All women experience emotional changes in relation to being a new parent. Pregnancy and birth are considered significant events that create physiological and behavioural adaptive responses known as emotions 1. There are often unexpected reactions of sadness, self-doubt, guilt, disempowerment, trauma, and loneliness 2,3. This essay will firstly describe how normal bodily changes that result from childbirth may affect the emotional wellbeing of the woman as she makes this transition. It will then use current literature to articulate the midwife’s role in caring for the woman’s psychological health at this time, paying particular attention to evidence on the midwife’s scope of practice, assessment of care needed, normal and abnormal expectations in the postnatal period, including health promotion, and increased risk factors. Lastly, this essay will describe some community resources that the midwife may offer the family to address any queries, concerns, and referral pathways that are needed. Anatomically a woman’s body changes in pregnancy and childbirth due to the physical changes of the physiological birth process 4. This includes significant breast changes, uterine involution and the body returning towards a pre-pregnant state 4. Depending on her perspectives about body image, these may affect her emotional wellbeing during her transition to parenthood 5,6. Hormonal puerperium changes have an effect on emotional states, namely the decreases in oestrogen and progesterone and an increase in prolactin and oxytocin 4. Changes in neurotransmitters such as serotonin, dopamine and norepinephrine also play a significant role in psychosocial and depressive behaviours 4,7,8. Within the midwife’s scope of practice, midwives care for and respond to a woman’s emotional state and offer access to needed support 9,10. Some evidence argues that this is an area midwives need to pay more attention to 11, haveing the potential to create an environment that may buffer the negative effects of obstetric complications post birth 12–14. Successful parental transitions have been attributed to the midwife’s ability to connect to women 15 and offer non-judgemental family focussed, consistent care that empowers women 16 built on a relationship of trust and understanding 17. How women are cared for by health professionals impacts how early parenthood is managed and emotional support is vital 18. This relationship is enhanced with continuity of care and being home-based where the woman feels safe, receives more quality time, experiences greater confidence, and a sense of community and cultural acceptance 11,19–21. When this level of support is achieved it strengthens the woman’s self-efficacy, her ability to organise support, and instigate constructive coping strategies 15. When assessing and prioritising the emotional care that may be provided to the post-natal woman, the midwife should ask the woman herself at each contact about her health and concerns 22. These are often called ‘listening visits’ 23. This may involve allowing a woman to debrief and share her birth experience 13,22,24. Some new mothers feel negatively towards their birth experience with emotions influenced by hormonal fluctuations, fear, depression and violations during labour 25. Others feel empowered, confident and more relaxed about their labour and birth experience 25. Listening involves tuning into the woman’s emotional state, and midwives are in the perfect position to screen for any issues 22,26. Creating these positive experiences should not exclude provision of honest information 27. The information a midwife offers should be based on evidence and promote emotional health appropriate to that family 9,10,28,29. This includes ensuring the woman is sufficiently informed and reassured about the realistic expectations of the post-natal period 15,24,27. They should inform the family of the new demands of parenthood, including increased mood-disorder and sometimes depression which diminishes self-regulation 30. Woman tend to emotionally regulate to their baby’s distress, their own sleep deprivation, any breastfeeding challenges, and the new family dynamics, so it is therefore important that these situations are anticipated 30. It is also recommended that there is discussion about the devalued postpartum body and the emotional expectations about ‘bouncing back’ 31. The woman