Author: Julia Santana Parrilla, MSc Population & Public Health at the University of British Columbia | Editors: Alex Lukey and Arrthy Thayaparan (Blog Coordinators)
Published: April 23rd, 2021
Perinatal mental health is considered a global public health issue.  So, why don’t we talk about it more?
In the Global North, pregnancy care and interventions developed exponentially throughout the twentieth century.  The medicalization of pregnancy and childbirth has led to significant innovations in care. It has also problematized the experience in ways that privilege medical expertise and suppress pregnant people’s agency. In the early 1900s, reproduction was commodified as pregnancy supplied the labour force for industrializing societies.  Given how babies are produced from our bodies, it is unsurprising that pregnancy was reduced to gestation. Over a century later, these foundations persist in our social imaginations and shape healthcare priority-setting. From research to funding, education to practice, and recommendations to policy, mental health has yet to be integrated in pregnancy care.
Mood and anxiety disorders are the most common types of mental ill-being locally and globally.  But, anxiety and depression occur more frequently among women than in men. [6,9,16] This lifetime prevalence is seen across cultures and most often manifests during reproductive years, particularly in times of dramatic hormonal fluctuations, such as during pregnancy and after birth. [10,16] Approximately ⅓ women may experience anxiety symptoms during pregnancy.  In British Columbia (BC), up to ⅕ will experience significant depression associated with pregnancy and childbirth. 
I dedicated my thesis research to understanding how anxiety and depression are addressed with pregnant people. In BC, people can choose to be cared for throughout pregnancy by a family physician (FP), obstetrician-gynecologist (ObGyn), and/or registered midwife (RM). I interviewed five FPs, four RMs, and three ObGyns practicing in the Lower Mainland to understand their attitudes and perspectives regarding anxiety and depression during pregnancy, those who experience them, and how to address them (identification and management). I perceived providers on the frontlines of pregnancy care to have the power to shape families’ health outcomes and the initiatives and policies that impact them. [13,20] Understanding provider perspectives is the first step in improving our healthcare system’s responsiveness to families’ needs.
Participants reported seeing anxiety and/or depression regularly. Some even expressed expecting to see them given how the journey toward parenthood is a “big change” [RM,7] full of unknowns that can cause much distress and call for psychosocial adjustments. [21,22] As this FP put it:
“[..] the antenatal period is very hard to come to terms with [...] there’s just so many changes going on, mentally, physically, emotionally. It’s hard for people to even A: recognize that there is an issue, and B: sort of come to terms or accept that there might be an issue.” [FP,5]
Feeling “[…] sad of the life you left behind, and being anxious of what’s going to happen, being afraid of giving birth […]” [RM,6] was considered natural by most. However, the aggravation of fears by perceived social pressures was a common frustration. As this ObGyn explained:
“[there] is a lot of pressure on women to do everything perfectly during pregnancy and the reality is it can be a lot harder than expected and that the expectation that are created are unrealistic.” [ObGyn,10]
Most participants found that messaging about how to be during pregnancy undermined the capacity for self-compassion essential to cope with unexpected emotions/moods. This requires disruption. As asserted by this FP:
“[…] when society and this culture is telling you so many things about how you have to be as a mom and like there’s so many outside pressures […] what would help? Like, changing that!” [FP,4]
The confluence of this “big life transition” [RM,8] with the stigma that befalls those who are experiencing anything other than the “ideal pregnancy” predicts and worsens anxiety and/or depression.  In response, providers centered the normalization of anxiety and depression in encouraging disclosures and supporting management. Often, this involved letting pregnant people know “[…] it’s common” [FP,3], and that they’ll “[…] figure it out together.” [RM,8]
Most participants favoured this approach over-relying on standardized screening tools, such as the Edinburgh Postnatal Depression Scale (EPDS) integrated into their antenatal care forms.  This is consistent with previous investigations. [3,7,8,13,14] Many expressed skepticism about the EPDS’ reliability. As an ObGyn with 16 years experience said:
“All of our patients were supposed to be filling it out, but it didn’t seem to be identifying things particularly well for us.” [ObGyn,10]
