Postnatal depression (PND) is under-diagnosed worldwide, with fewer than 40% of depressed mothers seeking help (Haynes, 2007). In the UK, the most commonly used assessment tool for PND is the Edinburgh Postnatal Depression Scale (EPDS), a questionnaire-based quantitative tool.
Identification and treatment of PND is vital as infant development is particularly sensitive to the quality of the mother–child interaction in the first postpartum year (Logsdon et al, 2006).
Antidepressant medication is frequently used in the care and treatment of women suffering with PND (Misri et al, 2004). Other treatments include cognitive behavioural therapy (Chabrol et al, 2002), psychodynamic therapy (Cooper et al, 2003) and counselling, whether this is provided at home, in a group or by telephone (Holden et al, 1989).
Aim of the study
The current study sought to shed light on the lived experience of older first-time mothers with PND. The central question addressed was: How is postnatal depression experienced by first-time mothers who are aged 30 years and above and have never suffered with depression in the past? On the basis of the results, the question is then posed: What are the implications of the results of this study on the appropriateness of clinical interventions and support currently offered to older mothers suffering from PND?
Ethical approval for the study was granted by the Metanoia Institute and Middlesex University.
PND and delayed motherhood
In 2014, a report produced by the Office for National Statistics (ONS, 2014a; 2014b) found that over half (51%) of all live births in England and Wales were to mothers aged 30 and over, with women aged 30–34 years producing the largest amount of babies. The postponement of childbearing to later in life is a trend in most developed countries.
Research studies of PND have included women (both primiparous and multiparous) from across the fertility spectrum (17–48 years), with assisted or non-assisted reproduction technologies. The limited research into older mothering suggests that older mothers' approach and adaptation to motherhood is different and more intense, with different personal expectations and higher levels of anxiety than younger mothers. Few studies to date have concentrated solely on older mothers' experiences of PND, so it remains unclear if the support needed by a single teenage mother with PND with an unplanned or unwanted baby is the same as that required by a 35-year-old professional woman in a stable relationship who develops PND after the arrival of a longed-for baby.
The growing number of older mothers with PND is likely to increase future demand on health professionals. Research that improves understanding of the nature of PND needs for these women can benefit health services and improve the appropriateness and cost-effectiveness of treatment programmes and clinical interventions offered to them.
Criteria
The inclusion criteria specified that all participants would be women who had their first child when they were aged 30 years or older. This child would have been born within the last 5 years and the mother would have to identify with feeling ‘down, with little interest or pleasure in doing things’ for a period of at least 2 weeks within 4 weeks of giving birth to the child, and had now recovered.
History of depression is identified as a major risk factor for PND, so women without a previous history of depression were chosen, to rule out any comparisons of previous depressive episodes. Primiparous mothers were chosen to capture a woman's first experience of PND rather than a second or third experience, whose impact might have been lessened by knowledge and practice of coping strategies learned from previous PND experiences. By choosing women aged 30+ this study specifically targeted the fastest-growing category of mothers in England and Wales.
Participants
Women were recruited via requests for participants on the social media pages of several PND support organisations. Four women came forward for interview. Three were aged 30–34 years and one was aged 35 when they had their first child. All four were White, middle-class, English-speaking, highly educated and married. Three were from the UK, where their first child was born, while the fourth woman and child were from outside of the UK. For the purpose of this study and confidentiality, participants were given pseudonyms and gave consent for the content of their interviews to be used in the writing up of the study.
Data analysis
The participants were interviewed twice, with a gap of 4–6 months between interviews. All interviews were transcribed in full and analysed using interpretative phenomenological analysis (IPA) (Smith, 1996). IPA is concerned with the detailed examination of human lived experience via in-depth interviews with a small number of participants.
A number of subthemes emerged from the participants' interviews, which were then grouped together into six superordinate themes that appeared to resonate strongly with participants' experience and are presented below.
