Perinatal Mental Health: Building Support and Community

by Angelica Al Janabi

CW: This blog references perinatal mental health, suicide, and substance use.

Note about language: Many sources used gendered terms in their data and research. I have maintained these terms when citing a source. That said, I know that genderqueer and trans folks may be left out of these numbers. It is likely that queer and trans birthing people have similar or even greater numbers of mental health conditions given societal oppression and harm.

My postpartum experience was a blur. I wasn’t aware of the correlation at the time, but I could check off personal experience with almost every factor I’ve seen for “increased risk” of postpartum depression.

Lack of support: check. Traumatic pregnancy: check. Breastfeeding challenges: check. Past and current adversities: check. And the list goes on. Some long-lost presentation I attended even mentioned that stress between the birthing parent and their own mother can increase risk: check.

Years postpartum, I felt validated as all the pieces came together and I began making sense of my experience.

Mental Health Conditions in the Perinatal Period  

In the United States, we have high mortality rates for infants and birthing parents relative to other developed countries. Additionally, birthing people of marginalized populations face inequities in health outcomes and health care access. These are all serious and worrisome realities.

That said, you may be surprised to learn that the most common reproductive complication is developing a mental health condition (1+ in 5 or 800,000 US families per year), and that suicide and overdose are the top causes of postpartum deaths. The following estimates show the rates of several common complications: depression (15+%), anxiety (6% pregnant, 10% postpartum), PTSD (9%), OCD (3–5%), and postpartum psychosis (1–2 of 1,000 births).^3

Perinatal mental health conditions are serious.

They not only impact the birthing parent; perinatal health conditions also have costly human and financial implications for the baby, family, community, and broader society.

Unfortunately, it is estimated that 75% of women do not receive appropriate care; in fact, fewer than 20% of pregnant or postpartum patients were even screened in 2019, and not even half of those scoring positive were given follow-up care.

Various factors are associated with higher risk for perinatal mental health challenges, such as a lack of support, childhood trauma, breastfeeding difficulties, life challenges (e.g., relationship issues), birth trauma, or prior mental health conditions. Unfortunately, racial disparities are also significant due to factors such as existing health disparities, access challenges, and discrimination.

My Difficult, Early Postpartum Experience

At the time, I just knew I was suffering.

I gave birth after a pregnancy that was extremely physically and mentally challenging. My nights in the hospital were constantly interrupted by medical staff; I began motherhood so sleep deprived and went home at a deficit. My daughter wanted to be held constantly when she was awake, and if she fell asleep in my arms, she might wake up screaming shrilly if I set her down.

At one point, desperate for a break, I put her in a stroller and paced in circles around my apartment, praying that the soothing movement would lull her cries. It did not. I even took her to the bathroom with me, at first, struggling to balance her body on my leg and support her floppy head while I squatted to change the giant towels and awkward mesh underwear the hospital gave me for postpartum bleeding. I was terrified that I would damage our attachment bond if I left her alone to cry.

Her screams kept me on edge. Not only were they so frequent, but they also felt like alarm bells. In each rare moment of calm, I was constantly bracing myself for the next time I would have to leap up and react. Often, my daughter cried even when I held her, and those were the most frustrating moments because nothing seemed to work.

While a colicky child might overwhelm any parent, my neurodivergent brain doesn’t handle noise well. I constantly felt like my brain was shutting down. I couldn’t think. I was also dealing with physical pain—some from my C-section, but that was fortunately an easy recovery for me. However, the postpartum contractions seemed to surpass my ability to cope. 

Nights and days blurred together because they were the same.

When did I wake up? I don’t know; I’ve been up every few hours for the last six weeks. When am I supposed to brush my teeth in the “morning”? I didn’t eat regularly. I didn’t sleep enough. Naively, before giving birth, I had read that newborns nap for 16 hours a day, so I figured I would have time to manage. I even considered taking a class during maternity leave that usually conflicted with my work schedule.

Now, I look back and can’t imagine what I was thinking. There wasn’t even time for showering. I survived on pop tarts and granola bars—which I do not recommend.

No matter how much time I had spent reading articles and taking classes, nothing prepared me for the intensity and exhaustion of early parenthood. 

Navigating Exhausting Feeding Challenges

Breastfeeding was probably the hardest part. I had armed myself with information and resources and stocked up on nursing bras and freezer bags. Unfortunately, my baby couldn’t latch.

Usually, when I tell this story, I hear some version of, “yeah, a lot of babies have trouble.” Maybe. But this comment is usually followed by some well-meaning version of, “…but when you get help or try harder, you’ll figure it out.” Every single friend thought they could fix my problem with a sentence, like, “you just have to lie on your back topless and let her crawl up.”

