Dr. Gisele Apter: Hi, everyone. My name is Gisele Apter, and I'm a perinatal and infant psychiatrist in France. I work at a University hospital, and I teach at the University of Rouen Normandy. I have been working for quite a while on perinatal mental health and the links between maternal mental health during pregnancy and the postpartum, and infant development.
This is really about what we could do about perinatal health during the pandemic, and is this-- has this been an issue during the past 18, 20 months for mothers during pregnancy, and during the postpartum, and eventually also, for their infants?
I'm going to try to make this lively and hope that it will answer some of the questions that you might be asking yourself, or that your patients might be asking you as mental health professionals, or as just first‑line primary care professionals.
Remember that postpartum and peripartum depression are actually the number one issue today in terms of prevalence of health issue during the peripartum. Actually, in rich countries in the West, the main health issue for mothers today is mental health.
It's the most important and the first risk for mothers, being anxious and depressed during pregnancy, and having this spill over during the first months of the peripartum. And when this happens, both mother and infant are at risk, and the whole family is often in dire need of help. So how has this been hit by the pandemic?
Well probably in many ways, and the first data that's coming out shows that there has been a rise in stress, a rise in anxiety, and therefore, most probably, even if we still need more figures and more follow‑up of our patients, this has also taken its toll on rise in PPD and peripartum depression.
Is this directly linked to COVID? Well, we don't have enough data to say that it would be the virus directly, but we have information that shows that both the epidemic and its consequences ‑‑ meaning the lockdown, meaning also all the restrictions that have been made to the population, to the women, to the OBs, to the way people were able to get visits during their stay in the hospital ‑‑ all this has impacted and raised a number of issues for women and for their families.
Remember that we don't have enough knowledge today of all the exact causes of PPD, but we do know that the risk of anxiety and depression is heightened by a number of environmental factors.
Everything that happens during pregnancy that raises stress will raise the risk for your patients. Everything that raises anxiety and stress during the immediate postpartum will raise risk for your patients. You can imagine then, during a period where at the beginning of the pandemic, we didn't know much about what was going on. Women didn't even know if they were more at risk for themselves, for their infants. We had a level of stress in the general population and in women during the peripartum that was extremely high.
Therefore, again, even if now we have a little more data and a little more information, there is still a lot of need to prevent a number of issues and to help to, let's say, reasonably limit the uncertainty linked to what is going on today and how long this is going to last, and be able to answer questions, because uncertainty is actually the biggest element that raises stress during this period.
For example, women need to be able to ask questions about their own health, the health of the baby: Will they or can they be vaccinated? Will they or can they be transmitters of the virus? Can they breastfeed? Can they communicate with other women, with other members of their family?
All these questions, it's important for us to be able to answer, and to answer with reliable data. In France, and in most of Europe, women during pregnancy are prioritized for vaccination. We recommend that they get more support during pregnancy, and during postpartum, than the general population.
We try to actually not apply the strict limitations of visits during hospital stays that are recommended for other patients, because women during pregnancy, birth, and the immediate postpartum need help. It is even incredible nonsense to think that women can be alone with a child once it is born, or that they can stay alone during their pregnancy.
This is an important factor to protect women, and not let them stay alone during pregnancy or during the postpartum. In most populations, women are never alone during this time of life. It is only in our very urban and protected environments that we have imagined that being alone would be something that would be better.
Obviously, in a pandemic, we are caught between trying to protect the women and the population and being able to offer enough help during this very specific period. So we need to remember that this is a time when anxiety rises, and therefore, risk rises. We have to be extra careful, and if anxiety rises, and if the risk for depression is there, we need to remind our patients that we have good care, that we have different levels of care for anxiety, stress, and depression during pregnancy and the postpartum.
We have non‑pharmacological interventions and pharmacological interventions that are safe, and that will help them get through this. There are websites to help your patients, but you can just remind them this, they are not alone. There are many, many people that face the same hurdles during this period. It is now a well‑known fact, so they are not guilty of anything. It is something that we can face together and that we can treat together.
It is not seeking help, or not having their family let them seek help and support them, that is really the most negative factor that could be offered.
We now have enough information to know that we can help cope. We can help diagnose. We can help treat, and even during the pandemic, when we know that there are more factors that will add to maternal stress and difficulty, we can protect, we can screen, we can support, and we can treat.
Obviously, if you need to go into more specific details, then we can have another conversation about how we can have these three levels of intervention, both during pregnancy and afterwards during the postpartum.
[There is]data coming out that's saying that at least the levels of anxiety and stress that we're seeing, that there have been some very quick prospective research. As you know, research has just exploded during this pandemic.
Some European countries, and some non‑European countries, have done very quick surveys online, trying to assess anxiety and screen for depression through various, through self‑questionnaires. Obviously, the level of what would be expected, which is already reasonably high, has risen.
There is a current prospective study going on to assess both impact of the pandemic and the one or two lockdowns of last year, and follow these women up after 6 months and 12 months, so we won't be able to analyze that data before the end of 2021. This is going on in close to, over 20 countries.
The data's going to be difficult to analyze, because there was the pandemic, where nobody knew anything. The first lockdown, where obviously the impact of the lockdown was probably even more important than the impact of the pandemic itself, because the lockdown stopped women from seeing anybody.
