Perinatal health and wellbeing Flashcards
1
Q
what is perinatal psychology?
A
- Perinatal – pregnancy (3 trimesters), birth, postpartum (<1 year), family planning, fertility treatment, high risk pregnancies, perinatal loss, mental health, maternal and infant outcomes
- Studies the father, infant, wider family, health professionals working with families
- At the intersection of clinical Psychology, Psychiatry, Obstetrics, Paediatrics, Nursing, and Midwifery
- Also of great interest to non-professionals because childbearing is a life event experienced by most people!
2
Q
why is perinatal psychology important?
A
- Approx. 353,000 babies born every day around the world
- That means approximately 800,000 new parents per day
- Every birth creates a new family network
- Parenthood viewed as a time of joy and fulfilment
- But even “normal” pregnancy brings significant, unique, biopsychosocial changes
- Time of apprehension and uncertainty in the smoothest of pregnancies
- Unfortunate reality that the transition to parenthood does not always go as planned:
- 12% of couples experience infertility
- 1 in 4 pregnancies end in miscarriage
- 1 in 200 end in stillbirth (death after 24 weeks in pregnancy)
- 1 in 4 births are assisted (i.e. caesarean section)
- 1 in 10 babies are born prematurely and are at risk of significant health problems
- 1 in 5 women will experience a clinically significant mental health problem during pregnancy or the postpartum
- Maternal suicide is the leading cause of maternal death up to 1 year postpartum
3
Q
typical course of pregnancy- hormonal changes
A
- hCG: Once egg meets sperm, hCG stimulates production of estrogen and progesterone. It also suppresses the immune system to support the growing baby.
- Estrogen: Helps the uterus grow, regulates the production of other key hormones, and triggers the development of baby’s organs
- Progesterone: encourages breast tissue growth and later helps soften ligaments and cartilage to prepare for labour.
- Relaxin: Relaxing muscles, bones, ligaments and joints later in pregnancy in preparation for labour.
- Oxytocin: Stimulating labour
Prolactin: Causes breasts to increase in size and eventually produce milk.
4
Q
early pregnancy (first trimester)
A
- Early pregnancy (first trimester 1-12 weeks)
- Nausea and vomiting is experienced by 70-85% of pregnant woman (ACOG, 2004)
- On a spectrum from mild to severe (hyperemesis gravidarum)
- Thought to be a direct effect of HCG
- Typically stabilises at 3-4 months
- Fatigue experienced by 96.6% of first trimester mothers (Zib, Lim & Walters, 1999)
Contributing factors include increased oxygen consumption, metabolic changes and estrogen/progesterone (Bialobock & Monga, 2000)
5
Q
further progression of pregnancy (2nd and 3rd trimester)
A
- Symptoms most likely to impact quality of life: Frequent urination, fatigue, and heartburn (75-88% of women; Nazik & Eryilmaz, 2013)
- Progesterone, estrogen, and relaxin responsible for digestive problems
- 63% of women experience progressive worsening of sleep quality during pregnancy
Fetal movement, pain, impaired movement, pregnancy-related anxieties
6
Q
typical course of pregnancy- postpartum
A
- Recovery from birth generally takes 6 weeks
- Huge drop in all pregnancy hormones
- Potential explanation for ‘baby blues’
- Newborns wake every 2-3 hours in the night so sleep quality is poor postpartum
Most common complaints 3 months after birth were fatigue (67%), back pain (47%), breast problems (37%), and urinary incontinence (29%) (Woodland et al. 2013)
7
Q
key social transitions postpartum- from a woman to a mother
A
- Emmanuel & St John (2010) suggest becoming a mother encompasses several psychosocial challenges:
- Changing from a known to an unknown reality
- Taking on a new maternal identity, with associated feelings, behaviours, and skills
- Renegotiating prior social roles, such as employment, relationship with partner, and wider family roles
- Balancing multiple demands
- Experiencing losses, such as loss of control, sleep, freedom, and sense of self
Normal adaptation to these changes can encompass both emotional challenges and personal growth
8
Q
key social transitions postpartum- relationship and sexual functioning
A
- Common belief that parenthood is central to a fulfilling romantic relationship (Hansen, 2012)
- Relationship satisfaction and sexual functioning decline moderately among men and women from pregnancy to the child’s first birthday (Mitnick, 2009)
- Increased marital conflict in the postpartum compared to during pregnancy (Hanington et al. 2012)
- Twenge et al. (2003) meta analysis of 90 studies comparing parents to childless individuals (n=30,000)
- Parents experience lower levels of relationship satisfaction than non-parents
- Parents of infants report lower levels of relationship quality than childless individuals or parents of older children
Key predictors of relationship quality include pre-pregnancy quality and duration, planned pregnancy, parents relationship status, and mental health status
9
Q
key psychological changes post partum- adaptive anxiety
A
- From an evolutionary perspective, anxiety is particularly adaptive during pregnancy and the postpartum
- To ensure health, wellbeing, and survival of mother in pregnancy and infant in postpartum
10
Q
evolutionary adaptation of childbearing anxiety?