But nothing worked.

For four days in the hospital, I had round-the-clock help from nurses and lactation consultants. “We might have to take a break,” one of them told me, frustrated, as my child screamed in hunger. “There’s nothing else I can do, really.” I tried everything they suggested, even when it hurt: “nipple sandwiches,” nipple shields, three different pillows. Countless positions with washcloths stacked and rolled trying to position everything to “fit.”

Finally, the hospital brought me a huge, medical-grade pump. I felt like a full-time cow, anxiously watching the droplets fall into the bottles, willing my body to make enough milk. When I wasn’t being “milked,” I time-consumingly dribbled this precious fluid into my baby’s body with a syringe meant to prevent nipple confusion, something that could supposedly make breastfeeding even harder.

At home, I paid to rent the hospital pump and continue the cycle: an hour ordeal (that we both hated) trying to breastfeed, another hour with the syringe, and one last hour of pumping and sterilizing. I enlisted more help. Because I had a C-section, I couldn’t drive. Because of my newborn’s immune system, I wasn’t allowed to take public transportation. Everyone in my life was at work, so they couldn’t drive me.

Desperate, I ended up paying $100 home visit fees with a lactation consultant—which I couldn’t really afford. We added tiny tubes that I had to tape to my body while pumping to funnel milk into my daughter’s mouth (this is often referred to as a supplemental nursing system), but even the milk intake scale showed that she wasn’t getting any food whatsoever. And all too often, the milk would leak onto the tape, loosening it so I’d have to redo the entire positioning. My daughter cried; I wanted to. No wonder breastfeeding issues contribute to postpartum mental health challenges.

This cycle also meant I slept even less. Shortening or skipping a step meant little when my daughter was supposed to eat every 2–3 hours. My TV was always on, paused, waiting for me to stumble out of bed and watch something to stay awake. Sometimes, I pinched or slapped myself to stop my eyes from closing. I was always undressed for this, so my blinds were always closed. I spent months in the dark, crying.

Everything felt like a failure. The first time I tried a bottle, I was relieved; what would have taken 45 minutes only took 10. I took a nap in the extra time, but then woke up troubled, worrying I had chosen my own comfort over my child’s well-being.

I was chained to my pump. If I went out, I had to worry about when bottles expired and carry ice packs to chill them. I felt like Cinderella rushing to get home before midnight, except my midnight was the next time I had to pump. If I missed a pumping session, my milk supply would decrease, or I would get mastitis, as I had once when I had the rare chance to sleep uninterrupted.

It was all too much work, so I just stayed home. Increasingly isolated. Alone. In the dark.

And always weighing on my mind, especially when I eventually supplemented with formula, was the guilt; the same people “helping” me sent me home with a brochure about the risks of anything but breastmilk.

Breaking My Silence and Getting Support

In the first several months  after my daughter was born, I also began having breakdowns. Every few days or so, I cried for hours. Each time, I sobbed that I hated what my life had become and that I dreamed of running away. Then, I felt guilty and ashamed for saying this about a child I loved so much.

I didn’t share my true experience with many people at the time, but I heard back some comments that pushed me further into isolation and secrecy: confusion about why I wasn’t enjoying “the beauty of motherhood” or blame that I was causing much of my own distress by, for example, not giving up sooner on breastfeeding or not wanting to enroll my daughter in daycare earlier so I could rest.

Later, I learned that my worries about topics like this were common, even for people who had easier babies and more support.

Still, I was afraid to share my true feelings with most people, for years.

My child was 2.5 before I finally told a doctor how much I was struggling. She immediately told me I had postpartum depression that had never gone away; I told her that wasn’t possible because my struggles were due to real-life circumstances (e.g., lack of support), not hormones, and she said it didn’t matter.

Even then, my answers to her questions were unnecessarily peppered with terse comments like, “but everything’s fine,” (not exactly true) and “I promise I’m taking good care of her, though” (that was true). I was terrified that my child would be taken away, either because I was so unhappy that I would be told I clearly didn’t want her and, therefore, shouldn’t have her, or because providers might assume I was hurting or neglecting her somehow.

Was I neglecting her? I wondered. I was always so drained that I probably wasn’t playing with her enough. Not tired from being busy, just drained and depressed. When I finally admitted that to a professional, she laughed, surprised, and said that is not neglect.

After I finally began counseling, I was guarded during my first appointments, and I asked the provider for reassurance that she wouldn’t report me somehow, to someone. This was the level of fear and isolation I was facing.

