The “Fourth Trimester” and Post-Partum Mental Health

By Annie Murray, Ph.D.

The period of time following childbirth, when a baby first transitions from the protected environment of its mother’s womb, is often called the “fourth trimester.” While the fourth trimester is a season of change for babies as they adjust and develop in the world, it is also a time of great change for mothers, as they too try to adjust and thrive in their new roles and environments. When mothers or babies experience complications, that process can be even more daunting. From a mental health perspective, the fourth trimester is a particularly vulnerable time for new mothers.

To a new mother, in many ways the fourth trimester can feel like falling off of a cliff. The support and attention that was given to an expectant mother seemingly disappears after a baby is born. Too many times, it is during these early post-partum months that new mothers especially need emotional and physical support and resources.

In the U.S., post-partum depression (PPD) is extremely common, but remains largely under-reported, and many new mothers go untreated. During the fourth trimester, an estimated 10–15% of new mothers report experiencing PPD, but that figure accounts for only reported cases. In one year alone, it is believed that more mothers suffer from PPD and related mood disorders than the combined number of new cases (men and women) of tuberculosis, epilepsy, leukemia, multiple sclerosis, Parkinson’s disease, and Alzheimer’s disease. Estimated rates of PPD are even higher for mothers who already bear the weight of poverty.

New mothers who have post-partum depression (PPD) or other post-partum mood disorders often go undiagnosed, largely because medical (and other) attention is focused solely on newborns. While newborn health is obviously very important, similar attention should be given to maternal mental health during the fourth trimester. Mental health stigmas often deter new mothers from seeking help; and in doing so, both new mothers and babies suffer. We know that maternal mood disorders have a negative impact on babies/children in terms of bonding, attachment, feeding, development, and behavior.

When discussing maternal mental health issues, a San Diego based obstetrician-gynecologist commented on the courage of new mothers who share their fourth trimester emotional struggles. In her own practice, she noted that by the time a new mother discloses her post-partum depression or anxiety, that mother has probably struggled for months.

This underscores the importance of universal mental health screening for mothers throughout the fourth trimester. Unfortunately, basic mood screenings for new mothers are not universally conducted; and when they are done, it is usually done at their first post-partum check-up (at least 6 weeks post-partum). Higher rates of new mothers attend scheduled infant wellness check-ups and monthly pediatric appointments; thus, infant care appointments may be an opportunity for screening of mothers as well as babies. Many practices, in fact, are now including basic post-partum mental health screenings for mothers in conjunction with infant check-ups. This is not a solution, but a starting point. Pediatricians, who receive training and guidance on how to communicate with new mothers regarding their mental health, may then direct new mothers to resources or treatment.

From my own experience as a Clinical Psychologist, I am aware that pregnancy and childbirth tend to heighten a mother’s emotional experience. Years ago, I vividly recall working at the hospital when a new mother came in. Her military spouse was deployed and she had been alone with a new baby, not sleeping, and without support or help. Depression crept in, insidiously, and she eventually stopped breastfeeding. After recognizing her own apathy towards breastfeeding as a chasmic shift in herself, she sought help. I remember how guilty and ashamed she felt in asking for help, as she believed that only her newborn should require support and care, not her, too. Years later, in dealing with my own post-partum complications following the birth of my sons, I think of her often. I better appreciate the emotional changes inherent in new motherhood and how vitally important support can be when someone is struggling.

Her story underscores the importance of supporting new mothers through the transitions of the first few months following childbirth. Perhaps the “fourth trimester” should be re-conceptualized as an important time to support both new mothers and babies through early post-partum adjustments and challenges. In doing so, we may recognize that the fourth trimester is equally as important to the health of the baby and mother as the previous three.

Topics: Maternal Health, Mental Health