Maternal Mental Health Matters
Ibone Olzaa , Patricia Fernández Lorenzob , Ana González Uriartec , Francisco Herrero Azorínd , Susanna Carmona Cañabatee , Alfonso Gil Sanchezf , Esperanza Amado Gómezg , María Emilia Diph
a) Perinatal Psychiatrist. European Institute of Perinatal Mental Health, Madrid.
b) Clinical psychologist. Health Zone III. Mental Health Service in the Principality of Asturias.
c) Health Service of Navarra. Infant-Juvenile Mental Health Centre in Pamplona (CSMIJ Natividad Zubieta).
d) Social educator. La Dinamo Acció Social, Valencia.
e) Neuroimaging Section, Experimental Medicine and Surgery Unit, Gregorio Marañón Health Research Institute, Madrid. Centre for Biomedical Research in the Mental Health Network.
f) Psychiatrist and obstetrician. European Institute of Perinatal Mental Health, Madrid.
g) Psychiatry Department. Puerta de Hierro University Hospital of Majadahonda, Madrid.
h) Clinical psychologist. Perinatal Mental Health Program. Vall d’Hebron University Hospital, Barcelona.
Originally published in Spanish: Propuesta de un modelo ecosistémico para la atención integral a la salud mental perinatal.
ABSTRACT:
Mental health care has traditionally paid little attention to mothers. Comprehensive perinatal mental health care programs are very scarce in our environment. We propose a framing model that serves for comprehensive perinatal care, including care for the mental processes of reproduction, pregnancy, childbirth, and postpartum from an ecosystemic vision inspired by the proposals of Urie Bronfenbrenner and John Bowlby, among others. The model integrates data from neurobiology and epigenetics and theories from systemic and intergenerational transmission of attachment and trauma. It is embedded in a gender and ecological perspective that allows to make visible the mother-baby dyad’s needs in the center as a starting point for prevention and attention during the perinatal period. We propose a perinatal view as a model to continue deepening care for mothers and families at the beginning of life, as well as to care for the professionals who care for them. We bet on listening, support and psychotherapy as basic tools in community and individual care for mothers, babies, and families.
Key words: perinatality; ecosystem; maternity; paternity; pregnancy; childbirth; puerperium; exterogestation; lactation
Reasons for an ecologically valid perinatal and developmental psychology
Public and private health systems pay scarce attention to MENTAL HEALTH OF WOMEN DURING PREGNANCY, DELIVERY AND POST-PARTUM. Traditionally, obstetrics has focused its attention on the more physical aspects, showing little interest in the psychological processes of reproduction. Too often, pregnant women and mothers have not been listened to, their suffering has been minimised or normalised; they have been told the typical ‘what are you complaining about if you have a healthy baby’ and they have even been judged and/or mistreated without health professionals being aware of this mistreatment1. The stigma surrounding mental illness, together with the misogyny that medicine is still permeated in, has made it difficult for mothers to seek and find effective help. During pregnancy many feel treated as mere containers, whilst biomedical care is often reduced to ensuring that the baby in the womb is well in immediate terms (we prefer not to call it a foetus). Health care is blatantly nonexistent regarding the needs of mothers during the postpartum period. The baby is also seen as an isolated entity, with no regard for the construction of its psyche or the necessary mother-baby symbiosis at the beginning of life. However, there is growing scientific evidence that the emotional state of women during pregnancy, childbirth and postpartum has enormous repercussions, both for her and the unborn child, for the physical and mental health of each and every member of the family, in the short and long term(2). In turn, a father is increasingly present on a daily basis as emotional support for the mother-baby dyad. His ability to care for and reposition himself in the family is important when considering the effect of this evolutionary crisis for the couple, which favours the growth and maturation of the whole family system and of each of its members.
Fortunately, sensitivity is growing also among professionals who are progressively approaching this reality wishing to not perpetuate paternalistic and medicalising dynamics. Many are searching for tools which allow to offer comprehensive care for the health of mothers and babies throughout the entire stage, taking into account consequences on development. As perinatal mental health professionals, we propose a framework that allows us to integrate all the aspects that have short and long-term repercussions on the mental health of both mother and baby, the couple and the extended family. In other words, we believe that mental health care of families around pregnancy, birth and parenting requires a broad, holistic and feminist vision that promotes the health of all and prevents psychopathology by integrating a gender perspective. It is time to unlearn and deconstruct inherited models that we believe to be inoperative and even harmful due to their reductionism or gender bias.
