Objective: Pregnancy and motherhood bring joy and fulfillment, but also significant responsibilities. This study aims to explore psychological problems among mothers’ experience during the postpartum period, focusing on screening and confirming nature of these disorders, identify risk factors, and providing recommendations for management.

Method: A cross-sectional study was conducted at Square Hospital's Child Development Center (CDC), suspected 7932 mothers for psychological problems from January 2022 to August 2024. Different Scales were used to assess and grade depressive symptoms.

Inclusion Criteria: mood swings, guilt, anxiety, suicidal ideation, and difficulty bonding with the baby.

Exclusion Criteria: Pre-existing mental disorders.

Results: Out of 7932 mothers, 292 (3.7%) mothers were at risk of psychological problems and majority mothers i.e., 125 (42.81%) pregnant mothers between 25-35 years age, all mothers were educated 7932 (100%), more than half of the mothers i.e., 154 (52.74%) were working. Medical history revealed that psychological problems were more during the antenatal period i.e., 167 (57.19%) than postnatal period 125 (42.81%). Screening was done by Edinburgh-Bangla Version Postnatal Depression Scale. Baby Blues affected only 98 (1.24%) mothers, this low numbers may be not receiving treatment due to lack of awareness, family supports and stigma. Confirming diagnosis by DSM-5 and was found Postpartum Depression (PPD) among 161 (2.03%) mothers and Postpartum Psychosis among 16 (0.20%) mothers respectively.

Conclusion: Maternal mental health should be prioritized from conception through postpartum, with families’ education on its importance. Breaking the stigma and providing  timely interventions will safeguard both mother and baby’s well-being.

Keywords: Pregnancy, Baby blues, Postpartum depression, Postpartum psychosis

METHODOLOGY

This facility-based cross-sectional study was conducted over 32 months from January 1, 2022 to August 31, 2024, at the Square Hospital Child Development Center (CDC) in Dhaka, Bangladesh, a well-known tertiary care private hospital. The CDC routinely conducts neurodevelopmental screenings for all neonates born at the hospital, typically between 15 to 28 days of age [11]. During these assessments, doctors and developmental therapists observed psychological distress among many mothers accompanying their newborns. This observation prompted the initiation of the study to investigate the psychological conditions of these mothers. The Edinburgh Postnatal Depression Scale (EPDS) is a well-known tool for the screening of depression during postnatal periods which comprises of 10-questions, each having scores as 0-3, with minimum and maximum scores as 0 and 30 respectively. This scale is validated in many countries including Bangladesh as The Edinburgh-Bangla Version Postnatal Depression [12] Scale The calculated Cronbach’s alpha value of the present scale was found to lie within range of 0.814-0.844, which was quite reliable [13]. The Edinburgh-Bangla Version Postnatal Depression Scale was utilized for screening of suspected mothers having psychological problems [14]. An informed consent was also taken from the mothers. The current psychiatric nosology in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) does not recognize postpartum psychosis as a distinct disorder; rather, if a woman meets criteria for a brief psychotic disorder, the DSM-5 suggests adding “with postpartum onset” as a specifier if the onset is during pregnancy or within 4 weeks postpartum [15]. Specific psychological disorders were confirmed using the DSM-5 diagnostic criteria [16]. All screenings and assessments were administered by a certified psychosocial counselor. All data was collected and analyzed by using SPSS version 25 and ethical approval for this study was taken from the ethical review committee of the study hospital.

Inclusion Criteria:

• Mood swings (persistent sadness, excessive crying, difficulty controlling anger)
• Disorganized appearance
• Inattentiveness
• Feelings of guilt
• Sleep disturbances
• Anxiety
• Loss of appetite
• Difficulty bonding with baby
• Hyperventilation
• Suicidal ideation

Exclusion Criteria:

• Mothers with pre-existing mental disorders before pregnancy

RESULTS

The study on psychological problems among mothers attending the Child Development Center (CDC) for Neonatal Rapid Neurodevelopmental Assessment (NRNDA) provided valuable insights into postpartum mental health. Among 7,932 mothers screened by EPDS, 292 (3.68%) experienced psychological issues (Figure 1).

According to DSM-5 criteria, 292 mothers having postpartum psychological problems, who were further evaluated. The study revealed the following distribution: Baby blues were experienced by 98 (1.24%) mothers, postpartum depression (PPD) was identified in 161 (2.03%) mothers, and postpartum psychosis was observed in 16 (0.20%) mothers and 17 (0.21%) mothers were found to have no psychological issues who were screened positive initially (Figure 2).

