These days it is popular to explain PND as feminine hormones gone awry - though the evidence for this is poor. We have a variety of pharmaceuticals at our disposal - and, of course, they can be helpful. But our over-reliance on the hormonal, "sickness" model has a serious pitfall. If all we do is rely on allopathic approaches we risk overlooking some of the very real situational factors that can cause depression. I believe we may be seriously downplaying the importance of mothers' emotional needs, discounting the things that wound them, and disregarding critical steps to restoring their well-being.

Among the Kipsigis
of Kenya, PND is
unheard of.

Every mother has been biologically programmed to expect an increase in emotional support when her baby arrives; she needs to be held, to feel secure and listened to by her partner, friends, and her own mother or kin. During gestation, childbirth, and the months that follow, mothers are emotionally fragile, and they require extra understanding. This is normal.

Fathers are vital protectors of their family's emotional welfare, and their lack of emotional support can be costly. Some women who suffer from PND report that their partners are either unsupportive or overly controlling. But even the most supportive partners may be insufficient, and in fact, both parents need the unflagging support of extended family, friends and community.

As at every other stage of mothering, a raft of emotional support for the mother is extremely important during labor. The sensitive support of a companion has such profound effects that it actually reduces medical complications quite significantly. Mothers who are accompanied by a female supporter - as well as their male partner - have a shorter labor, less incidence of caesarean section, and their babies are less likely to require neonatal intensive care.

Some of the emotional volatility experienced by new mothers might in fact be normal and healthy. Like the proverbial "mother-bear", it is natural for some mothers to become more reactive than usual. This temporary surge of protective instincts is called "lactation aggression". Because they are not reassured that there are valid reasons for these feelings, mothers feel ashamed and guilty. To top it off, they feel afraid of their own irritability, afraid of what it might do to their baby, and too embarrassed to seek the relief that comes with talking about their feelings.

Every mother needs
ongoing empathic support.

At times, clues to a mother's PND might be hidden in her own childhood history. Some mothers who felt emotionally deprived in their early years find the demands of a baby particularly nerve-racking; and this places them at risk of PND.

A new baby powerfully evokes from our unconscious memory a plethora of feelings, both positive and negative, that we felt when we ourselves were infants. Though a mother may not suspect it, her baby's cries could be triggering her own painful memories of infancy. If a mother has unresolved pain about loss or abandonment, this pain may re-emerge when she enters motherhood - though she may have no idea why she is crying. Women who had difficulties with attachment to their own mothers, who feel their mothers were not caring enough, or that their fathers were overprotective, are more likely to suffer from PND.

If our own childhood emotional needs weren't met, we might find our children's dependency hard to tolerate. It is hard to give what has not been given us, and our babies' cries assail our ears - unbearably. Researchers have found that women who are more bothered by the sound of a baby crying are more likely to develop PND once their own baby arrives.

A group of American psychologists who were working with mothers who were having trouble bonding with their babies, invited them to talk about their own childhoods. They helped these mothers to connect with their own childhood pain, and to weep. Immediately after this emotional release, these mothers spontaneously cuddled their babies. Their nurturing energies had been walled up behind a layer of frozen, unexpressed grief. For many PND sufferers, unresolved grief is the key.

An ongoing emotionally supportive and empathic relationship with her own mother can be a most potent vaccine against PND. If this is not possible, then it can be helpful - indeed, necessary - for a woman to talk openly and grieve her past, in the presence of trusted others.

For some mothers, PND may be a mistaken diagnosis: they might in fact be suffering from Post-Traumatic Stress Disorder (PTSD). For many women, the experience of labor can be highly traumatic. Around 20 per cent of mothers lose at least some memory of the labor experience: they report being in a "fog". This partial amnesia is a kind of dissociation, and a classic symptom of PTSD. British psychologists have found that 2 to 5 per cent of mothers develop PTSD after a difficult childbirth. A much larger proportion suffer symptoms of PTSD, such as nightmares, intrusive thoughts, problems with breastfeeding, feelings of failure, feelings of estrangement and difficulty bonding to their baby.

The cold, clinical atmosphere of labor wards and the intrusiveness of defensive obstetrics are, for many women, thoroughly violating. More than any other time, childbirth is a scary passage when mothers need a profound and ongoing empathic connection; they need their fears validated. Mothers usually feel extremely vulnerable at this time, and modern obstetric wards place little emphasis on their emotional needs. Many women feel that their control is taken away from them, that procedures are carried out without their understanding or consent, and that their fears are dismissed by hospital staff. Moreover, in hospitals that separate new mothers from their infants, their powerful, instinctual need to remain close is brushed aside. Many mothers feel devastated by this separation; they feel strangely empty or bereft, perhaps without knowing why.

