Perinatal health and Wellbeing- Lecture 6 Flashcards
Importance of Perinatal health and wellbeing
> 353000 babies born every day around world
Every pregnancy brings unique set of biopsychosocial changes in person
1 in 5 women will experience clinically significant mental illness during or after pregnancy
Hormonal changes:
Human chorionic gonadotropin
Egg meets sperm, hCH amps up Est. and prog.
Hormonal changes:
Estrogen
Uterus growing, regulating other key hormones, triggers dev. of baby’s organs
Hormonal changes:
Progesterone
Encourages breast tissue growth, later helps soften ligaments and cartilage to prepare for birth
Hormonal changes:
Relaxin
Relaxing muscles, bones, ligaments and joints in preparation for birth
Hormonal changes:
oxytocin
Stimulating labour
Hormonal changes:
Prolactin
Causes breasts to increase in size and produce milk
Early pregnancy: 1st trimester (1-12 weeks)
Key bio changes
>Nausea and vomiting- 70-85% (ACOG, 2004): direct effect of hCG >Fatigue- 96.6%: (Zib, Lim & Walters, 1999) Contributing factors: -increased oxygen consumption -metabolic changes
2nd Trimester (12-27 weeks) & 3rd trimester (28-birth) Key bio changes
> Symptoms most affecting QoL are increased urination, fatigue and heartburn (75-88%)- Nazik and Eryilmaz (2013)
Worsening of sleep quality during pregnancy (63%)
Due to:
-Fetal movement
-Impaired movement
Postpartum
Key bio changes
-Healthy recovery usually takes 6 weeks approx- huge drop in pregnancy hormones
-Poor sleep quality- newborn wakes every 2-3 hrs
Woodland et al. (2013) most common complaints 3 months after birth= fatigue, back pain, breast probs & urinary incontinence,
Key social Transitions
The Woman
Emmanuel & St. John (2010)
Becoming a mother encompasses several psychosocial challenges:
-Known > unknown reality
-New maternal identity- w/ assoc. feelings & behaviours
-Renegotiating prior social roles- e.g. family, work, partner
-Balancing multiple demands
-Experiencing losses
Normal adaptation to these» personal growth
Key Social Transitions:
Relationship and sexual functioning
> Common belief that parenthood is central in fulfilling romantic relationship (Hanson, 2012)
> Sexual and relationship satisfaction and functioning declines from preg. to 1st b-day (Mitnick, 2009)
> Increased marital conflict compared to during pregnancy (Hanington et al. 2012)
> Twenge (2003)- meta analysis: parents vs non-parents
-P’s = lower relationship satisfaction and quality
Key Social Transitions:
Relationship and sexual functioning
Key predictors…
Twenge (2003)
> pre-pregnancy quality and duration
planned pregnancy
parents relationship status
mental health status
Key psychological changes
-Adaptive Anxiety
Anxiety = adaptive in pregnancy and postpartum
>health
>wellbeing
>survival of mother and infant postpartum
tightly linked to period of childbearing
(Fallon et al. 2016)
Adaptive anxiety is tightly linked to the specific period of childbearing one is at
Anxiety is adaptive at:
>Pregnancy- to avoid miscarriage, birth complications, health of infant
>Postpartum- for attachment, infant safety, routine care of infant, breastfeeding and coping
Key psychological changes:
Stress response and coping
> Stress decreases as pregnancy progresses (Entringer et al 2010)
Cope with stress better during pregnancy
-avoidant coping
strategies used less
- -> avoidant strategies assoc. w reduced preparation for parenting, bonding problems
Key psychological changes:
Why do we stress less and cope better during pregnancy
Exposure to high stress= potential to adversely impact fetal development etc. (Van den Bergh, 2005)
**Innate protective mechanisms to preserve fetus at critical periods in development? **
Key psychological changes:
Postpartum blues
Mood changes common in postpartum- 50% of women
3-5 days PP peak in blues
»thought to be due to drop in hormones
Initial studies study variants of depression:
- found increased tearfulness and lower mood
Postpartum blues:
Issues with literature
All negative findings in earlier studies
Findings due to focusing on negatives
Newer studies look at both + & - :
>Found that the predominant mood experienced is happiness (e.g. Edborgh, 2008)
