Maternity Blues: Revealing the side B of motherhood

"In the setting of a decaying yet familiar house, I could hear the voices of my son and my husband. Both of them in their swimwear. Both splashing in the blue plastic pool with the water at thirty-five degrees. It was a Sunday on the eve of a public holiday. I was just a few steps away from them, hidden among the weeds. I was spying on them. How was it that I, a weak and sickly woman who dreams of a knife in her hand, was the mother and wife of those two individuals? What was I going to do? I laid my body deep in the ground. I wasn't going to kill them. I dropped the knife. I went to hang the laundry as if nothing had happened."

Ariana Harwicz is an Argentine author of the book "Die, My Love." The novel tells the story of a young mother who experiences postpartum psychosis while taking care of her baby alongside a husband who struggles to connect with his wife's emotions.

According to Harwicz, women disliked her book more than men. In fact, one of the most common criticisms towards the author was for writing about "murderous mothers who reject or hate their children."

The idea of a mother not feeling love for her firstborn was inconceivable.

Why did Ariana Harwicz dare to break with the idealization of motherhood? Who was this author questioning the image of smiling and perfect mothers portrayed on magazine covers? Who dared to challenge what many women define as "the happiest moment of their lives"? "Die, My Love" was published in 2012, and at that time, it faced strong rejection from Argentine and Spanish publishers.

Over the years, perspectives have evolved, and in 2022, readers began interpreting the book differently. Along with this reinterpretation, the novel's sales increased, a successful theatrical adaptation starring Érica Rivas was created, and a film adaptation with Jennifer Lawrence in the lead role was announced, directed by none other than Martin Scorsese.

Harwicz’s words revived old conversations with mothers. Timid, similar conversations filled with fear of being judged. The stories had certain common points: the prevalence of moments of exasperation during the postpartum period, the presence of delusions with intrusive thoughts related to their babies, and that all - every single one - felt shame, silenced their emotions, and went through this difficult time alone.

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"Maternity blues" or postpartum sadness is a common reaction associated with the hormonal changes a woman experiences after childbirth. It reaches its peak between the fourth and fifth day after childbirth, gradually decreases in intensity, and disappears, normally, after 10 days. 

Dr. Victoria Santé, a specialized psychiatrist, explains that "maternity blues" is not considered an affective disorder itself but a typical response of most women to this new stage of life. It occurs due to abrupt changes in baby care and life in general. It is a transient disturbance that has a short-term psychological impact and between 50 and 90 percent of women experience it.

In contrast, postpartum depression involves a psychiatric diagnosis. According to Dr. Santé, it has an incidence rate of 12 to 20 percent, and although the symptoms are not different from depression outside the postpartum context, there are some differences. Postpartum depression can include dysphoria, irritability, anxiety, instability, agitation, fears related to baby care, and sleep deprivation.

"Having irregular sleep patterns can trigger any psychiatric disorder. Not sleeping throws anyone off balance", Santé asserts

The most severe condition among postpartum disorders is postpartum psychosis. It is a clinical entity that falls under the umbrella of mood disorders and, being a polymorphic condition with extensive symptoms, it presents differently in each woman. Its prevalence is much lower than the previously mentioned diagnoses, affecting only 0.1 to 0.2 percent of women.

Dr. Santé emphasizes the importance of recognizing that this stage is part of a woman's hormonal cycle and involves drastic and intense hormonal, physical, and emotional changes. Additionally, during this period, there is a redefinition of the environment and an adaptation to the constant care of another person for months, or even years. This process requires psychological flexibility, which is closely associated with interpersonal relationships, the environment, and the socio-cultural network that women have.

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“What leads mothers to kill their children”, a harrowing documentary released in 2022 by German public broadcasting service “DW”, tells the story of Carol Coronado a young mother living in the United States. On May 20, 2014, a day filled with violet and strange ideation, Coronado murdered her three daughters.

On the day she committed the crime, Carol called her mother for help, stating that she felt unwell and strange. In the documentary, Carol’s husband mentions repeatedly that he was "raised to work, to provide" and explains that his wife was responsible for "all the household chores and the complete care of the three girls." He further mentions that on the morning of the worst day of his life, Carol was acting "strange, crazy," and for that reason, he decided to leave for work early and left her alone with the three girls because he simply "couldn't deal with it."

This is what Dr. Santé refers to when talking about the woman's socio-cultural network. In Carol Coronado's case, she was alone.

Both her family circle and the healthcare system failed her.

