Women's experiences and perceptions of anxiety and stress during the perinatal period: a systematic review and qualitative evidence synthesis

"It is not all glowing and kale smoothies": An exploration of mental health difficulties during pregnancy through women's voices

OBJECTIVES

This study aimed to explore the experiences of women with moderate-to-severe mental health difficulties during pregnancy, with a focus on establishing their psychological needs. Psychological distress caused by mental health difficulties during pregnancy is common and can significantly impact women and their babies. However, women's subjective experiences of difficulties with their mental health throughout pregnancy, alongside their experiences of staff, services and treatments are less well understood.

DESIGN

In this qualitative study, an Interpretive Phenomenological Analysis (IPA) approach was used.

METHODS

Semi-structured interviews were conducted with participants recruited via a regional Perinatal Mental Health Service. Interviews were transcribed and analysed following the IPA methodology.

RESULTS

Five superordinate themes were identified which represented the lived experiences of the 11 participants on their journey through pregnancy whilst living with mental health difficulties and subsequent psychological distress: (i) Feeling the 'wrong' feelings, (ii) Societal pressures and a desire for greater acceptance, (iii) Searching for answers despite a lack of resources, (iv) What made a difference and (v) Experiences and expectations of service provision. Within these themes, 13 subordinate themes were also identified.

CONCLUSIONS

These themes highlight the need for greater awareness and acceptance of mental health difficulties during pregnancy as well as postnatally. While perinatal mental health services are evolving, there is still an urgent requirement for services to continue to develop to meet women's needs, as well as to develop the role of clinicians as facilitators of engagement with needs-matched care.

Perinatal Predictors and Mediators of Attachment Patterns in Preschool Children: Exploration of Children's Contributions in Interactions with Mothers

Insecure and disorganized attachment patterns in children are linked to poor health outcomes over the lifespan. Attachment patterns may be predicted by variables that influence the quality of children's interactions with their primary caregivers/parents (usually mothers) such as prenatal and postnatal exposures and the children's own behaviours in interactions. The purposes of this exploratory study were to examine: (1) prenatal predictors of children's attachment patterns, and (2) postnatal mediators and moderators of associations between prenatal predictors and children's attachment patterns, with adjustment for relevant covariates. Mother-child dyads (n = 214) from the longitudinal Alberta Pregnancy Outcomes and Nutrition (APrON) cohort were studied using valid and reliable measures. Hayes' mediation analysis was employed to determine direct and indirect effects. Mothers' prenatal cortisol levels directly predicted disorganized (versus organized) child attachment in unadjusted models. Children's passivity (in adjusted models) and compulsivity (in unadjusted and adjusted models) in parent-child interactions mediated the pathway between mothers' prenatal cortisol levels and children's disorganized attachment patterns. Serial mediation analyses revealed that mothers' cortisol levels predicted their children's cortisol levels, which predicted children's compulsivity, and, ultimately, disorganized attachment in both unadjusted and adjusted models. No predictors were correlated with children's insecure (versus secure) attachment. This exploratory research suggests that prenatal exposure to mothers' cortisol levels and children's behavioural contributions to parent-child interaction quality should be considered in the genesis of children's attachment patterns, especially disorganization. Interventions focused on parent-child interactions could also focus on addressing children's behavioral contributions.

A qualitative examination of factors influencing pregnancy-related anxiety in Northern Ghana

INTRODUCTION

Despite high prevalence of anxiety among pregnant women in low- and -middle-income countries, research on context-specific conceptualisation, measurement, and predictors of pregnancy-related anxiety (PrA) is limited in these contexts. We explored local conceptualisations of factors influencing PrA in the Northern Region of Ghana.

METHODS

We conducted 15 focus group discussions with antenatal care seekers in the Mion District, Savelugu Municipality, and Tamale Metropolis of the Northern Region, in July and August 2021. Multistage stratified purposive sampling was used to select respondents (n = 108). The data were audio-recorded and transcribed, and then we conducted a thematic analysis of the data.

RESULTS

At the individual level, fear of anaemia; pre-existing health conditions; challenges with daily activities; and physical, emotional, and sexual abuses from spouses contributed to PrA. Health system failures resulting in unexpected out-of-pocket payments, negative health worker attitudes, diagnostic errors, constraints on birth preparation and birth process, and potential adverse birth outcomes were understood as driving PrA. Socio-cultural factors influencing PrA comprised beliefs and practices around baby naming/outdooring ceremonies, fear of spiritual attacks, social construction of gender roles, and contextual factors such as transportation challenges.