Then the first lockdown really had very strict visiting measures when women did give birth. They were really separated from their families in a very drastic manner. Then people came out again, and data started coming out that, No, mothers during pregnancy were not at high risk of transmitting the virus to their infants. That was very reassuring, and that also, they could go on breastfeeding. That was also very reassuring. It helped.
Then data trickled out slowly also, that there might be a slightly higher risk of prematurity and a slightly higher risk of more severe infection when women were pregnant, than if they were not pregnant. Since most of these women are young, this did not take them either into the ICU, or cause major life‑threatening risk. But still, it did raise the level of anxiety. However, the main issues are the isolation, the anxiety about family, the difficulty during the pregnancy and the postpartum of being able to keep contact with family, if it is a high‑risk pregnancy.
I very recently had a patient who had to spend close to four months in hospital due to a really life‑threatening pregnancy. She was isolated and only had contact with her other children and family through video. This is not something that we have been brought up to live through.
Obviously, she did have human contacts, thanks to being in a very nice hospital department, but still, being separated from your children, from your spouse, is not something that on top of having a life‑threatening pregnancy, that you want to go through again.
We really need to help their families and primary care professionals understand that these women will need more support to help them go forward and to try to not heighten the risk that they already have, some of them, for depression in general, even without the pandemic.
Obviously, when you have life‑threatening pregnancy, you have a higher risk, anyhow. Once again, the impact of a worldwide disaster is-- the consequences of that disaster, sometimes are even higher than the disaster itself.
We keep comparing this pandemic to, for many months, we were comparing it to the 1918 Spanish flu. There was not much data. There's no footage. There's not much recording, compared to something that happened over a hundred years ago, so it's difficult.
It's even more important to think about it in terms of mental health for this age population, since these are young people who are at risk of being infected. Because this is pregnancy and the postpartum, the risk for this specific mental health issue, which is PPD and/or anxiety linked to it, since there are different facets to PPD, that is a very high risk.
It's considered something like 12, 13 percent of the general population without a pandemic. You can imagine that, when you have a high‑risk situation added on to an already high‑risk illness, then you are talking about probably at least one in four, or one in five, women who are at risk. Therefore, we need to think about this specifically for every single woman who is going to give birth or who is going to be alone with an infant during this time.
Remember that pregnancy is already a period of life where the risk of, unfortunately, being neglected, abused is higher than during the rest of your life. This is something that's counterintuitive for many people, but actually, it's data.
Consider the fact that, even if pregnancy is something that happens to most women, it is a period of increased vulnerability so systematically screen them during pregnancy if you have access to them during pregnancy.
If you only have access after birth, then systematically screen after birth. There are many easy screening instruments to use. The one that's most common and known is the Edinburgh Postnatal Depression Scale, which actually works also antenatally.
Just 10 questions, but actually, you can even simply ask two or three questions to your patients, and if you get a yes to, "I'm not feeling the way I used to. I can't do what I used to be able to do, or I'm just not able to feel as happy as I thought I would be feeling happy," that's enough to get you to think, "OK, I want to talk a little more with this patient and take a little more time with this patient."
It's not a diagnosis, obviously, but you might be in so many different settings that you might not have all that you need to make a formal diagnosis. What you want is just to not let these women be alone, not be screened, and not be diagnosed.
Being very pragmatic, start by asking a few questions about how they feel and leaving it open, not making it closed, like, "You are feeling nice, aren't you?" No, well if you say that, obviously someone during the peripartum is going to feel too guilty to say no. You have to leave it open.
Also, during pregnancy, one of the ways that we can easily, as non‑mental health professionals, get an idea of what's going on for our patients is to ask if they have many complaints.
If they complain about more than two, three, or four issues that most women just brush aside ‑‑ pain, irritation, feeling slow, sleeping problems, not eating as well as they should, or eating more than should ‑‑ and anything that becomes really difficult, when it should just be something that most women brush aside, then again, think, "OK, maybe I can try to take a little more time and see if this woman can open up."
I can help her say how she feels and if she's feeling anxious, and if she has questions that she doesn't dare to ask.
Remember, most women still feel that they should be feeling happy, that they should be saying that this is the best moment of their lives. Even, OK, there's COVID, but, "this should be the best time of my life. I should be the happiest woman on Earth. I should be so happy to be pregnant or to have this wonderful baby," and that just isn't true. It hasn't been true for centuries.It's not true, even if afterwards, everything gets back on track, it just isn't true.
We need to help our patients get over that, rather than say, "Oh, yes, this is what you should be feeling." You're helping your patients, and you're helping their offspring.You are helping the next generation.
This is the best way to help both the mother and the infant, and we have now enough interventions that are available in most places, and if these interventions are too far away, we can try, now that COVID has helped us develop a lot of eMedicine. We can really something about it.
It's not just something that's going to be diagnosed, and then you're going to get a diagnosis, and the thing's going to be done. It means we can help, and things can get much better pretty quickly, actually.
You deserve it. We all deserve to help these women, and these women deserve to be helped.
Note from Dr Apter: Please visit momsduringCOVID.org to learn more about ongoing research into the impact of the COVID19 pandemic on perinatal mental health.
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