The latter, healthcare systems, focuses almost exclusively on the care of the newborn and pays little attention to the mother's symptoms and physical and psychological well-being.

As for risk factors, Santé mentions a history of mood disorders, a history of postpartum psychosis in previous pregnancies (after a first episode in a first pregnancy, the chances of it recurring in a second pregnancy increase to 60 percent, and after experiencing postpartum psychosis in two previous pregnancies, there is a 90 percent chance of it occurring in a third pregnancy), hospitalizations during pregnancy for bipolar disorder or psychotic episodes, family history of affective disorders, first-time mothers, and complications during childbirth. Pharmacological treatment will vary depending on the case.

As mentioned earlier, although postpartum psychosis has a very low prevalence, it is a disorder with a high recurrence rate that usually has a good prognosis with appropriate medical intervention.

"Once a woman receives treatment with strict follow-up, the outcome is usually favorable," Santé points out.

Marina Martínez Jorde, a Spanish midwife, highlights the importance of a new service that first-time mothers in Spain are turning to: private doulas.

"Of course, we are talking about mothers who can afford it, who have the money. Doulas are figures who are not part of the public system but are fulfilling a role that helps the mother. They provide support to the woman before, during, and after childbirth," she explains.

Just like Martínez Jorde envisions a public system that funds a greater presence of midwives in primary care, with a focus on the mother, other women from all over the world are initiating the same debate among the over 8,000 comments on DW's YouTube documentary.

These women describe, in an online space where they feel free from prejudice and accompanied, characteristic symptoms of postpartum psychosis. Dr. Santé lists these features, which include difficulty sleeping, mood fluctuations accompanied by anxiety, hallucinations, delusional thoughts related to the newborn (such as fears about their safety), disorientation, confusion, and alterations in mental state. "Usually, the first thing the environment notices are the person's strange behaviors," she explains.

"When my babies were born, I experienced everything they mentioned, but thanks to my husband, who took care of washing, cooking, and the baby when he returned from work, I only went through that difficult stage for a short time. Fortunately, I was able to overcome this terrible stage." 

"I experienced postpartum depression after the birth of my baby. My children were only 17 months apart. I never wanted to harm them, but I had abnormal thoughts, hallucinations, and sensations that scared me. I knew something was not right, so I sought help immediately. It was a dark place." 

"I suffered from postpartum psychosis. I even told my son that he was the devil and I imagined, on more than one occasion, drowning him in the bathtub. I went through it alone, without telling anyone, not even my husband. I felt ashamed, but I was lucky. Seven years later, I found out that my mother had also suffered from postpartum psychosis when she had me, which is why I lived with my aunt for a few months." 

"If I complained of any pain, my mother told me to shut up, that it was no longer important, that the baby's well-being was what mattered now."

A quick search for "postpartum psychosis" on Google yields dozens of news articles about women who, like Carol Coronado, committed infanticide.

However, statistics show that the real highest risk of these disorders is the high rate of maternal suicide. 

For this reason, postpartum psychosis is a psychiatric emergency.

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In 1960, my grandmother, a rural woman in an unfavorable economic situation, went to the nearest hospital to have her first baby there, with better care. It was a painful, unpleasant experience. There, she experienced first hand what obstetric violence was. She decided never to give birth in a hospital again and followed the tradition of other women in the village: giving birth at home with a midwife who had no medical qualifications but had assisted in over a hundred births. The midwife accompanied mothers from the early months of pregnancy, guided women's and their families' health practices, shared her knowledge of traditional medicine, provided care and support during childbirth, and also assisted in the postpartum process by collaborating in baby care. My grandmother gave birth at home, accompanied, supported, and held by another woman who did not leave her side even when things became complicated.

Nowadays, in births considered "normal" according to current standards, women are discharged from the hospital in just one or two days. The automatic doors of the hospital close behind them, and the new challenge begins: what many label as "the best moment of your life" could actually not be so great for others.  Mothers will start facing the weight of symbolic violence hidden beneath the romanticization of motherhood. They must understand and manage the hormonal surge whilst having to learn to deal with a baby who won't stop crying, whom they must love with all their heart, all their soul, and all their strength, unconditionally, like no one else. 

Women need support after giving birth. Childbirth may be commonly labelled as the greatest experience in life, this feeling isn’t mutual for all women globally. Understanding and recognising postpartum psychosis as a psychiatric emergency is just the first step. It is at this moment, when women are in their most vulnerable and lonesome state, when a solid network of care and support is needed more than ever.