Week 7-Perinatal health and wellbeing

Question 1

Define perinatal

Answer 1

Pregnancy (3 trimesters), birth, postpartum (<1 year), family planning, fertility treatment, high risk pregnancies, perinatal loss, mental health,
maternal and infant outcomes

Question 2

What is perinatal psychology?

Answer 2

■ 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!

Question 3

Why is perinatal psychology important?

Answer 3

■ 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 is 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

Question 4

What statistics back up the unfortunate reality that the transition to parenthood does not always go as planned?

Answer 4

■ 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

Question 5

What are the hormonal changes in pregnancy?

Answer 5

■hCG: Once the egg meets the sperm, hCG stimulates the production of estrogen and progesterone. It also suppresses the immune system to support the growing baby.

■Estrogen: Helps the uterus grow, and regulates the production of other key hormones, and triggers the development of the 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

Question 6

What are the key biological changes in
Early pregnancy (first trimester 1-12 weeks)?

Answer 6

■ Nausea and vomiting is experienced by 70-85%
of pregnant women (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)

Question 7

What are the key biological changes in the
further progression of pregnancy (2nd
trimester [weeks 13-27] and 3rd trimester
[weeks 28-birth]?

Answer 7

■ 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

Question 8

What are the key biological changes
Postpartum (after birth)?

Answer 8

■ 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)

Question 9

What are the several psychosocial challenges when becoming a mother according to Emmanuel & St John (2010)?

Answer 9

■ 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

Question 10

What are the key social transitions –
Relationship and sexual functioning?

Answer 10

■ 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)

Question 11

What did Twenge et al. (2003) find when comparing parents to childless individuals?

Answer 11

■ Twenge et al. (2003) did a 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

Question 12

What are the key psychological changes –
Adaptive anxiety?

Answer 12

■ 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

Question 13

What are the evolutionary adaptations of childbearing anxiety?

Answer 13

-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

Question 14

What are the Key Psychological Changes –
Stress response and coping?

Answer 14

-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

Question 15

Why do we stress less and why are we better at coping with it during pregnancy?

Answer 15

■ 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?

Question 16

What are the Key Psychological Changes –
Postpartum “blues”?

Answer 16

■ 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)

Question 17

What is the shadowing effect of perinatal
depression (PND)?

Answer 17

■ 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

Question 18

What are the statistics on perinatal depression and what is involved in it?

Answer 18

■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

Question 19

True or false: PND and new fatherhood cannot be explained by biological factors, as with maternal PND

Answer 19

True! Suggests social, psychological and
interpersonal factors are independently important in the onset

Question 20

What are fatherhood risk factors for experiencing distress? (Dudley et al. 2001)

Answer 20

– Infant problems (feeding/sleeping)
– Prior experience of fatherhood
– Relationship quality

Question 21

How common are paternal depression rates?

Answer 21

-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)

Question 22

How can fathers offer protection against the
effects of maternal depression?

Answer 22

-Shields infant from negative outcomes (Field, 1998)

-Reduces maternal parenting stress (Jackson, 1999)

-Minimizes negative maternal child-rearing attitudes (Brunelli et al, 1995)

Question 23

How prevalent is perinatal anxiety?

Answer 23

-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)

Question 24

What are the types and presentations of perinatal anxiety?

Answer 24

1. GAD - Fear of miscarriage, fear of infant harm, fear baby will be born with an abnormality
2. OCD – Fetal exposure to alcohol, cigarettes in pregnancy, repeatedly checking infant, compulsively washing self or baby
3. Panic disorder – Sudden fear baby has stopped breathing either in utero or after birth
4. Social anxiety – Anxious about pregnant appearance, self-consciousness in public

Question 25

What are the issues with measuring perinatal anxiety?

Answer 25

-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)

Question 26

Why are pre-existing, general perinatal anxiety measures problematic?

Answer 26

-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)

Question 27

How is Perinatal anxiety different to stress?

Answer 27

–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 events
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

Question 28

What are the effects on the infant postpartum?

Answer 28

■ 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 interactions
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

Question 29

Define PTSD

Answer 29

Post-Traumatic Stress Disorder (PTSD) occurs
in response to a very stressful, life-threatening, or traumatic event

Question 30

What constitutes a traumatic event?

Answer 30

-DSM (1980) originally stated “the person must
have experienced an event that was outside the
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”

Question 31

What are the risk factors for post-traumatic stress after childbirth?

Answer 31

–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 ~

Question 32

What are the symptoms of birth-related PTSD?