should be informed that between three to seven days postpartum, she may experience what is known as ‘baby blues’ 4. She should be informed that this is a normal transient physiological stage where the adjusting hormones are said to cause tearfulness, mood changes, irritability, forgetfulness, fatigue and some minor stress and anxiety in 50% of mothers 4. Families should also be educated to watch for abnormal signs of continuing emotional disturbances that escalate to post-natal depression (PND) and postpartum psychosis 4. These affect 10% and 3% respectively and include exacerbated sleep and anxiety symptoms as well as reduced self-esteem and weight loss which may escalate to delusions and hallucinations 4. Included in a midwife’s emotional health promotion of the post-natal period should be some recommendations for a range of supports for this transition as pharmacological and psychotherapeutic therapies may not offer complete solutions 32. Partner, family and social support has a positive impact on maternal wellbeing and reduces depression and anxiety 2 24. So too does religion, infant bonding, forming friendships, education, and utilising childcare 33. It has also been shown that exercise can increase positive feelings 34 and singing to babies can strengthen emotional thoughts towards them 32. When addressing the emotional care a midwife may provide a post-natal woman and her family, we cannot ignore that one in three women experience post-traumatic stress (PTS) following giving birth 12,13. This may have been brought about by obstetric violence, including spoken humiliation, ignored needs and wishes, invasive or forced medical procedures or interventions, an unwell baby, previous life events, pregnancy trauma and concerns around babies wellbeing 18,25. For 1.7-9% of women, this can develop into post-traumatic stress disorder (PTSD) where there is intense or prolonged psychological distress 35. Both PTS and PTSD symptoms lead to poor maternal health, infant bonding and family relations 35, and should be treated with heightened awareness, extra consistent, non-dismissive, supportive, emotional care to reduce early parenting difficulties 18. Time should be allowed for reflection and validation 18 and a referral should be made if appropriate 22. Current literature also shows other risk factors for poor mental health that include a caesarean birth 4,18,35,36, pre-existing emotional experiences 4,18,30,35, an unwanted pregnancy 2, separation from family and culture 33, birth complications, low income 4,27, relationship issues, poor social and emotional support, and the death of baby 4. Particular attention would need to be considered in these situations when a midwife is assessing the level and content of care to provide. Some helpful community resources that a midwife could suggest would be to consult the woman’s General Practitioner with any issues or questions but to also inform her that Victoria has a free Maternal and Child Health (MCH) Service that is focused on the health outcomes for children and families including maternal emotional factors 3. A visit from an MCH nurse is scheduled in their home within two weeks of birth and in-clinic support is offered until the child is school age. The MCH service is guided by the ‘Perinatal mental health and psychosocial assessment’ 37 and includes using the Edinburgh Postnatal Depression Scale (EPDS) screening tool. This tool is used to improve the detection of postnatal depression and is part of the COPE best practice guidelines. The Centre of Perinatal Excellence (COPE) is a national not-for-profit organisation focused on reducing the effects of emotional and mental health problems in the perinatal periods. Their website is easy to navigate and includes many areas of evidence-based support for women and families. COPE have been working with governments and professional bodies since they transitioned from Beyond Blue in 2013. Beyond Blue focuses on anxiety and depression but in a much broader context. They have specific pregnancy and postnatal information and checks. Perinatal Anxiety and Depression Australia (PANDA) is a more specific organisation supporting recovery from perinatal anxiety and depression for individuals and families. Many of the organisations have ‘hotlines’ and have been listed in the resource list Appendix A. In conclusion, when reviewing the