Grounds for an ecosystemic model of perinatal mental health care
The ecosystemic model we propose is based on systemic epistemology and, in particular, on the theory developed by Urie Bronfenbrenner in his book, “The Ecology of Human Development”(3). His systemic and phenomenological approach seems to us to be a good starting point for a valid and flexible integrative model applicable to perinatal understanding and care.
In turn, we integrate the attachment theory masterfully developed by John Bowlby and Mary Ainsworth as an epigenetic model of the development of the individual(4,5). They explained the relevance of the mother, the primary attachment figure, as a secure base from which to explore the world and warned about the consequences in the socioemotional development of individuals if this bond was damaged. The most recent findings in neurobiology of attachment at molecular and epigenetic levels demonstrate the intergenerational transmission of attachment style(6), which ratifies the classic contributions of systemic theory and its application in family therapy. We incorporate recent research in neurosciences that, based on evolutionary biology and epigenetics, show us the importance of habitat for human beings in their neurodevelopment, ratifying the need to promote practices such as breastfeeding or early and close contact between mother and baby in order to take care of the physical and mental health of both of them(7).
To all of these proposals we incorporate a gender perspective that we consider essential. Too often clinical practice of women in their transition to motherhood has been interpreted from a male subjectivity(8). The growing presence of women professionals and researchers in this field allows us to continue reworking the data, incorporating readings that place women as the protagonists of their maternity and as a priority figure for the integral development of the children to whom they give life.
Bronfenbrenner criticised something that we consider accurate when he pointed out how “a good part of developmental psychology, as it exists today, is the science of the strange behaviour of children in strange situations, with strange adults, for as short a time as possible”(3; p. 38). In contrast to the reductionism of psychology laboratory of that period, which studied the development of children while ignoring many of the environmental variables, his proposal for understanding psychological development was to integrate ecological environment, which he conceived as a set of serial structures, each of which fits into the next, like the Russian Matryoshka doll or the layers of an onion. We will now explain this model of layers or concentric circles, which allow us to see the environment in its totality, as someone who sees the forest beyond the tree.
Ecosystemic perinatal integration
- a) Microsystem
In Bronfenbrenner’s ecological scheme, the innermost layer corresponds to the developing individual. We admire the author’s sensitivity and intuition in saying: “every child needs at least one adult who is irrationally crazy about him or her… First, last and always”. From this approach, the basic unit in human development would be the mother-baby dyad. We consider the two together because of the development that motherhood entails also for the woman: if one of the two members undergoes a developmental process, the same will happen to the other(3; p. 86). It is a two-way relationship that continues to exist phenomenologically even when they are not together and it extends far beyond the immediate puerperium, extending to what authors, such as Esther Ramírez Matos, call the “emotional puerperium”(9).
This level corresponds to the study of the baby´s biological reality from the beginning of uterine life, taking into account genetic aspects and trying to understand the effects and consequences of aspects such as exposure to toxins including, amongst others, maternal stress. The neonatologist Nils Bergman draws from neurobiology, epigenetics and evolutionary biology to underline that “the mother´s body is the baby´s natural habitat”(10,11). In particular, it considers the changes that occur during exterogestation (the period that covers the first eight or nine months of life, in which the baby needs almost continuous contact and support) and throughout the duration of breastfeeding as a facilitator of neurodevelopment. Knowing the relevance of preserving the newborn’s natural habitat allows us to intervene to favour -as much as possible- physiological birth, non-separation after birth and all types of care practices that involve attending to the dyad as a system.
The development of the baby’s psyche from pregnancy onwards takes place in close contact with the mother’s body and psyche. Being that the mother is so relevant for the child’s development and knowing that she is experiencing, at the same time, her own maturation process, we need to understand the crisis and transformation that each new motherhood brings about. Mother psychology remains largely unknown in academic and clinical circles. Historically, there has not been sufficient sensitivity to this area. We propose to continue studying it in depth from a feminist framework that also integrates the spiritual(12), based on the contributions of psychology, in recent neuroimaging research(13), in understanding attachment and its transgenerational transmission. We cannot forget the gender context and the socio-political framework of motherhood, honouring its transformative dimensions and its creative potential. Along with what is common to all mothers, we pay attention to the individuality of each one from their psychobiography, their own bonding story, and taking into account expectations, experiences and representations that they make of their babies and of themselves as mothers.