‘When the women found themselves falling short of their own expectations, they experienced disillusionment… They were used to coping and working successfully through any difficulties they encountered’
Findings
Striving to be a perfect mother
This theme highlights the participants' intent to be the best mother they could possibly be. All had been looking forward to becoming mothers and were excited about having a baby. They all held expectations, not only about the kind of mother they wanted (and were going) to be, but also about how the experience of motherhood should be for them. Rachael's pre-delivery expectations of motherhood were clear:
‘I thought I wanted this [baby] for so long, I've been given this chance and it must be perfect, it must be amazing and I'll never be able to do this again.’
For some, being the ‘perfect’ mother meant giving the baby the ‘perfect’ start. For others, it was about enjoying motherhood in an effortless way, projecting a ‘perfect mother’ image to others, or having a baby that was soothed quickly.
Mary expected motherhood
‘would all just happen naturally and that I would be really good.’
All four participants said they had expected to adapt ‘naturally’ to motherhood and enjoy it, but over time they found the lived experience of being a mother very different from their expectations.
When the women found themselves falling short of their own expectations, they experienced disillusionment, feeling perplexed and despondency. They were used to coping and working successfully through any difficulties they encountered in their lives before motherhood. Not questioning the appropriateness or relevance of the standards they expected to achieve, but rather questioning themselves, they began to believe they were at fault or doing something wrong. Ultimately, all of them felt deskilled, with a deep sense of failure.
‘I can't suffer with postnatal depression, there's nothing wrong with me, I'm fine. It doesn't affect people like me’
All of the women knew quite soon after birth that something was wrong, but not all of them identified their symptoms as PND.
Feeling a failure
Failing to live up to their own expectations of being the perfect mother was a concerning new experience for the women and one for which they felt ill-equipped. The sense of failure had a self-punishing element as the women turned on themselves for their perceived inadequacy.
Mary described her sense of failure:
‘I'm not very good when I can't do something, when most things come to me quite easily… So I think part of me was that I had failed and that I had failed [my child].’
This new world of perceived failure challenged the women's self-identity and unsettled them, blinkering them to the positive things that were happening for their children. In reality, all the babies were thriving and reaching developmental milestones without concerns about their progress being raised at the health clinics their mothers were attending.
‘Punishment’ for the women's perceived failings as a mother was never directed outwards towards the baby or others, but was internalised. One woman resorted to self-harm and others considered it in an attempt to cope with the feelings they were experiencing:
‘Never was there a thought of breaking anything or harming anything, just… me… I was always thinking I was failing… I didn't know what to do at all and once I was on a complete downwards, I would try and hurt myself.’
The women's unspoken worry about how different and inadequate they felt caused shame and concern about not being understood by others:
‘I've never really failed at anything so people just don't expect me to struggle with things or find things difficult, and I think when, when I did tell them they thought I was partly joking.’
The diagnosis of PND seemed to increase the women's sense of failure, rather than help clarify or explain it.
‘I can't suffer with that, there's nothing wrong with me, I'm fine. It doesn't affect people like me.’
All four participants were capable, professional women who were not accustomed to feeling that they were failing in life. It was the women, rather than the babies, who were in danger. Their continuing attempts to make the situation ‘better’ by providing the baby with what they felt it deserved were being made at the expense of their own self-care. Caught in this daily cycle, the women had problems eating and sleeping. They began losing their appetites, their personality, their energy and their desire for anything.
Shame of the other's gaze
This theme shows how part of the experience of motherhood with PND involves shame: both at being seen as deficient by others and also at feeling unable to ask for help. This led the women to withdraw from family, friends, other mothers and health professionals. Participants were aware of the stigma attached to mothers with PND and had mixed feelings about letting other people know of their difficulties.
Sophie took pains to disguise her inner turmoil:
‘If I took Jonny into [his father's] work, I had to make sure I put make-up on and done my hair and was looking like we were a happy family and “be jealous of us because we've got it all going on…” Because I was so controlled and good at my job before I had him, I can't seem that I'm failing… The myth, the image, you've got to keep that up!’
The stigma of mental ill-health, and the fear and risk of being judged by others because of it, acted to silence the women. When Rachael told her parents about her PND diagnosis, she found herself battling their incomprehension and prejudice:
‘Mum was very upset and was very concerned that it was something she'd done… Dad didn't want to talk about it at all.’