literature, we can see that not only do normal physiological changes affect the emotional wellbeing of the woman as she makes this transition to motherhood, but that there are many other factors that need to be considered within a midwife’s scope of practice to offer evidence-based support. This essay covered the assessment needed for care and the normal and abnormal expectations in the postpartum period. It included health promotion solutions and some of the increased risk factors for psychological illness. Lastly, it described some community resources that the midwife may offer the family to address any queries, concerns, and referral pathways that may be needed. References (1) James, W. II.—WHAT IS AN EMOTION ? Mind 1884, os-IX (34), 188–205. https://doi.org/10.1093/mind/os-IX.34.188. (2) Abdollahpour, S.; Keramat, A. The Relationship between Perceived Social Support from Family and Postpartum Empowerment with Maternal Wellbeing in the Postpartum Period. J. Midwifery Reprod. Health 2016, 4 (4). https://doi.org/10.22038/jmrh.2016.7612. (3) Sanders, R.; Lehmann, J.; Gardner, F. Parents’ Experiences of Victoria’s Maternal and Child Health Service during the Transition to Parenthood. Aust. J. Child Fam. Health Nurs. 2018, 15 (1), 9–16. (4) Rankin, J. Puerperium—the Mother. In Physiology in childbearing e-book : With anatomy and related bioscience; Elsevier Health Sciences, 2017; pp 592–595. (5) Prinds, C. Yummy Mummy — The Ideal of Not Looking like a Mother. Women Birth 2020, 8. (6) Rodgers, R. F. A Biopsychosocial Model of Body Image, Disordered Eating, and Breastfeeding among Postpartum Women. 2018, 6. (7) Osman, N. N.; Bahri, A. I. Impact of Altered Hormonal and Neurochemical Levels on Depression Symptoms in Women During Pregnancy and Postpartum Period. 2019, 9. (8) Rihua, X.; Haiyan, X.; Krewski, D.; Guoping, H. Plasma Concentrations of Neurotransmitters and Postpartum Depression. 2017, 8. (9) International Confederation of Midwives. International Code of Ethics for Midwives https://www.internationalmidwives.org/assets/files/general-files/2019/10/eng-international-code-of-ethics-for-midwives.pdf. (10) COAG Health Council. Woman-Centred Care: Strategic Directions for Australian Maternity Services. Department of Health August 2019. (11) Fenwick, J.; Butt, J.; Dhaliwal, S.; Hauck, Y.; Schmied, V. Western Australian Women’s Perceptions of the Style and Quality of Midwifery Postnatal Care in Hospital and at Home. Women Birth 2010, 23 (1), 10–21. https://doi.org/10.1016/j.wombi.2009.06.001. (12) Baptie, G.; Andrade, J.; Bacon, A. M.; Norman, A. Birth Trauma: The Mediating Effects of Perceived Support. Br. J. Midwifery 2020, 28 (10), 724–730. https://doi.org/10.12968/bjom.2020.28.10.724. (13) Baxter, J. Postnatal Debriefing: Women’s Need to Talk after Birth. Br. J. Midwifery 2019, 27 (9), 563–571. (14) Deninotti, J.; Denis, A.; Berdoulat, É. Emergency C-Section, Maternal Satisfaction and Emotion Regulation Strategies: Effects on PTSD and Postpartum Depression Symptoms. J. Reprod. Infant Psychol. 2020, 38 (4), 421–435. https://doi.org/10.1080/02646838.2020.1793308. (15) Walker, S. B.; Rossi, D. M.; Sander, T. M. Women’s Successful Transition to Motherhood during the Early Postnatal Period: A Qualitative Systematic Review of Postnatal and Midwifery Home Care Literature. Midwifery 2019, 79, 102552. https://doi.org/10.1016/j.midw.2019.102552. (16) Wiklund, I.; Wiklund, J.; Pettersson, V.; Boström, A.-M. New Parents’ Experience of Information and Sense of Security Related to Postnatal Care: A Systematic Review. Sex. Reprod. Healthc. 2018, 17, 35–42. https://doi.org/10.1016/j.srhc.2018.06.001. (17) Woodward, B. M.; Zadoroznyj, M.; Benoit, C. Beyond Birth: Women’s Concerns about Post-Birth Care in an Australian Urban Community. Women Birth 2016, 29 (2), 153–159. https://doi.org/10.1016/j.wombi.2015.09.006. (18) Priddis, H. S.; Keedle, H.; Dahlen, H. The Perfect Storm of Trauma: The Experiences of Women Who Have Experienced Birth Trauma and Subsequently Accessed Residential Parenting Services in Australia. Women Birth 2018, 31(1), 17–24. https://doi.org/10.1016/j.wombi.2017.06.007. (19) Cummins, A.; Griew, K.; Devonport, C.; Ebbett, W.; Catling, C.; Baird, K. Exploring the Value and Acceptability of an Antenatal and Postnatal Midwifery Continuity of Care Model to Women and Midwives, Using the Quality Maternal Newborn Care Framework. Women Birth 2021, S187151922100041X. https://doi.org/10.1016/j.wombi.2021.03.006. (20) Forster, D. A.; McKay, H.; Davey, M.