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4

How to help mothers with mental health problems

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Contents

Objectives

When you have completed this chapter you should be able to:

Why pregnancy and childbirth are stressful periods

4-1 Why is the time around pregnancy and childbirth so stressful?

Change of any kind can be stressful for people to cope with. During pregnancy and around the time of childbirth, women experience changes in body, self-image, expectations and relationships. They are also faced with new challenges and responsibilities. It is a major life transition that can be difficult to adapt to. Women who have difficulties in making adjustments are vulnerable to mental illness.

4-2 Is it more stressful for women in low-income settings?

Poor women and girls have a greater chance of experiencing severe traumatic events during their lives than those who have more supports. Domestic violence, rape, crime, HIV, a lack of supportive relationships and previous traumatic births or unplanned pregnancies are just some of the challenges pregnant women may face in settings of poverty. These situations can make the difficult time around childbirth even more stressful, particularly where there are few resources.

Poor women often face many stressful experiences.

4-3 Why is the health or social worker’s relationship with a mother so important?

A mother who is experiencing emotional difficulties is more likely to have health problems, such as birth complications, traumatic birth experiences and postnatal depression. These problems can be avoided or improved if the mother receives gentle and compassionate care. This is why the role of the health worker is so important.

By caring for a mother’s overall wellbeing, the health or social worker can also have a positive impact on the mother’s ability to care for her baby and the development of her child. A mother who feels safe, understood and well cared for will be better able to bond with, breastfeed, and care for her baby.

The Better Births Initiative (BBI)

4-4 What is the Better Births Initiative (BBI)?

The BBI is an international project which aims to improve the quality of care during labour and childbirth. By adopting the BBI principles and practices – which are based on scientific evidence – health workers can prevent harm and improve the health of mothers and their babies. The BBI principles are useful, widely used in South Africa, and have been adopted in many maternity units in low- and middle-income countries.

The Better Births Initiative aims to improve the quality of care during labour and delivery.

4-5 What are the principles of BBI?

BBI is based on four main principles:

4-6 What are the practices and procedures around childbirth that BBI recommends health workers should avoid?

Avoid practices which have no proven benefit, for example:

Avoid procedures for which there is no proven benefit, for example:

4-7 What are the practices around childbirth that BBI promotes?

BBI promotes practices which have proven to be of benefit:

Note
If you would like to know more about the BBI:

Speak to the BBI representative or manager at your facility

Read more online at http://r4d.dfid.gov.uk/PDF/Outputs/HEHCAPbbiconceptdoc.pdf or at http://samj.org.za/index.php/samj/article/download/2513/1772

4-8 What influences the emotional state of women during pregnancy and around childbirth?

We usually expect women to be happy about being pregnant and having a baby, but for many women this is a time of extreme stress.

Her emotional state can be influenced by:

Figure 4-1 shows the different factors which can influence a woman’s emotional state during the perinatal period.

Figure 4-1: Factors affecting a woman's emotional state in the perinatal period.

Figure 4-1: Factors affecting a woman’s emotional state in the perinatal period.

4-9 Why is understanding different backgrounds and circumstances important?

In order to provide better care, health and social workers need to consider a mother’s whole life experience. Each mother is different. It is challenging, yet very important, to care for each woman as an individual. Life circumstances may influence the risk of developing mental distress. It is important to understand the factors that impact health and behaviours for the following women:

Note
At the end of this chapter, there is an activity that may be helpful for you to better understand the point of view of the mothers in your care. See Activity 1: The ‘secret history’.

4-10 What positive influences may affect how a mother feels about her pregnancy?

Emotional changes are common during pregnancy and in the first weeks following the birth of a baby. There are many stressful events that can arise at different stages of pregnancy and have a negative effect on a mother’s emotional health. However, there are also many positive aspects that can benefit the mother.

During the first trimester of pregnancy, the following may influence emotions in a positive way:

During the second trimester of pregnancy, the following may influence emotions in a positive way:

During the third trimester of pregnancy, the following may influence emotions in a positive way:

4-11 What negative influences may affect how a mother feels about her pregnancy?

During the first trimester of pregnancy, the following may influence emotions in a negative way:

During the second trimester of pregnancy, the following may influence emotions in a negative way:

During the third trimester of pregnancy, the following may influence emotions in a negative way:

4-12 What may a mother feel about her maternity care?

