The impact of postnatal depression on the health and development of the newborn

Introduction

Depression of pregnant women or mothers is a risk factor that affects the health and development of the newborn. Approximately one in seven women develop postnatal depression. The highest incidence is found in the USA (82.1%), and the lowest incidence is found in Germany (1.9%)^(1-3).

The World Health Organization (WHO) recognized in 2020 that depression is the most significant cause of disability worldwide⁽⁴⁾.

Pregnancy and then childbirth are physiological processes for the woman’s body, but which come with numerous changes necessary for the good development of the fetus and the newborn^(4,5).

The body adjusts so that it is able to support the harmonious development of the future child, but this transformation also brings with itself numerous changes^(6,7). Some are at a hormonal level, others have to do with the visible physical changes of the pregnant body. In addition to all these, appear the worry and the avalanche of questions about how these will all come together eventually with the new member of the family, predisposing the pregnant woman to depression^(7,8).

Childbirth, another crucial moment for women, also comes with numerous hormonal changes which, on a favorable background and in the absence of quick and effective interventions, can trigger postnatal depression⁽⁹⁾.

A depressed mother is a risk factor for the newborn, infant or child, a risk factor whose severity varies to the point where the child’s life is endangered⁽⁵⁾. Depression is a pathological condition in which the mother often neglects the child, with unfavorable consequences for them. The age of the child is inversely proportional to the risks to which they may be exposed^(10,11).

Thus, we aimed to bring to the attention of the medical staff the importance of early identification of depression and the adverse effects that can occur to the child in the absence of an effective and rapid therapeutic management. We want to team up with the ones who make the efforts to transform the prevention of depression into a priority at a global scale, with information based on current specialized studies alongside fundamental theoretical notions^(10,12).

Risk factors of prenatal and postpartum depression

Compared to men, a higher number of women are affected by depression, the hormonal changes that occur in women, both monthly and throughout life, being correlated with the higher prevalence present at the female sex⁽¹³⁾. Major depression is the main cause of disability among women^(12,14). 

The risk factors are multiple. When dealing with a female who presents risk factors for depression, both doctors and nurses should have a higher degree of attention, empathy and care^(1,5,13).

A poor socioeconomic status and the physical and verbal violence of the husband are risk factors for the onset of prenatal and postnatal depression.

According to certain studies, postnatal depression is more common in middle- and low-income countries, probably due to the lifestyle of people with middle or low socioeconomic income, and this should be an alarm signal for medical professionals who practice in these areas⁽¹⁵⁾.

Lifestyle can be a risk factor or, conversely, a protective factor. We will now focus on the risk factors arising from lifestyle and list some, like smoking and the lack of physical activity.

Prenatal risk leave takes the woman out of her environment and isolates her, so the longer it is, the higher the chances of depression^(4,16). Caesarean birth, long hospitalization due to complications, umbilical cord prolapse, meconium pass while still in the womb, along with a premature newborn or with birth complications are factors that will surely contribute to the onset of depression^(16,17). Lack of sleep or poor-quality sleep is also a risk factor, along with pathological personal antecedents in the psychiatric sphere such as depression, premenstrual syndrome, anxiety, sexual abuse, exhaustion, or other forms of abuse.

In addition to the socioeconomic level, the geographical distribution plays an important role, with significant statistical variations being observed between different regions of the planet. Following this theory, the highest percentage was found in the Middle East, where approximately 26% of women experienced postpartum depression; to be noted the fact that these percentages refer to women without a history of depression^(4,17,18).

Clinical manifestations of postnatal depression

Although the percentage is approximately equal to that of postpartum depression, prenatal depression is far less diagnosed, and according to specialized studies, the chances of maintaining depression in the postpartum period are significant^(19,20).

Postpartum depression represents the onset of a depressive episode with varying degrees of severity, which sets in during the first four to 12 weeks^(4,21).

Common manifestations of depression are appetite and sleep disturbances that lead to changes in weight, feelings of worthlessness or guilt, impaired ability to concentrate, lack of energy, or a persistent state of fatigue with a depressed mood present most of the time^(16,18,19).

The role of medical personnel
in the prevention and rapid identification of postnatal depression

Approximately half of the women who suffer from postnatal depression do not end up being diagnosed and treated, especially because of family and entourage, so the new mother chooses not to communicate out of fear of being perceived as problematic^(1,22).

