Although obstetricians may certify when women are physically able to return to work, mental health professionals have little advice for mothers about the normal challenges of working while being responsible for an infant or a young child, or while dealing with clinically significant problems of mood, anxiety, or cognitive efficiency, all of which may be compromised in the postpartum period.
For example, a third-year medical student with a good academic record delivered her first child at the end of her psychiatry clerkship. She insisted on returning to take her exam 4 weeks later, only to fail and receive a conditional grade.
Another example: Returning to work after 10 weeks of unpaid leave under the Family and Medical Leave Act, an administrative assistant was offered the opportunity to work 30 instead of 40 hours per week. She decided she could not afford to reduce her hours, only to receive a disappointing performance evaluation because she had to take off too many days for child-related responsibilities.
Normal Psychological Concerns
There is no simple answer to the question of what compromises or facilitates a mother’s successful return to work. One must evaluate maternal factors (general health, sleep, fatigue, mood, and cognitive impairment); work-related factors (length of paid and unpaid leave, degree of control over the work environment, economic support, physical qualities of the workplace); support for childcare and the woman’s own values and desires. Professionals must weigh studies that show that returning to work is a source of significant stress for new mothers against other data that show employment may be of substantial benefit to a mother’s mental health.
One obvious source of stress is the intrinsic difficulty of fulfilling multiple, demanding roles. Although gender roles have evolved in the past 50 years, employed mothers typically assume a greater proportion of household responsibilities than employed fathers.1 This unequal distribution of tasks may contribute to fatigue and depression, negatively influencing a working woman’s ability to cope during the transition to working motherhood.1
Work-related factors play an equally important role in overall well-being after returning to work. Employment provides women with financial resources, social support, and a sense of accomplishment. The effects of employment may be damaging if conditions are physically or psychologically overwhelming, or if the woman faces opposition from her family about returning to work.
The qualities of a beneficial job include paid leave, job security, and control over work load (including work schedule). Job security is defined as the perceived probability of retaining one’s job without fear of termination and its consequences. Job control increases with high-status and high-skill occupations that allow individuals a greater say in what they do and how they go about doing it.
Social psychological research has shown an association between low levels of both job security and job control with increasing risks of developing depression and anxiety.2 The likelihood of reporting psychological distress is significantly higher for women returning to work postpartum with fewer favorable employment conditions vs. women with a greater access to such conditions.2
Studies also find stress arising from “spillover” between job and home or home and job. An example of job-to-home spillover would be the necessity of a woman bringing work home, which takes away from time that a mother could spend with her new baby; this also deprives her of a sufficient break from work. A woman who is experiencing home-to-job spillover may have to leave work unexpectedly for family-related reasons, reducing her productivity.
Both types of spillover are associated with lower mental health scores, a consistent finding from several studies.3 One study found that women who felt it was easy to bring work home scored worse on mental health assessments vs. women who reported finding it difficult to do so. In this study, women with more flexible work schedules tended to work more hours overall, suggesting that job flexibility may have unintended adverse effects on work-life balance in the postpartum period.3
A variety of studies suggest that women overall report more negative than positive aspects of returning to work, at least in the United States, where adequate, paid maternity leave is not guaranteed and good quality childcare is often hard to arrange. Unfavorable conditions related to return-to-work may contribute to overt psychopathology. A prospective cohort study of 661 women found that factors significantly associated with better postpartum mental health included better overall health, absence of prenatal mood symptoms or disorders, increased accessibility of social support from both family and friends, perceived control over home and work demands, and lower job stress. This study also found that better general health at 11 weeks postpartum was significantly associated with less job stress and more co-worker support; women in this study who reported that they felt as though their co-workers were a source of support throughout the pregnancy had significantly better postpartum health. Nevertheless, women in this study reported significant physical and psychological symptoms at 11 weeks postpartum, indicating that mothers need support in preparation for returning to work, and ongoing support after they do.4
Satisfaction with childcare makes a positive experience in returning to work more likely. Women who feel comfortable and confident with their childcare arrangements tend to be more satisfied with their decision to pursue work outside the home. Nichols et al documented this association during the early months through 1-year postpartum.1 Cooklin and colleagues found that maternal mental health was not significantly associated with the type of childcare used or the amount of time children spent in the care of someone other than the mother, emphasizing that the mother’s perception of a childcare arrangement is the crucial contributor to her successful adaptation.2
Social support is widely recognized as a protective factor for women’s mental health postpartum, specifically in its correlation with lower levels of anxiety and depressed mood. However, even studies that identify the workplace as an additional source of support emphasize that women’s multiple roles in the home and in the occupational setting may still cause significant stress.
Social networks are positively linked to mental well-being in women, especially at times of increased stress. Providing women with information about making childcare arrangements and also creating supportive relationships with others in the workplace could help facilitate their transition to work postpartum.1,3,5
Impact of Work on Clinical Psychiatric Status
Cognitive capacity clearly affects the ability to manage the demands of a structured workplace. The large hormonal shifts of the early postpartum period may affect cognition as well as mood. Estrogen binding sites abound in the hippocampus and related circuits that are known to be critical for short-term memory.6
Although pregnant women and mothers of young infants consistently complain of “motherbrain,”7,8 objective studies of cognitive function related to pregnancy have been inconsistent in relating cognitive capacity directly to hormonal status.7 By excluding women with depression, these studies focused entirely on cognition may underestimate the impact of hormones, as depression may be an important marker for sensitivity to estrogen flux or deprivation. Sleep deprivation, a common occurrence in both pregnancy and during the first postpartum months, is well-known to impair cognition.9
A more stringent method for assessing the effect of pregnancy or childbirth upon cognition and return-to-work would be to follow selected women from preconception through pregnancy and the early postpartum period. In the absence of such studies, clinicians can only advise women that they should consider cognitive as well as physical recovery in planning for maternity leave, to the extent that they have a choice in the matter.
