Stepping up to Motherhood among Inner-City Teens

Examining Women's and Men's Ideal Criteria Before Forming Families

In the United States, family formation decision-making is more complex than the predominant models that have been used to capture this phenomenon. Understanding the context in which a pregnancy occurs requires a more nuanced examination. In-depth interviews were conducted with 60 men and women, aged 18-35, who had children or were pregnant. Using grounded theory analysis, themes emerged that revealed participants' ideal criteria desired before pregnancy. We stratified by those who met and did not meet these criteria. Almost universally, participants shared ideal criteria: to graduate, gain financial stability, establish a relationship, and then become pregnant. Many participants did not accomplish these goals. Those who had not met their criteria had experienced traumatic childhoods and suffered economic concerns. For this group, having children prompted positive changes within their control, but financial stability remained limited. Efforts should focus on improving circumstances for all individuals to fulfill their criteria before pregnancy.

A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression

BACKGROUND

Postnatal depression (PND) is a major depressive disorder in the year following childbirth, which impacts on women, their infants and their families. A range of interventions has been developed to prevent PND.

OBJECTIVES

To (1) evaluate the clinical effectiveness, cost-effectiveness, acceptability and safety of antenatal and postnatal interventions for pregnant and postnatal women to prevent PND; (2) apply rigorous methods of systematic reviewing of quantitative and qualitative studies, evidence synthesis and decision-analytic modelling to evaluate the preventive impact on women, their infants and their families; and (3) estimate cost-effectiveness.

DATA SOURCES

We searched MEDLINE, EMBASE, Science Citation Index and other databases (from inception to July 2013) in December 2012, and we were updated by electronic alerts until July 2013.

REVIEW METHODS

Two reviewers independently screened titles and abstracts with consensus agreement. We undertook quality assessment. All universal, selective and indicated preventive interventions for pregnant women and women in the first 6 postnatal weeks were included. All outcomes were included, focusing on the Edinburgh Postnatal Depression Scale (EPDS), diagnostic instruments and infant outcomes. The quantitative evidence was synthesised using network meta-analyses (NMAs). A mathematical model was constructed to explore the cost-effectiveness of interventions contained within the NMA for EPDS values.

RESULTS

From 3072 records identified, 122 papers (86 trials) were included in the quantitative review. From 2152 records, 56 papers (44 studies) were included in the qualitative review. The results were inconclusive. The most beneficial interventions appeared to be midwifery redesigned postnatal care [as shown by the mean 12-month EPDS score difference of -1.43 (95% credible interval -4.00 to 1.36)], person-centred approach (PCA)-based and cognitive-behavioural therapy (CBT)-based intervention (universal), interpersonal psychotherapy (IPT)-based intervention and education on preparing for parenting (selective), promoting parent-infant interaction, peer support, IPT-based intervention and PCA-based and CBT-based intervention (indicated). Women valued seeing the same health worker, the involvement of partners and access to several visits from a midwife or health visitor trained in person-centred or cognitive-behavioural approaches. The most cost-effective interventions were estimated to be midwifery redesigned postnatal care (universal), PCA-based intervention (indicated) and IPT-based intervention in the sensitivity analysis (indicated), although there was considerable uncertainty. Expected value of partial perfect information (EVPPI) for efficacy data was in excess of £150M for each population. Given the EVPPI values, future trials assessing the relative efficacies of promising interventions appears to represent value for money.

LIMITATIONS

In the NMAs, some trials were omitted because they could not be connected to the main network of evidence or did not provide EPDS scores. This may have introduced reporting or selection bias. No adjustment was made for the lack of quality of some trials. Although we appraised a very large number of studies, much of the evidence was inconclusive.

CONCLUSIONS

Interventions warrant replication within randomised controlled trials (RCTs). Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty.

FUTURE WORK RECOMMENDATIONS

Several interventions appear to be cost-effective relative to usual care, but this is subject to considerable uncertainty. Future research conducting RCTs to establish which interventions are most clinically effective and cost-effective should be considered.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42012003273.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Pregnant adolescent women's perceptions of depression and psychiatric services in the United States

PROBLEM

Adolescent mothers and their children are at high-risk for depression and the associated negative educational, social, health, and economic outcomes.

BACKGROUND

However, few pregnant adolescent women with depression receive psychiatric services, especially low-income or racial/ethnic minority adolescent women.

AIM

This qualitative study explores perceptions of depression, psychiatric services, and barriers to accessing services in a sample of low-income, pregnant racial/ethnic minority adolescent women. Our goal was to better understand the experiences of depression during pregnancy for these vulnerable adolescent women, and thereby improve their engagement and retention in services for perinatal depression.

METHODS

We recruited 20 pregnant adolescent women who screened positive for depression from 2 public health prenatal clinics in the southeastern United States. Participants were low-income and primarily racial/ethnic minority women between 14 and 20 years old. Data were collected through individual in-depth, ethnographically informed interviews.