Once a mother becomes part of the clinic or a hospital system, she may feel:

4-13 What may a mother feel about labour and childbirth?

Labour and childbirth can be an extremely stressful time for mothers and fathers. A mother may be:

These feelings may affect the progress of labour and the way in which the mother is able to work with the staff during labour.

4-14 What may a mother feel after the birth?

Mothers usually experience a mixture of feelings after the birth. These can be both positive and negative. Some of the positive emotions may be:

Some of the negative emotions may be:

In the first few days after birth, many new mothers can be irritable, sad and anxious, or cry a lot. This emotional state is usually called ‘the baby blues’ (see chapter 1). The ‘baby blues’ is very common and can be related to hormonal changes linked to breastfeeding, or related to exhaustion, unexpected birth experiences and the adjustment to a new role.

Emotions can be felt very strongly because of the physical changes and discomfort new mothers experience. These include:

4-16 How might the mother express her feelings?

Sometimes, the mother’s feelings are expressed in a negative way. She may express her fear as:

  1. ‘Flight’: missing appointments, not taking responsibility, ignoring advice, or
  2. ‘Fight’: being rude, showing aggressive behaviour.

Health and social worker support

4-17 How does a health or social worker’s behaviour influence how a mother may feel?

It can be difficult for a health or social worker to realise the underlying cause of these behaviours. Rough treatment or uncaring health and social workers can easily upset new mothers, especially if they are having difficulty adjusting to their new situation and responsibilities.

For example, if a new mother is finding it difficult to breastfeed, she may feel like she is a ‘bad mother’ and any harsh treatment may make her feel very emotional or depressed. This will make the problem with breastfeeding much worse. Some want to be ‘mothered’ and looked after, while they learn to mother their own baby.

Women who experience negative emotions need a supportive approach from health and social workers. Harsh or disapproving treatment can make things worse for both mother and care worker.

‘When I shout at a mother who is not co-operating, I end up feeling exhausted at the end of my shift. It also doesn’t make her listen to me.’ Midwife, Cape Town

4-18 How may the emotional state of the health and social workers influence the way they work?

Health and social workers involved with pregnancy and childbirth have a very important role to play in the lives of mothers and babies. There are many physical and psychological demands made on health workers and mothers. The work may be rewarding and exciting, but it can also be stressful and draining. Care workers may also face many stresses, both in their professional and personal life. They also need support, compassion and appreciation. In order to provide the best possible care for mothers and babies, care workers need to ensure the best possible care for themselves.

The emotional state of health workers influences the way they work.

4-19 What are the personal factors that may affect health and social workers?

Factors range from external pressures (such as the work environment and personal relationships) to internal pressures (how they are feeling).

Care workers, like everyone else, are influenced by their own experiences, families, communities and cultures. They have their own expectations and attitudes to the mothers they work with, no matter how professional and experienced they are. Understanding how all these factors affects both the health workers and the mothers in their care, helps them to step back and separate personal issues from work ones.

4-20 What are the external stressful factors at work that affect health and social workers?

Care workers often identify the following stressful factors related to work:

4-21 What are the internal personal issues that can affect a health or social worker’s job performance?

Examples of personal issues which can affect care workers’ performance are:

4-22 What can happen when stressed health or social workers interact with distressed mothers?

As a care worker, it is easy to become angry and irritated with mothers who are in a poor emotional state before, during or after birth. However, allowing frustrations to show could make the situation much worse. If care workers or staff shout at mothers, or are aggressive in other ways, mothers can feel more frightened and threatened, and become more angry and uncooperative.

Note
At the end of this chapter, there is an activity that may help you to understand your own stressors and emotional reactions. See Activity 2: Understanding your own reactions.

4-23 What strategies may help the health or social worker build good relationships with women in her care?

The relationship with a mother may improve if the care worker is able to keep these thoughts in mind:

4-24 What self-care strategies can help health and social workers to improve their wellbeing?

It is important that care workers take care of themselves. These are some suggestions for how this can be done.

Ask for help

Speak to someone you trust when you feel anxious, sad or stressed. Talking about your feelings can help you feel better. Ask your supervisor or manager for help in identifying support services, such as counselling.

Identify your support networks

Figure 4-2: Speaking to a trusted colleague can help you deal with stressful situations at work and at home.