CONCLUSION

Pregnant women in the region understood, experienced, and could identify perceived predictors of PrA. To address PrA, we recommend that mental health services should be integrated into the basic package of antenatal care and rural health services should be improved. Perceived predictors of PrA identified here could be included in the design of a context-specific PrA measure for use in the region.

Transition to Motherhood: Adverse Childhood Experiences, and Support from Partner, Family and Friends

BACKGROUND

The complex identity changes women have to go through to become mothers makes it a challenging transitional period. Especially, mothers who have experienced childhood adversity (ACEs) may be vulnerable to poor adjustment to motherhood. However, support from a partner, family and friends can act as a buffer to cope with this challenging transitional period. Therefore, the aim was to study whether ACEs and experienced social support (partners, family, and friends) were related to the adjustment to motherhood or 'motherhood constellation' of women after the birth of their first child.

METHOD

Data were collected via an online questionnaire among first-time mothers from June-September 2020. Motherhood constellation was measured with four items based on the descriptions by (Stern, 1995) about the motherhood constellation, i.e. worries about Life/Growth, Emotional Engagement, Support Systems, Identity Organisation. Multiple regression analyses with pairwise deletion were conducted.

RESULTS

ACEs were related to all four themes of motherhood constellation, indicating that the more frequent these adverse experiences occurred in the past the more concerns, both about the child and herself, the mother had. Moreover, after controlling for ACEs and other forms of support, only support from friends was related to the use of support systems and identity organisation. Finally, statistically significant interactions were found between ACES and support from friends with life/growth and between ACES and support from family with identity organisation. These interactions indicated that contrary to the expectation the positive association between mother's ACEs and worries was stronger for mothers who experienced more support.

CONCLUSION

The consequences of ACEs seemed to show up in the transition to motherhood, indicating that interventions targeting first-time mothers should address the motherhood constellation that may arise from earlier adverse life experiences. Moreover, especially support from friends seemed to be associated with less worries among mothers. Social support has no buffering effect for the negative consequences of ACEs on the themes of motherhood constellation. Further research is clearly needed to get more insight into these themes and to understand the meaning of different types of social support during the transition to motherhood.

Exploring the first-time transition to parenthood in mainland China: a qualitative study on the experiences of fathers and mothers using the transition shock model

Background

The transition to parenthood, which is influenced a lot by local parenting culture, is a dramatic stress for both men and women. Chinese social and cultural contexts form specific parental culture, shaping the unique experience of transition to parenthood. However, the understanding of the transition to parenthood in mainland China is limited. Additionally, few qualitative studies explored the transition to parenthood from both dyadic perspectives.

Aim

To explore the first-time transition to parenthood experience among mothers and fathers in mainland China during pregnancy, and compare the similarities and differences between their experiences in this transition period.

Methods

A descriptive qualitative study was conducted with 36 parents, including 18 primiparous women and their husbands. Data were analyzed by directed content analysis guided by the Transition Shock Model. The interview texts were first analyzed at individual levels and subsequently at the couple level to identify dyadic themes.

Results

Five themes and thirteen sub-themes emerged from the data analysis, including role integration, health risk, dilemma of preparation, protective isolation, and multi-dimensional expectation. Unexpectedly, the experiences and perspectives of mothers and fathers regarding the transition to parenthood were found to be similar, with the exception of the sub-theme extra-care requirement.

Conclusion

The findings shed light on the complex emotional journey and expectations of parents, as well as the challenges they face in terms of physical well-being, limited coping resources, and restricted social connections. Notably, fathers in China often shared the stress of the whole process during the transition period alongside mothers but often lacked accessible avenues for seeking and receiving support. These findings underscore the importance of actively involving fathers as a key support population in perinatal care, as well as the need for comprehensive support systems and tailored interventions to enhance the well-being and adaptation of parents.

The impact of perinatal maternal stress on the maternal and infant gut and human milk microbiomes: A scoping review protocol

OBJECTIVE

The objective of this scoping review is to review the research evidence regarding the impact of perinatal maternal stress on the maternal and infant gut and human milk microbiomes.

INTRODUCTION

Perinatal stress which refers to psychological stress experienced by individuals during pregnancy and the postpartum period is emerging as a public health concern. Early exposure of infants to perinatal maternal stress can potentially lead to metabolic, immune, and neurobehavioral disorders that extend into adulthood. The role of the gut and human milk microbiome in the microbiome-gut-brain axis as a mechanism of stress transfer has been previously reported. A transfer of colonised aberrant microbiota from mother to infant is proposed to predispose the infant to a pro- inflammatory microbiome with dysregulated metabolic process thereby initiating early risk of chronic diseases. The interplay of perinatal maternal stress and its relationship to the maternal and infant gut and human milk microbiome requires further systematic examination in the literature.

