Postpartum Depression: One Date Won't Be Enough

Reading time: 14 mins

"I thought I was crazy, but I knew it was part of being a mother." These harsh words, Sophie Adriansen entrusts them with modesty. Victim of postpartum depression (PPD) between her two pregnancies, the young mother, 34 years old at the time, only became aware after the fact of the disease from which she suffered for three years. "I kept asking myself, 'What the hell am I doing here? I told myself that if I disappeared it wouldn't change anything, that it might be better for my baby..."

The pathology prevents her from taking care of her child as she had imagined. “I was there, but without being there. I took care of my baby in a very mechanical way, without any enthusiasm. I felt neither legitimate nor in my place.” She puts everything on the fault of fatigue. But even when her child sleeps through the night, nothing changes. “I was always invaded by an emotional weariness. I didn't want anything." For lack of awareness, Sophie locks herself away day after day in this state that she keeps secret. “I never asked for help because I was unable to know what was happening to me, and therefore to realize that I needed it.”

100,000 mothers affected each year

A nurse in an nursing home, Nabila had also never heard of this disease before experiencing it. “And yet, this is my fifth child!”, she is surprised. After a difficult pregnancy and childbirth, the 40-year-old mother is seized with anxiety. “My baby had jaundice and there, all of a sudden, I found myself in a neonatal [medical service specializing in the reception of newborns] for several days. I don't leave him day and night. I can't trust the professionals, and inevitably my condition takes a hit: anxiety, fear, panic... I don't know what to think anymore and no one reassures me.

Ten days later, her child's condition improves and the family can finally go home. “Make way for happiness”, thinks Nabila. However, from the first day, anxiety overwhelms her again. "I did not sleep, I chained the attacks of anguish, the crises of tears, I did not know what happened to me." Completely lost, she goes to the Maternal and Child Protection (PMI). The diagnosis falls: postpartum depression. “For fifteen days, I have been on antidepressants and anxiolytics. A psychologist follows me daily, but the anxiety attacks are still present.

Like Nabila and Sophie, nearly 100,000 women in France suffer from postnatal depression each year, according to an OpinionWay survey in August 2021. Understand: between 15 and 30% of women after giving birth. Exhaustion, loss of appetite, absence of joy… Symptoms of depression are mixed with the feeling of being a “bad” mother. Many of them show anxiety about their ability to take care of their baby properly.

A systematic interview from 2022

An aggravating factor, only 5% of mothers claim to have been diagnosed by a specialist. A finding confirmed by the High Authority for Health (HAS), which draws up recommendations on the subject of identification, diagnosis and management of perinatal mental disorders. In her November 2020 framework note, she deplores that a “significant part of depressive disorders remains undiagnosed and untreated”. The detection of these “perinatal mental disorders” has become a “public health issue”, especially since the health crisis. According to Emmanuelle Toujas, a psychologist in Nîmes, the first confinement in the spring of 2020 generated a major increase in the number of DPPs due to the isolation imposed.

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So many reasons that prompted Adrien Taquet, Secretary of State for Children and Families, to announce, on September 28, 2021, during the Mental Health and Psychiatry Conference, a new support for young mothers: “A systematic interview around the fifth week after childbirth”, which will be introduced at the beginning of 2022. Concretely, the attending physicians or midwives “sensitized” to this disease will be responsible for identifying mental fragility in the young mother. And if they detect signs of distress, they will redirect her to a psychologist or psychiatrist. "For women at risk, it will be followed by a second interview around the twelfth week," said Adrien Taquet.

If professionals have welcomed this measure as a step forward, many of them believe that it is only a first step in the face of such a complex depression. "It's better than nothing at all," says Sophie Baconin, author of the book Les secrets du post-partum. “Yes, we can say that it is a step forward,” joins Sophie Adriansen, who has also tackled postpartum depression in her novel Linea nigra and her comic strip La Replacacante.

Even for midwives, the measure allows “an additional security lock”, underlines Elisa Corini, a recent graduate in this profession. "Us, in normal times, we don't really have time to be there for the mothers, it's super frustrating." The smooth running of existing systems and the implementation of other additional measures are a prerequisite. But raising awareness upstream should not be neglected.

The weight of loneliness

“When my son was born, I realized that I lacked information about what was going to happen to me, the mother, confirms Sophie Baconin. I was unbeatable on the development of the baby, his brain… But not on the consequences in the body and the spirit of a young mother. This lack of information increases the already great anxiety among young mothers. “During the follow-up of the pregnancy, we have the impression that the end point is the delivery. We are not told about the aftermath. I had never heard of postpartum depression before talking to other mothers, when I gave birth in 2019!”, she adds.

But how does the disease insinuate itself into the minds of young mothers? Child psychiatrist Patricia Do Dang calls the disease "bio-psycho-social", with a swarm of causes. Fluctuations in hormones, complications during certain deliveries, integrated social norms... In the most serious cases, suicidal thoughts enter the mind of the depressed young mother.