Figure 4-2: Speaking to a trusted colleague can help you deal with stressful situations at work and at home.

Take time out

We all need time to relax. It helps to take time to be alone, to reflect, to sit quietly, breathe deeply or to listen to music as a relaxation technique. Take a walk. Time outside in the fresh air can be relaxing. Step outside for your tea break, or take a walk after work with a friend, colleague or relative.

Get enough sleep

Lack of sleep can impact on your functioning, your mood, and how you are able to cope with stress. Drinks with caffeine after lunch time can affect the quality of your sleep.

Pay attention to your nutrition

Try not to skip meals, especially breakfast. Pack a lunch to take to work. Healthy meal choices can give you energy. Too much caffeine, sugar, nicotine, salt or starchy foods can make you feel tired and worsen your mood or stress symptoms. Remember to drink enough water.

Pay attention to your physical wellbeing

Identify what happens to your body when you feel sad, stressed or angry.

Knowing how you react to stress can help you be prepared and take better care of yourself during stressful times.

Note
At the end of this chapter is an activity to help understand the feelings of health workers and the women in their care. It looks at what help and support they may need. See Activity 3: Two sides to every story.

Counselling mothers

4-25 What help do mothers who experience mental distress need?

Mothers experiencing mental distress need:

Note
At the end of this chapter is an activity to help understand the kind of person someone with emotional problems may want to help them and talk to. See Activity 4: Who can you talk to?

4-26 What messages should an emotionally distressed mother hear?

There are three messages that a woman suffering from emotional distress should hear:

These reassuring messages can be provided as part of good counselling.

4-27 What are basic counselling skills?

Counselling is an important tool in addressing mental distress. It is not about giving advice: it is about listening, validating, and empowering the person to think through her problems, develop her own solutions and put them into practice.

Learning how to be a professional counsellor requires special training. However, there are some simple, yet powerful skills that any health worker can use when caring for mothers, such as:

4-28 What is positive regard?

Positive regard is an attitude of acceptance, respect and support of a person, regardless of what the person says or does. Positive regard means relating in a positive, helpful and constructive way rather than in a negative, critical and destructive way.

4-29 How does giving information help?

One way to provide supportive care to a mother in distress is to give her information and educate her about pregnancy and childbirth. Information can empower a woman and help her to feel in control of her situation. This can also make her feel less afraid and anxious. Below are some things that can be done to help an anxious or scared pregnant woman feel calm and reassured:

  1. Explain what to expect during labour. This is especially important for first-time mothers. Taking the ‘mystery’ out of childbirth can help a woman relax.
  2. Describe the signs of labour. Explain to the woman what is normal and what is not normal. This can help her to remain calm, and to know when to ask for help if her labour is not progressing normally.

Be careful not to scare her with too much or too complicated information. Stories of other women’s bad pregnancy outcomes can be very frightening.

4-30 Why is listening important?

Knowing how to listen is an important step towards understanding what a mother needs and knowing what type of help she requires. Many doctors and nurses are trained to focus on the physical side of health care. Yet, people find it easier to cope, and to find solutions to their problems, when they talk to someone who is really listening. The simple act of listening can be a great support. By listening to the mother, it gives her a valuable opportunity to:

4-31 What is ‘active’ listening?

Active listening is paying careful attention to what someone is saying, as well as their verbal and non-verbal communication. The listener uses their own body language to show they are listening and that they care. The listener gives sincere feedback to show empathy and that they have understood what the person has said. In this way, the speaker feels heard and her feelings are validated. The listener’s responses should focus on the client, and not express judgement or personal opinions.

4-32 How do you actively listen?

Listening requires more than just hearing what the mother is saying. It involves observing other aspects of her behaviour. The table below summarises the many ways all the senses are used to really listen to a client.

Active listening skills  
With your body Lean towards the mother
With your heart Feel the mother’s distress, e.g. empathy
With your eyes Make eye contact, watch and observe body language
With your ears Listen carefully to understand, and respond sincerely
With your mouth Respond to what you’ve heard in a warm, friendly and helpful way

4-33 What is empathy?

Empathy is the act of identifying, understanding, being aware of or being sensitive to the feelings, emotions or experiences of another person. This happens without necessarily having experienced the same feelings, emotions or experiences yourself. Empathy is different from sympathy. Sympathy is ‘feeling sorry for’ or feeling pity for someone else’s suffering. Empathy is considered to be a more useful action when dealing with mental distress: it is trying to understand what the client is going through, so as to provide appropriate care.