A
- Reductions in grey matter in brain regions associated with social cognition i.e., the theory of mind network, promotes mother-infant bonding (Martinez-Garcia et al., 2021)
- Salience network activation (Seeley et al., 2007)
- Threat detection
- Focus on infant wellbeing and harm-avoidance
Paralimbic structural activation
11
Q
key psychological changes postpartum- stress response and coping
A
- Psychological reactions to stress are attenuated during pregnancy when compared to non-pregnant controls (Glym et al. 2004)
- Stress reduction as pregnancy progresses
- Lab studies using the Trier Social Stress Test (5 min free speech and mental arithmetic tasks in front of an audience) found lower stress responses in late pregnancy compared with early pregnancy (Entringer et al. 2010)
- We also cope with stress more effectively during pregnancy (Hamilton & Lobel, 2008)
- Avoidant (negative) coping strategies are used less
- Avoidant strategies associated with reduced preparation for parenting, bonding problems, and less preventative health care
- Why do we stress less and why are we better at coping with it during pregnancy?
- Exposure to high levels of maternal stress during pregnancy has the potential to adversely impact fetal development, birth outcomes, and subsequent child and adult health outcomes (Van den Bergh, 2005)
- Innate protective mechanism to preserve fetus at critical periods in development?
12
Q
key psychological changes- postpartum blues
A
- Initial studies in the area used variants of depression measures that focus on negative mood
- Found increased tearfulness, lower mood hence “baby blues”
- Newer studies use instruments that measure both positive and negative mood
- Based on the premise that happiness and sadness are not on a continuum but can occur concurrently
- Found that the predominant mood experienced is happiness (e.g. Edborgh, 2008) BUT both positive and negative mood states are significantly elevated in the first 10 days after birth (Wilkinson, 1999)
13
Q
the shadowing effects of perinatal depression
A
- Research, detection, and diagnosis of perinatal mental health problems have focused primarily on PND
- Other mental health conditions are often incorporated into depression diagnoses
- Lack of information for women experiencing symptoms that fall outside of PND
- Potential to ‘miss’ other conditions with similar presentations by only measuring depression
- Co-morbidity may only be diagnosed with depression
Incorrectly being diagnosed with PND
14
Q
perinatal depression
A
- 9-16% prevalence from pregnancy through to the first year postpartum
- Prevalence is higher in areas of high socioeconomic deprivation
- Often co-morbid with anxiety
- Why do I feel so sad when I should be so happy?
- Gives rise to additional feelings of guilt, incompetence, hopelessness
- Paradox of loss theory (Nicholson, 2001)
- Loss of autonomy, loss of time, loss of appearance, loss of sexuality, loss of occupational identity
15
Q
PND and new fatherhood
A
- Cannot be explained by biological factors, as with maternal PND
- Suggests social, psychological and interpersonal factors are independently important in onset
- Risk factors for experiencing distress (Dudley et al. 2001)
- Infant problems (feeding/sleeping)
- Prior experience of fatherhood
- Relationship quality
- Paternal depression rates are double the national average for nulliparous men in the same age group in the US (Paulson et al. 2006)
- Elevated still if partner is being treated for a mental health condition (Paulson & Basemore, 2010)
- Fathers can offer protection against the effects of maternal depression
- Shields infant from negative outcomes (Field, 1998)
- Reduces maternal parenting stress (Jackson, 1999)
Minimizes negative maternal child- rearing attitudes (Brunelli et al, 1995)
16
Q
perinatal anxiety
A
- Perinatal anxiety is highly prevalent ~ up to 43% (Kuo et al. 2004)
- Commonly under-recognised (Muzik et al. 2000; Wenzel et al. 2005; Paul et al. 2013)\
- Types and presentation:
- GAD - Fear of miscarriage, fear of infant harm, fear baby will be born with abnormality
- OCD – Fetal exposure to alcohol, cigarettes in pregnancy, repeatedly checking infant, compulsively washing self or baby
- Panic disorder – Sudden fear baby has stopped breathing either in utero or after birth
- Social anxiety – Anxious about pregnant appearance, self-consciousness in public
17
Q
issues with measuring perinatal anxiety
A
- Some research assumes that when anxiety is present, in any form, the woman is “pathologically anxious” (Matthey, 2016)
- Remember: Some increases in anxiety are normal and adaptive
- Where is the cut-off point for clinically concerning anxiety?
