Stigma and maternity care

A current priority within maternity care is to identify and support women with mental health problems and stigma is a major barrier to achieving this. Stigma has its roots in difference. A mental or physical difference that is characterised as unacceptable and leads to strong negative appraisal from others (external stigma) or to stigamatised individuals attaching stigma to their own identity (internal stigma). Women with mental illness experience delay in seeking and attending antenatal care, as they fear encountering stigma and judgemental attitudes of healthcare professionals (Moore, Ayers, & Drey, 2017). Women may also experience internal stigma because they consider themselves a failure and may experience guilt and shame for not meeting their own expectations of motherhood. These experiences can be very damaging to a woman’s identity as a mother.

External stigma has many different sources and some of them come from within our health care systems. People with mental illness report that health professionals, providing both mental and physical health care, are an important source of stigma and discrimination in many countries worldwide (Thornicroft et al., 2016). McCauley, Elsom, Muir-Cochrane, and Lyneham (2011) explored the perceptions of a group of midwives in Australia in relation to their own mental health skills, knowledge and experiences when working with women with mental illness in the perinatal period. Midwives reported that women with mental illness were often ‘difficult’ to interact with, resisted care and tended to be viewed as ‘potentially aggressive’. More than 60% of midwives in the study identified negative responses to the women and said that most of the time the midwives they worked with avoided women with mental illness. Mental health stigma has also been reported to be widespread in the medical profession (Wallace, 2010). As with midwives, at least part of the problem was perceived to be the low priority given to mental health during professional training and this is an important mechanism for reducing stigma in health care.

Stigmatising behaviour in maternity care may not always be easy to identify, because stigma thrives in the shadows. For many women, talking about their illness is uncomfortable as they may feel ashamed and many may not even know how to talk about such issues. The midwife’s role is crucial in facilitating an enabling environment where a woman feels safe to disclose worries regarding her mental health. Women can pick up on cases where midwives feel discomfort and lack of confidence when talking about mental health (Darwin, McGowan, & Edozien, 2016). The introduction of screening questions is an attempt to help women discuss their problems with midwives; however, stigma can subtly creep in, particularly when questions are administered verbally and not completed in written format by the woman. It is vital that midwives are trained appropriately to ask screening questions in a sensitive manner as this can determine their acceptability (Howard et al., 2018). Despite the standardised format of screening questions, women at antenatal clinics have anecdotally reported that when asked about mental health a comment may be made such as ‘this won’t apply to you, but …’ or ‘sorry, we have to ask these questions, but …’. Such comments may aim to make the situation more comfortable, but they create an ‘us’ and ‘them’ encounter and women with mental health problems may find it even harder to disclose a problem when a discussion takes this turn.

Even if we succeed in removing the barriers to disclosure of mental health problems, stigma and discrimination may also subtly creep into treating the physical health needs of women with mental health problems during pregnancy. There is strong evidence from the stigma literature that the physical health needs of people with mental illness are neglected, including the problem of misattribution of physical and mental health complaints, so-called diagnostic overshadowing (Thornicroft et al., 2016). This may be particularly complex in pregnancy as some pregnancy-related symptoms such as disturbed sleep, appetite and low levels of energy are also associated with mental health disorders.

To transform identification and treatment of perinatal mental health problems, we need to address stigma and how it impacts on our thoughts and behaviours. In the perinatal period, stigma has been associated with being a teenage mother, a woman with HIV, a woman with a disability or a woman with mental health problems, to name just a few examples. Also, there are examples of stigma and stigmatising behaviour changing over time; for example, the stigma of being an unmarried mother has lessened over the past 50 years. Things can change, but we need to be proactive about dealing with stigma in maternity care. In a review of interventions to reduce mental health-related stigma and discrimination, Thornicroft et al. (2016) found that social contact was the most effective type of intervention to improve stigma-related knowledge and attitudes in the short term. However, the evidence for longer-term benefit of such social contact to reduce stigma was weak. Much remains to be learned about the mechanisms through which individuals, health services and communities may challenge stigma and the contexts which facilitate or hinder this process. A good starting point is reflecting on our own research and practice.