4-34 What is validation?

To validate someone’s feelings means to give value to her feelings, and show acceptance that they are true and real. This is done through active listening.

4-35 What is the difference between a good listener and a poor listener?

Good listeners…

Poor listeners…

Figure 4-3: Active listening empowers mothers to think about and solve their own problems.

Figure 4-3: Active listening empowers mothers to think about and solve their own problems.

4-36 When you are listening, how should you respond?

Part of listening is being able to respond in a helpful way. Below are three useful ways of responding:

4-37 What is clarification?

Sometimes it is useful to check with the mother that her problems are clearly understood. Asking for clarity is a way of showing her that she is being listened to because the health worker is taking more time to understand her story. It also helps the mother to focus on the issue, which is helpful when she is feeling very emotional or confused.

Seek clarity by asking the mother gentle questions when appropriate. For example:

Be careful not to interrupt, or to ask too many questions.

4-38 What is paraphrasing?

Paraphrasing is repeating what the mother has said in your own words. It is a way of showing the mother that what she has said is important and that the health worker has been listening. It is also provides an opportunity to check with the mother if her story has been understood correctly. Try starting sentences with these words and paraphrasing may come more naturally:

4-39 How should you give feedback?

Once the health worker has understood what the mother is saying, and has asked for clarity about certain issues, feedback can be given. It is a way to share understanding, insights and reactions with the mother. This should be done in a sensitive, supportive manner.

Giving feedback also gives the health or social worker the opportunity to validate the mother’s feelings and concerns, and so empowers the mother as she realises her feelings and problems are real and important. For example, if the mother says ‘I am depressed’, the health or social worker could validate her feelings by saying: ‘I can hear that you are down. This must be difficult for you right now.’ Not validating her feelings would be to deny that her feelings are real: ‘I’m sure that you’re not depressed, maybe you’re just having a bad week?’

4-40 What are the guidelines for listening and responding?

Guidelines for listening and responding

Do Don't

Show positive regard

Empathise

Help her find her own solutions

Emphasise the positive aspects

Accept how she feels

Look for examples of where she has shown strength in the past

Explore feelings

Be judgemental

Impose your morals

Sympathise or pity

Encourage blaming

Solve her problem

Be shocked

Negate feelings

Make false promises

Say you know how she feels

Ask too many questions about facts and details

4-41 How could you respond if she says the following?

The table below gives some examples and possible responses to comments that might be made by mothers that health or social workers are listening to:

Responding appropriately

If she says You could say
I hate my husband. What bothers you about him?
There's no God. What makes you feel that way?
I'm such a failure. You're finding everything very difficult right now, aren't you?
It's all his fault. Tell me how he's involved.
What should I do? What are your choices? Let's talk about them.
I'm so tired because my baby cries all the time. It takes courage to say how you really feel.
I smacked my baby really hard. What do you think drove you to do this?
How often has it happened?
I think you need to be referred to someone to help you with this problem.
(More information about child abuse is in chapter 6.)
I'll never be the same again. That must be a scary feeling.
I feel terrible. Tell me about your feelings.
I want to kill myself. Why do you think suicide is a way out?
How long have you been feeling this way?
(More information about suicide is in chapter 5.)

© Adapted from Liz Mills

Chapter summary

Case study 1

A mother, with two small children, is pregnant once again. This is not a planned pregnancy. She had a late miscarriage in her previous pregnancy. She is HIV negative and had vaginal deliveries for both her children. She has recently moved to the area from a different city where her husband is still working. He sends her money on a monthly basis. She has been chatting to other pregnant women while waiting to see you. Her children appear well dressed and cared for.

1. What factors can you identify that may be stressful during this pregnancy?

2. What positive factors can you identify that may influence her mental wellbeing?

3. Why is the health worker’s relationship with this mother so important?

Women who experience emotional difficulties are more likely to experience physical health problems. Gentle and compassionate care from the health worker is likely to have a positive influence on the mother, her pregnancy and her interaction with the child.

Your facility has adopted the principles and practices of the Better Birth Initiative (BBI). You want to explain to this mother what she can expect during labour, based on the practices that BBI promotes.

