blues” are feelings of sadness and worry that start in the first 3-4 days after delivery, result from postpartum hormone levels changing, and resolve by the end of the second postpartum week. 

Feelings of sadness, hopelessness, and/or worry that start more than 2 weeks after delivery are red flags for postpartum mental disorders. The main mental health problems that can emerge postpartum include depression, anxiety, post-traumatic stress disorder, and psychosis. All of these conditions can be triggered by postpartum hormonal shifts, and can impact mothers' ability to function and mother-baby bonding, and can have negative ramifications on postpartum life.

Postpartum depression (PPD) is the most common postpartum mental health disorder, affecting up to 15-20% of new moms. There is emerging evidence that rates of PPD have significantly increased since the start of the Covid-19 pandemic in 2020. Rates of PPD amongst mothers of NICU babies are even higher, approaching 40%.

Mothers with PPD experience feelings of extreme sadness and worthlessness. Per the Postpartum Support International (PSI) website, PPD is also associated with the following signs and symptoms: 

• Anger and/or irritability
• Lack of interest in the baby
• Appetite and sleep disturbances
• Frequent crying and sadness
• Feelings of guilt, shame, or hopelessness
• Loss of interest, joy, or pleasure in things that used to be enjoyed
• Possible thoughts of harming the baby or yourself

Any mother who has feelings of wanting to harm herself or others needs emergent psychological evaluation as these are warning signs of possible postpartum psychosis.

Symptoms of postpartum depression typically begin within the first year after giving birth and, in most cases, emerge in the first 4-6 weeks after delivery.  It can sometimes be difficult to tell the difference between the “baby blues” and PPD. If a new mother is still suffering from “baby blues” symptoms at 3-4 weeks postpartum, she should have a depression screening to check for PPD by a professional. 

Women who have a history of depression prior to pregnancy are at a higher risk of postpartum depression than mothers who have never experienced a depressive episode. Having a family history of depression or mental illnesses also puts one at an increased risk of PPD. Other risk factors for PPD include all of the following:

• Having PPD after a previous pregnancy
• Going through infertility treatments to get pregnant
• Experiencing pregnancy complications
• Giving birth prematurely and/or having a baby in the neonatal intensive care unit (NICU)
• Major stresses or life events during pregnancy and/or postpartum, i.e. marital or financial stress, moving, job loss, etc.
• Underlying chronic health problems, such as thyroid disease, autoimmune disorders, and diabetes mellitus
• History of other hormonal-associated mental health issues, i.e. premenstrual dysphoric disorder (PMDD)
• Giving birth to multiples (twins or triplets)
• Extreme sleep deprivation 
• Being isolated and lacking social supports

Mothers who experience breastfeeding problems may experience feelings of shame and inadequacy, putting them at a higher risk of developing PPD. Per the Academy of Breastfeeding Medicine (ABM), “Breastfeeding difficulties and perinatal depression symptoms often present together, and management of depression should include a discussion of the mother’s experience of breastfeeding.”

The ABM also states the following about PPD and breastfeeding-related sleep deprivation: “The demands of nighttime breastfeeding can be challenging for mothers for whom interruption of sleep is a major trigger for mood symptoms. In these cases, it may be helpful to arrange for another caregiver to feed the infant once at night, allowing the mother to receive 5–6 hours of uninterrupted sleep. A caregiver may also bring the infant to the mother to feed at the breast and then assume responsibility for settling the baby back to sleep, thereby minimizing maternal sleep disruption.”

Postpartum moms with possible depression or anxiety should be evaluated by a health care provider (obstetrician or midwife) or a mental health professional in a timely manner.  The Edinburgh Postnatal Depression Scale is the most common tool that is used to screen new mothers for PPD.

There are multiple treatment options for PPD, which are best summarized in this statement from Postpartum Support International: 

“Treatment plans are different for each woman but might include increased self-care, social support, talk therapy or counseling, and treatment of symptoms, with medication when necessary. Self-care includes proper rest, good nutrition, assistance with baby and other children, and caring for personal needs such as exercise, relaxation, or time with partner/spouse. Social support includes talking with others (either on the telephone, online or at a support group) who understand and provide encouragement. Talking with a counselor or therapist who understands perinatal mood and anxiety disorders can be extremely beneficial. Finally, medications are available to address both anxiety and depression.”

The most commonly prescribed medications for PPD are safe for mothers to take during the postpartum period and breastfeeding. The first-line medications for PPD are selective serotonin reuptake inhibitors (SSRIs), which include Zoloft (sertraline), Prozac (fluoxetine), and Celexa (citalopram). Most of the other medications that doctors prescribe are also compatible with breastfeeding. The best resources for mothers to use to learn about the safety of medications while breastfeeding and their side effects are the Infant Risk Center’s website and the NIH’s LactMed database.

When it comes to trying to prevent PPD, knowledge is power. PPD is the most common postpartum complication, so all women should receive information about PPD when they are pregnant. It’s especially important to recognize which pregnant women are at high risk for the development of PPD so that they can receive appropriate counseling and be hooked up with mental health resources ahead of time. Resources to explore during pregnancy include therapists who specialize in maternal mental health, breastfeeding consultants, and support groups for moms of newborns. 

The partners of pregnant women should also be educated about risk factors and signs of PPD prior to delivery so that they will be able to recognize worrisome symptoms that might emerge. Additionally, all partners and support individuals should learn how important it is to give new mothers plenty of time to rest and recover during the postpartum period. This includes encouraging partners to take over household duties and chores during the first few postpartum months. 

Having realistic expectations for postpartum life can help to ameliorate some risk factors for PPD. Mothers who are able to form a postpartum “village” of helpers ahead of time will be less likely to experience isolation, lack of social supports, and stress than those who do not make plans. Likewise, we need to encourage moms to not be afraid to reach out to family and friends for help if/when they need it, and to view asking for help as a sign of strength instead of a weakness. 

As a society, we can work on preventing PPD by recognizing the importance of frequently checking in on our friends and loved ones with new babies. The postpartum period can be isolating and it’s important for new moms to be asked how they are doing and receive validation about how hard it can be to have a newborn baby. The onus is on all of us to monitor our loved ones for PPD, especially if we know that they are at high risk of developing depression. 

Postpartum depression is one of the most common problems experienced by new mothers. Spreading information about PPD symptoms, risk factors, and statistics can help it to be people’s radars as something to monitor new mothers for. Postpartum Support International has an excellent website full of information about PPD and also has an emergency hotline to call for help: 800-944-4473. Other excellent PPD resources include the Postpartum Stress Center website and the American College of Obstetrics and Gynecology’s website.

References

Breastfeeding Challenges: ACOG Committee Opinion, Number 820. Obstetrics and Gynecology, 137(2): e42-e53. 2021.

Davenport, M., et al. Moms Are Not OK: COVID-19 and Maternal Mental Health. Front. Glob. Women’s Health. 2020.

Gianni, et al. Breastfeeding Difficulties and Risk for Early Breastfeeding Cessation. Nutrients: 11(10). 2019.

O’Hara, M, and McCabe, J. Postpartum depression: current status and future directions. Annu Rev Clin Psychol, vol 9: 379-407. 2013.

Sriraman, N., Melvin, K., Meltzer-Brody, S., and the Academy of Breastfeeding Medicine. ABM Clinical Protocol #18: Use of Antidepressants in Breastfeeding Mothers. Breastfeeding Medicine. 2015. Volume 10 (6): 290-298.

U.S. Preventative Services Task Force committee. Interventions to Prevent Perinatal Depression: U.S. Preventative Services Task Force Recommendation Statement. JAMA, 321(9): 580-587. 2019.