- b) Mesosystem
We include here the relationships that the dyad establishes with other environments in which it actively participates. The partner, families of origin, the woman’s work environment or health personnel are other individuals that most usually accompany mother and baby. Again we quote Bronfenbrenner, who indicates that the capacity of a dyad to serve as an effective context for human development, is “crucially dependent on the presence and participation of third parties, such as spouses, relatives, friends, and neighbors… If such third parties are absent, or if they play a disruptive rather than a supportive role, the developmental process, considered as a system, breaks down; like a three-legged stool, it falls over more easily if one leg is shorter than the others”(3). Actively participating in diverse environments has enormous evolutionary potential throughout development, but necessary conditions must be in place. It is vital to be aware of the latter and to take care of the start of each new relationship to which this delicate system is exposed.
In this sense, it is therefore important to understand and take care of the father or partner as well, be aware of his changing psyche and the characteristics of his bond under construction, which benefits from observing and sustaining the dyad. Neuroscience also evidences the independent role of paternal interaction in neurodevelopment, and not only as emotional support. It is necessary to delve into the history of the couple and what defines it, explore possible episodes of violence experienced in the present or past, inside or outside the current affective relationship, bearing in mind that pregnancy increases the risk of suffering gender-based violence(14). We must explore family dynamics, the story of attachment for each parent in their own families of origin and the stressors that may add to the developmental crisis of birth for each offspring.
We carefully observe each encounter between the dyad and the healthcare environment, encouraging professionals to become aware of the crucial position they occupy and their work. Hence, training in interviewing, observing and listening skills is urgently needed to enable emotional accompaniment. Training of each professional should include personal work and supervision that will allow them to get to know themselves and heal their own emotional wounds in order to be able to accompany without unintentionally harming others. Self-knowledge favours the improvement of the bonds and dynamics that are established in work teams. It is also important to take care of physical spaces that focus on the dyad as an indivisible unit, which often means rethinking the architecture of maternity wards, delivery rooms, neonatal ICUs, etc. The figure of the clinician and, in particular, that of the psychotherapist represents a role analogous to that of a mother, offering a secure base from which to explore the world and situate oneself in it(15).
We must also take into account and care about women´s working environment. Their explicit and implicit work conditions, the adjustment of tasks, goals and priorities are to be creatively and specifically adapted to favour both the company and each mother and her baby. It is imperative that all systems be aware of their significance for the well-being of the dyad and that they conceive parenting and development as a social value in which everyone assumes a differentiated role calling upon the benefits of cooperating for the better growth of our species.
- c) Exosystem
On this level of analysis, we observe the dynamics and actions that engage the environments surrounding and affecting the dyad, even if the latter does not actively participate. The developing baby and its parents considered as a system may be partly and indirectly affected by contexts in which they are not present. We refer here to the relationships, for instance, between health and labour systems that have an impact on the mother without her participation; for example, the non-transferable paternal leave recently approved in our country. This measure, although conceived with the good intention of interfering in the hiring decisions of companies, has not taken into account the interests and needs of each mother, the best option for each family, let alone the baby’s own needs, even though it is a measure that affects all of them. We make this extensive to medical protocols that establish generic practices in childbirth care without considering the story and needs of each woman regarding her physical or mental health and breaching individual freedom or increasing the risk of complications in the outcome of childbirth. From our ecosystemic framework, we observe with confidence the currents and initiatives that, from social, educational and health fields, seek to value the role of care and motherhood as guarantees for the neurodevelopment and mental health of the individual. In this sense, we highlight proposals such as the network of baby-friendly hospitals (IHAN) promoted by UNICEF, NIDCAP neonatal units, and support groups of breastfeeding or Milk Banks for mothers, among many others. It is important that the work carried out by different public services is used to nurture the dynamics of the previous layers (microsystem and mesosystem); to cover needs without losing sight of the relational dimension in which the person participates, as mothers are often extracted from their context through a misunderstood ‘individualised and specialised care’ and intervention is –supposedly- carried out with objectivity and neutrality that denaturalises what is happening with a crippling simplification that hinders a subsequent healthy relational dynamic. We find this framing especially necessary in the context of social services for the support and protection of early childhood.
Hence the ecosystemic model lays the foundation on the community dimension of the public, abstracting it and making it explicit in every action and interaction. It also facilitates a work model between mental health and neonatal and maternity services(16).