Some participants reported refraining from using the EPDS due to perceived harms. They expressed worry about isolating people, giving them a stigmatizing label (i.e. mentally ill), and/or triggering the very issues they are trying to identify, prevent, and manage. One RM referred to screening tools as “systems of triggers” [RM,6] adding, “I feel like it is quite isolating, and I feel like it is quite stigmatizing.”[RM,6]
Discussing mental health openly was considered less alienating than using a screening tool. Participants explained how dialogue feels innocuous (safe) whereas tools feel official (intimidating). They considered identification an important first step toward management and supporting healthy pregnancy outcomes. Unfortunately, the stigmatization and complexity of mental health presents challenges in communication. As this RM said:
“one of the things [providers] find challenging is that […] there’s different ways that you can check in with people and people respond very differently to different types of communication.” [RM,8]
Negative perceptions of mental health and reluctance to talk about it mean that there is “[a] fine line between trying to help and offending people” [RM,7]
This is cause for concern given how anxiety and depression during pregnancy often manifest in avoidance of care, poor adherence to recommendations and poor health habits relating to sleep and nutrition. [11,15,18] All exacerbate mental health conditions and risks of poor health outcomes.  Providers expressed concern about keeping clients engaged.
Additionally, feeling underprepared and overburdened in supporting pregnant people experiencing anxiety and/or depression was commonplace. All wished they received the systemic support to “make it easier!”[RM,8] beginning with their training. As this RM said:
“[…] perinatal depression is the number one, uh, issue in pregnancy. Not, you know, preeclampsia, and not, you know, whatever, it’s perinatal depression […] and we’re so not educated in it […]” [RM,6]
Even though some may think of mental health as within the scope of their care responsibilities, it is not perceived to be facilitated. Most reported:
“[…] I feel like I try to do my best.” [RM,8] but when “[…] people, resources, money and resources that are… scarce.” [RM,7], “[…] healthcare providers take on a lot of responsibility and a lot of worry.” [FP,1]
Generally, there is a sense of insecurity in the quality of care provided given the lack of mental health integration.
When discussing what would be advantageous to their efforts, many echoed this RM in needing a “multi-pronged approach” [RM,9] that allocates resources to provider capacity, specialist availability, and resource accessibility (affordability and relevance). They emphasized this is our systems’ responsibility and insisted that funding translates to care priority. In this RM’s words:
“[…] the government decides how they’re going to fund us and what they’re going to pay for […] if they don’t put funding into programs to support mental health and wellness, then… then just the programs don’t exist for us to refer people to.” [RM,8]
Simply, we need “[to] build a government that supports mental health care” [FP,1]
To create demand for existing structures to change in favour of integrating mental health, we need to think about who has the power to stimulate adaptations by the healthcare system. While I entered this project assuming primary care providers had this power, participants identified that the changes need to happen upstream where the money comes from. It is with sincere alignment with participants that I assert the need to fund perinatal mental health research, training, and care. When perinatal mental health is not represented in priority-setting and decision-making documents and spaces, it minimizes the urgency of the issue, trivializes avoidable adverse health outcomes, and erases the people (and families; communities) experiencing them.
The World Health Organization and the United Nations Population Fund have jointly decreed there can be “no health without mental health”. Perinatal Services British Columbia recognizes that early detection of mental health challenges before, during and after pregnancy offers opportunities to improve health outcomes for parents and families.  Mental health promotion, prevention and early intervention show positive investment on returns.  Our Ministry and health authorities are responsible for making mental health services available and accessible, from prevention to management. 
Far more than producers of the next generation/s, pregnant people’s care should not be exclusive to physiology and babies’ gestation. To care for populations equitably, we must recognize how the erasure of complexity in people’s experiences perpetuate health and social inequities. We must make room for the experiences that are silenced, erased, and stigmatized to be demystified and supported.
Disclaimer: To meaningfully address perinatal mental health disparities, all pregnancy experiences within our colonial, cisgender, ableist, hetero-patriarchy must be accounted for.
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