- “Perinatal anxiety becomes problematic when it consumes a significant proportion of a woman’s time, prevents her from fulfilling her parenting role, and interferes with self-care” (Wenzel, 2011)
- Pre-existing, general measures are problematic:
- Somatic items present in general measures occur naturally in the postpartum, which might overinflate scores
- Do not address specific maternal or infant focused anxieties (Phillips et al. 2009)
18
Q
perinatal anxiety vs stress
A
- Terms often used interchangeably in perinatal literature
- To an extent whereby items on stress questionnaires overlap with items on anxiety questionnaires
- Stress = The cumulative negative emotional impact of everyday event
- Anxiety = Negative emotional impact, without an obvious identifiable cause (often the product of excessive stress)
Excessive stress, per se, is not a mental illness, but excessive anxiety may well be
19
Q
effects on the infant postpartum
A
- Maternal stress, anxiety and/or depression during pregnancy increases risk of adverse psychosocial developmental outcomes
- Wide range of outcomes – lower birthweight, prematurity, challenging temperament, more sleep problems, lower cognitive performance, emotional problems
- Poor mental health after birth can make it more challenging for a mother to think and respond to her infant in a sensitive and emotionally responsive fashion (i.e., ‘mind-mindedness, Meins, 2001)
- Measured via observing mother-infant play
- Number of attuned/non attuned interaction
- Example Attuned: “Oh, you want that toy”
- Non attuned comment: “You’re not interested in that toy any more”
Evidence that mothers with mental health conditions have more inaccurate reflections of what infants might be thinking or feeling.
20
Q
post traumatic stress after childbirth
A
- Post-Traumatic Stress Disorder (PTSD) occurs in response to a very stressful, life-threatening, or traumatic event
- What constitutes a traumatic event?
- DSM (1980) originally stated “the person must have experienced an event that was outside the usual range of human experience”
- Not birth then!
- Contributed to a lack of research into PTSD until recently
- Revised in 1994 (DSM-IV) to recognise the importance of individual appraisal of the event
“Person must believe her own or another person’s life was threatened and responded with intense fear, helplessness, or horror”
21
Q
PTSD after childbirth risk factors
A
- Risk factors:
- Trauma exposure pre-birth (e.g., childhood sexual abuse; Lev-Wiesel et al., 2009)
- Trauma exposure during birth (e.g., Stillbirth, assisted or emergency births, perceived threat, care and support during birth)
- Pre-birth mental health difficulties and trait anxiety (Czarnocka & Slade, 2000)
- Perceived low support from partner and/or staff (Czarnocka & Slade, 2000)
- Perceived blame and low-perceived control in labour (Czarnocka & Slade, 2000)
~ Subjective birth experience is more important than objective severity of birth ~
22
Q
symptoms of birth related PTSD
A
- Intrusive images of labour and birth
- Fear and avoidance of giving birth in the future
- Poor self-image and feeling inadequate
- Relationship difficulties
- Difficulty in feeding
- Lack of interest in, and avoidance of, sex and shunning physical contact
- Difficulty with bonding with your baby, and guilt as a result
- Isolation and loneliness
- Postnatal depression (PND)
Avoidance of medical treatments like smear tests
23
Q
PND and PTSD overlap
A
- Misdiagnosis of PTSD with PND is common, due to overlapping symptoms
- Are often co-morbid (resulting in up to 25% of women with PTSD going undetected)
- Witnessing a traumatic birth can also lead to the onset of PTSD
- Complex PTSD also common:
“Caused by multiple, long-lasting, repeated or continuous traumas”
24
Q
post traumatic stress after childbirth is problematic to treat
A
- PTSD after childbirth is particularly problematic to treat (Slade et al., 2016)
- Re-experiencing symptoms, such as upsetting thoughts, images and nightmares about the event
- Hard not to relive symptoms when you are required to care for the product of your symptoms (i.e., your baby) 24/7
- Avoidance and numbing, such as trying to avoid thoughts or reminders of the event
- Tricky as you can’t avoid your baby!
- Hyperarousal symptoms such as sleep disturbances, being overly vigilant, and irritable
- Confounded by the normal by-products of the postpartum – adaptive anxiety, blues, lack of sleep etc..