Answer 32

■ 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

Question 33

What is the overlap between PND and PTSD?

Answer 33

■ 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”

Question 34

What are the common experiences of those experiencing post-traumatic stress after childbirth?

Answer 34

PTSD after childbirth is particularly problematic to treat (Slade et al., 2016):
1. 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

2. Avoidance and numbing, such as trying to
   avoid thoughts or reminders of the event
   – Tricky as you can’t avoid your baby!
3. 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.

Question 35

What are the consequences of birth-related PTSD
and opportunities for intervention?

Answer 35

■ 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)

Question 36

What is Postpartum psychosis?

Answer 36

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 (murder of child), and suicide
• Often results in a psychiatric emergency which
  requires hospitalisation (Many mothers are separated from infants as lacking specialist units)

Question 37

What is Morality in health?

Answer 37

■ Frequently utilised 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

Knowledge is not equal to Behaviour change

Question 38

What is the link between morality and motherhood?

Answer 38

■ 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)

Question 39

What are the consequences of guilt and shame?

Answer 39

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)

-Intervening early can prevent the onset of the above

Question 40

What are some causes of high-risk pregnancies?

Answer 40

■ 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:
1. Biological: multiple pregnancies, pre-eclampsia, diabetes, bleeding, growth restriction, infection, genetics
2. Sociodemographic: age, poverty, unmarried, ethnic background – African American women have twice the rate of prematurity (born early)
3. Lifestyle: smoking, alcohol use, substance use, and stress

Question 41

What are the parental responses to high-risk pregnancies?

Answer 41

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)

Question 42

What are the experiences of high-risk infants – life in Special Care Baby Unit (SCBU)/Neonatal Intensive Care Unit (NICU) with a preemie?

Answer 42

-These infants experience higher mortality, morbidity, and adverse outcomes across the lifespan

–Grief over the loss of the parental role: intensity of grief similar to the grief of parents whose infant died in the newborn 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)

Question 43

What is the power of skin-to-skin contact in high-risk infants?

Answer 43

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 and 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”

Question 44

What are the 3 main types of perinatal loss?

Answer 44

1. Miscarriage: pregnancy loss up to 20 weeks
   gestation
2. Stillbirth: pregnancy loss > 20 weeks gestation
3. Neonatal death: death of a born infant during the first 28 days after birth

Question 45

How is parenthood a key development in
one’s adult identity?

Answer 45

–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 the reproductive story
and changes the concept of parental identity

–Grief during an already emotionally vulnerable period

Question 46

Perinatal loss and grief: When does attachment start?

Answer 46

■ Historically, attachment was thought to be a learning process, developed through mother-infant
interaction
–Perinatal loss is thought of as “non-event”, unlikely to have serious consequences

■ Now there is uncontested agreement that attachment starts during 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”

Question 47

What do grief reactions vary based on?

Answer 47

■ Grief reactions are thought to vary based on the “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 the intensity of grief response and emotional reactions in subsequent pregnancy

Question 48

Pregnancy and parenting before age 20
is associated with what?

Answer 48

■ Pregnancy and parenting before 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?

Question 49

What are the poorer outcomes of teenage pregnancy?

Answer 49

–Less prenatal care, low birth weight infants, preterm birth, c-section birth

–Ongoing maternal growth is a risk factor for low birth weight (Wallace et al. 1997)

Question 50

What are the poorer outcomes after teenage birth?

Answer 50

–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

Question 51

What are the positives of teenage pregnancy? (Clemens, 2003)

Answer 51

Clemens (2003) synthesised findings from 25 qualitative studies on teenage mothers and found five themes, some of which indicate the potential for positive outcomes:
1. The reality of motherhood brings hardship
–Lack of knowledge, Lack of time for self, Always responsible
2. Straddling the two worlds of motherhood and
adolescence
–Challenges at school, having time for friends, self-care
3. Motherhood as positively transforming
–New life, new identity, a new understanding of the importance of relationships
4. The baby as a stabilising influence
– Stopping risk-taking behaviours, working harder at
school/college
5. 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

Question 52

Why does cultural context matter for pregnancies?

Answer 52

– 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)

Question 53

Why does cultural context matter for childbirth?

Answer 53

–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

Question 54

Cultural context matters: What is the Theory of hot and cold?

Answer 54

–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

Question 55

What is the Biomedical model and the medicalisation of pregnancy dominating Western cultures (Onoye, Goebert, & Morland. 2016)?

Answer 55

–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 healthcare utilisation

Question 56

What is pregnancy viewed as in some Eastern cultures?

Answer 56

-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