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PARENTS WHO RECEIVE A PRENATAL DIAGNOSIS OF A LIFE-LIMITING CONDITION ARE AT AN INCREASED RISK FOR PERINATAL MENTAL HEALTH COMPLICATIONS.
The anticipatory grief and anxiety experienced following the diagnosis and throughout pregnancy continuation are risk factors for mood disorders in the antepartum and postpartum periods for both mothers and fathers.
Since perinatal loss has negative impacts on parents, both psychologically and socially, it is imperative that medical professionals intervene as early in the carrying to term process as possible. Early intervention and management of perinatal mental health issues help parents find support, create coping strategies, and receive appropriate medical treatments. Early intervention and management also promote healthy processing and adjustment not only for the parents but also for any children they have or plan to have.
Parents navigating a life-limiting prenatal diagnosis and pregnancy continuation often lack the support and resources they need to identify, understand, and manage perinatal mental health complications, because it can be difficult for both patient and practitioner to distinguish between a parent’s grief and their overall mental health. The experience of grief and the process of mourning are normal, valid, and expected following a diagnosis, throughout pregnancy, during labor and delivery, and in the bereavement period that follows the death of the baby.
Grief- the internal experience of loss and the thoughts and feelings that accompany it- and mourning- the external expression of grief- do not follow a set timeline, pattern, or set of rules; however, the process of grieving and mourning usually begins to lessen over time. It starts out acute, intense, and overwhelming, and it slowly becomes more manageable, predictable, and less frequently experienced. Parents never truly stop grieving the loss of their baby or babies, but they do become better equipped to handle the emotions and experiences that trigger memories or an emotional response regarding the loss.
Perinatal mood and anxiety disorders are characterized as being prolonged, intense, and overwhelming. They are marked by thoughts and behaviors that are ego-dystonic, or in conflict with who the parent was before the diagnosis and loss and in conflict with that parent’s ideal self-image. The line between grief and a perinatal mood disorder can be thin and hard to differentiate, and as such, it is so important that medical professionals be aware of the risk factors for their patients and their patients’ significant others and continue to regularly assess the parents’ mental health at each step of the process.
Perinatal mental health issues are best managed through regular check-ins via conversations and screenings, self-care and lifestyle changes, social support, and professional support, as well as medical intervention and treatment when necessary and appropriate.
“Perinatal mental health issues are best managed through regular check-ins via conversations and screenings, self-care and lifestyle changes, social support, and professional support, as well as medical intervention and treatment when necessary and appropriate.”
CONVERSATION
The primary method for assessing a carrying to term parent’s mental health should be conversation. Each appointment these parents have with the medical professionals providing on-going care and support should include time to discuss the parents’ experiences and how they feel about the process.
Patients who feel heard and have the opportunity to express their worries, discuss their questions, and process with their medical professionals exhibit less stress and anxiety, and they are better equipped to make the necessary decisions throughout the pregnancy.
By creating a safe space for your patients and their significant others to discuss the emotional aspects of their pregnancy continuation, you are giving parents the permission and freedom to prioritize their emotional well-being. You also have the opportunity to prepare your patients by setting expectations regarding grief and perinatal mental health complications. When parents are equipped to recognize a perinatal mood disorder, they are more likely to seek help and support. Perinatal mood disorders can stir up feelings of guilt and shame, and parents often do not speak up for fear of judgement.
Providers can learn a lot about a patient’s emotional well-being and mental health based on how a patient processes, communicates, and engages during each appointment. This information coupled with a patient’s history and identified risk factors allows providers to identify and regularly check-in on patients with a higher risk for perinatal mental health complications.
Risk factors for mental health complications include:
- having a prior history of loss
- having a prior history of trauma
- having a prior history of mental health issues
- having a family history of mental health issues
- lacking a network of support
- lacking understanding regarding the process
- feeling incapable of navigating decision-making
- not receiving regular check-ins about emotional well-being
- not receiving in-person postpartum follow-ups
- feeling angry, mismanaged, or victimized throughout the experience
- currently experiencing stresses in work or home life in addition to the diagnosis
Every carrying to term parent should be assessed and screened for perinatal mental health complications regularly throughout the antepartum, postpartum, and bereavement periods, as well as throughout the duration of pregnancy after loss and the postpartum period that follows.
SCREENING
Though open and honest conversations with patients should be the primary method for assessing a patient’s mental health, evidence-based screenings should be utilized throughout the carrying to term process. These screenings should be conducted at regular intervals to ensure that patients are closely monitored.
The two most commonly used screening tools are the Patient Health Questionnaire (PHQ-9), found here, and the Edinburgh Postnatal Depression Scale (EPDS), found here.
These evidence-based tools were designed to assist- not replace- clinical judgement. As the medical professionals, trust your training and judgement regarding your patient and utilize these screenings to help you determine the best course of treatment and support for your patient. These screenings provide valuable insight and allow professionals to identify parents- mothers and fathers- who need increased psychological and social support.
When regularly utilizing screening tools such as EPDS and PHQ-9, it is important that you communicate with your patient as to why you are taking this approach. Your patient should know that you not only value their physical health but also their mental and emotional health as well as that of their significant other. Inform your patient that you will be making time for regular conversational check-ins and that you will conduct a screening at each appointment.
As you incorporate conversational assessment and evidence-based screenings into your care plan for carrying to term patients, it is important that you have stress and anxiety management information, medical intervention recommendations, social support suggestions, and professional mental health service referrals readily available.
