The exact causes of postnatal depression are unknown. For many women, PND begins for no obvious reason, but a number of different stresses may trigger it. The important thing to remember is you should not feel guilty or that it is your fault. All pregnancies are major life events and can cause stress that triggers an illness such as postnatal depression. Some
of the most common causal factors are described below:
Pregnancy Complications and Difficult Deliveries
Multiple pregnancies are considered to be at higher risk of complications such as excessive vomiting, twin-to-twin transfusion syndrome (TTTS) and preeclampsia. It is therefore not surprising if you feel exhausted and depressed before your babies even arrive. Poor quality antenatal care and a difficult delivery can also trigger PND. It can be hard to come to terms with the fear, pain, and loss of control associated with traumatic births. You may feel angry that the delivery was mismanaged or you were not kept informed. Feelings of disappointment that your babies’ birth was a stressful, rather than wonderful experience are also common. If you’ve had a traumatic birth experience, you may be suffering from a form
of post-traumatic stress disorder rather than postnatal depression. It can help to visit the hospital team afterwards and discuss your notes. Reflecting on what happened can help you come to terms with the experience.
The Experience of Having babies in NICU (Neonatal Intensive Care Unit)
Parents of babies in NICU, also known as SCBU (Special Care Baby Unit), are thought to be at greater risk of developing PND, particularly if they have been separated from their baby for an extended period of time. They often describe a sense of ‘ambiguous loss’ that while they should be celebrating their babies’ birth, they are instead coping with feelings of distress, worry, regret, guilt and loss. Some mothers also find that if they are the only parent of multiples on NICU it can be an alienating experience.
Feeling Overwhelmed by More Than One Baby
As a mother of multiples, it is simply not possible to give each baby the same time and attention as you could have given a single first baby. The first year is an exhausting time and you may feel that you are being constantly split in two and are not able to give enough time to each child. Feeling this way is understandable and it can take some time to get used
to. Indeed, feeling so overwhelmed that you want to walk away from your babies is more common than you might expect, having occurred to 59% of all mothers of multiples in the Tamba survey, including those women who did not suffer from PND. 9% experienced this desire frequently. In some cases, this is simply just a recurring fantasy of booking into a hotel
room and having a decent night’s sleep (alone!) However, in other cases the feelings are more acute and may lead to self-harming or contemplating suicide.
Illness and Crying Babies
Feelings of being overwhelmed with PND can be most acute when your babies are ill, even if it is just colds, teething problems or stomach upsets. Having one or more baby suffering from colic appears to be a particular trigger for PND in the first three months. One mother has described how “One day I decided I didn’t want the babies anymore. I wanted to walk over to my local shopping centre and leave them somewhere, I rang my husband [and told him] what I was going to do, and he came home from work to help me. Both babies had colic and I couldn’t cope.”
Lack of Sleep
Exhaustion and fatigue are common problems in the first year of your babies’ lives. If you are sleeping less than five hours a night, you are in good company. Only 14% of mothers of multiples have six or more hours sleep in the first year. For many mothers, even these few hours of sleep are frequently broken by night-waking, feeding and settling babies. Although
insomnia and early morning waking can be symptoms of depression, it can be difficult to tell whether sleep problems are due to PND or whether you are depressed due to lack of sleep, or perhaps even both. Feelings of emotional distress can seem overwhelming in the middle of the night when there is no-one else awake to talk to. If you need to talk to someone, please see the telephone helplines at the back of this guide (several of which are open 24 hours a day).
Reality versus Expectations of Parenting Multiples
When your hopes and dreams of motherhood do not match up to the reality, it can be hard to cope with the feelings of disappointment, sadness, shock and even regret. Unmet expectations can be a particular problem for women who have struggled with the stress of infertility treatment. Research by Australian researcher Dr Jane Fisher and her colleagues at the University of Melbourne suggests that mothers who have had IVF treatment are more
likely to suffer from postnatal depression and doubt their abilities as mothers. Your much-longed for babies may be loved, but they may not match up to the fantasy baby that has built up in your mind through the many months of hoping and waiting to become a mother. Mothers experiencing PND after IVF say they find it hard to talk to friends and family about
their feelings in the face of comments like “Aren’t you lucky – this is all you’ve ever wanted?” Women do not always instantly bond with their babies and you should not feel ashamed of initially having the ‘wrong’ feelings or even no feelings.
Single Baby Envy
It is also not unusual to feel robbed of the typical mother-child bond that singletons appear to enjoy. As a mother of two or more, you may struggle to adapt your expectations of what being a mother involves. For example, one mother said she “felt cross about having twins because all my friends were blissfully happy with their one baby, going out easily to baby massage classes, swimming etc. I felt that I was always struggling, that I didn’t have time to enjoy my babies or give them the level of intimacy with me that I should because there was always something else that needed doing; it was like a production line of feeding and changing etc. I felt guilty for not being all that happy.” Dealing with these feelings will take time,
but try to remember that you have enough love to go around and your children will not know any different. It is only ever the first-born singleton who receives their parents’ exclusive attention and there can be advantages to not being the eldest or an only child!