In my private practice, over the years, I have heard so many mothers complain bitterly that when they express such feelings to hospital staff, they feel dismissed, and are told they are being "irrational". Some hospital staff trivialize and minimize mothers' emotional ups and downs through this delicate process - their terror, pain, and feelings of helplessness, as if the only thing that matters is that mother and child have survived the process physically unscathed. Depression begins when women's attempts to voice their feelings are met with the message: "You have nothing to complain about". This is completely crushing. We close our eyes to these traumas and their consequences at a grave cost to mothers, their babies and their partners.

Jean Robinson, research officer at the UK Association for Improvements in the Maternity Services, says that the incidence of PTSD among new mothers has risen along with an increase in interventions such as induced labor and caesarian section. But even after normal births, symptoms of PTSD can arise when mothers are made to feel helpless and disempowered, and their right to make birthing decisions is taken away from them.

Often, what knocks mothers into a depression is that some fundamental emotional needs surrounding pregnancy, the birth of her child, and the day-to-day life of mothering are not being met. She may not even know how to validate these needs herself. The moment her baby comes, when her need for support is most acute, she finds herself alone for hours at a time, faced with a baby who wails for her attention. For many mothers, when they are alone, the day can drag on interminably. The task of mothering, along with her baby's natural, healthy but unceasing calls for attention, ends up feeling like a terrible burden. It was all supposed to feel wonderful, instead it feels like tedium. She expected to be bathed in joy, instead she finds herself struggling. She feels shocked; her illusions about mothering are dashed, and she blames herself. No one told her it was going to feel like this.

Our culture fails mothers.

There are many more causes beyond those listed here - as many as there are sufferers. A one-size-fits-all diagnosis can shut the door on empathy and understanding. We have dangerously underestimated women's emotional needs surrounding pregnancy, childbirth and mothering - so much so that much of what we consider "normal" and unremarkable is in fact traumatic. We undervalue maternal needs for support, empathy and practical help at a great cost to families. If we are to reduce, even eliminate, the incidence of PND, then there is much more to be done to ensure that mothers' psychological needs are taken care of, throughout the parenting journey.

Heading PND off at the Pass

Dealing with PND means being proactive against its onset. Here are some things to think about while you are pregnant:

• Make pregnancy sacred: meditate, dance, talk to your baby, have a Blessingway ceremony.
• Choose natural birthing wherever possible. Drugs used in labor interfere with the natural release of ecstatic and loving hormones.
• Examine your own birth and early childhood. Have counseling if necessary.
• Make sure there is plenty of emotional support - from partner, friends, doula. Mother or other elder women are particularly important.
• Involve the father as much as possible in the pregnancy and birth process so that he can be there to support you.
• Don't fight the depression: instead, welcome it and its invitation to introspect, to slow down, to feel and to heal. Keep a journal, draw.
• Don't stay alone at home longer than is pleasurable. Spend time with other mothers in cooperative parenting groups.
• Don't bottle up feelings. Cry, express, talk about how you feel - a lot.
• Surround yourself with good listeners.
• Breastfeed. This releases oxytocin, the hormone of love and joy.
• Don't push yourself to engage in work or responsibilities before you are ready. Plan for a "baby moon" - the month following birth - as a retreat into your process of birth, of becoming a new family and of transition. Arrange before the birth for domestic support during this month - meals made, housework and laundry done. Friends and family can make up a roster - a real birth gift.

LIST OF REFERENCES  

American Psychiatric Association (1994) Diagnostic and Statistical Manual, IV  

Bailham D., and Joseph S. (2003) "Post-Traumatic Stress Following Childbirth: A Review of Emerging Literature and Directions for Research and Practice". Psychology, Health and Medicine,   Vol. 8 (2)  pp 159-168.  

Boyce P., Hickie I. and Parker, G. (1991) "Parents, Partners or Personality? Risk Factors for Post-Natal Depression" Journal of Affective Disorders, Vol. 21,  pp 245-255.  

Edgerton, Robert B. (1992) Sick Societies: Challenging the Myth of Primitive Harmony, New York: The Free Press.  

Gonda B. (1998) "Postnatal Depression or Childbirth Trauma?"  Psychotherapy in Australia  Vol. 4(4) pp 36-41.  

Hrdy, Sarah B. (2000) Mother Nature, Vintage.  

Karen, Robert (1994) Becoming Attached, Oxford University Press.  

Klaus, M.H. et al (1986) "Effects of Social Support During Parturition on Maternal and Infant Morbidity", British Medical Journal, Vol. 293, pp 585-587.  

Little, B.C., Hayworth, J., Benson, P., Bridge, L.R., Dewhurst, J. and Priest, R.G.

(1982) "Psychophysiological Ante-Natal Predictors of Post-Natal Depressive Mood", Journal of Psychosomatic Research, Vol 26(4), pp 419-428.  

Treloar, S.A., Martin, N.G., Bucholz, K.K., Maden, P.A.F. and Heath, A.C. (1999)

"Genetic Influences on Post-Natal Depressive Symptoms: Findings from an Australian Twin Sample", Psychological Medicine, Vol. 29, pp  645-654.  

Beyond Blue: The National Depression Initiative  

The Unspeakable Trauma of Childbirth