The Reality of Perinatal Mood and Anxiety Disorders or PMADs

Pregnancy, birth, and postpartum can be incredibly hard, and mental health challenges during these periods are common.

It’s crucial that folks have support in addressing their mental health needs during this tumultuous time. These challenges can impact the birthing parent’s overall well-being (mental and physical), sometimes long term; perinatal mental health conditions can also impact families, causing challenges with baby bonding, partner relationships, and much more. 

For cultural and systemic reasons, many birthing parents find that all attention shifts to the baby after birth, and that they are simply expected to move on—whether dealing with birth trauma, postpartum depression, physical pain, or even just feeling unsure about their new identity.

Many people are also hesitant to open up about the challenges of early parenting; it’s common to laugh over minor struggles, but few people share darker thoughts or deeper hardships. 

Additionally, policies and practices that could better support families are common in some countries/cultures but generally lacking in the US: frequent postpartum home visits or supports with nurses, extended paid parental leave for birthing parent and partner, access to recovery support (e.g., pelvic floor therapy), ritual periods of isolation for the baby/birthing parent, or strong community/intergenerational support.

The lack of community and intergenerational support sometimes means that birthing parents have little prior experience with babies and are less aware of what to expect and how to prepare.

Furthermore, too many people struggle with access due to limited availability in some locations, wait lists, discrimination/inability to find appropriate care (e.g., culturally/linguistically relevant, LGBTQIA+ friendly), inadequate screenings and referrals, lack of insurance or other financial concerns, scheduling challenges, and much more.

Let’s Do This Together

I am sharing my story because I want to help others—both people experiencing perinatal mental health conditions and those, like birth workers, who support them.

We need to normalize talking about mental health challenges (perinatal and more broadly) as well as the general difficulties that can come with pregnancy, birth, and postpartum (beyond the minor cute and funny ones).

I did not realize how common many of my own issues, feelings, and experiences were until I began straightforwardly and openly sharing my own several years later. In return, many parents told me privately that they experienced something similar; I also spoke with providers who acknowledged how common this hesitation to share really is.

There is still too much stigma around discussing mental health topics and even opening up about more serious parenting or personal challenges. Many communities in the US also lack the deeper trust, unity, and relationship building that really encourage this kind of openness, sharing, and support.

Unfortunately, this means that multiple people may face similar issues but feel incredibly alone.

We also need to normalize accessible and affordable support throughout pregnancy and postpartum, including emotional and logistical support, from birth workers, friends/family/community, and/or other caregivers, clinicians, or support providers. This should also include frequent, open, honest, and non-judgmental conversations about these topics and how things are really going—and offering or referring to appropriate support as needed. 

Lastly, I recommend birth workers and clinicians actively check in with clients, ideally beginning in early pregnancy or pre-pregnancy, about challenges that can contribute to perinatal mental health challenges, such as support systems and relationships, trauma histories, personal and family mental health histories.

It is also critical to ask about the birth and postpartum experiences to provide support, validation, appropriate care, and opportunities to process these complex and life changing experiences. Because of how significantly breastfeeding challenges impacted me, I also recommend flexibility around breastfeeding recommendations and guidance, with more support and compassion and less stigma, judgment, and fear mongering (e.g., about outcomes) directed towards birthing parents who are unable or prefer not to breastfeed, particularly when breastfeeding is contributing to adverse mental health. 

Overall, bringing these topics up frequently, directly, and early may improve the early detection and prevention of perinatal health concerns, especially when done in a compassionate way.

As a public health worker, I believe that birth workers are an essential part of a birth team, and I am excited about the ways we can contribute to individual healing and cultural shift. 

Angelica Al Janabi (she/her) is a public health professional who has worked in American Indian/Alaska Native health since 2017.

Her career has focused on health equity and supporting special populations, and she previously worked with several diverse groups, including refugees. Most of her current work and much of her past work focused on mental health topics, from providing direct services to advocating to carrying out and evaluating programs. In addition to working with indigenous communities on behavioral health topics, Angelica is actively involved in mental health endeavors at her workplace, to include drafting postpartum policy recommendations and helping create a postpartum group for employees. She first worked on reproductive health topics as a master’s student (supporting a rural Ugandan program) and later through work on Zika virus. Angelica gave birth to a child in 2019 after extremely challenging pregnancy and postpartum experiences (and fortunately, a good birth experience). She decided to train as a full-spectrum doula in the years after her birth in hopes of integrating reproductive health topics into her public health work and support others with similar challenges. Recently, she received a scholarship to carry out a reproductive health research study with Black birthing parents exploring connections between birth, identity, and trauma.