According to the sixth report of the National Confidential Inquiry into Maternal Deaths (ENCMM), over the period 2013-2015, suicides were the second leading cause of death among mothers up to a year after childbirth. “It was loneliness, dark thoughts,” describes Karine*, a young mother who suffered from baby blues on the second day after giving birth. “In the maternity ward, I was already telling myself that I had done something stupid. Alone, I wondered what I could do to kill myself. I wanted to run away." An unhappiness so deep that he even once directed himself at his baby: “One day, my partner was sleeping with our son. When I thought about the fact that he might run over her, which was normally a stressor for me, I thought at least that would be fixed.

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Deconstructing the myths around motherhood

In February 2020 already, Illana Weizman, French sociologist and feminist, launched a call for testimonials on the networks under the hashtag #MonPostPartum in order to show the other side of the postpartum decor. Behind the happy event, not easy to show its flaws. And even less to spot them. On her Instagram account, she shares daily testimonials from young mothers who have gone through a PPD, as well as advice on trying to get out of it. "It's even more complicated because we are faced with years of wonderful representations of the fulfilled woman as soon as she becomes a mother."

A discrepancy with the standardized representations from which it is necessary to leave in order to allow the victims to accept their illness, to then embark on the path of healing. “We must not minimize the self-censorship that we impose on ourselves in order to meet the social expectations of heroic and fulfilled mothers, shares sociologist Illana Weizman on her Instagram profile. One interview is probably not enough to break this silence.”

Because the disease is the subject of a real taboo. Also according to the poll conducted by Opinionway, 78% of parents had never heard of postnatal depression during medical appointments. “Already, there is fatigue which impairs judgment and above all the shame of saying to oneself “I am not a good mother”, says Sophie Baconin. And then communicating on mental health, it remains very delicate. We don't talk about it and we tend to think that it will pass on its own.

Child psychiatrist Patricia Do Dang has observed this: young mothers find it difficult to recognize their problems and talk about them to those close to them. The feeling of guilt slows them down: “Not being happy when your baby is born is not socially acceptable, becoming a mother is considered the natural role of women and the ultimate destiny of women.”

Getting out of shame

With this in mind, discussion groups have been set up by the Maman Blues association, which has specialized in maternal difficulties for fifteen years. Saving meetings for Karine*: “Talking about it, getting out of the shame and knowing that I was not alone allowed me to get back on track. I saw that there was worse than me, it reassured me a little. Each session of one and a half to two hours allowed her to discuss with other mothers their feelings and the difficulties encountered by each.

Young mothers and professionals also plead for psychological follow-up from childbirth. “Spotting postpartum depression alone is not enough. If a mother arrives collapsed, you need balls to redirect her according to her particular suffering, ”claims the president of Maman Blues. For Élise Marcende, the mistake would be to design a strict protocol for this depersonalized interview. Maman Blues has therefore created a directory of professionals to whom the members refer suffering mothers: “We do nothing for them, we accompany them as closely as possible to their individual needs.”

A few weeks too early

Placed five weeks after delivery, an appointment is far from optimal. Admittedly, the experts agree on the fact that the peak of depression is around three months postpartum, however, the disease is not in reality circumscribed in time, as confirmed by Emmanuelle Toujas, psychologist: "Among the young mothers I have followed, depressive syndromes have sometimes declared themselves several months later: they hide it unconsciously before this Pandora's box explodes in their body.

A much more complex scheme than the measure announced by Adrien Taquet, as Sophie Adriansen tells it. “If someone had asked me how things were going after five weeks, I would surely have replied that everything was fine. The peak of depression in mothers is around the three months of the child, so professionals can easily miss it. Thus, a single appointment, and limited to this period, does not make it possible to detect all the depressions.

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Lack of time or training for practitioners

Moreover, all of them wonder about the skills of midwives and general practitioners to conduct this interview, rather than a healthcare professional. Mental Health. “If the attending physician asks the mother how she is, she will not immediately answer that she is depressed, whereas a professional in the psychiatric field would be better able to understand her”, pleads Sophie Baconin. In addition, many first-line practitioners, including general practitioners, are "little or badly informed, and often do not have the time to listen", observes child psychiatrist Patricia Do Dang.

Axel Gross, childcare nurse and Grand Est regional delegate of the National Association of Graduate Childcare Workers and Students (ANPDE), points out, however, that three to four hours of his training were devoted to postpartum depression. "We learn to recognize the symptoms and the different manifestations: gestures of rejection, the way the mother looks at her child, lack of reaction to crying..." Anything that could help detect a lack of attachment on the part of the mother in the first days, which are decisive in preventing depression.

But for lack of time, lack of means, lack of personnel, patients and doctors do not always make use of the appointments fixed during pregnancy. Made compulsory in May 2020, the prenatal interview is considered essential to identify whether the future mother has psychological vulnerabilities during pregnancy. However, the last national perinatal survey, dated 2016, revealed that only 28.5% of women used it. Sylvaine Elhomsy, gynecologist, also mentions the existence of an appointment 6 to 8 weeks after childbirth, to detect pathologies, including depression: “We are already carrying out an interrogation to find out if they manage to recover, if they are not too tired. The mothers confide quite easily and I know them so I can see that.”