4. What are practices that BBI promotes during labour?

5. What can you explain to her about the practices and procedures that BBI would avoid?

Case study 2

A first-time (primigravid) mother who you have seen throughout her pregnancy has just given birth. In her first trimester you were aware that this was an unplanned pregnancy. She felt physically well and did not suffer from nausea. Her mother-in-law was very pleased that she was going to have a grandchild. However, her husband felt that they should have waited as he wanted to be earning more money before they had a child. During the second trimester, the mother was knitting clothes and blankets for the baby. She and her husband were saving money to buy a cot. During the third trimester, she was very uncomfortable and could not sleep properly as the fetus was active at night. She stopped working and stayed at home alone. Her husband was very excited about the baby’s arrival but was very worried that they would not have enough money. Her mother-in-law said she would come and help in the house when the baby arrived.

1. List the positive factors that may have influenced how this mother was feeling.

2. List the negative factors that may have influenced how this mother was feeling.

As this mother had not given birth before, she asked many questions about the facility and about the birth process. She was very worried before she went into labour.

3. What are some of things that might have been influencing how she felt?

After the birth, the mother kept crying and then smiling at her baby. She was relieved that the delivery had gone well. She felt disappointed that she had a girl when her husband had wanted a son. She was exhausted but pleased that she was able to breastfeed and that the baby latched on well. She was worried about giving the baby a bath and what would happen when she got home. She was proud to be a mother but feeling overwhelmed by the responsibilities.

4. Identify the positive emotions that this mother feels.

5. Identify the negative emotions that this mother feels.

Case study 3

A colleague at work is often absent. You think that she may have developed a drinking problem after her husband left her for another woman. When she does come to work, she is often late and explains that the trains are unpredictable. Recently, she took a taxi and had her bag snatched and lost her money for groceries. She is very overweight and has hypertension. This colleague has been asked to be responsible for ordering the urine dipsticks. The supplier company has not delivered them when they promised and you have now run out. The sister-in-charge shouted at your colleague, in front of the other staff and the patients and told her that she is incompetent. There are many women waiting to be seen and not enough staff on duty. Your colleague has hidden in the locker room and is crying.

1. Identify the personal issues in this health worker’s life that may be influencing how she feels.

2. Identify the stressful factors at work that may affect how she feels.

3. What support can you and the others on the staff provide to this colleague?

4. What self-care strategies could this colleague adopt to improve how she is feeling?

If your colleague does not get help and is feeling upset and unhappy, she may act in an uncaring and harsh manner towards mothers at the facility.

5. How might her clients react to this treatment?

Case study 4

Sr Michaels, a colleague at your facility, is very stressed at the moment. Her youngest child is sick and her older one is going out late at night and not doing his school work. Sr Michaels has been trying to get hold of the children’s father, but he is working in another city and does not reply to messages on his cellphone. She is now wondering whether he is having an affair. She worries that she has not been a good mother because she has to work so much.

Elise is a teenager who has not kept her regular appointments. Elise comes from a broken home and her boyfriend is much older than she is. She does not know if he will be with her when she delivers as he is often unavailable. She is scared about delivering on her own and worried that she will not be able to look after this new baby.

Sr Michaels was cross with Elise when she arrived at the facility today. She told her that if she missed her appointments, she could put the baby’s health in danger. Elise is now being sulky and uncooperative.

Both women are distressed.

1. What do you think both women need to help with their distress?

2. Why do you think that Elise is being sulky and uncooperative?

Elise is scared and worried. When Sr Michaels was cross with her, she reacted with a ‘flight’ reaction. This is a way of expressing her emotions.

Elise is being uncooperative, so it is taking longer for Sr Michaels to see to all her patients, and she will get home late again after her shift. This makes her more frustrated and stressed. As a professional, she needs to separate her own issues from her interaction with Elise.

3. What are the basic counselling skills that Sr Michaels could use to help in her interaction with Elise?

4. Do you think that Sr Michaels showed ‘positive regard’ to Elise when they interacted?

No, she was cross and judgemental. ‘Positive regard’ is an attitude of acceptance, respect and support, regardless of what the person says or does.