This should draw the attention of the medical staff who come in contact with the pregnant woman or the woman who has just given birth, as well as the one of the pediatricians who, through attending the child, come in contact with the mother perhaps more often than other medical specialists, to keep their awareness high and act upon it.

The correct screening of this pathological process, found in an alarmingly high number of women who choose to give birth to a child, could lead to prevention and increase the percentage of a correct diagnosis, which ultimately leads to treatment, where necessary^(12,17,19).

Educating pregnant women and their husbands about the main changes that occur in this physiological process, along with presenting the main signs of depression and encouraging the family to ask for specialized help are essential to reduce the women’ stigma regarding this medical issue. If not managed properly, it could lead to the abandonment of the family^(4,23,24). This help must be carried out by the multidisciplinary medical staff with whom the woman comes in contact during pregnancy and afterwards post-partum, and the partner could also be trained in the early identification of signs and symptoms associated with depression⁽²¹⁾.

However, according to the study conducted by Bilszta et al. in 2010, information about pre- and postnatal depression was not a point of interest in prenatal courses, because women did not think they could be affected by this pathology⁽⁷⁾.

These statements show once again the mentality present at a large percentage of the population, who consider that education and medical prevention are not necessary, due to the fact that “it can’t happen to them”, an idea that is erroneous and with a negative effect on people, the medical system, and the economy.

According to specialty studies, the Edinburgh Postnatal Depression Scale (EPDS) is clearly superior to other screening tools for prenatal and postnatal depression, being easy to apply in family medicine, gynecology, or pediatrics offices^(19,20).

Postnatal depression management

Once established, depression requires a specialized and individualized approach where cognitive-behavioral therapy plays an important role in the therapeutic management of depression.

There are studies revealing the superior advantages of cognitive-behavioral therapy as monotherapy versus pharmacological monotherapy or combined therapy⁽²⁵⁾.

In a study by Huang et al., based on an analysis that included 20 randomized controlled trials, they showed the beneficial effects of telephone cognitive behavioral therapy, with a statistically significant (p<0.5) decrease in postpartum maternal depression⁽²⁶⁾. The improvement of symptoms was statistically associated with internet therapy, as well (p<0.5)⁽¹²⁾.

The results of a meta-analysis with 2366 participants, from ten studies regarding the effects of technology-based interventions on postpartum depression, reveal that these interventions are more favorable than the standard ones. Thus, telemedicine enjoyed greater acceptance in women, and reduced the symptoms of depression⁽⁴⁾. This analysis supports the need for future studies on the impact of telemedicine on the effective therapeutic management of depression and – why not – on a more effective way of prevention than the standard one^(4,23).

Although telemedicine seems to be an easier way and better accepted by women, cognitive-behavioral therapy – regardless of the implemented way, whether standard or through telemedicine – is the first option that women choose, especially those who are breastfeeding^(1,25). However, when this treatment method does not prove itself effective, the medical staff should encourage the use of pharmacological therapy. Thus, selective serotonin reuptake inhibitors (SSRI) show a reduced risk for the breastfed baby and, through a good communication and lots of empathy from the medical staff, the woman can breastfeed while treating her depression^(1,27).

Transcranial magnetic stimulation is a noninvasive method, recommended especially for women who are breastfeeding and do not have a favorable response to cognitive-behavioral or pharmacological therapy, with the mention that this treatment method requires an increased number of sessions (up to five sessions per week, for 4-6 weeks) which can be a problem for a new mother^(1,18).

How the child is affected

The importance of a healthy mother-child relationship for the good physical, mental, cognitive and social development of the child has been emphasized for a long time in the specialized literature⁽²⁴⁾. The concept appeared for the first time in the mid-1970s, then it was taken on a larger scale in research and analysis⁽²⁴⁾. Although studies show the importance of a good mother-child relationship, at the moment, approximately 50 years after this concept was born, this relationship does not benefit from the support it should have, considering the fact that both the family and the future adult depend on the efficiency of the mother-child relationship, and that the first 1000 days are crucial for an optimum development of the future adult^(24,28).