FINDINGS

Generally, participants lacked experience with psychiatric services and did not recognize their symptoms as depression. However, participants perceived a need for mood improvement and were interested in engaging in services that incorporated their perspective and openly addressed stigma.

DISCUSSION

Participants reported practical and psychological barriers to service engagement, but identified few cultural barriers. Family perceptions of psychiatric services served as both a barrier and support.

CONCLUSION

Adolescent women are more likely to engage in psychiatric services if those services reduce practical and psychological barriers, promise relief from the symptoms perceived as most meaningful, and address underlying causes of depression. Culture may affect Latina adolescent women's perceptions of depression and services.

Perceptions and experiences of interventions to prevent postnatal depression. A systematic review and qualitative evidence synthesis

BACKGROUND

More women experience depressive symptoms antenatally than postnatally. Supporting women through the antenatal period is recognised as important in mitigating negative outcomes and in preventing postnatal depression (PND). A systematic review was conducted which aimed to provide a detailed service user and service provider perspective on the uptake, acceptability, and perception of harms of antenatal interventions and postnatal interventions for preventing PND.

METHODS

A comprehensive literature search was conducted in 12 major bibliographic databases in November 2012 and updated in December 2014. Studies were included if they contained qualitative evidence on the perspectives and attitudes of pregnant women and postnatal women who had taken part in, or healthcare professionals (HCPs) involved in delivering, preventive interventions for PND.

RESULTS

Twenty-two studies were included. Support and empowerment through education were identified as particularly helpful to women as intervention components, across all intervention types. Implications for accessing the service, understanding the remit of the service and women's preferences for group and individual care also emerged.

LIMITATIONS

The majority of the included studies were of moderate or low quality, which may result in a lack of rich data consistently across all studies, limiting to some degree interpretations that can be made.

CONCLUSION

The synthesis demonstrated important considerations for devising new interventions or adapting existing interventions. Specifically, it is important that individual or group interventions are carefully tailored to women's needs or preferences and women are aware of the remit of the HCPs role to ensure they feel able to access the support required.

A comparative assessment of early adult life status of graduates of the North Carolina adolescent parenting program

PROBLEM

What is the comparative impact of a second pregnancy prevention program for teen mothers on those who graduate from the program compared with a sample of young mothers of similar age and social circumstances who did not participate in the program?

METHODS

Fifteen program graduates and 20 nonprogram cohorts were surveyed regarding a range of life domains.

FINDINGS

Data indicated that program graduates were on a more positive life course: greater primary responsibility for housing and utilities, greater higher education enrollment, more job stability, and greater focus on career goals.

CONCLUSION

The differences demonstrate the value of programs designed to assist teen mothers through the challenges of parenting and their own adolescent development. Teen mothers who received these resources became more capable, happier, and confident, which in turn will make them better parents and more empowered to pursue their own personal development.

Grandparental investment: past, present, and future

What motivates grandparents to their altruism? We review answers from evolutionary theory, sociology, and economics. Sometimes in direct conflict with each other, these accounts of grandparental investment exist side-by-side, with little or no theoretical integration. They all account for some of the data, and none account for all of it. We call for a more comprehensive theoretical framework of grandparental investment that addresses its proximate and ultimate causes, and its variability due to lineage, values, norms, institutions (e.g., inheritance laws), and social welfare regimes. This framework needs to take into account that the demographic shift to low fecundity and mortality in economically developed countries has profoundly altered basic parameters of grandparental investment. We then turn to the possible impact of grandparental acts of altruism, and examine whether benefits of grandparental care in industrialized societies may manifest in terms of less tangible dimensions, such as the grandchildren's cognitive and verbal ability, mental health, and well-being. Although grandparents in industrialized societies continue to invest substantial amounts of time and money in their grandchildren, we find a paucity of studies investigating the influence that this investment has on grandchildren in low-risk family contexts. Under circumstances of duress - for example, teenage pregnancy or maternal depression - there is converging evidence that grandparents can provide support that helps to safeguard their children and grandchildren against adverse risks. We conclude by discussing the role that grandparents could play in what has been referred to as Europe's demographic suicide.

'I only give advice if I am asked': examining the grandmother's potential to influence infant feeding decisions and parenting practices of new mothers

BACKGROUND

Australia has high breastfeeding initiation rates however, at 3 and 6 months exclusive breastfeeding rates fall below global recommendations. Research suggests significant others in a woman's life can influence infant feeding decisions and practices but how and why they do so needs investigation.

RESEARCH QUESTION

This study explored grandmothers' perceptions of their role in supporting new families and examined the potential for grandmothers to influence infant feeding decisions and parenting practices of new mothers in an area of Sydney, Australia, with low breastfeeding maintenance rates.

PARTICIPANTS AND METHOD

A qualitative, descriptive study was conducted in South Western Sydney, Australia. Eleven grandmothers participated in one to one interviews and three of these also participated in a group discussion.