>Found BOTH neg and pos moods elevated (Wilkinson, 1999)
Psychopathology during pregnancy and the postpartum
Aetiology
> Biological- History of MH problems, genetics, substance use, MASSIVE DROP IN HORMONES (ESTROGEN AND PROGESTERONE)
Social- Intimate relationships, supports, people at work
Psychological- Personality, attachment style, cognitive style, coping techniques
Interpersonal- role transitions, grief and loss, interpersonal disputes, birth of baby, breastfeeding difficulties
Perinatal Psychopathologies
Focus on Perinatal Depression (PND)
Largest mental health focus on PND
Problematic:
-Lack of info for non PND women w/ symptoms
-Comorbidity goes undetected (blanketed by PND)
-Over diagnosis of PND even when not present
-Mothers who are not diagnosed as depressed may have other conditions that go undetected
Perinatal Psychopathologies
PND
- Can occur at any time from pregnancy> 1st year postpartum
- Prevalence rates- 9-16%
- Higher in deprived areas
- Often comorbid with anxiety
- Linked to Paradox of loss theory (Nicholson, 2001)
Perinatal Psychopathologies
PND in Fathers
-Prevalent in some fathers
»suggests social, psychological and interpersonal factors are independently important in onset
-paternal depression rates twice that of average men (Paulson et al. 2006)
Perinatal Psychopathologies
PND in Fathers
Predictors
(Dudley et al. 2001)
> Infant related problems (feeding/sleeping)
Prior experience of fatherhood
Relationship quality
Perinatal Psychopathologies
PND in Fathers
Predictors
Paulson & Basemore (2010)
Meta analysis- having a depressed partner increases the risk
Perinatal Psychopathologies
PND
Paternal protection
Fathers’ support:
>found to shield the infants of chronically depressed mothers from negative outcomes (Field, 1998)
> Reduces mother’s parenting stress (Jackson, 1999)
> minimises negative maternal child-rearing attitudes (Brunelli et al, 1995).
Perinatal Psychopathologies
Issues with Perinatal Anxiety literature…
Important to remember that some increased anxiety is adaptive in the perinatal period–
Where is the line?
>Many studies assume any anxiety present is “pathological” (Matthey, 2016)
> Measurement problematic:
general measures include somatic items naturally occuring in postpartum» should not be used in pregnancy as =likely to be normal & lead to misdiagnosis
> Anxiety or stress? important to distinguish as excessive stress not mental illness but excessive anxiety may be
Perinatal Psychopathologies
PTSD after childbirth
Defining what was traumatic event in DSM- blurred lines
>had to be out of usual range of human experience (but birth is inside this)
REVISED- 1994…
-Added personal appraisal of the event- ‘life threatening’
Perinatal Psychopathologies
Birth factors predicting PTSD
- Stillbirth
- Assisted or emergency births
- Perceived threat
- Care and support during birth
- *but subjective experience more important than objective**- what is not traumatic to one may be to another
Perinatal Psychopathologies
Particularly problematic PTSD to treat…
> Re-experiencing symptoms, such as upsetting thoughts, images and nightmares about event (Hard not to relive when caring for product of them)
> Avoidance and numbing, trying to avoid thoughts or reminders of the event
> 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.)
Tocophobia- Definition
Extreme fear of pregnancy
»as a result of PTSD
—-but can also heal the woman (go either way)
Perinatal Psychopathologies
Postpartum Psychosis
> Severe mental illness with dramatic onset shortly after birth (Brockington, 2006)
Significant danger to self and child
1/1000 mothers
childbirth= trigger of mood episodes w/ psychotic features
Pre-existing bipolar increases risk=570/1000
REQUIRES HOSPITALISATION- many mothers and babies separated= lacking specialist units
Perinatal wellbeing
Health in pregnancy should not just focus on negatives, should be balance» positive psychological aspects
This can help inform interventions aimed at promoting wellbeing, rather than reducing risk of mental health
Cacioppo and Berntson (1999)
Just as a positive affect is not the opposite of a negative affect, wellbeing is not the absence of mental illness.
