But this vigilance did not dominate my working day. I had been taught that most parents adapted well, were resilient and did the best by their children because they loved them, and in my experience this was indeed the case. As health visitors, we felt we should trust them to get on with it, offering support when necessary. We knew of the link between postnatal depression (PND) and hormonal changes, but it was a rare diagnosis in those days.
Not any more. PND has become a major concern for health visitors, midwives and GPs. We are told to screen all mothers for it (and, in some places, fathers) because some 10% to 15% of women will suffer from it, along with an unknown number of men.
This is promoted as an improvement in the way we work. We are told that by searching for PND, we are taking mums (and dads) seriously, recognising rather than trivialising their problems. But I am not convinced. The change, I believe, has less to do with addressing a new and real problem - the growth in depression - than problematising parents and their relationships with children.
The emphasis is now on parents' - particularly mothers' - perceived vulnerability, as opposed to their coping ability. But vulnerability is a woolly and poorly defined term. PND is routinely assessed using a (non-validated) screening tool: the Edinburgh postnatal depression scale (EPDS). Developed in 1987, this is a 10-point self-reporting tool to help identify women with PND. It consists of 10 statements, such as "I have felt sad and miserable" or "I have felt scared and panicky for no good reason". A new mother's responses to these statements are given a score of between zero and three: zero indicates absence of symptoms and three maximum severity, while scores of one and two are for intermediary statements. Perfectly normal adjustment to change is thus pathologised.
The Department of Health promotes the notion that the months surrounding the birth of a baby carry the greatest risk of mental-health problems for women, who are anyway much more likely than men to suffer such problems. It has also been suggested that 5% of new mothers suffer post-traumatic stress disorder. Motherhood is therefore now widely promoted as a cause of mental illness.
A major factor behind the supposed need to identify PND is the supposed consequence that non-detection of PND might have on babies and children. We are told that a depressed parent can pose a risk to a child. Thus psychological experiences and adjustments related to parenthood are now considered a social problem, too. We no longer assume that these feelings will pass. Instead, we screen, spot, diagnose and treat. We also believe that if we don't intervene, the children of "depressed" mothers will be damaged.
Parenting does make an important contribution to a child's development, but it does not determine outcome. Social, environmental and cultural influences play an equal if not a greater part. But increasingly, there is a sense that constant professional involvement is needed to judge the quality of parental interaction with children, and, if necessary, to intervene in the interest of the parent or child.
Should a parent refuse to complete the EPDS, for example, the health visitor is urged to consider whether non-compliance represents a child protection concern. Although the scale should not replace the clinical judgment of the practitioner, it can and does. I know of a health visitor who miscalculated the scores upwards and was so concerned that she returned to see the mother that evening, unannounced and in the middle of a dinner party.
Parents in my experience (which includes 15 years of health visiting) are no less able to cope than in the past; they are just perceived that way. Our preoccupation with parents' mental health means, however, that minor problems related to children's emotions, behaviour and sleep - once the bread-and-butter issues for health visitors - are no longer being addressed directly with parents. Children are instead referred to their GP or to child and adolescent mental health services.
And so the basic practical help required and valued by parents from health professionals - the advice about feeding, immunisations and childhood illnesses; the introductions to other mothers; the information about scarce childcare places or welfare benefits - is less available today. We're far too busy searching out constructed problems such as PND to meet parental needs or to support properly those women who actually are depressed and happen to have a baby.
· Brid Hehir is a former midwife and health visitor
This was first published here 31 May 2004
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