- d) Macrosystem
It refers to the beliefs and values that comprise and embrace the ideologies of each culture and society. They are expected to permeate each of the above layers. The manner of conception, gestation, birth and upbringing is the reflection of underlying management in each culture. Ours, in the 21st century, is a technological and urbanised society undergoing significant changes and dragging along a lengthy crisis in its socio-economic model. The crisis of the model has repercussions on the diverse options that are emerging simultaneously and that, undoubtedly, affect family and the status of motherhood for each woman in her life and in the many roles that she carries out simultaneously. In Bronfenbrenner´s words: “members of a changing society forcibly undergo evolutionary change at every psychic level: intellectual, emotional and social”(3; p.288), so the macrosystem in motion is the means through which change is possible.
Being a mother in our Western culture has been understood over time in a stereotypical and univocal way(17). Many women felt suffocated in this private task and stripped of their own identity. As Victoria Sau said: “under patriarchy, we are all motherless”(18). She refers to the mother as a subject, with all her individuality, and not to the mother as an institution or entity with well-defined and unique frames. In current neoliberal societies, babies are third-rate citizens who are not being taken into account on a psycho-emotional level and are considered by many as a market product that can be easily torn away from their maternal roots. Birth and upbringing continue to be experienced primarily from a biomedical-technological point of view, which emphasises exclusively on guaranteeing the baby’s life as an immediate result.
Feminist struggles have made it possible for women to have rights and options, often disregarding babies and motherhood as an identity and as a life choice. Understanding the history of feminist struggles allows us to understand the crisis of motherhood and mothers, who are also women, who undergo a transformation towards a broader identity that -for a long time- includes the developing baby to whom she remains attached. Contemplation of society and culture also requires understanding where motherhood has stood throughout history and its link to the presence of the father for the recognition and legitimisation of her and her baby. Even though we have moved towards new and broader family models, motherhood is still valued for its product and hardly for the transformative experience it entails. But as a society in crisis that is being built from below, from the individual to the collective, we highlight the proposals that converge in broader movements and visiblise respectful care and citizenship of individuals and the environment that surrounds us and of which we are a part.
The social status we have reserved for childhood influences the devaluation of all the processes of upbringing and accompaniment. Adult-centric society is defined in the image and likeness of the male and healthy adult and all the rest are transitions, incomplete and devaluated realities. Children need a social, ecosystemic model that recognises them with their needs and desires, that sees them in relation to a fundamental part of the social system. They are not appendages, they are not family burdens that cause dysfunctions, but a reality that owing to their demand helps to structure and generate social cohesion. The macrosystem makes it difficult for us to see beyond the future projects that children represent, but in our view, their present and daily existence is fundamental. We are also convinced that a precarious childhood condemns the future well-being of society as a whole.
The perinatal view
The perinatal view that we propose from this ecosystemic framing as a frame and guide for our work is based on contemplating the baby, placing it at the centre together with its mother. Cultivating this gaze means constantly asking ourselves questions while observing and respecting the individuality of each individual: How is the baby experiencing this? How will he or she perceive my emotion? How does it affect him or her? What does he or she need? It is urgent to acknowledge that each baby feels and suffers, communicates, expresses and needs to be listened to, observed and loved. What they experience is engraved on them and marks them, having an effect throughout their development, even when they are unable to name it or identify where it comes from. Ours is a view that cultivates amazement and fascination. We observe the here and now of the baby, extending the focus to all its possibilities and competences: “I look at the babies and their families with empathy, love and compassion in order to work with the best, with the healthiest part we all have, even during the most difficult transitions and the most adverse circumstances”. Observing babies in their natural habitat(19,20), looking intimately and closely at all those people who surround them, enabling psycho-emotional development, is a life lesson for the observer, as well as a therapeutic tool at the service of neurodevelopment.
Beside the baby is its mother. Beyond what mothers have in common, we contemplate and accompany them in their individuality: What does this mother need? What is she feeling now? What can I contribute? How has she taken in my words? We delve into the psycho-biography of each one, which helps us to understand her values, fears and priorities. We know that she needs to be supported in order to sustain and we investigate in each case where and how does she need support at all times. As feminists, we value the needs and rights of the dyad, adding the father or partner as emotional support. He or she is also born into his or her new identity and has few peers in his or her immediate environment to guide him or her regarding childcare. We will try to guide the parent or partner to understand and admire the miracle of life that takes place in his or her partner and through her. It is important to humbly and courteously help them to find their loving place, reminding them how essential their role is in caring. It is therefore necessary in many cases to facilitate individual or group therapeutic spaces in which we can deconstruct the patriarchal discourse around parenthood.