A self-questionnaire as the main tool

To identify their discomfort, other methods can also bear fruit. Nathalie Piqué practices gestalt therapy. In her offices in Paris and Épinal, the former liberal midwife relies on neuroscience by appealing to the bodily and emotional feelings of mothers. She also uses the Edinburgh Postpartum Depression Scale, created in 1987: the most widely used tool for detecting signs of postpartum depression.

This is a self-administered questionnaire consisting of ten short questions on mood, anxiety or guilt. For each, four answers are proposed, rated from 0 to 3, according to the severity of the symptoms. Example: “I felt so unhappy that I cried: yes most of the time, yes very often, yes sometimes, no never.” If the total of the answers exceeds 10.5/30, this may be a sign of postnatal depression. But the diagnosis of this questionnaire can only be confirmed with a clinical interview carried out by a health professional.

“If I had a magic wand, I would make sure that all the mothers with a positive Edinburgh scale passed an Urkind© mapping, so that we know where it hurts, what hurts. Is it family history? A memory? The body?”, explains Nathalie Piqué. Urkind©'s cartography is its workhorse.

She has been trying to publicize the tool for more than ten years. She describes it as a “radar”: “I present ten images to the mother, to discuss with her several vulnerability factors. The support she receives or not, her bodily experience, the difference between the dream baby and the real baby are some of the tracks mentioned. Then I ask him to answer me with a weather slider, from sun to storm, on a scale of 1 to 5. A mother who was hoping for a little girl and gives birth to a boy can therefore, for example, illustrate her feelings with a storm if she sees it as a tragedy.

Techniques to be developed with professionals

Based on the elements collected during the discussion, the practitioner establishes a "life energy level" and directs the patient to an appropriate professional: wise -woman, osteopath, social worker… Nathalie Piqué recognizes that this phase is almost “no man's land”: “Treating depression is complicated because it no longer belongs to obstetrics but not yet to psychology. There are very few trained people.”

The Regional Health Agency of Bourgogne-Franche-Comté is also working with it on a training system on these issues, in particular through mastery of cartography. This is a pilot experience over two or three years.

As part of the Assizes of mental health and psychiatry, an appeal was launched with 10 million euros to "consolidate the offer in perinatal psychiatry" by "opening five to ten new joint care units parents -baby and creating fifteen to twenty new mobile teams. The Secretary of State insisted on the “six to eighteen months of waiting in the medico-psychological centers (CMP) infanto-juveniles”, a duration which one “cannot be satisfied”.

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Working with mother-baby units

In this sense, to remedy and prevent depression, professionals advocate increasing the length of hospitalization to provide mothers with more consistent follow-up. "The malaise can be reinforced by an early return home", regrets Sylvaine Elhomsy, gynecologist.

The first days of maternity are essential to detect and counter potential negative thoughts, questioning and feelings of guilt. “Without support, mothers risk slipping gradually into depression. We therefore try to value them as much as possible, for example by complimenting them on the way they carry their baby, ”explains Axel Gross, childcare worker. The objective is to counter the vicious circle that could undermine the self-confidence of mothers.

Martine Valton-Jouffroy, psychotherapist and maternologist, insists on the need to work with mother-baby units, which sometimes welcome families for several months. The Société Marcé Francophone (branch of the international association for the study of puerperal and perinatal psychiatric pathologies) lists twenty full-time mother-baby units in France. “We must be extremely vigilant in observing the bond between the mother and her baby. There are not only DPPs, there are also depressions. It takes several days and several weeks to see whether or not a mother connects to her baby,” recalls Martine Valton-Jouffroy.

Today, no statistics can predict that a mother, before giving birth, will trigger a PPD: “We can do a little prevention with follow-up, but some women who experience pregnancy serenely and fulfilled 'collapse at birth,' she explains.

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Include the father more

Another line of research: the extension of paternity leave, much shorter than that of the mother. “Mothers are locked up in a certain solitude, at home, during this critical period when the depressive phase can intervene”, regrets Sophie Adriansen. Passed from fourteen to twenty-eight days last July, paternity leave is still considered insufficient. In Spain, since 2021, it has been extended to sixteen weeks, which is as much as maternal leave. Psychologist Emmanuelle Toujas pleads for better inclusion of the father in therapeutic consultations. “Mothers don't have to carry this alone: ​​we introduce the question of conjugality. We must not forget that this change is co-shared and that a mirror effect can be declared.

And indeed, the fathers she met at the clinic sometimes experience depressive “moods”, even better concealed than the depression of their partner. Two striking statistics from the OpinionWay survey: 18% of fathers encounter psychological problems after the birth of a child, but 42% of them still think that "only mothers are concerned"...*Name has been changed