RESULTS

Analysis revealed three themes: 'Presence'; 'Position'; and 'Power versus Preservation' which provide insight into the complexity of the grandmother-new mother relationship and describe the potential influence that grandmothers may have on infant feeding and parenting.

DISCUSSION AND CONCLUSION

The findings highlight challenges and dilemmas faced by grandmothers in their supportive role for the new mother in her breastfeeding and early parenting experience and the difficulties grandmothers face in balancing potential risks and rewards in their interactions with the new family.

Approaching the adolescent-headed family: a review of teen parenting

In the USA, as many as 1 in 6 women nationwide become adolescent mothers, making adolescent pregnancy and childbearing issues a frequently encountered occurrence by pediatricians and adolescent medicine health care providers. Both social and medical programs focus on prevention and management of adolescent pregnancies; however, caring for the adolescent-headed family is less well understood. For many teen parents, various environmental and behavioral risks contributed to early childbearing and parenting. Following delivery of the infant, many of these same psycho-social, environmental, and educational factors continue to play a role in the teen's ability to parent effectively. This review explores these factors in relation to teen parenting as well as describes the limited data available on outcomes of adolescent mothers and their infants. Despite negative social stereotypes regarding adolescent fathers, research suggesting that most fathers desire involvement with their infants and the impact of and factors influencing father involvement is explored. Understanding the dynamics of the coparenting relationship, an expanding field of study, will aid practitioners in strengthening and supporting teen parenting by both mothers and fathers. As most teen parents continue to reside with their families, teen parenting has an important impact on the multi-generational family structure. These relationships can serve both to support and at times to hinder the adolescent parents' development as an individual and as a parent. Successful interventions and programs to support the adolescent-headed family take on various forms but are usually comprehensive and multidisciplinary and consider the developmental status of both the parent and the child. To best care for adolescent-headed families, pediatricians and adolescent medicine providers should understand the psychosocial, developmental, educational, and relationship issues that influence adolescent parenting.

Interpersonal psychotherapy with pregnant adolescents: two pilot studies

OBJECTIVE

To test the feasibility, acceptability and helpfulness of group Interpersonal Psychotherapy (IPT-PA) for depression in pregnant adolescents.

METHOD

Two open clinical trials were conducted of IPT-PA delivered in group format in a New York City public school for pregnant girls. Study 1 tests IPT-PA for management of depressive symptoms by delivery during health class to pregnant girls with varying levels of depressive symptoms (N = 14; 10 Hispanic, 3 African-American and 1 bi-racial). Study 2 tests IPT-PA for treatment of depression by delivery after school for self-nominating pregnant girls with DSM-IVR diagnoses of depressive disorder or an adjustment disorder (N = 11; 8 African-American, 1 girl Hispanic and 2 bi-racial). Depressive symptoms were assessed using the Beck Depression Inventory and the Edinburgh Depression Scale (for its sensitivity to severe symptoms, the Hamilton Depression Scale was added in Study 2). Clinical diagnosis was assessed using the Schedule for Affective Disorders and Schizophrenia for Children (K-SADS). STUDY 1

RESULTS

At 12-week termination, level of depressive symptoms had decreased by 50%; 13/14 girls showed a decrease in level of symptoms. STUDY 2

RESULTS

At 12-week termination, level of depressive symptoms had decreased by 40%; 10/11 girls showed decrease in level of symptoms and in DSM-IVR clinical diagnosis; treatment gains were maintained at 20-week post-partum follow-up.

CONCLUSION

IPT-PA appears feasible and helpful in managing and treating depression in pregnant girls.

Depression and treatment with inner city pregnant and parenting teens

BACKGROUND

Between a quarter and half of pregnant adolescents are estimated to be depressed (Beardslee et al. 1988). Two recent open clinical trials found significant drops in depression levels among pregnant and newly parenting inner city teenagers after 12 weeks of Interpersonal Psychotherapy modified for pregnant teenagers (Miller et al. submitted). The current study addresses the nature of and contributors to participants' depression, and the active ingredients in their healing.

METHOD

Qualitative analyses of therapy sessions, clinical notes and post hoc interviews of clinicians were integrated with questionnaire data.

RESULTS

The most common symptoms of participant depression (n = 80) were anger/irritability and sadness and the cluster of depressive symptoms with the greatest variance was characterized by shame and guilt. Participants attributed symptoms of depression to feeling trapped or wronged, when family members were sad or rejecting and when the symptoms functioned to help participants meet their needs. Experiences associated with symptom relief were validation of pregnancies, successful use of self-advocacy and boundary setting skills and recognition of passage through important transitions. Support from participants' mothers was instrumental.

CONCLUSIONS

Interpersonal contexts may be pivotal in contributing, maintaining and/or alleviating depression among poor urban pregnant and newly parenting adolescents.