-A.; Small, R.; Cullinane, F.; Newton, M.; Powell, R.; McLachlan, H. L. Women’s Views and Experiences of Publicly-Funded Homebirth Programs in Victoria, Australia: A Cross-Sectional Survey. Women Birth 2019, 32 (3), 221–230. https://doi.org/10.1016/j.wombi.2018.07.019. (21) Forster, D. A.; McLachlan, H. L.; Davey, M.-A.; Biro, M. A.; Farrell, T.; Gold, L.; Flood, M.; Shafiei, T.; Waldenström, U. Continuity of Care by a Primary Midwife (Caseload Midwifery) Increases Women’s Satisfaction with Antenatal, Intrapartum and Postpartum Care: Results from the COSMOS Randomised Controlled Trial. BMC Pregnancy Childbirth 2016, 16 (1), 28. https://doi.org/10.1186/s12884-016-0798-y. (22) NICE; RCOG. Postnatal Care NICE Guideline. National Institute for Health and Care Excellence April 20, 2021. (23) Lowenhoff, C.; Appleton, J. V.; Davison-Fischer, J.; Pike, N. NICE Guideline for Antenatal and Postnatal Mental Health: The Health Visitor Role. J. Health Visit. 2017, 5 (6), 290–298. https://doi.org/10.12968/johv.2017.5.6.290. (24) Slomian, J.; Emonts, P.; Vigneron, L.; Acconcia, A.; Glowacz, F.; Reginster, J. Y.; Oumourgh, M.; Bruyère, O. Identifying Maternal Needs Following Childbirth: A Qualitative Study among Mothers, Fathers and Professionals. BMC Pregnancy Childbirth 2017, 17 (1), 213. https://doi.org/10.1186/s12884-017-1398-1. (25) Khajehei, M.; Doherty, M. Women’s Experience of Their Sexual Function during Pregnancy and after Childbirth: A Qualitative Survey. Br. J. Midwifery 2018, 26 (5), 318–328. (26) Moss, K. M.; Reilly, N.; Dobson, A. J.; Loxton, D.; Tooth, L.; Mishra, G. D. How Rates of Perinatal Mental Health Screening in Australia Have Changed over Time and Which Women Are Missing Out. Aust. N. Z. J. Public Health2020, 44 (4), 301–306. https://doi.org/10.1111/1753-6405.12999. (27) Rizzo, I.; Watsford, C. The Relationship between Disconfirmed Expectations of Motherhood, Depression, and Mother–Infant Attachment in the Postnatal Period. Aust. Psychol. 2020, 55 (6), 686–699. https://doi.org/10.1111/ap.12472. (28) NMBA. Code of Conduct for Midwives. Nursing and Midwifery Board of Australia. 2018. (29) NMBA. Midwife Standards for Practice. Nursing and Midwifery Board of Australia. October 1, 2018. (30) Cao, H.; Zhou, N.; Leerkes, E. M.; Qu, J. Multiple Domains of New Mothers’ Adaptation: Interrelations and Roots in Childhood Maternal Nonsupportive Emotion Socialization. J. Fam. Psychol. 2018, 32 (5), 575–587. https://doi.org/10.1037/fam0000416. (31) Johnson, S. “I See My Section Scar like a Battle Scar”: The Ongoing Embodied Subjectivity of Maternity. Fem. Psychol. 2018, 28 (4), 470–487. https://doi.org/10.1177/0959353518769920. (32) Fancourt, D.; Perkins, R. Associations between Singing to Babies and Symptoms of Postnatal Depression, Wellbeing, Self-Esteem and Mother-Infant Bond. Public Health 2017, 145, 149–152. https://doi.org/10.1016/j.puhe.2017.01.016. (33) Russo, A.; Lewis, B.; Joyce, A.; Crockett, B.; Luchters, S. A Qualitative Exploration of the Emotional Wellbeing and Support Needs of New Mothers from Afghanistan Living in Melbourne, Australia. BMC Pregnancy Childbirth 2015, 15 (1), 197. https://doi.org/10.1186/s12884-015-0631-z. (34) Hutt, R. L.; Moore, G. A.; Mammen, M. A.; Symons Downs, D. Postpartum Mothers’ Leisure-Time Exercise Behavior Is Linked to Positive Emotion During Partner Discussions. Res. Q. Exerc. Sport 2017, 88 (4), 447–454. https://doi.org/10.1080/02701367.2017.1375450. (35) Simpson, M.; Schmied, V.; Dickson, C.; Dahlen, H. G. Postnatal Post-Traumatic Stress: An Integrative Review. Women Birth 2018, 31 (5), 367–379. https://doi.org/10.1016/j.wombi.2017.12.003. (36) Alderdice, F. Psychosocial Factors That Mediate the Association between Mode of Birth and Maternal Postnatal Adjustment: Findings from a Population-Based Survey. 2019, 13. (37) Victoria State Government. Perinatal Mental Health and Psychosocial Assessment. Victorian Government 2019. Appendix A
Emotional Wellbeing Resources Pregnancy and Post-Natal COPE - https://www.cope.org.au/ PANDA – 1300 726 306 - https://www.panda.org.au/ General Beyond Blue – 1300 22 4636 - https://www.beyondblue.org.au/ SANE Australia - 1800 18 7263 MindSpot Clinic - 1800 61 44
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