Enfº. Alain Pires Delgado

Maternal and Obstetric
Health Specialist Nurse

Nursing perception of triggers for mental health changes in pregnant women

HPA Magazine 21 // 2024

The couple's pregnancy is usually associated with an event considered happy, exciting, and desired. This is generally the overall feeling conveyed in society, but on an individual and intimate level, the issue is much deeper and deserves analysis.
The various changes caused by motherhood at different levels can be challenging to handle and accept. Every pregnant woman experiences pregnancy in a personal way, and many cope with factors during pregnancy that can create extreme pressure, potentially jeopardizing their mental and emotional balance.
Statistically, 1 in 5 women experience mental health problems during pregnancy or within a period that can extend up to a year postpartum.

The most common concerns and thoughts that lead to stress and anxiety can include:
> Symptoms and discomforts that jeopardize well-being (hyperemesis, back pain, edema)
> Altered self-image (physical dimorphism)
> Fear that there may be an issue with the fetus
> Role change, becoming a mother, leaving work
> Do we have sufficient economic stability?
> Feelings of guilt
> Will I have support, or will I be overwhelmed?
> Do I have close family support, or can that support, if it exists, be a source of stress and conflict in the relationship? (conflictual family relationships)
> What might change in the relationship?
> Will I be a good mother?
> Pregnancy complications
> Fear of childbirth itself

These factors, whether individually or in combination, can lead to an accumulation of stress and anxiety. These situations should be demystified and discussed, as they can happen to any woman, even without prior history. The most common disorders are anxiety and depression, affecting 10 to 15 out of every 100 women.
There are risk factors that should be carefully monitored during the gravid and postpartum phases:
> History of mental illness
> Discontinuation of medication during pregnancy
> Recent traumatic events such as the death of 
   family members or the end of a relationship
> Feelings about being pregnant
> Traumatic childhood memories
> History of eating disorders (especially anorexia 
 or bulimia) may worsen acceptance of weight 
  gain or self-image
> Some pregnancy symptoms such as irregular 
  sleep or lack of energy may be confused 
  with depression.

What are the symptoms that may indicate fragile mental health?
> Sadness, easy or more frequent crying
> Lack of satisfaction in previously enjoyable 
  activities
> Lack of energy or motivation
> Excessive worries
> Sleeping too much or experiencing insomnia
> Overeating or eating too little
> Difficulty concentrating
> Difficulty making decisions
> Feelings of guilt or hopelessness
> Feeling that something bad will happen
> Physical complaints or nonspecific pains
> Feeling worthless
> Excessive concern about the baby
> Feeling incapable or unwilling to care for the baby
> Negative thoughts about the baby
According to the World Health Organization (WHO), fragile mental health during the perinatal period may be associated with a higher risk of obstetric complications, such as preeclampsia, hemorrhage, premature birth, or an increased risk of suicide. This increased risk may be explained by pregnant women with fragile mental health missing more obstetric surveillance appointments, leading to more erratic pregnancy monitoring.
In accordance with the guidelines set forth by the World Health Organization (WHO), a woman with deteriorating mental health and without proper support has a higher risk of undesirable fetal outcomes. There is also a greater risk of low birth weight for newborns, making them more susceptible to physical illnesses. Additionally, their behavioral and emotional development in childhood may be affected, and these children may face difficulties in feeding and forming attachments with their parents.

Some examples of risk factors that may lead to situations of mental fragility include:
> Teenage pregnancy
> Previous traumatic childbirth experience
> Poverty
> Gender discrimination
> Inadequate nutrition
> Limited educational opportunities
> Debilitated physical conditions
> Low social support
> Pregnancy during natural disasters
> Domestic violence or other conflicts
> Unwanted pregnancy
> Fertility difficulties
> Substance abuse

The key to addressing these situations is to identify pregnant and postpartum individuals at risk and to prevent with appropriate and timely assistance. Distinguishing between everyday concerns and clinically significant symptoms can be very challenging. Women should be asked about their feelings regarding their symptoms, whether they perceive them as severe, how long they have been experiencing them, and if they affect their functional capacity and ability to cope with problems.
The World Health Organization (WHO) believes that mental support should be provided during routine consultations, and strategies for stress control and management can be offered, utilizing the support of friends and family.
In our clinic, we have an instrument as part of the pregnant woman's process, which includes an information sheet and a self-assessment questionnaire. If the woman answers positively to any of the questions, she is invited to schedule a consultation/teleconsultation with the Maternity Clinical Psychologist, Dr. André Galvão de Castro.
In the maternity ward, a questionnaire administered by the nursing team is also used. This survey conducts a new screening for the mental health of the pregnant woman upon admission, complementing it with data collection that evaluates other components of physical and emotional well-being. If there are warning signs, the Obstetrician immediately refers to the department's Psychologist for specialized assessment and ongoing support. Every pregnant woman showing signs of risk is offered assistance, and she should feel comfortable accepting it, being encouraged to seek help.
Therefore, the multidisciplinary team should strive to identify these risk factors, always offering help and expressing availability to listen to the individual.