Baseline Characteristics of 292 mothers are plotted bellow Table 1. They were grouped by age into three, 49 (42.81%) mothers belonged to 18-24 years, 125(42.81%) mothers to 25-35 years and 118(40.41) mother in 36-50 years. Majority of the mother belonged to 25-35 years of age (Figure 3). There was a striking feature that educational qualification levels showed that all mothers were educated, with 98(33.56%) holding undergraduate degrees, graduate 83(28.42%), post graduate 66(22.60%) and 45(15.41%) mothers have PhDs (Figure 4). Professional status indicated that more than half of mothers 154(52.74%) were employed, while 138(47.26%) were housewives (Figure 5).

The distribution of children indicated that most mothers had one child 143(48.97%), two children among 80(27.40%) and three or more children among 69(23.77%) mothers (Figure 6). Psychological problems observed more in mothers who had one child. Socioeconomic status of the mother was divided in three groups, middle income group (MI) mothers were 21(7.19%), monthly income in between 20,000- 40,000 BDT, upper middle-income group (UMI) were 124(42.47%), monthly income in between 40,000-60,000 BDT and high-income group (HI) mothers were 147(50.34%), monthly income more than 60,000 in BDT respectively.

One important finding from the medical history was that psychological problems were more prevalent during the antenatal period, with 167 (57.19%) mothers, compared to 125 (42.81%) mothers in the postnatal period (Figure 7). Another significant observation was that psychological problems were more common in mothers with unplanned pregnancies 157 (53.77%) than in those with planned pregnancies 135(46.23%) (Figure 8).

DISCUSSION

During the antenatal period, expectant mothers often experience shifting anxieties as their pregnancies progress. These emotional shifts are tied to physical changes, concerns about the baby, and fears about childbirth. During first trimester, discomfort arises from early physical changes, fears of miscarriage, and increased irritability. During second trimester, mother could feel the growing presence of the baby can influence emotions and heighten anxiety and during third trimester, fear of impending childbirth and the uncertainties surrounding delivery dominate [1]. In the postpartum period, around 85% of women experience some form of mood disturbance. While most symptoms are mild and short-lived, 10-15% of women may develop more serious symptoms of depression or anxiety. Postpartum psychiatric illnesses are classified into three main categories: postpartum blues, postpartum depression (PPD), and postpartum psychosis, representing a spectrum from mild to severe disorders [17-19]. Postpartum baby blues appears up to 85% of mothers within the first few weeks after delivery [20]. Symptoms include sadness, mood swings, tearfulness, anxiety, or irritability. These symptoms typically peak on the 4th or 5th day after delivery and last for a few hours or days, remitting spontaneously within 2-3 weeks. Does not interfere with a woman's ability to function, and no specific treatment is required beyond reassurance [21]. In Bangladesh, the prevalence of psychological conditions during the postpartum period, such as baby blues, postpartum depression (PPD), and postpartum psychosis, mirrors global trends, but it is influenced by local socio-economic factors and healthcare access. Global prevalence of baby blues around 50-75%, and these figures are similar in Bangladesh, particularly in urban areas [22].   In this study, 1.24% of mothers experienced baby blues, which is significantly lower than the general prevalence. This less number may be due to not all suspected mothers with Baby blues were willing to seek psychosocial services due to social stigma and lack of support from family or in-laws except those mothers who were suffering from major depressive illness. Postpartum Depression (PPD) usually emerges within the first 2-3 months postpartum but can appear at any time after delivery. The global prevalence of PPD is 100-150 per 1000 births (10- 15%)²¹. Symptoms include depressed mood, tearfulness, and fatigue, sleep disturbances, feelings of worthlessness, poor concentration, and poor bonding with child. Edinburgh Postnatal Depression Scale is a widely used tool, and a score of 12 or greater or an affirmative answer on question 10 (presence of suicidal thoughts) indicates a need for thorough evaluation [23]. In this study, 2.03% of mothers were diagnosed with PPD and were managed by both psychiatrists and counselors. Postpartum Psychosis is the most severe form of postpartum psychiatric illness, affecting 1-2 per 1000(0.1-0.2%) women after childbirth [23]. In Bangladesh, postpartum psychosis has similar incidence [22]. Onset of symptoms often occurs within the first 48-72 hours postpartum, with most cases emerging within the first two weeks. Early signs include restlessness, irritability, and insomnia, followed by more severe symptoms like disorientation, delusional beliefs, and auditory  hallucinations. Postpartum psychosis is associated with a high risk of infanticide and suicide [19,24]. This study found that 0.20% of mothers were diagnosed with postpartum psychosis, which is consistent with the global prevalence. This study revealed more interesting findings like psychological problems more during antenatal period than the post postnatal period, more in unplanned pregnancy than in the planned pregnancy. These problems are more in mothers who had single child. Their education level quite impressive and more than half of the mother were doing job. The mothers who had baby blues were managed by counseling and reassurance at CDC but Postpartum depression (PPD) and Postpartum Psychosis received psychiatric consultation and counseling. However, the study highlights the importance of mental health screening during both the antenatal and postnatal periods, especially considering the impact of unplanned pregnancies. It also emphasizes the need for continued support for working mothers and the need for interventions in various socioeconomic and educational groups.