»Can be achieved by individual with a diagnosis
Factors promoting wellbeing i perinatal period
Role satisfaction
Role competence
Social support
Good health
Perinatal Psychopathologies
-The effects on the infant in pregnancy
Foetal programming- foetus involved in dynamic communication with the mother
Maternal stress affects the foetal hypothalamic pituitary adrenal axis (central stress response) increasing cortisol released in baby.
Infant birth outcomes related to Perinatal Psychopathologies
>Lower birth weight >Prematurity >Challenge temperament >More sleep problems >Lower cognitive performance >Emotional problems
Pros of using Childbearing specific measures
Studies using childbearing specific measures have more predictive power
>stress as related to childbearing rather than general stress
Perinatal Psychopathologies -Effect on the infant post-partum
Maternal mind-mindedness
Poor mental health after birth> makes responding to child in a sensitive and emotionally responsive fashion more difficult
Evidence: mothers with mental health conditions > more inaccurate reflections of infants thoughts and feelings
Mind- mindedness importance
Thought to be a vital cognitive component of relationship between mental health and maternal responsiveness
Measured during free-play in attuned or non attuned comments
Meins (2001)
Mind mindedness is the “parental tendency to think and comment appropriately on their infants internal states”
High risk pregnancies
Rates
15% of pregnancies affected by e.g. - Gestational diabetes, pre-eclampsia, and preterm labour (Davis and Miles, 2016)
> Preterm labour most common- 1 in 10 (WHO, 2018|)
-Premature rupture of membranes
Risk factors of having a high risk pregnancy
Biological: Multiple pregnancies, preeclampsia, , diabetes, bleeding, growth restriction, infection, genetics
Sociodemographic: age, poverty, marital status, ethnic background (African American women = 2X rate of prematurity
Lifestyle: smoking, alcohol use, substance use, stress
Parental responses and coping with high risk prenancy
> Ride range of emotional reactions- shock, uncertainty, sadness, excitement and happiness (Price et al., 2007)
Depression and anxiety much higher - but levels of cortisol remained the same» Suggests it is ‘perceived stress’ of high risk that contributes to the onset of symptoms
Stark & Brinkley (2007)
Mental illness due to H.R. pregnancies results in lower use of health promoting behaviours, such as:
>Diet
>Exercise
>Attendance at prenatal appointments
White et al. (2008)
Mental illness due to H.R. pregnancies results in lower quality of maternal-fetal attachment particularly in hospitalised women
High risk infants
Life in SCBU/NICU
Hamilton et al. (2010)
Smaller and younger infants have highest rate of problems»_space;stay in NICU/SCBU
-hospital stays range from days>years
What Premature babies are at risk of…
higher mortality, morbidity, and adverse outcomes across the life span
Parents of NICU infants
Emotional reactions
Pelcovitz (1996): “horrifying life event” that doesn’t compare to anything else like “coping with life threatening illness in one’s child”
Franck et al. (2005:
-Grief over loss of parental role similar to that of losing a newborn
High risk infants
-Using skin to skin contact in NICU
“Kangaroo care”
Initially in low -income countries as NICU under resourced
>Found infants had better health outcomes and less mortality
»Transferred to high-income countries as means of promoting healthy attachment
Skin to Skin contact effects
Improves:
>parenting competence, knowledge, responsiveness, infant sleep, want to breastfeed
Decreases:
>Depression, Infant crying, Pain responses, Length of stay
- Effects continue after discharge
- Critical in improving maternal and infant health by humanising the NICU experience
Perinatal Loss
Miscarriage: loss upto 20 weeks
Stillbirth: loss 20> weeks
Neonatal: death in newborn period (28 days)
Perinatal loss
Affects many areas of psychological functioning as it:
-occurs in already emotionally vulnerable individual
Hughes et al. (2002)
Depression, anxiety, and post-traumatic-stress disorder (PTSD) increased depending on whether the mother:
- Had no contact with stillborn
- Saw the stillborn
- Held the stillborn
Perinatal Loss and The Reproductive story
Jaffe et al, 2011
One aspect of identifying as adult is development of parental identity
- thoughts abouts parenthood and logistics start from young age implicitly
- perinatal loss interrupts this and changes concept of parental identity
Perinatal loss and Grief
When does attachment begin?
