"There is a smell of ketones off him," said the public health nurse.
She sat on our couch, drinking a cup of tea made by my husband and told me my newborn baby boy was eating his own body because his useless mother didn’t notice the smell of ketones (when the body burns fat for energy).
I can smell two-day old garlic on a stranger’s breath from the back of a bus, but I missed the scent of starvation on my newborn.
I was a 28-year-old American living in Ireland when I had my first child. I had an easy, straightforward pregnancy and horrendously painful (so normal) labour. A supportive husband, financial resources and no history of depression.
But I still became one of the 10-15 per cent of women who experience postnatal depression and anxiety. Those memories around breastfeeding are some of the only ones from my son’s first year. I am ashamed, resentful and angry that I didn’t get help for my postpartum depression until my son was almost 10 months’ old.
No one checked, no one asked and, despite my awareness of the disorder before I gave birth, I was too sick to recognise I needed help. As an immigrant, with little to no social-support system, I had an increased risk for postnatal depression and still no one asked.
I welcome the launch of Every Woman, the National Women's Council of Ireland's model for reproductive healthcare. As a mother who experienced postnatal depression and continues to live with the effects caused by the disorder, I urge the Government to adopt a woman-centered maternity service that respects and empowers women. Maternal health must be a priority to ensure healthy child development.
The current Irish maternity model of consultant-led, hospital-defined care too often treats pregnancy in isolation from the well-being of the mother. New mothers need physical and mental healthcare but the current system does not provide continuity of care or adequate screening or treatment options for postnatal mood disorders. Ireland’s reproductive health system must acknowledge the integral connection between maternal and natal health at all stages of reproductive healthcare. Mothers will continue to suffer from life-threatening depression without diagnosis and treatment until this change has been made at a policy and service level.
Serious mood disorder
There are normal feelings of sadness and anxiety caused by hormonal shifts in the days following the birth of a baby. But postnatal depression is a serious mood disorder that has a later onset and more severe symptoms.
While it's normal to be nervous and exhausted as a new mother, it is not normal to be crippled with silent shame for months after you stop breastfeeding. It is also not normal to view formula as poison that will cause your newborn son to choke and die. It is in no way normal to know your son will die in his crib. It is not normal to visualise tripping on the stairs with your baby and watching him tumble and bounce down to the first floor. It is not normal to insist your husband check the baby in the crib so you don't have to be the one to find him cold and still because you know he will die.
When you have a physical health condition, you can rely on your brain to know you need help. When you have a mental-health condition, you can no longer rely on your own judgement and brain – which is terrifying.
Awareness, knowledge and active screening for postnatal depression (PND) is critical, so partners, friends and healthcare providers can help new mothers by talking to women about their health.
I should have memories that don’t involve rage, sadness, and terror. Postnatal depression, anxiety and psychosis have dangerous mental and physical health impacts for both the mother and child, so public health nurses and GPs should screen for it.
There is currently no screening policy for PND in Ireland.
There is huge international variation in screening rates and methods because, like many women’s reproductive health issues, there is not sufficient funding to implement research or intervention programs. A 2013 study of first-time Irish mothers found social and professional supports were predictors of postnatal depression at 12 weeks post-birth. Mothers with low levels of emotional supports had a risk almost three times higher for PND at 12 weeks compared with mothers with high levels of emotional support. Maternal mothers, partners and public health nurses are the main sources of support after birth. In my case, my mother lived 5,000 miles away. My husband was present for the first public health nurse visits and so could have been connected to information about detecting and treating PND.
Our public health nurse was a kind and caring professional, but she was tasked with visiting a huge number and range of patients; not just new mothers and babies.
Kari Glavin and Patricia Leahy-Warren compared perspectives on postnatal depression and public health nursing from Norway and Ireland in 2013 and determined that public health nurses need to identify women at risk of PND and that universal screening should be achieved through adequate resourcing and training. There is currently no screening for mothers undertaken by public health nurses in Ireland at the postnatal visits. An intervention in one Norwegian municipality found when nurses had training and were asked to speak with mothers about depression, a significant decrease in PND symptoms was detected at six weeks.
Referred to my GP
If I had been referred to my GP then, I might not have lost those precious months in my mind. I had no follow-up appointment with an ob-gyn – I didn’t meet the consultant supervising my care during my pregnancy or delivery at all. Maybe if I had ‘gone private’, I would have had more patient-provider relationship but that is irrelevant to most women. There is also not enough specialised support or care for women once they are diagnosed.
There are three perinatal psychiatrists working part-time in Dublin. PND can turn deadly when left untreated and it can be critical to get care immediately when a woman does speak out to her GP, a nurse, or other caregiver. The lack of continuity between the hospital based ob-gyn system and primary care makes it difficult for caregivers to develop a trusting relationship with patients. The stigma around mental illness and psychiatric medication is intensified for a new mother, whom caregivers assume to feel joy, love and gratitude.
How selfish must you be to instead feel despair, rage, and resentment and how terrifying is it to admit that to someone you don’t trust?
Treating women and pregnancies separately in reproductive healthcare is not best practice. Ireland needs to strive for best practice in maternal healthcare along the spectrum from pre-to post-natal care. I hope Irish law makers will spend less time obsessing about the how and why women conceive and start prioritising a mother’s health, physical and mental, in the postnatal months.
Ireland is far ahead of the United States by offering paid maternity leave, universal maternity care and public health nurse visitation. If I had given birth in my native country, I would have owed thousands in medical bills (in addition to insurance costs), been discharged within two days, had no home nursing care, and returned to work within two or three months. The Irish public health nursing and GP system of primary family care is well-placed to implement screening but practitioners need referral networks and treatment options for women that currently don't exist.
I am still ashamed at my gaps in memory and I am ashamed that that the few memories I do have I want to avoid.
My boy deserved a healthy mom.
Instead he got me.
I worry he never be able to forgive me. The nasty voice of postpartum depression has reappeared at different times during his eight years. The pattern is the same. I am destined to fail him. I am embarrassed. I am no good for him. I am ashamed I was depressed and now I am scared to write about it. I know my sickness is not connected to my love for my beautiful, sensitive son, but I am scared he won’t know that or he will feel responsible for his sad mom. But I am more scared that nothing will ever change and moms will continue to suffer in secret.
Children will then learn that depression is shameful and I don’t want my kids or your kids to hide from sadness. I want the Irish healthcare system to provide caring, comprehensive reproductive healthcare services for every woman and her children, so it is time to talk and time to listen.