5. As Elise is scared and worried about the birth, what information could help her?

Case study 5

A colleague from work has just had a phone call from her brother. The brother’s son was involved in a motorbike accident and is unconscious and in hospital. She is very upset and tells you that she is very worried that her nephew will be brain damaged. The clinic has been quiet today, and you were hoping to get home early. While she is telling you this, you pack up your locker, you send a text message to your husband to say you hope to be leaving shortly, and then do up the buttons on your coat. In order to reassure your colleague, you interrupt her and say: ‘I was in a car accident and spent time in traction. It’s not so bad. I’m sure he was wearing a helmet, so he will be okay. Anyway, your brother is crazy to let him ride on a bike when our roads are so bad! He should buy him a car.’

1. What poor listening skills have you just demonstrated?

2. If you were to actively listen, what would you do differently?

In this conversation, your colleague said: ‘I am so worried. My nephew, Henry, has always been a bit wild. He could have been drinking! He has put so many grey hairs on my brother’s head. Maybe he caused the accident? There could have been other people hurt in the accident! My brother will be frantic with worry about all this. Henry could have permanent damage. I just don’t know what to do to help!’

3. How could you paraphrase this conversation?

You could say: ‘What I am understanding is that you are worried that Henry could have caused the accident and you want to support your brother. Is this right?’

4. How can you give feedback?

You could say: ‘You sound very worried about the situation with Henry, but nothing you have told me indicates that he has actually done anything wrong. Do you think you could find out more?’ Or you could say: ‘It sounds as if you want to support your brother. What do you think he would like from you right now?’

Your colleague decides that she will take the rest of the week off to help her brother. The other sister on the team is already on maternity leave. This is going to mean that you will have to deal with a greater patient load. You think that your colleague has not thought about what the consequences will be if she takes time off.

5. How would you show positive regard?

Showing positive regard would mean that you support her, regardless of what she does. So, you would say: ‘I’m sure that your brother will appreciate your support’ rather than ‘If you take time off, then I will have to cope with more patients.’

Activities

Activity 1: The ‘secret history’

The clinical setting does not usually allow you to get to know each mother very well. The mother may not have the opportunity to tell you her story. However, it is helpful for you to try and understand the point of view of the mothers in your care. You may be able to do this by trying to imagine her ‘history’. The following activity can help you with this.

Try to imagine the ‘secret history’ of any of the following:

Answer the following questions as if you, yourself, were one of the mothers described:

Your notes

After thinking about these questions, write down some points which would be important to remember when dealing with mothers from any of the above circumstances.

There may be reasons why women do not feel comfortable speaking about their lives. Different status or home language, levels of education, poverty, or gender could be barriers to women revealing their story. Women who are poor or uneducated could be disempowered and find it difficult to tell their story. This is known as ‘the silence of powerlessness’.

Activity 2: Understanding your own reactions

If you understand how personal stresses affect your thoughts, feelings and actions, you may be able to manage your own emotions better, improve your own wellbeing, as well as the quality of your work. This allows you to provide better care to mothers, while still taking the best care of yourself.

Sometimes health workers can have a strong positive or negative emotional reaction to a mother. It is important to reflect on why they feel this way. The following activity is a quick way to understand your feelings about a mother and how they might affect your behaviour towards her.

Think about a mother to whom you have had a strong negative reaction.

Be aware of situations which may cause strong reactions. For example:

Activity 3: Two sides to every story: The secret history of Sr Sarah Jack and Johanna Booi

In order to provide the mother with quality care and support, it is necessary to understand her untold story as best you can. At the same time, you need to be aware of the stresses and strains in your own life and how they can affect your work. This can be difficult to do, but the next activity may help. This activity is designed for health workers, and intended as a group activity. Half of the group ‘become’ Sr Sarah Jack, the other half ‘become’ Johanna Booi. Halfway through the journey, the groups exchange roles, becoming the other person.

Step 1

Read through the following journeys of two women, a health worker and a pregnant mother. Imagine yourself as each of these women. You will find out a bit more about each woman as the journey progresses. Reflect on what you think your feelings and needs would be at each point along the way.

First antenatal visit

You are Johanna Booi from Township X. You are 23 years old with one child and are unbooked at 25 weeks pregnant. You arrive for your first visit at 10am at the clinic where you delivered previously.

You are Sr Sarah Jack, a divorced mother of two children, aged four and two. You are working two extra shifts this week to make enough money for rent. Johanna is three hours late for her first visit.