Children who come from mothers with untreated depression will have multisystemic impairment, so they are more likely to develop behavioral and emotional disorders. The analysis of the development up to the age of 5 years old in children whose mothers were diagnosed with depression reveals a lower socioemotional and cognitive development compared to children who were raised by mothers without a diagnosis of depression⁽²⁹⁾.

 Delays in language development have been observed since infancy, where fewer vocalizations were made, compared to children raised by mothers without depression⁽³⁰⁾. This is explained by the fact that depression associates slow thinking, tiredness and lack of desire to communicate, so the newborn and, later on, the infant will hear a much reduced number of words from a depressed mother^(30-32).

Disorders in cognitive, socioemotional and language development were also identified in a meta-analysis that studied the impact of depression and anxiety in prenatal and postnatal women⁽³³⁾. The stress to which the product of conception is subjected during pregnancy also has repercussions in the extrauterine life; thus, the introduction of screening programs for pre- and postnatal depression is justified⁽¹¹⁾.

Feeding newborns and infants exclusively with breast milk in the first six months of life comes with multiple benefits for the mother-child couple, but also for family harmony and socioeconomic well-being, reducing the costs related to the child’s multiple hospitalizations and those resulting from mother’s vacations for the care of a sick child^(28,33). It is already well known that breastfeeding is a protective factor for multiple ailments and a must for a stronger immune status. Non-initiation of breastfeeding or early interruption brings along unfavorable effects on the child, both in the short term, as well as in the long term.

Black et al. presented a study that revealed a 15 times higher risk of infant death in the absence of breastfeeding⁽³⁴⁾.

On our continent, it is sad to admit that we have the smallest number of newborns who are breastfed. In this context, the percentage of infants who reach the age of 6 months old to be breastfed becomes extremely small. Maternal depression is an important factor for not starting or for an early stopping of breastfeeding^(34,35).

The height-weight deficit is also present, since the mother does not properly take care of the newborn, and this drags along repercussions that can vary from mild to severe. Thus, the baby’s nutrition will lack macro- and micronutrients essential for a good development. In order for us to better understand this fact, we will exemplify, as it follows, how deficient nutrition has a major impact on the general development of the child^(28,36-38).

Let’s take proteins, for instance. They are an essential macronutrient required for good growth and development, precursors of enzymes, nucleic acids, hormones and antibodies. So, when their intake is deficient, it leads to a reduction of muscle mass, anemia, growth retardation, and associates a decrease in the body’s resistance to infections^(36,37).

Lipids represent another nutrient with a major role in the development of the nervous system and the retina. Lipids also ensure the absorption of fat-soluble vitamins A, D, E and K, being vital during the infant and toddler period^(39,41).

Carbohydrates are the main energy source of the body. They ensure the proper functioning of the intestinal transit, and are essential for the physiological functioning of the cells, the central nervous system being the largest consumer and organ dependent on carbohydrates^(41-43).

Malnutrition is responsible for approximately 3.1 million deaths annually among children under the age of 5 years old. A study conducted on 232 mother-child pairs in Ethiopia revealed that maternal depression was present in 22.8% of cases, and it had a statistically significant association (p<0.05) with the inadequate nutrition of infants aged between 5 and 10 months old⁽¹⁵⁾. Maternal depression is associated with inadequate diversification and subsequent undernutrition^(44,45).

Conclusions

Prenatal and postnatal depression afflicts a significant number of women, with adverse consequences for the child that reach the point where the baby’s life is endangered. The stigma according to which depression is a shame, translating the woman’s inability to adjust to the new role, must be removed as quickly as possible from the mentality of the population. Thus, we consider it auspicious for doctors and nurses who participate in the process of educating and reducing the prevalence of prenatal and postnatal depression, but also in the rapid diagnosis of this pathology.

Analyzing the information presented before, the development of national health programs with the aim of preventing and quickly diagnosing prenatal and postnatal depression are more than necessary, along with the increase in the number of specialized studies on this topic, with the aim of understanding, preventing, or treating effectively prenatal and postnatal depression.   

Corresponding author: Heidrun Adumitrăchioaiei E-mail: ad.heidi91@gmail.com

Conflict of interest: none declared.

Financial support: none declared.

This work is permanently accessible online free of charge and published under the CC-BY licence.