Giving birth can bring such profound physical, mental and emotional changes that a woman may have no idea how well, or not, she is coping six weeks later. Yet, this is when she is routinely discharged from maternal healthcare by a GP.
Between 10 and 15 per cent of women experience some level of postnatal depression, which may not develop until long after six weeks. Suicide, which is at the extreme end of mental health risks associated with early motherhood, is the leading cause of “late” maternal deaths (ie between 42 days and one year after the end of pregnancy) in Ireland. The numbers are very small, but each one is a tragedy with far-reaching consequences.
Of the 19 late maternal deaths reported to the Maternal Death Enquiry Ireland from 2020-2022, eight were by suicide, making up the majority of the 10 fatalities attributed directly to having been pregnant; the other two direct deaths were due to pulmonary embolism – a blood clot in an artery to the lung. (Of the remaining nine deaths, five were linked to various indirect causes and another four considered coincidental.) The latest triennial figures represent a statistically significant increase on those for the previous decade.
It is nearly 10 years since the National Maternity Strategy identified poor-quality and inconsistent postnatal care, support and advice as one of the weaknesses of the Irish maternity system. Measures introduced since have included expansion of perinatal mental health services within maternity units, and the opening of five community postnatal hubs, with eight more planned.
However, the strategy’s recommendation that the next review of the Maternity and Infant Care Scheme should look at providing an extra GP check-up for mothers at between three and four months, to address any ongoing pregnancy-related concerns, is yet to be acted on. “Such a safety check has particular merit in terms of early intervention for pelvic floor, nutrition and perinatal mental health issues, which may not be apparent at the six-week appointment,” according to the strategy published in January 2016.
I was afraid to talk to family or friends about it for fear of being judged, or worrying other people. I also didn’t know where else to go, apart from my own GP. And I didn’t feel that was an option at the time
— Aolish Gormley
A lack of structured postnatal care is “a silent crisis affecting thousands of women across Ireland”, says Aolish Gormley, a Co Sligo mother who runs a preschool in Coolaney and also works in a new out-of-hours adult mental health support service, Solace, in Sligo town.
In May, Gormley will launch a Year of Care campaign (yearofcare.ie) to highlight the issue. It will advocate for 12 months of postnatal supports for mothers, including improved access to healthcare and funding for peer-led community networks.
The campaign has evolved from a peer-led, maternal mental health community project that Gormley set up two years ago in Sligo, called Ardú – rise together. It runs events to bring women together, improve their wellbeing and break the stigma around talking about postnatal depression.
“I was hearing the same stories again and again of women feeling like they were left behind, struggling, and talking about this huge gap that’s in postnatal care for them,” she says.
“I realised these weren’t isolated stories; we’re all part of a wider systemic issue that can’t be solved with just community supports. That’s why, with a Year of Care, I wanted something that pushed for a change at a national level.
“It’s a public health issue, because mothers are the backbone of families and communities, and we’re strengthened in society as a whole if we support them.”
Extension of post-partum care to at least three months was one of 10 recommendations on perinatal mental health made in a National Women’s Council report last year. The report also stressed the need for increased funding of specialist services, more public health nurses, and research into how marginalised women are faring.
Revision of the Maternity and Infant Care Scheme is stalled pending the conclusion of a strategic review of general practice. The latter, led by the Department of Health with the support of the HSE, aims to identify what is needed to improve GP services for all patients as part of a primary-care-focused health service. GP capacity, funding, training and out-of-hours services are among the areas being examined.
But the maternity review “remains a priority for the Department of Health and the National Women and Infants Health Programme”, according to a department spokesman. Planning and scoping work for the review is already under way within the HSE, he says, and “will be carried out when the strategic review of GP services is complete”.
When that time comes, the review will consider preconception, antenatal, and postnatal care, says an HSE spokeswoman, “and will assess the feasibility of extending the scheme to include additional visits or consultations”.
[ Review into baby and maternal deaths will begin this year, HSE confirmsOpens in new window ]
When that time comes, the review will consider preconception, antenatal, and postnatal care, says an HSE spokeswoman, “and will assess the feasibility of extending the scheme to include additional visits or consultations”.
Gormley herself developed postnatal depression after the birth of her second child three-and-a-half years ago. Having not experienced anything like that after the birth of her first child and with no history of mental health concerns, there was no “red flag”, she points out, at any of her antenatal appointments. It hadn’t begun by the time of her six-week and final postnatal checkup.