25
consequences of birth related PTSD and opportunities for intervention
- Often associated with avoidance of subsequent pregnancies and a longer length of time before next pregnancy
- If subsequent pregnancy does occur, this can lead to a severe fear of childbirth (tokophobia)
- Subsequent pregnancy has the potential to heal or re-traumatise
- Midwifery and clinician-led, early (administered within 72 hours of traumatic childbirth), psychological interventions are more effective than usual care in reducing PTSD symptoms at 4–6 weeks postpartum (Miller et al., 2021)
Research investigating longer-term outcomes (i.e., 6–12 months plus) are required to substantiate the evidence base and to justify implementation in routine care (Miller et al., 2021)
26
post partum psychosis
- Severe mental illness with dramatic onset shortly after birth (Brockington, 2006)
* Relatively low prevalence: affecting 1/1000 mothers
* Childbirth acts as a “trigger” of mood episodes with psychotic features
- Most cases of postpartum psychosis represent a variant of bipolar disorder (Brockington, 1996)
- Pre-existing diagnosis of bipolar increases risk to 570/1000
- Hallucinations and delusions are often related to one’s baby
- Increases risk of abuse, neglect, infanticide, and suicide
- Often results in psychiatric emergency which requires hospitalisation
Many mothers separated from infants as lacking specialist units
27
morality in health
- Frequently utilised to in health promotion and research
* E.g. ‘healthy’ versus ‘unhealthy’ food
* ‘Good’ and ‘bad’ fats
- Ineffective:
* Stigma and perceived judgement for ‘bad’ behaviours have adverse effects on mental health
* Can increase use of the ‘unhealthy’ behaviour e.g., increase overeating, number of cigarettes smoked
28
morality and motherhood
- Same is true of parenting:
* ‘Breast is best’
* Co-sleeping
* 'Gentle parenting’
- Often there is no ‘this’ or ‘that’
- Discrepancy between one’s actual and ideal self
Belief that one is a ‘bad mother’ (Murphy, 1999)
29
consequences of guilt and shame
- Negative maternal mental health:
* Elevated depression and parenting stress (Rizzo et al., 2013)
* Exhaustion and anxiety (Wall, 2010)
- Negative consequences for infant:
* Child behavioural development difficulties (Netsi et al., 2018)
* Poorer breastfeeding outcomes (Fallon et al., 2016a, 2016c; Komninou et al., 2016)
* Poor maternal-infant attachment (Bonacquisti et al., 2020)
30
high risk pregnancies- causes
- 15% of pregnancies are affected by significant medical complications for mother and/or fetus – deemed high risk (Davis & Miles, in Wenzel, 2016)
* Gestational diabetes, pre-eclampsia, and preterm labour (<37 weeks)
- Pre-term labour is the most common (labour <37 weeks)
* Births <24 weeks are generally considered non-viable - cannot possibly result in a live born baby.
- Risk factors
* Biological: multiple pregnancies, preeclamsia, diabetes, bleeding, growth restriction, infection, genetics
* Sociodemographic: age, , poverty, unmarried, ethnic background – African American women have twice the rate of prematurity
* Lifestyle: smoking, alcohol use, substance use, and stress
- High risk pregnancies- parental responses
* Qualitative work indicates a wide range of emotional reactions to high risk pregnancy
* Struggling to maintain hope
* Shock, uncertainty, sadness, excitement and happiness (Price et al. 2007)
- Women across all types of high risk pregnancy have higher levels of depression and anxiety than healthy pregnant controls
* BUT their levels of cortisol remained the same (King et al. 2010)
* Suggests it is the perceived stress of high risk pregnancy that contributes to the onset of symptoms
- This has specific health and behavioural consequences for the high risk pregnancy
* Lower use of health promoting behaviours – diet, exercise, attendance at prenatal appts (Stark & Brinkley, 2007)
* Lower quality of maternal-foetal attachment particularly in hospitalised women (White et al. 2008)
31
high risk infants- life in NICU with a preemie
- These infants experience higher mortality, morbidity, and adverse outcomes across the life span
* Grief over the loss of the parental role: intensity of grief similar to the grief of parents whose infant died in the new born period (Franck et al. 2005)
“There are few life events as horrifying and as far outside the range of normal experience as coping with a life threatening illness in one’s child” (Pelcovitz, 1996)
32
high risk infants- the power of skin to skin contact
- NICU admission often results in mother-infant separation
* Disrupts attachment
- Kangaroo care:
* The practice of skin to skin contact between an infant and parent in NICU
* Associated with better infant health outcomes and lower risk of mortality, and…
* Improves parenting competence, knowledge about infant care, responsiveness, lowers depression, promotes breastfeeding
* Effects continue after discharge
* Improves infant sleep, reduces crying, inhibits pain response, shortens length of NICU stay
* Humanises NICU experience (less traumatising)
“Watching my baby’s life hang in the balance and not being able to do anything – not even hold her hand – broke my heart”
33
perinatal loss
- Miscarriage: pregnancy loss up to 20 weeks gestation
- Stillbirth: pregnancy loss > 20 weeks gestation
- Neonatal death: death of a live born infant during the first 28 days after birth
- For many, parenthood is a key development in one’s adult identity:
* Decision making process starts implicitly from a young age (Do I want children? How many will I have? How will I raise them? What will my family be like?