The women's accounts made it clear that sometimes health services failed to provide them with a safe haven. Some health professionals did not seem to understand how disempowering and unfamiliar it was for new mothers to think they were being seen as deficient. The delicacy of the women's situation—their need for reassurance, their fear of judgement and their own fragility—was also reflected in their interactions with health professionals. Sophie strove to keep up appearances:
‘Particularly to the health nurse, because she was there to judge me—that was her job! Really her job is to make sure that we're OK and that our babies are OK, but I thought, “She's judging me…”’
PND brought the women a great deal of shame, which silenced and entrapped them.
Feeling stuck and overwhelmed
Central to this aspect of their experience of PND was the women's inability to ask anyone for help: they felt they should be able to sort things out for themselves. Anxious to understand what was going wrong, they could see only one solution: to try harder and ‘push on’ with their efforts while ‘pushing down’ their sense that all was not well. This cycle is one of hopelessness and entrapment.
Sophie described the ‘nightmarish’ quality of this experience, which she likened to a ‘vortex’ that was sucking her in though she was desperately trying to get out.
The women hid their difficulties rather than burden others, trying to protect their loved ones from worrying about them. This led them to disguise the full extent of their distress, so that the pain travelled inwards rather than outwards. This downward spiral of emotional turmoil contained an embodied element: a splitting-off or dissociation which Rachael described as ‘just like an out-of-body experience’. In order to manage their emotional distress, the mothers not only had to disconnect physically from others but also experienced an internal emotional disconnect, as if to prevent them having to acknowledge the change in themselves and their circumstances.
Two months after having her baby, Judy knew she ‘wasn't quite right’ but did not want to go to her GP:
‘I knew she would just write a prescription and send me away… That wasn't what I wanted.’
As the mothers struggled desperately to understand what was going on, they were conscious that something big and important was happening, which needed to be understood so it would not happen again. None of them saw medication as offering that explanation.
Becoming lost
Having sacrificed their ‘old’, professional selves, the women experienced themselves differently and this triggered identity issues. Sophie recognised the difference between her new self and her old one:
‘Old me was professional in my job, my job was timelines and process and controlling… But all of a sudden I was responsible for someone else who didn't fit my order… There was no turning off… I lost all sense of who I was. I lost “me” completely, because “me” didn't exist… I just didn't understand how I could completely lose my personality and there was no hope of that ever coming back.’
Giving up responsibility for the child was not considered an option, as this could potentially further damage the women's already fragile sense of self.
‘It never crossed my mind to leave her with anybody else… That's the last thing I wanted… I wanted to keep looking after her even though I couldn't really cope with it very well.’
It seems the women became objectified as mothers and lost their own personhood and identity. The prioritising of the child overshadowed the needs of the woman herself, who became lost in the process.
This invisibility is reinforced by the attitudes of health professionals:
‘They [health visitors] never asked about me, they only ever asked about breastfeeding and they seemed quite pleased that I was doing that, not for me though, but for the baby. They never asked me questions about “how are you coping with that” or… night feeding or anything, it was just about the practical implications for the baby, umm, but very little about me.’
‘It made me think maybe I'd have been much better if I'd had more severe postnatal depression, then they'd have to take notice.’
What emerges from the women's narratives is their yearning to be seen and acknowledged as a person, not just as a mother. To be ‘found’ appears to be connected to acceptance that the experience of motherhood has led to a changed existence. This was a frightening prospect for the women. Mary described this process of acknowledging and incorporating a changed self:
‘I guess maybe by accepting [a new me]… I guess you had to acknowledge that the experience had happened, really happened and it wasn't something that was actually going to go away and it was something that was actually going to be part of me.’
The participants described losing their former identity and, for a while, not having a new identity into which they could step comfortably and confidently. The process of being ‘found’ is, however, aided by counselling. Participants mentioned various reasons why counselling had proven helpful. Firstly, it gave them the opportunity to speak to an independent person, someone unconnected to them who would not be burdened by their worries. Secondly, it seemed connected with feelings of not being judged. Thirdly, counselling was seen as removing the threat of someone stepping in and taking the child away by its promise of emotional support, help and understanding.