“It started slowly where I was just feeling really low all the time and I hadn’t any energy or just didn’t have the same joy for life that I always would have,” she says.
Coming six months after the birth, she knew this was much more than “baby blues”, a common transient phase in the first week of motherhood. At the time, she did not feel there was anywhere to go to share what she was experiencing.
“I was afraid to talk to family or friends about it for fear of being judged, or worrying other people. I also didn’t know where else to go, apart from my own GP. And I didn’t feel that was an option at the time.”
The important thing is for any new mother to ask for help if they are experiencing any symptoms of postnatal depression
— Aileen Hickie, Parentline
Gormley believes the extent of gaps in maternal healthcare depends partly on where a woman is living. For instance, while in Sligo they are “lucky”, she says, to have one of the five operational postnatal hubs, these are focused on supporting women for up to a fortnight post-partum.
There are other services, she acknowledges, but women have to really look for them, and when it comes to counselling there are usually waiting lists. “I feel like we’re dealing with a system that acts too late in Ireland. Crises shouldn’t be the trigger for care,” she says. It should be there for prevention, not just damage control.
[ One-third of maternal death due to suicide, report findsOpens in new window ]
A key reason behind the development of the postnatal hub model was the recognition that women’s postnatal health needs have historically been under-prioritised, the HSE tells The Irish Times. The 2019 National Maternity Experience Survey “indicated that many women felt their postnatal care was at times overly baby-focused, with insufficient attention to their own physical and emotional wellbeing”.
In addition to Sligo, there are hubs in Cork, Kerry, Kilkenny and Portiuncula, Co Galway. Each operates across two to three community-based sites and runs a range of services. “With regard to maternal mental health and wellbeing, birth-reflections services are offered, and those identified as requiring further support can be referred to specialist perinatal mental health services,” the HSE spokeswoman says.
The first year of motherhood is always difficult “because it’s such a shocking rite of passage”, says Krysia Lynch, chair of the Association for Improvements in Maternity Services, Ireland (aimsireland.ie). Describing postnatal care as “the Cinderella” of our maternity service, she says it is an area her organisation has targeted with policymakers. The National Maternity Strategy did lead to the provision of perinatal mental health midwives in each of the 19 maternity services, along with access to psychiatric and psychological support.
“We have women who are traumatised after a highly medicalised birth experience and we also have women who do not have family support in the way they did 40 years ago,” Lynch says.
While acknowledging postnatal hubs are popular with mothers, Lynch says “it’s disappointing that the woman has to go to the care and the care isn’t coming to the woman” in those early days. New mothers on the Domino scheme, home birth or community midwife schemes, have the midwife coming to them for postnatal visits in the home, she says.
[ Call for overhaul of mental health services for new mothersOpens in new window ]
Mothers do not have to leave the comfort of their own homes to avail of Parentline’s national Postnatal Depression Support helpline (01 873 3500). It offers information and guidance to mothers and others suffering from baby blues or postnatal depression, over the phone and in confidence.
“What we hear from parents is that very often a depressed mother finds it difficult to get dressed and get her baby organised to leave her own house,” says Parentline chief executive Aileen Hickie.
Volunteers trained in offering support and guidance in relation to perinatal and postnatal depression can signpost the new mother or father to their GP or public health nurse, community-based support group or a professional counsellor.
“The important thing,” she adds, “is for any new mother to ask for help if they are experiencing any symptoms of postnatal depression.”
Some women hire a postnatal doula for support. The Doula Association of Ireland says care provided by a postnatal doula “can be crucial in filling the gap that currently exists for women in their post-partum care and may be essential in identifying underlying physical or mental health issues that would otherwise be missed in a perinatal health system that is overworked and under-resourced”.
For Gormley, a chink of light appeared the day she felt compelled to start running – and so began her recovery from postnatal depression. “I wasn’t a runner at all, I still don’t think I’m a runner, but I just had an instinct to go running. My son was going to football; I just needed to get out of the house, to be honest, and I ran. I felt this shift in how I felt and so I pursued that feeling,” she says.
“I ran a lot, and so it was looking after my physical health then that got me up and about again.”
In the months that followed, she began speaking to other mothers about it and realised that many other women had similar experiences, which led to Ardú – and now, Year of Care.
