Childbirth is not only complex: it may also be dangerous

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Childbirth is not only complex: it may also be dangerous MARTA B. RONDON Universidad Peruana C. Heredia, Lima, Peru

In Latin America, a pregnant woman has the certainty of having skilled health staff attention during delivery only in Cuba, Costa Rica, Chile, Argentina and Uruguay. The maternal mortality rate in our countries averages 190 per 100,000 live births (1). While there is wide public knowledge of modern contraceptive methods, they are not always available and abortion is illegal in most countries (2). Post-partum disorders must be viewed in this context of lack of attention even to the most visible aspects of childbirth. History taking in overburdened emergency maternity wards does not allow for collection of data about the mother’s psychiatric history, let alone her current emotional status. Very short stays and lack of follow-up make 98

early recognition of emotional disorders very unlikely. And yet, everyday we witness the consequences of undiagnosed and hence untreated puerperal disorders. Accounts of puerperal women killing their children are the most prominent examples, but our high rates of child abuse probably reflect irritability and fatigue in depressive mothers as well as difficulties in the mother-infant relationship, an area that needs to be investigated further, as stated by Ian Brockington. Whether maternal emotional disturbances are causative of developmental delays and adjustment problems in the children or whether they just coexist, being both the result of unfavorable circumstances, needs to be elucidated. Some researchers in Latin America have looked into the prevalence and incidence of post-partum depression. In Chile, Jadresic and Araya (3) reported World Psychiatry 3:2 - June 2004

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that around a third of post-partum women had depressive symptoms. Risco et al (4), also in Chile, found that up to 48% of women, surveyed 12 weeks post-partum, had a score on the Edinburgh Postnatal Depression Scale above 9. When a sample of Chilean women was compared with two samples of Costa Rican women, the rates of depression and dysphoric mood following childbirth were similar (34% vs. 47% reported current dysphoric mood, 40% vs. 48% reported an episode of major depression sometime during their life and one third of the Costa Rican women reported dysphoric mood following the birth of a child), in spite of differences in demographics. The current thread in these papers is the importance of psychosocial factors. The findings of Risco et al (4) and Wolf et al (5) clearly show an association between post-partum depression and unwanted pregnancy, having three or more children already, lacking a partner, vaginal delivery, having conjugal conflicts or being single, having few years of education and living in crowded households. Apparently, the lack of sexual and reproductive health (expressed in unwanted pregnancy) is linked to postpartum mental disorders. Women with less education and lower socioeconomic status seem to be at a higher risk of having a pregnancy they do not desire. Single women, teenagers and women over forty also tend to present more unwanted pregnancies. Particularly worrisome is the situation of pregnant adolescents. Young age is a recognized risk factor for puerperal depression (5). Pregnancy for a young girl means the interruption of schooling and of personal growth and it is a harbinger of future poverty. It may also mean estrangement from the family, either because the pregnancy is the result of incest or because the family holds very rigid conservative values. For the children of these young mothers, there is an increased risk of rejection and neglect. Young girls living in an institution for pregnant teenagers in Lima showed lack of knowledge about their own anatomy and physiology

(even after childbirth), had difficulties relating to their children, who were subject to neglect and abuse, and suffered not only from depression, but also from post-traumatic stress disorder (6). These girls lived under the protection of Catholic nuns, as their own mothers had thrown them away from the house – in an exquisite disqualification of maternal love – and they faced the possibility of becoming live-in maids once they were discharged from the shelter. Lack of social support becomes more important as people migrate to big cities, fleeing violence or starvation. With the disappearance of the extended family, the rituals that insured that women received social recognition and instrumental help after parturition are falling into oblivion. For the high percentage of women that work in the informal sector, social protection is lacking: no maternity leave, no provisions for breast-feeding, no child care available. Maternity is overvalued in our countries, and yet it is unprotected: the complex emotional experience of motherhood is not taken into account, as becoming a mother is glorified as if it were indispensable for womanhood. It is very difficult among non-professionals and professionals to recognize that a woman who has had a child recently might be undergoing psychiatric problems, mostly depression, as this contradicts the expectation of bliss and happiness supposed to be part of becoming a mother. Mental health professionals have a tough task: they must educate themselves regarding these disorders and they must disseminate the information at all levels, from the medical schools to the executive and legislative bodies. The improvement of obstetric and mental health services for women in Latin America will not be possible without the participation of knowledgeable users and providers.

3. Jadresic E, Araya R. Prevalence of post partum depression and associated factors in Santiago de Chile. Rev Med Chil 1995; 123:694-9. 4. Risco L, Jadresic E, Galleguillos T et al. Depresión post parto: alta frecuencia en puérperas chilenas, detección precoz, seguimiento y factores de riesgo. Psiquiatría y Salud Integral 2002;2:61-6. 5. Wolff A, De Andraca I, Lozoff B. Maternal depression in three Latin American samples. Soc Psychiatry Psychiatr Epidemiol 2002;37:169-76. 6. Vega-Dientsmayer J, Mazzotti G, Stucchi-Portocarrero S et al. Prevalencia y factores de riesgo para depresión en mujeres post parto. Act Esp Psiquiatr 1999;27:299-303. 7. Yactayo M, Rondón M, Mendoza M. Trastorno de estrés post traumático en adolescentes embarazadas en Lima. Psiquiatría y Salud Integral 2001;1:127-32.

References 1. United Nations Population Fund. Maternal mortality update 2002. New York: United Nations Population Fund, 2003. 2. Langer A. El embarazo no deseado: impacto sobre la sociedad y la salud en America Latina y el Caribe. Pan Am J Public Health 2002;11:192-204.

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