We will point our gaze outwards to include the environments close to each dyad, considering the opportunity for growing that each new being brings to all of those around. As professionals we observe ourselves knowing that we are part of what is being observed and that our vision and message is always impregnated with our own story. Hence it being essential to turn our gaze inwards, contemplate our own nature, from the skin and whole body. Becoming aware of what we feel in our heart, womb and entrails. In the present and in the memory of our own story that our body holds. From our circling view we know the effect of our presence and attitude for the developing dyad.
As professionals we are instruments of change and as such we are constantly fine-tuning our work tools. We do not neglect self-care. Thus, in our training and in our work, we propose to constantly review our feelings and actions as daughters, mothers and women. We are aware of our own symptoms of distress and those of the teams with which we work and we seek to create multidisciplinary spaces where we can share emotions and needs, which serve as mutual support and broaden our gaze at the same time. We contemplate our own “baby self”, through our memories as the children and daughters we were. We look at ourselves as women and as mothers of each of our children. Men and women, we were all babies and we have memories, feelings and lessons that we can remember and re-tell. Our story represents us and brings us closer to the babies we accompany, to our mothers, to their mothers.
How to care for ourselves and for those we accompany, occupies a central place in the stage of perinatal care. Our work is based on self-observation, knowledge and understanding of our story as health professionals, as a society, as women and men in it, but it is also based on the individual story of each one of us as the sons and daughters we were and the mothers and fathers we are or could be. By observing ourselves and getting to know ourselves we can observe another individual, knowing where we start off from, with what similarities and differences, with what resonates from their story. Listening is part of the observation. Listening to mothers and fathers from a horizontal and not hierarchical vertical position. With a humanistic attitude we will develop respectful and attentive listening. Listening in clinical practice will seem as an apprentice who admires the teacher to then integrate what he or she has learnt, thus deconstructing patriarchal hierarchies attached to the biomedical model. Our gaze allows us a richer and deeper understanding of each human being in his or her culture and environment. Through experience of attentive and contextualised listening, we re-tell each story starting with our own, that of each one of us in our origins and early bondings; finding stories that help us to understand ourselves and to understand, prevent, heal, raise and grow. We care for each word, using them with respect and moderation, especially when we re-tell the story of each baby, then child, as he or she comes into the world and when we seek to rewrite our clinical practice to enhance its therapeutic and healing power. We care by respecting our rhythms and those of others, and also when we contain and embrace. We care when we flow with those with whom we resonate when sharing feelings and knowledge. We care by learning together, sharing lessons to collectively build knowledge. We make the most out of science, but we do not waste the richness of shades that we gain with the experience and intuitive gaze after observing with our heart and guts. We allow enjoyment and pleasure to guide us; our body works as a thermostat because we care with it, from it and through it.
Our ecosystemic model does not leave out the surrounding environment. We take advantage of our natural potential, knowing that we interact with the environment and pursue it for mutual benefit. It is ecopsychology: understanding growth and development in a healthy environment, which protects the healthy part of our nature. Ecology begins in the womb, respecting the maturational rhythms of baby and mother, preserving a toxin-free environment for both. It continues with parenting which promotes a connection with the natural environment; a skill that children frequently have. As adults who have become disconnected from cycles and rhythms, we will learn to rethink our own by respecting the times and needs of each baby. Breastfeeding is also the ecological option that we encourage and offer to each dyad as a means for mutual development, as a freely-chosen option and with the necessary support. Understanding and totally respecting the decisions that each mother makes on the delicate issue of infant feeding, which are often marked by previous stories of great suffering and/or bodily disconnection.
Motherhood, for us, is an intimate task, but one of enormous personal and social impact (21). We sustain each woman’s motherhood, supporting each woman in her individuality in an attempt to expand the healing and empowering role of giving life and bringing life into the world; we accompany her in doing so. We want motherhood to be a life choice that does not imply loneliness or isolation, but rather a wide network, a succession of healing concentric circles. We are thus breaking the intergenerational transmission of violence starting with the upbringing and what it means for children, mothers and fathers. We are making way for relationships based on love, care and cooperation.
1 In her recent report of July 2019, the UN rapporteur described obstetric violence as a global problem, something that the WHO had previously acknowledged (1).
REFERENCES
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