Loss of Identity
For your first baby(ies), it is quite common to go through a period of mourning the ‘old you’, particularly if you have no immediate plans to return to work. Some mothers also resent the process of dehumanisation, for example 24 / MARCH 2010 www.tamba.org.uk / 25 being called “Twinmum” “Tripletmum” or “Mum” by health professionals. New mothers (and fathers) often describe a disproportionate sense of loss at the thought of missing out on hobbies, going out, not being able to wake up late at the weekends and read the paper in bed – little things which represent their old carefree way of life. Many women also experience a sense of anticlimax once the excitement of pregnancy and childbirth is over; they enjoy being pregnant, the sensation of carrying their babies, the care lavished on them and the interest they receive from strangers, especially in a high-risk pregnancy like a multiple birth. Much as you may love your new babies, it is possible you may feel slightly resentful that they are now the centre of attention while nobody seems bothered about how you are anymore.
Isolation
Given all the time-consuming activities that caring for two babies involve, you may find it difficult to leave your home as much as you might like or be used to. Indeed, Tamba’s 2008 survey found that mothers of multiples are frequently alone, with half of mothers (48%) spending less than an hour a day talking to another adult. Loneliness is strongly associated
with PND and you may find yourself getting trapped in a vicious cycle, whereby you no longer want to talk to other people or feel others will not enjoy your company. As one mother described, “My PND meant I felt very isolated and alone. I did not enjoy doing things and started to withdraw from going out. I genuinely felt that everyone would be better off without me”. While it will undoubtedly be difficult to get out, it is important that you have contact with the outside world, be it speaking to old friends and family members, or joining your local multiples club or baby/toddler group. Not all interaction is positive however, and it may be wise to wait until you feel strong enough in yourself before being around people
who are not supportive, make you feel uncomfortable, or find faults in your parenting. There are several websites where mothers of multiples or women experiencing PND can chat with each other and this can be a helpful support mechanism (see resources at the back of this guide). There are also several freephone numbers, which you call and talk to a sympathetic
person, including TAMBA’s own Twinline (0800 138 0509).
Personal History of Depression or Negative Life Events
PND is more common in mothers who have previously had episodes of depression or mental health issues. A history of depression in family members also increases the risk, probably via genetic (inherited) factors. If you have had any previous experience of depression, you may want to let your GP know so you can be monitored more closely and early action taken if symptoms occur. Becoming a parent can also trigger many emotions and evoke memories
of negative life events such as bereavement, miscarriage, termination or loss of a baby, or an unhappy childhood marred by violence, abuse or loss of a parent. For example, one mother described struggling with PND and having “real difficulty dealing with the past and this was haunting me day and night, 24 hours a day”. In twins and higher order multiples (triplets and quads), loss of one of the babies may also increase the risk of PND.
Lack of Practical and Emotional Support
Trying to look after two or more babies on your own is physically and emotionally wearing and lack of support is a key cause of PND. Unfortunately not all mothers have people around who can help them. Single mothers, women whose partner works long hours or travels frequently, and women living far from their extended family are particularly vulnerable, but
so too are mothers with elderly parents or strained relationships with their family, especially if they do not want to help. Talk to your health visitor or doctor if you are struggling to cope, as there may be some local support available (college students, Homestart, community nursery nurses), but even this is often limited to a few hours a week and may not be available where you live.
Changing Body Image
Feeling uncomfortable with your new body image can be a source of disappointment for many mothers. It can be quite a shock to see the exhausted woman looking back at you in the mirror still wearing maternity clothes well into the first year, but it takes time for your body to recover and for you to mentally adjust to your altered body shape. Be kind to yourself and remember your body has just done something wonderful – carried and given birth to more than one baby.
Non Baby Related Stress:
Financial and job concerns can often be enough to trigger postnatal depression, as can other worries or bad events happening in your life. When possible, it can help to talk about these feelings with your partner, family member, friend or professional.
Will PND Recur?
If you have previously had postnatal depression, you are at a higher risk of developing PND and other types of depression again, although there are no precise figures for a recurrence. You and your family should be alert to the symptoms and seek help at the earliest opportunities. Practical steps you can take involve arranging plenty of support for the first few weeks and months, particularly to help care for older children (e.g. Homestart). If you can afford it, paid help like doulas or maternity nurses can be useful. Many mothers are also advised to take extra precautionary measures from late pregnancy onwards. Your doctor, midwife or health visitor may be able to arrange extra psychological support during pregnancy and in the period immediately after the birth. Some GPs offer a very low-dosage
anti-depressant during the latter stages of pregnancy and then increase the dosage after the birth; others recommend starting antidepressants immediately after the birth. Although it is always preferable to take as little as possible in the way of medication during pregnancy, some doctors believe that the risks need to be balanced and in some cases the benefit to the mother outweighs the risk to the baby.
Life After PND
When your depression finally lifts, you may have mixed feelings about what to make of the whole experience. Some mothers are embarrassed and feel guilty about how it affected their partner and family. Others are pragmatic, acknowledging that it is something that happens to a lot of new mothers. Unlikely as it may seem, it is possible that the depression can make a positive long-term difference to your life. Going through PND can be a learning process and help you to come to terms with unresolved issues, especially if you have had professional help. Some women say the experience has made them a more compassionate person and more aware of other people around them. They now look out for other mothers of multiples
who are struggling, often by becoming actively involved in their local multiples club. You may be surprised at how many other people suffer from depression and how much you have to offer them, even if it is just a sympathetic ear. PND is not the end – there is life afterwards.
Courtesy of Tamba - www.tamba.org.uk
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