SELF-CARE AND LIFESTYLE CHANGES
For many patients, one of the best strategies for preventing perinatal mental health complications is making lifestyle changes and practicing self-care. Some parents may find that taking temporary leave or permanently quitting stressful jobs can help alleviate some of the anxiety they feel throughout the carrying to term process. For some parents, something as simple as taking a break from social media, parent groups, and involvement in volunteer activities can help reduce the stresses and pressures in their lives. For other parents, eating a healthy, balanced diet and prioritizing light physical activity can help them feel more emotionally stable.
Encourage your patients to identify and implement self-care strategies that promote emotional, physical, spiritual, and social self-care. Self-care helps parents navigate and cope with the range of emotions, triggers, difficult decisions, and the general overwhelming nature of receiving a life-limiting prenatal diagnosis. To help your patients understand and create a practice of self-care, we created a guide to provide insight into the different types of self-care. You can find our self-care for parents guide here.
SOCIAL SUPPORT
A good network of support is a protective factor against perinatal mental health complications like depression, anxiety, and post-traumatic stress disorder. An involved and informed network of support can lessen the isolation felt by carrying to term parents, and this network of friends and family can help parents assess their own mental health and emotional well-being. When needed, they can help parents navigate getting professional support and resources while continuing to provide the personal and on-going support that carrying to term parents need.
Encourage your patient to identify the friends and family that would be the most helpful, supportive, and encouraging to them throughout pregnancy continuation and the bereavement period. Parents need four types of social support: emotional, peer, informative, and tangible.
Emotional social support looks like people who listen when they need to process their experience and talk about their baby or babies. These support people enter in and build up parents when they feel disheartened, isolated, or in need of validation.
Peer support looks like connecting with people who have a similar diagnosis or similar experience. This support offers insights to parents and provides a community where parents can share their story with people who understand.
“A good network of support is a protective factor against perinatal mental health complications like depression, anxiety, and post-traumatic stress disorder. An involved and informed network of support can lessen the isolation felt by carrying to term parents, and this network of friends and family can help parents assess their own mental health and emotional well-being.”
Informative support looks like people or organizations that provide information, insight, tools, and specialized knowledge for carrying to term parents. As the medical professionals, you fall under this category, though you may also fall under emotional and peer support, too. Organizations like Carrying To Term and local support organizations or professionals are important resources for you to be aware of and provide to your patient.
Tangible support looks like the meeting of practical needs. It is not uncommon for carrying to term parents to feel both too overwhelmed to handle all of life’s responsibilities and too much of a burden to ask for help. Encourage your patient to lean on their network of support to help them navigate tangible needs.
When you provide insight into your patient’s need for social support and you encourage them to seek it, you are providing emotional support to your patient. You are telling your patient that their mental and emotional needs are important and that you will help them get the support and care they need.
PROFESSIONAL SUPPORT
For some parents, social support through a network of friends and family is the best protective factor against perinatal mental health complications. However, for many parents, the personal nature of social support does not adequately address their emotional and mental health needs. Professional- or specialized- support is a powerful process and tool to help parents feel heard, validated, understood, and equipped with coping mechanisms, processing skills, and the support they need to make decisions throughout their experience.
Over the course of the carrying to term process and the bereavement period, a parent’s need for support will likely evolve. There are different types of specialized support, and not every option will be the right fit for every parent. As you assess and screen your patients, you can determine and provide your patients with the method of professional support best suited to their needs.
Professional support can take the form of prenatal counseling with the medical professionals on their care team, counseling- both individual and couples- with a licensed professional therapist or clinical social worker, in-person support groups, online support groups, and connections with local support organizations.
Like social support, professional support helps lessen the isolation experienced by grieving parents. It equips your patients to balance everyday life in the middle of trauma, loss, and the grieving process. It helps parents navigate communication, relationships, and the reality of their experiences. Parents who are provided with insight, understanding, coping skills, tools for communication, and a safe place to process exhibit less anxiety and mood disorders throughout pregnancy continuation, the bereavement period, and in subsequent pregnancies.
“Parents who are provided with insight, understanding, coping skills, tools for communication, and a safe place to process exhibit less anxiety and mood disorders throughout pregnancy continuation, the bereavement period, and in subsequent pregnancies.”
MEDICAL INTERVENTION
While self-care, lifestyle changes, social support, and professional support are all valid and protective factors against perinatal mental health complications, many parents will require more support through medical intervention. Receiving a prenatal diagnosis of a life-limiting condition and facing the loss of a baby is a traumatic experience. The ongoing stresses and changes that come with pregnancy continuation, labor and delivery, and the bereavement period can cause perinatal mood disorders that are best managed through the use of medication.
For some parents, receiving a diagnosis of a perinatal mood disorder can feel traumatic given their experience of receiving a prenatal diagnosis for their baby. It is important that providers remind their patients that by receiving a diagnosis of a mood disorder, providers and patients can work together to find the right treatment plan and system of support to help the parents feel cared for and balanced. Medication is a valid yet often overwhelming option for parents, and as such, it should be presented to patients with sensitivity, careful explanation, and room for questions and discussion.
As the medical professional providing this information as well as the medication itself, it is very important that your patient knows that there is nothing wrong with needing medication as they grieve. Patients need to understand that needing medication is not a sign of weakness or in any way a statement on their ability to parent, process, or navigate a carrying to term experience. This is also true for the pregnant woman’s significant other. The significant others need to know that they also are at risk for perinatal mental health complications, and there is support and interventions available to them as well.
A prenatal diagnosis of a life-limiting condition and navigating all that follows is a complicated experience. Your patients could have all the tools in the world and feel fully equipped for this process and still struggle with perinatal mental health complications. As the medical professionals providing ongoing care to these parents, it is important that you normalize the experience of perinatal mood disorders, monitor your patient regularly, create a safe environment for open and honest conversation, and stay up-to-date on the resources, tools, and support available to your patient.