‘I think it's also speaking to someone who has no experience of what I went through or vested interest in me or anything like that, which makes it easier to have that conversation I think… Not kind of worrying if I describe what's happening, you're not going to feel, “Oh God, I could have been more supportive”… I think that's what I've found helped with the counselling at the time; being able to have a conversation and not having to worry about the impact of what I was saying.’ (Mary)
‘It was just nice to open up and just tell somebody all the panics that I had got into… Somebody who understood why you were saying it and somebody who was reminding you that it was an illness and not to feel guilty about it.’
Discussion
Perhaps the most compelling finding from this study was that for the participants, the antidote to being lost was being found again. They embarked on a recovery journey of personal understanding and increased self-awareness, made possible through counselling.
What is clear from the current study is that even though at times the participants were not fully aware of what was wrong with them, they instinctively felt that medication alone would not be sufficient to make them well, release them from their emotional ‘vortex’ and ultimately satisfy their need to understand what was happening to them and how to fight a possible recurrence of these difficulties in the future.
The women's need to talk about their experiences with a person for whose feelings and reactions they did not feel responsible is a prominent and unambiguous finding of the current study. This finding adds a fresh dimension to previous research. In the current study, most of the participants had social support and accessible family around them but felt that they could not ‘burden’ their families with their problems, particularly because they were used to dealing successfully with and feeling responsible for their own problems.
The reluctance of the participants to rely solely on medication as a means to overcome their PND, and their determination to get to the root of the problem, raises the possibility that such attitudes may be part of the PND experience of older women who are used to overcoming problems and achieving success in their lives. Not wanting to burden family members with their problems emphasises the need for these women to be given the opportunity to explore and/or express feelings in a ‘safe’, non-judgemental environment, away from family and friends.
The gap between women's expectations of motherhood and the reality they experience has been noted in research containing women's narratives (Antonis, 1981; Blum, 2007). There is considerable scope for future research into how ideals of being the ‘perfect, natural mother’ are formed. The current study highlights the natural desire of each mother to provide for her child. This appears to spring not from a sense of duty but rather from a position of love for the child and a desire to take responsibility for the care of the child. The participants did not seem to consciously deny their own needs; rather, their own needs simply did not seem to enter the frame or occur to them, so all-consuming was the nature of their care for the child.
It seems the ideology surrounding motherhood as a happy and fulfilling experience (Ussher, 1990; Nicolson, 1993) continues to permeate contemporary society, setting women up to develop a sense of failure when reality does not match their expectations. The image usually projected is of women feeling fulfilled in their new role as a mother (Nicolson, 1990), happily attending to the needs of their children and adapting seamlessly to the tasks of motherhood (Sears, 1985). The role played by the media in forming people's ideals and reinforcing myths has been investigated to some degree (Choi et al, 2005; Hadfield et al, 2007). However, there would appear to be scope for further research into socially constructed, idealistic media representations of ‘perfect’ mothers and motherhood, and the impact these may have on new mothers.
Beck (2001) lists some of the significant predictors that have been recognised as putting mothers at risk from PND: low self-esteem, childcare stress, prenatal anxiety, weak social support, poor marital relationships, history of previous depression, infant temperament, maternity blues, marital status, socioeconomic status, and unplanned or unwanted pregnancy. On the basis of this list, the participants in this study do not emerge as ‘obvious’ PND candidates, given that they did not have many of the risk factors.
The participants themselves seemed to know at varying points after giving birth that they felt ‘different’ or that something was ‘wrong’. However, it took time for them to label their symptoms as PND, despite all of them being well-read in mother-and-baby literature and aware of the existence of PND.
While acknowledging that among some women there may be a resistance to being labelled with a PND diagnosis, these findings question the accuracy of symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association, 2013) and support other findings that challenge the appropriateness of the DSM diagnosis (O'Hara and Swain, 1996). For example, within the DSM diagnosis there is no mention of certain experiences described by the participants in this study: the gap between their expectations of motherhood and the reality; feeling a failure; not wanting to burden others; feeling too ashamed to ask for help; and putting up a front. The absence of these dimensions may contribute to confusion in diagnosis.