* Development of one’s reproductive story (Jaffe et al. 2011)
* Perinatal loss interrupts reproductive story and changes the concept of parental identity
Grief during an already emotionally vulnerable period
34
perinatal loss and grief
- Historically, attachment was thought to be a learned process, developed through mother-infant interaction
* Perinatal loss thought of as “non event”, unlikely to have serious consequences
- Now there is uncontested agreement that attachment starts in pregnancy
* Loss results in painful, lasting, and often complicated grief reactions
* Still minimised, particularly for early miscarriage
* “You can always try again”
* …at least you weren’t further along”
- Grief reactions are thought to vary based on “assignment of personhood” (Cote-Arsenault & Dombeck, 2001)
* The degree to which a woman experiences the loss of the foetus as an actual person
- Measured by asking women:
* What they felt they lost (pregnancy, baby, a baby named…, a child who would….)
* Whether or not a memorial was held (yes/no)
Higher scores on this measure significantly predict intensity of grief response and emotional reactions in subsequent pregnancy
35
teenage pregnancy
- Pregnancy and parenting prior to age 20 is associated with compromised biopsychosocial outcomes (Logsdon, Hipwell & Monk, 2016)
* Competing biological demands of maturing and carrying a baby simultaneously
* Social tension between adolescence and pregnancy/parenting
* More common in low SES groups and in individuals with depression – is teenage pregnancy, per se, that causes poorer outcomes? Or the groups of people it tends to occur in?
- Poorer outcomes in pregnancy:
* Less prenatal care, low birthweight infants, preterm birth, c-section birth
* Ongoing maternal growth is a risk factor for low birthweight (Wallace et al. 1997)
- Poorer outcomes after birth:
* Mother: Less likely to perform well in school, negative impact on relationships, reduced parenting skills
* Infant: Poor educational attainment, increased risk of mental health problems, increased risk for child abuse
36
teenage pregnancy- any positives
- Clemens (2003) synthesised findings from 25 qualitative studies on teenage mothers and found five themes, some of which indicate the potential for positive outcomes:
- The reality of motherhood brings hardship
* Lack of knowledge, Lack of time for self, Always responsible
- Straddling the two worlds of motherhood and adolescence
* Challenges at school, having time for friends, self care
- Motherhood as positively transforming
* New life, new identity, new understanding of importance of relationships
- The baby as a stabilising influence
* Stopping risk-taking behaviours, working harder at school/college
- Positive influence of social support in reshaping the future
* Social support is a key mediator of risk factors. Positive relationships allow them to be positive with their infants
37
cultural context matters
- Pregnancy:
* Non-planned pregnancy is associated with poorer mental health outcomes in non-Western cultures
* E.g. Shameful for women to become pregnant before marriage in Japan (Hertog & Iwasawa)
- Childbirth:
* In some Asian cultures fathers are not involved in the birth process at all, in others the father speaks for the mother during birth
* Chinese and Japanese women report that minimal noise and verbal expression of pain is accepted during childbirth – it is shameful to scream and uses up needed energy
38
cultural context matters- theory of hot and cold
- Theory of hot and cold:
* Common in Eastern and South Eastern cultures (Tung, 2010)
* Belief that good health requires balancing the environment and intake of hot and cold substances (Darby, 2007)
* Childbirth involves loss of blood, which is hot, therefore the postpartum is considered a cold period
* The mother requires hot food and warm conditions
* Cold weather, or cooled foods including drinks, raw fruit, and vegetables are avoided
Exercise is avoided
39
cultural context matters- biomedical model
- Biomedical model and the medicalisation of pregnancy dominate Western cultures (Onoye, Goebert, & Morland. 2016)
* Doctors and hospitals primarily responsible for prenatal and postpartum care
* Routine antenatal care in the absence of a problem
* Contributed to high rates of assisted birth (induction/c section), and women lacking control over their pregnancy and postpartum choices
Increase in help seeking behaviours and health care utilisation
40
cultural context matters- eastern cultures
- In some Eastern cultures, pregnancy is viewed as a normal experience which does not require intervention unless there is a problem
* The elder of the family provide information and guidance during this time
* Stigma around mental health conditions more generally
Less likely to seek help, particularly for adjustment issues