Several studies have examined return-to-work as a protective factor against postpartum depression. A Japanese study found that employment, particularly full-time employment, was significantly related to a decreased risk for postpartum depression when compared with unemployment. This is consistent with research done in the United States that found women who were not employed full time reported moderate to severe depressive symptoms more often than those employed full time. Women with professional or technical jobs had significantly lower risks for postpartum depression. However, the Japanese study found no association between household incomes or maternal and paternal education levels and the risk for postpartum depression.10,11
Role of Health Care Providers
Women surveyed about the support systems in place during their return to work, rarely, if ever, mention health care providers.4 Patient-centered clinicians could do much more to recognize return-to-work issues as a major aspect of women’s lives beyond delivery. A majority of mothers in one study believed that prenatal health care providers should discuss returning to work with pregnant women. Those who reported having such a conversation reported that they, not their health care providers, initiated the discussion.12
The appropriate role of physicians, nurses, social workers, and pediatricians in helping women with the transition to paid work during early motherhood requires further study. Although the medical care system cannot substitute for social policies regulating conditions of employment, clinicians may point women toward appropriate options. Providing resources as well as suggesting coping strategies for anticipated stress and conflicts could ultimately improve the adjustment of women returning to work. Such resources might include helping women prepare specifically by arranging childcare, organizing finances, and identifying external support to help with the expected demands of returning to work. Mental health clinicians in particular may play an important role in providing documentation of the medical necessity of adjusting workplace conditions in light of a psychiatric disorder.
Most women who plan to return to work postpartum are able to do so. However, the measure of success should be more than whether or not a woman enters or resumes an occupational role. It is important to assess whether a pregnant or postpartum woman is able to remain employed, how well she is able to function at home and at work, and how well she manages the stress that comes along with this major adjustment.4
Overall, employment is associated with better physical and psychological health. However, such health benefits can be blunted by conflicts experienced by working mothers. As more is learned about the risks and rewards of work during pregnancy and postpartum, health care providers can play an important role in supporting women with resources and advocacy to minimize the conflicts that may arise, fulfilling their responsibility to promote women’s physical and mental health.
- Nichols MR, Roux GM. Maternal perspectives on postpartum return to the workplace. J Obstet Gynecol Neonatal Nurs. 2004;33:463–471. doi:10.1177/0884217504266909 [CrossRef]
- Cooklin AR, Canterford L, et al. Employment conditions and maternal postpartum mental health: results from the Longitudinal Study of Australian Children. Arch Womens Ment Health. 2010;14:217–225. doi:10.1007/s00737-010-0196-9 [CrossRef]
- Grice MM, McGovern PM, et al. Balancing work and family after childbirth: a longitudinal analysis. Womens Health Issues. 2011: 21(1):19–27. doi:10.1016/j.whi.2010.08.003 [CrossRef]
- Killien MG. The role of social support in facilitating postpartum women’s return to employment. J Obstet Gynecol Neonatal Nurs. 2005;34(5):639–646. doi:10.1177/0884217505280192 [CrossRef]
- McGovern P, Dowd B, et al. Postpartum health of employed mothers five weeks after childbirth. Ann Family Med. 2006;4(2):159–167. doi:10.1370/afm.519 [CrossRef]
- Buckwalter JG, Stanczyk FZ, McCleary CA, et al. Pregnancy, the postpartum, and steroid hormones: effects on cognition and mood. Psychoneuroendocrinology. 1999;24:69–84. doi:10.1016/S0306-4530(98)00044-4 [CrossRef]
- Janes C, Casey P, Huntsdale C, Angus G. Memory in pregnancy. I: Subjective experiences and objective assessment of implicit, explicit and working memory in primigravid and primiparous women. J Psychosom Obstet Gynecol. 1999;20:80–87. doi:10.3109/01674829909075580 [CrossRef]
- Workman JL, Barha CK, Galea LA. Endocrine substrates of cognitive and affective changes during pregnancy and postpartum. Behav Neurosci. 2012;126(1):54–72. doi:10.1037/a0025538 [CrossRef]
- Goel N, Rao H, Durmer JS, Dinges DF. Neurocognitive consequences of sleep deprivation. Semin Neurol. 2009;29(4):320–339. doi:10.1055/s-0029-1237117 [CrossRef]
- Miyake Y, Tanaka K, et al. Employment, income, and education and risk of postpartum depression: the Osaka Maternal and Child Health Study. J Affect Disord. 2011;130:133–137. doi:10.1016/j.jad.2010.10.024 [CrossRef]
- Rubertsson C, Wickberg B, et al. Depressive symptoms in early pregnancy, two months and one year postpartum-prevalence and psychosocial risk factors in a national Swedish sample. Arch Womens Ment Health. 2005;8:97–104. doi:10.1007/s00737-005-0078-8 [CrossRef]
- Clinch CR, Grzywacz JG, et al. Characteristics of mother-provider interactions surrounding postpartum return to work. J Am Board Family Med. 2009;22(5):498–506. doi:10.3122/jabfm.2009.05.090010 [CrossRef]