Previously»Perinatal loss = non event with no serious consequences as thought attachment begins after birth
BUT- widespread argument that attachment starts in pregnancy ,so…
- Loss results in painful, lasting, often complicated grief
- But still minimised particularly in early miscarriage
Assignment of Personhood
Dombeck et al. (2001)
Grief reactions based on how much parents regard foetus as a person
-Measured by asking women:
What they felt they lost (pregnancy, baby, a baby named…, a child who would….)
-High scores (more person assignment) significantly predicted intensity of grief response
Special populations
Teenage pregnancy
biopsychosocial outcomes
Pregnancy and parenting prior to 20> worse biopsychosocial outcomes (Logsdon et al., 2016):
-competing bio demands of maturing and carrying baby
-social tension between adolescence and pregnancy/parenting
-more common in low SES groups and depressed individuals
»> could being in these groups cause worse outcomes?
Special populations
Teenage pregnancy
Pregnancy outcomes
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)
Special populations
Teenage pregnancy
Postpartum outcomes
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
Positive outcomes
Clemens (2003)
25 qualitative studies on teenage mothers- 5 themes some positive:
1. Reality of motherhood brings hardship
- Straddling the two worlds (motherhood+adolescence)
- Motherhood as positively transforming
- Baby as a stabilising influence
- Positive influence of social support in reshaping future
Teenage pregnancy-
What about the ‘planned’ pregnancies
Coleman and Cater (2007)
Teenage pregnancy is always viewed as negative- an accident
Found themes:
-changing direction from volatile background
-gaining new identity, role
-positive and generic preference for parenthood
Special populations
Cultural context
In pregnancy
Experience of pregnancy and childbirth can be strongly rooted in culture (Kitzinger, 2001)
Unintentional pregnancies > with poorer mental health outcomes in non-Western cultures
E.g. Shameful for women to become pregnant before marriage in Japan (Hertog & Iwasawa)
Special populations
Cultural context
During childbirth
During 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
Special populations
Cultural context
Postpartum
In non-Western cultures the postpartum period is believed to last 40 days
New mothers rest and recuperate (confinement) while family take care of the rest
>THEORY OF HOT AND COLD -rebalancing the environment
- mother requires hot things and avoids cold things + exercise
In western cultures:
>Nutritious diet and exercise are promoted
Special populations
Cultural context
Medicalised pregnancies in West
Biomedical model of pregnancy dominated western culture
>high use of hospitals and doctors
>regular appointments despite no problems
»>can become a cycle of birthing negativity
Special populations
Cultural context
Normalisation of pregnancies in East
> 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
»lessens likelihood of creating a vicious cycle of fear
Special populations
Infertile individuals
Fertility declines as women age
Advancing maternal age increases pregnancy risks e.g. diabetes or hypertension.
Special populations
Infertile individuals
Fertility awareness
Studies suggest women are not aware of the risks of aging on fertility and pregnancy.
Particularly relevant > career-focused women or in higher education as these groups are more likely to put off childbearing (Lampig et al. 2006)
Special populations
Infertile individuals
Psychological consequences of infertility
> Unable to achieve a desired life-course change (Matthews & Martin Matthews, 1986)
- -Sense of isolation and alienation for the “fertile world”
- -Loss of control and identity
Treatment is stressful, invasive and prone to failure
Special populations
Infertile individuals
Psychological-infertile cycle
(Van Balen, 2002)
Psychological distress and infertility are linked :
>Not being able to conceive causes stress
>Stress reduces the chances of pregnancy