Cradle of despair?

March 19, 2004

Is the increasing tendency to label normal reactions to childbirth as postnatal depression undermining our ability to cope as parents? asks Ellie Lee

Is postnatal depression an epidemic? According to a recent survey by Prima Baby magazine, one in five new mothers has the condition - many more than most people might expect. Some claim men are suffering from PND, too. A new National Health Service scheme, Fathers Matter, aims to identify them and offer counselling.

Those who emphasise the problem of PND argue that motherhood has always been depressing, but society is only now beginning to appreciate this. As a result of awareness-raising efforts, the problem is at last being recognised.

Motherhood has certainly never been easy, and has always been unsettling and disturbing for some. But while some characteristics of modern life have made childcare easier, others have introduced new stresses. Researchers, for example, often highlight problems associated with changes in geographical proximity to family.

But is it right to conclude that so many parents are depressed? What is taking place may not be so much the recognition of an existing problem as the construction of a new one.

One very marked aspect of British culture over the past ten or 15 years especially is the emergence of a way of discussing experience that emphasises how people have been allowed to "suffer in silence". Society, it is argued, has trivialised the emotional difficulties people experience leaving them to cope with these problems alone.

This is the case now being made for parenthood, especially motherhood. As Susan Maushart, author of the bestselling book The Mask of Motherhood puts it: "Society propagates a ridiculously positive myth of pregnancy." This creates big problems for women, because it attempts to "minimise the difficulties we face, insisting that motherhood is no big deal after all". Shifting the culture and recognising how motherhood is a "big deal" is viewed as the appropriate response.

In this sense, the problem of PND is not really about mental ill health. The term forms part of a bigger argument that says becoming a parent needs to be viewed as an ordeal. Raising awareness is the aim - to encourage people to feel their problems are recognised by others. And why not include men too? They, like new mothers, can find becoming a parent difficult, so they too can have PND, and this should be recognised.

A notable aspect of this definition of PND is the way it challenges previous distinctions between the "blues" (transient psychological disturbance) and PND (much more severe and lasting problems). Concept slippage between these categories frequently takes place, especially in advice books for new mothers.

Kate Figes, author of Life after Birth , writes: "PND is a sliding scale, starting with the 'baby blues' affecting 80 per cent of women, and ending with puerperal psychosis. The vast majority of women sit somewhere on this scale."

In Feelings after Birth , journalist Heather Welford argues: "If you include in your definition of postnatal depression all post-childbirth distress and misery, including the more shortlived forms, it's probable that the majority of mothers recognise many of the symptoms."

Siobahn Curham, author of Antenatal and Postnatal Depression , goes further. "As many as 90 per cent of new mothers experience some feelings of depression after birth."

Arguments of this kind inevitably bring with them claims that health professionals need to do more. This role is one that policy-makers seem keen to encourage. The Department of Health emphasises that mental ill health is more widespread than in the past, and that PND needs to be highlighted as part of this phenomenon. In particular, it is health visitors who are seen as the front line in the campaign to raise the profile of PND, by screening new mothers to see if they are depressed and need counselling. Some psychiatrists argue that as many as one in ten women has PND (previous estimates were one in 20).

Some, such as Ian Brockington, professor of psychiatry at Birmingham University, contend that it is acceptable to overlook definitional problems with PND because the increasing use of the term to describe the experience of motherhood has "legitimised maternal depression in the minds of the public. It has aroused concern about an important public health problem".

What effect will this have? It is true that society has often promoted an idealised and unrealistic portrayal of motherhood. But is the current reaction against this the best answer? Is there evidence that it will make things better for new parents? Will it help if more and more people make sense of their difficulties as parents by thinking they have depression and need professional intervention to cope?

Properly funded childcare and practical help from midwives and health visitors are things parents most certainly need. There are good reasons, on the other hand, to be concerned about the implications of efforts to increase recognition of PND as it is now defined. There is every possibility that through doing so, parents will come to experience the normal disruption that parenthood brings as highly disabling and find themselves less able to manage.

Society would do better to trust that most new parents can, just as they always have, cope alone with their feelings.

Ellie Lee teaches social policy at Kent University and is the author of Abortion, Motherhood and Mental Health: Medicalizing Reproduction in the United States and Great Britain , published by Aldine de Gruyter, £15.49.

PND: PAST AND PRESENT

Janet, two children, born 1967 and 1969

"My first baby was a forceps delivery after a very long labour, and I was totally exhausted.

"The baby was very distressed most of the time. After about a year, I used to wonder if I could ever be normal again. It was a funny feeling. I felt ill all the time, I didn't know what had hit me because my life had completely changed.

"It's difficult to describe. Things just weren't right - it all felt unreal. Sex with my husband was difficult and he was cross a lot. I got pregnant again, and the feeling of not being normal just went away when the second child came. That was a normal delivery, and immediately I felt relaxed.

"I'd heard of the baby blues. It was a common term in those days. 'You'll get over it,' they said. But I never thought that's what I had. I just thought I was exhausted. I just blamed lack of sleep, but I did have my mum and my husband's mum around to help a lot.

"My cousin had four babies, and she became seriously deranged each time.

She had to have psychiatric treatment in hospital. That's what I call postnatal depression. You lose a grip on reality, and you can't keep going - but that wasn't me."

Andrea, one child, born 2003

"It's funny with postnatal depression, because nobody I know says they have had it, and I haven't experienced it myself.

"Talking to friends with babies, they say they are having a hard time with something or are knackered. No one has said they are depressed. But it's become part of what people say about having a baby, what they think it will be like.

"The midwives, when they came to visit, asked me if I was feeling depressed. Aside from the home visits, you go for a check at the doctor's, and they ask if you are depressed.

"One friend who doesn't have children asked me how things were going. I said, 'really good', and she said: 'Wow, that's great, you haven't even had PND.'

"The assumption was that I got off quite lightly and I was unusual because I hadn't got it. It's like the idea that you will put on loads of weight if you have a baby. People think the same, you will be depressed."

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