All participants in this study were looking forward to becoming mothers. Feeling a failure was a new experience for them. The ‘punishment’ for their perceived failing was directed inwards towards themselves, not towards the baby, with one of the four participants resorting to self-harm. Self-criticism was universal; none of the women reported being openly criticised by anyone else.
Together with their sense of failure, the participants experienced a profound loss of optimism. They seemed to have no expectation that things might get better, sending them ‘spiralling downwards’ (Beck, 2002: 453) into a vortex.
The women attended meticulously to their babies' needs; if anything, they ‘over-loved’ their offspring, to the detriment of their own wellbeing. The babies were stimulated emotionally, socially and educationally by their depressed mothers. As they tended to their babies, the women kept their suffering locked away from family members, other mothers, health professionals and close friends. They seemed imprisoned in the practice of self-silencing. The shame they experienced at not enjoying motherhood was kept hidden until they found the safety of the counselling room.
One aspect of this self-silencing, which does not feature in previous studies and which may be of particular relevance to older mothers, is that many older mothers may have been trying for some time to have a baby, or may previously have been told they were unlikely to have children. In the current study, Rachael was a case in point; when she was about to start IVF, she conceived naturally. She said of motherhood:
‘It came along and it was really grim and so I thought I really do want to complain now but I can't because I've got this precious little gift, miracle, and he's still hard work.’
Perhaps the socially constructed view that older mothers might ‘have it all’—a strong, long-term relationship, a high educational level, a professional background, sufficient financial resources to be a full-time mother, and success in pushing biological boundaries to have a healthy baby—merits further investigation as a possible contributory factor to their experience of PND. Expectations around such women feeling ‘grateful’ for their situation may contribute to their inability to speak out.
‘The difficulties that many women experience in their transition to motherhood need to be reframed as part of an adjustment process, rather than as evidence of personal inadequacy’
Limitations of the study
It bears emphasis that this study rests on a small, self-selected and somewhat homogeneous sample. Despite the fact that the researcher's request for participants was advertised by PND organisations throughout the UK, only these women came forward for interview. The author therefore did not have to turn any possible participants away. Against the author's initial expectation, when setting out on this research, that all participants would be situated locally to the author and would come from different ethnic, educational and cultural backgrounds, all participants were White, middle-class, highly educated career women living in different parts of the UK. Although they had been supported by several different PND organisations, there was still considerable overlap in terms of their experience of PND.
To counter questions arising from this homogeneity of participants, future research should perhaps attempt to base itself on a broader cross-section of women, comprising different socioeconomic groups. However, given that the purpose of this study was to explore the lived experience of a specific category of women (older mothers who had PND after the birth of their first child, having never suffered from depression before), its focus was not on the transferability and generalisability of findings. Instead, it sought to understand the lived experience of a specific group of women in a particular context.
Recommendations and implications for practice
There appears to be a growing body of evidence from research studies that suggests that PND experiences are different for older mothers and those women of advanced maternal age (AMA), that is, aged 35 years and above. This study recognises three areas that would benefit from attention to ensure that adequate and appropriate support is being provided for these women:
Antenatal care
The antenatal identification of women who may go on to suffer PND following birth seems to be significant. The need for appropriate, age-sensitive antenatal education emerges clearly from the current study, and the role for psychology and psychologists in the design of such education is essential. For example, workshops might be offered on the less positive aspects of motherhood, including its ability to feel like a conflicted space in which women's expectations are not met and where they can feel disillusioned and cheated. These workshops may highlight the difficulties women have transferring competency skills from their work life to their new motherhood life, as found in Carolan's (2003) research, and the feelings of failure and underperformance that may be associated with this. It is important that women are warned that, along with the excitement of having a new baby, they may also experience elements of loss relating to their role and life before motherhood. The difficulties highlighted in these workshops that many women experience in their transition to motherhood need to be reframed as part of an adjustment process, rather than as evidence of personal inadequacy. Opportunities should be offered to recognise and challenge socially constructed images of happy, contented, ‘perfect’ mothering.