RISK FACTORS

Several risk factors contribute to the occurrence of postpartum psychological problems in Bangladesh, often intertwined with the country’s socio-cultural context. Mental illness often carries stigma, and a lack of emotional or practical support from family members can worsen the mother's psychological well-being. Women face societal expectations regarding their roles as mothers and caregivers, and failure to meet these expectations can lead to feelings of inadequacy, contributing to mental health issues. Medical complications during pregnancy, childbirth, or the postpartum period also increase the risk of postpartum psychosis. Traumatic or high-risk deliveries, preterm births, or neonatal complications elevate the psychological burden on the mother. Sleep deprivation, which many new mothers face, exacerbates existing mental health issues or triggers new ones, while the physical fatigue of childbirth combined with continuous care for a newborn adds to emotional and psychological strain. Drastic hormonal fluctuations, particularly in estrogen and progesterone after childbirth, are also thought to contribute to postpartum psychosis. Social isolation, especially for new mothers in urban settings or nuclear families, can lead to feelings of helplessness and depression. In traditional Bangladeshi families, insufficient spousal or family support may leave a mother feeling overwhelmed, further contributing to psychosis. Additionally, a family history of psychiatric disorders, especially bipolar disorder or schizophrenia, increases the likelihood of postpartum psychosis.

MANAGEMENT

The management of postpartum depression (PPD) involves a combination of pharmacologic and non-pharmacologic approaches, tailored to the individual’s symptoms and needs. The following are some key interventions:

Pharmacologic Treatment:

• Antidepressants: Medications such as selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed for PPD. They help to regulate neurotransmitters like serotonin, which play a role in mood Antidepressants can be used safely during breastfeeding, but should always be prescribed under medical supervision [25].
• Hormonal Therapy: In some cases, hormone therapy, such as estrogen supplementation, may be considered to counteract the drop-in hormone levels that occurs after childbirth. However, more research is needed to fully understand its efficacy in treating

Psychological and Therapeutic Interventions:

• Interpersonal Therapy (IPT): This therapy focuses on addressing interpersonal issues that may contribute to PPD, such as relationship conflicts, social role transitions, and the stress associated with becoming a mother. IPT has been shown to be effective in treating PPD by helping women develop better communication skills and social support.
• Cognitive-Behavioral Therapy (CBT): CBT helps mothers identify and challenge negative thought patterns, which can exacerbate feelings of depression. This therapy is beneficial in providing coping strategies to manage the stress, anxiety, and mood disturbances associated with PPD [26].
• Psychodynamic Therapy: This form of therapy aims to address unresolved emotional conflicts that may contribute to PPD, helping mothers understand how their past experiences influence their current emotional state and relationships [27].
• Couple Counseling: For mothers experiencing relationship stress, couple counseling can provide a supportive environment to improve communication, share concerns, and work through This helps reduce emotional strain and isolation.

Lifestyle and Supportive Interventions:

• Physical Activity: Engaging in regular exercise has been shown to reduce symptoms of Physical activity helps boost endorphin levels, which can improve mood and energy levels.
• Social Support: Encouraging mothers to talk to close friends and family can alleviate feelings of isolation. Creating a strong support network is crucial in preventing and managing PPD.
• De-stressing Techniques: Relaxation techniques such as mindfulness, meditation, and deep-breathing exercises can help reduce anxiety and stress These strategies promote emotional well-being and are useful as part of a holistic approach to managing PPD.

Counseling and Support Groups:

• Peer Support: Joining support groups for new mothers can provide emotional support and Sharing experiences with others going through similar challenges can be reassuring and help build coping skills.
• Professional Counseling: Regular sessions with a mental health professional (e.g., psychologist or psychosocial counselor) can offer mothers a safe space to explore their feelings and receive guidance on managing their mental health.

Integrated Care Models:

• In many cases, a multidisciplinary approach involving pediatricians, obstetricians, psychiatrists, and therapists may be ideal to ensure comprehensive care for both mother and

So, in summary, while medications such as antidepressants can be crucial for treating PPD, non- pharmacologic treatments, especially various forms of psychotherapy are highly effective. A combination of counseling, lifestyle changes, and social support plays a central role in the management of PPD. Integrating these interventions based on individual needs can lead to a successful recovery and improved mental health outcomes for new mother [28].

CONCLUSION

Pregnancy is often seen as a joyful time, but it can also bring emotional and psychological challenges. Prioritizing maternal mental health from conception through the postpartum period is crucial for the well-being of both the mother and the baby.

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  Table 1