Second antenatal visit

Johanna Booi: You are one week late for your second appointment as your previous employer threatened to fire you for days of missed work. Now your contract is over and you are unemployed, but your neighbour wanted help with a casual laundry service this morning. This was the first opportunity for you to earn money in two weeks as your child had been sick at home with TB. The sister starts to ask why you did not come at the proper time.

Sr Sarah Jack: The full quota of 18 new bookings was filled at 7:30am as usual. You are the only sister in the clinic and are halfway through seeing your patients. You have not taken tea yet. Johanna has a blank face when you ask why she did not attend her second appointment.

Third antenatal visit

Johanna Booi: You default the clinic date that was given to you as you were beaten up by your boyfriend the day before and had had to move out and stay with a friend in another township. You did not have money for taxi fare on that day. It is now two weeks later. You are still staying with your friend. You finally manage to attend another clinic visit. The same nurse calls you into her cubicle.

Sr Sarah Jack: You have had a bad night with a sick child. You had to get up at 4am to take him to your ex-mother-in-law to look after him for the day. Johanna tells you she no longer lives in the catchment area of your clinic.

Labour

Johanna Booi: You are back living with your boyfriend in Township X. You are 36 weeks pregnant now and had a huge fight with him last night. Your membranes ruptured at 5:00am. It is now 2:00pm. You have had to arrange child care for your child and have had to borrow money for taxi fare to take her to your mother. You arrive in the labour ward where you see the same sister.

Sr Sarah Jack: You are on labour ward duty even though you have been working full shifts in the clinic because your colleague has gone off with her fourth migraine this month. You have just delivered a 15 year-old primigravida who swore at you throughout the labour. You see Johanna arrive and see from the notes that her membranes ruptured many hours ago.

Postnatal visit

Johanna Booi: After delivery, the baby was transferred to another hospital for respiratory distress and discharged two days later. You went home to your boyfriend’s house only to hear that he said he is not the father. You have not been able to sleep at night even though you are exhausted. You attend the clinic on Day Four for postnatal care. The same sister is on duty.

Sr Sarah Jack: You have been called by the junior nurse in the postnatal clinic to give advice about the weight loss and dehydration of Johanna’s baby. Johanna has said that she cannot breastfeed and requests help with getting formula.

Step 2

After thinking about Sr Jack’s and Johanna’s secret histories, write down your thoughts about how each of them are feeling. Then write down what help and support they need.

Activity conclusions

You may have come to the following conclusions from this exercise:

Activity 4: Who can you talk to?

Close your eyes, and think about a period in your life when you were very unhappy. If you could choose someone with whom you could talk and share your pain, even if they could do nothing to change your painful circumstances, what qualities would you want that person to have?

You are likely to choose someone you trust who would:

Additional resources

Useful contact numbers for health workers in South Africa

ICAS (an employee wellness support organisation)

In many provinces, health workers and their dependants have access to the ICAS employee wellness service.

SADAG (South African Depression & Anxiety Group)

SADAG offers referrals to psychologists, psychiatrists or support groups by trained counsellors.

Lifeline

Lifeline offers support for personal crisis, trauma, abuse or rape.

Toll-free number: 0861 322 322

FAMSA (Families South Africa)

FAMSA offers counselling for couples and families, with branches throughout South Africa.

National office telephone number: 011 975 7106/7

Resources for pregnant women and new mothers

The following resources can be photocopied and given to pregnant or new mothers.

A few suggestions…

About one out of every three pregnant women suffers from depression or anxiety during or after pregnancy. It is not your fault. You are not a bad mother. You can and should get help.

Useful phone numbers

Organisation Contact number
FAMSA (Families South Africa) (011) 975 7106/7
Lifeline 0861 322 322
SA Depression and Anxiety Group 011 262 6396
AIDS Helpline 0800 012 322

Other (add your own notes here)

Organisation Contact number
   
   
   
   

Listening: A poem

You are not listening to me when…
You do not care about me;
You say you understand before you know me well enough;
You have an answer for my problem before I’ve finished telling you what my problem is;
You cut me off before I’ve finished speaking;
You finish my sentence for me;
You feel critical of my vocabulary, grammar or accent;
You are dying to tell me something;
You tell me about your experience, making mine seem unimportant;
You are communicating to someone else in the room;
You refuse my thanks by saying you haven’t really done anything.