Recognising that ‘intense mothering’ is targeted to middle-class women and that Pridham et al's (1991) research suggests that higher levels of education contribute negatively to the process of maternal adjustment, this is an area where midwives and other health professionals should be mindful of some of the challenges older pregnant women fitting this description may face when attending clinics. The challenge of socially constructed images of the ‘type’ of woman who might develop PND can also be addressed—particularly as this current research project dispels Beck's (2001) ‘typical’ postnatally depressed woman—which might also limit feelings of shame. Asking for help should be encouraged at this stage antenatally; women need to know that feeling overwhelmed can lead to feelings of detachment and that, despite this, their babies are safe and well cared for. In common with other research, this study highlights the importance of optimism, self-soothing and stress management for mothers seeking a way out of the emotional vortex of PND. However, women cannot be taught the value of hope if they are encouraged to approach motherhood with unrealistic expectations and remain ignorant of the challenges that lie ahead. Such a situation leaves them ill-prepared for difficulties and can add to their sense of being ‘cheated’ out of an enjoyable transition to motherhood.
Postnatal identification of women with PND
The identification of women with PND symptoms who perhaps have not recognised those symptoms as being PND also appears to be an issue in postnatal care. In the UK, the most commonly used assessment tool for PND is the Edinburgh Postnatal Depression Scale (EPDS), a questionnaire-based quantitative tool used for mothers of all ages. Yet in this study, the majority of participants failed to recognise their symptoms as PND. It is also worth noting that many of the experiences described by participants are not included in the DSM diagnosis of PND (American Psychiatric Association, 2013). This is an area where there may be scope for change which could help with identification of women suffering with PND early on so they can access treatment programmes.
Relevant treatment
In this author's view, there is an opportunity for a new assessment tool for PND to be developed for older and AMA mothers that is more relevant, suitable and better able to capture the PND experience of these women. The EPDS was developed in 1987, when the landscape of motherhood was very different to today. An up-to-date assessment tool that reflects and acknowledges women's differing age categories and life experiences on entering motherhood, based on the growing body of evidence that supports the differing PND experiences of women at different points of their lives, could be of great help in identifying women with PND. For example, the findings of this study suggest that older mothers, particularly those in the 30–34-year-old category, may identify less with the current EPDS statement, ‘I have been anxious and worried for no good reason’ and more with other statements, such as:
The gap between expectations of motherhood and reality, which has been raised in numerous studies, could also form part of this new PND assessment tool; for example, statements such as ‘I feel I should be doing a better job at being a mother’. Once these women are identified, appropriate treatment and care programmes need to be based on the growing body of research which captures older mothers' experiences of PND.
It seems older mothers are reluctant to rely solely on medication as a means of overcoming PND. This study has highlighted participants' need to understand the difficulties they are experiencing and the value they placed on an ‘independent’ person to share their difficulties with, for whose feelings they did not feel responsible. Perhaps befriending and counselling services should be encouraged on a national scale. Further research into the positive aspects encouraging recovery from PND would help support this. A poignant finding for midwives and other health professionals is that despite the mothers in this study having social and family support, their feelings of responsibility, shame and inadequacy prevented them from accessing that support. There should not be an assumption that women who have access to close family and a network of friends will be adequately provided for emotionally.
Conclusion
Women experiencing PND require increased opportunities to create their own cultural practices and to alter the way they are conceptualised by others, whether that be health professionals, family and friends, or other mothers. In this study, the researcher encountered difficulties in locating just four women who fitted the criteria and were prepared to take part; there appears to be a reluctance on the part of women to come forward. Perhaps this reflects a more general reluctance to ‘speak up’ about PND. If this is the case, it is hoped that this study contributes to an opening up of discussion and stimulates further research into women's lived experience of PND, which encourages the provision of relevant treatment containing practical parenting skills, educational workshops, appropriate assessment tools and emotional support from informed health professionals. Such support for older mothers is required both antenatally and postnatally, to boost their confidence and generate optimism.