You are listening to me when…
You come quietly into my private world and let me be;
You really try to understand me even if I’m not making much sense;
You grasp my point of view even when it’s against your own sincere convictions;
You realise that the time I took from you has left you a bit tired and drained;
You allow me the dignity of making my own decisions even though you think they might be wrong;
You do not take my problem from me, but allow me to deal with it in my own way;
You hold back your desire to give me good advice;
You do not offer me religious solace when you sense I am not ready for it;
You give me enough room to discover for myself what is really going on.

Speaking and being heard: a true story

The following story was written by Ntombomzi, a Perinatal Mental Health Project service user.

Things are easier for women today, because we are independent. Our mothers were not respected. They didn’t have the rights we have now and didn’t have the same opportunities. They were like slaves. These days if there is a problem, there is help available, something that I was fortunate to have when I discovered that I was suffering from postnatal depression.

When I first became a mother, I didn’t know about depression. Now I would like to let everyone know about this problem so that people can stand up and do something about it.

I was born one of twins. My parents divorced when I was only two months old. Because my mother was alone she couldn’t do what she was supposed to do as a mother and I grew up with her family. There was really no one to talk to or to discipline us and I became pregnant at the age of 14. I have suffered depression since then.

Having a baby at such an early age was really hard. I had to leave school and was forced to work as a domestic worker, which I couldn’t really do because I was so young. I tried very hard, but I just couldn’t do it. So, I decided to go back to school when my baby was three years old. I passed my standard nine [penultimate year of high school], but didn’t have enough money to register for my final year. I was forced again to go back to work as a domestic worker; which I am still doing to this day.

When I was twenty-one years old, I got married to my husband. He is not the father of my first child. A couple of years after being married, we had a child together. I again suffered very much from postnatal depression, although I did not know what it was called at the time. The clinic I went to in the township did not know anything about depression. So, I was unable to get help from them. Luckily, my husband was always there for me and supportive throughout my depression, even though he didn’t always understand what I was going through.

Since then, I suffered from depression until I was able to get help from the Perinatal Mental Health Project in 2004. This was the first time I heard about perinatal or postnatal depression. I had suffered from depression all these years, but I didn’t really know what it was. Finally, I was able to get help.

When I was pregnant with my last baby, I was working for Linda, a psychologist. I was not at all happy to be pregnant. I was just very stressed and worried about telling her. I knew it was not the right time for me to become pregnant and I was very concerned about my job and all the things that I needed money for. But I realised that I needed to tell Linda, not only because she was my employer, but because I needed help. Everything was very hectic for me and nothing that I was experiencing seemed to be good. I knew that I was becoming more and more depressed.

I finally told Linda when I was five months pregnant. It turns out that she specialises in women who have perinatal and postnatal depression and when she heard my history she thought I was suffering from it. She decided to take the step to get help for me by sending me to the Mowbray Maternity Hospital which provides the Perinatal Mental Health Project.

At Mowbray, I met with a counsellor. It was very good to speak to her about how I was feeling and to just talk out about everything. That was what was killing me, having to keep all my feelings inside of me for a long time. I was so lonely and there were so many things that I needed someone to listen to. I needed to express my feelings and to be heard when I was saying something. I needed someone who could understand and who could listen when I was talking. Meeting with this counsellor gave me that chance to finally speak out, which helped so much. They also sent me to a psychiatrist to get medication for my depression. Now I am doing just fine and coping very well with motherhood.

Dealing with perinatal and postnatal depression is a very difficult thing. When you are depressed there are so many things that are affecting you. You may not be able to tell exactly what it is that is making you feel so bad, but just that you can’t get out from the fog you are in. Everything can feel like it is just falling apart, that nothing is happening right or according to plan. You may not know to take it seriously when you are first suffering from it, but it is very important to address it and to find a way out. There are so many women who are dying inside from this thing. They don’t know how to deal with it or how to cope. Everything in their lives is turning upside down. And they need someone who will understand and not judge them.

That is why I talk about this depression with everyone. I even talk to mothers I see on the bus. I want everyone to know about this problem. I want the mothers to listen.

If I could have my way, each and every one of the hospitals would have these kinds of counsellors, especially the government hospitals which are for everybody. That way everyone, including all black women who really don’t know anything about this depression, could get help.

Until that happens, I hope that all the mothers out there, who are suffering from perinatal and postnatal depression, will take care of themselves and find support. You only live once, and it does not have to be a life filled with depression!