INCLUSION CRITERIA

This scoping review is an exploratory mapping review which will focus on the population of mothers and infants with the exploration of the key concepts of maternal stress and its impact on the maternal and infant gut and human milk microbiome in the context of the perinatal period. It will focus on the pregnancy and the post-natal period up to 6 months with infants who are exclusively breastfed.

METHODS

This study will be guided by the Joanna Briggs Institute's (JBI) methodology for scoping reviews along with use of the Prisma Scr reporting guideline. A comprehensive search will be conducted using the following databases, CINAHL Complete; MEDLINE; PsycINFO, Web of Science and Scopus. A search strategy with pre-defined inclusion and exclusion criteria will be used to retrieve peer reviewed data published in English from 2014 to present. Screening will involve a three-step process with screening tool checklists. Results will be presented in tabular and narrative summaries, covering thematic concepts and their relationships. This protocol is registered with Open Science Framework DOI 10.17605/OSF.IO/5SRMV.

Lived experiences of mothers with postnatal anxiety: a qualitative phenomenology study from Pakistan

OBJECTIVE

The prevalence of postnatal anxiety is high among women during the first year of childbirth globally. Rates are higher in low and middle-income countries (LMICs), that is, 24%. Existing literature on maternal mood and its impact on child development has largely focused on postnatal depression. Postnatal anxiety has been recognised to have significant independent effects similar to those of postnatal depression, including negative effects on various aspects of maternal well-being including quality of life, parent-child interaction and child development. The evidence exploring lived experiences of postnatal anxiety is limited from LMICs. This study explored the lived experiences of anxiety in postnatal mothers in Pakistan.

DESIGN

A phenomenological approach was used for this qualitative study. The audio-recorded interviews were transcribed and analysed using the process of thematic analysis.

SETTINGS

The study was conducted in two community settings in Karachi, Pakistan; the Bin Qasim and Gadap town.

PARTICIPANTS

Women who were 18 years of age or older, had a live childbirth within the previous 12 months and had a score of 10 or higher on the Generalised Anxiety Disorder-7.

RESULTS

In-depth, one-to-one interviews were conducted with 10 participants. The qualitative data comprised of three themes. Theme one: Factors perceived to be associated with postnatal anxiety, Theme two: The perceived impact of postnatal anxiety and Theme three: Support needs. The first theme was further subdivided into two subthemes, that is, Mothers' perception of navigating domestic responsibilities and sociocultural norms of motherhood and financial constraints.

CONCLUSION

Despite the high prevalence of postnatal anxiety in LMICs there is not any published evidence on exploring this phenomenon through in-depth research in Pakistan. Understanding the lived experiences will help health professionals to identify women at risk of developing postnatal anxiety and to develop effective culturally appropriate interventions for women with anxiety during this postnatal period.

Cardiovascular disease and maternal mortality: perceptions in a Midwest birthing population

BACKGROUND

Missouri has one of the highest rates of maternal mortality in the United States. To date, there are currently no studies describing birthing peoples' knowledge or perceptions of contributing causes of maternal mortality. An improved understanding of population-specific knowledge can help to define how best to design targeted interventions to reduce disease-specific causes of maternal mortality.

OBJECTIVE

This study aimed to examine the knowledge and understanding of maternal mortality in a Missouri birthing population.

STUDY DESIGN

A 46-question, cross-sectional survey to assess the familiarity with local maternal mortality rates, groups affected, and causality was developed by the Missouri Perinatal Quality Collaborative and the Maternal-Child Learning and Action Network and emailed to a random sample of birthing people across Missouri. Those who identified as someone with birthing potential with a Missouri zip code and who were ≥18 years of age were eligible for inclusion. Unadjusted descriptive statistics were generated and stratified by age, race, and region.

RESULTS

Among 2196 surveys sent, 1738 people completed the survey. Of those who responded, 78.2% were aware of the risk of pregnancy-related death with 14.7% reporting that they intimately knew someone who died. When asked if a certain group is affected disproportionately more, 66.4% responded affirmatively. Black (58.7%), uninsured (61.8%), poor (71.0%), those with substance abuse disorders (57.4%), and Native American (28.8%) birthing people were identified as groups that were perceived as suffering higher rates of maternal death. When polled on etiology, severe bleeding (56.9%) was believed to be the leading cause of death, and the second stage of labor was thought to be the period of highest risk (42.3%). Beliefs about the timing of death differed by age (P=.042) but not race (P=.81) or region (P=.191).

CONCLUSION

Missouri birthing people are cognizant of the social factors associated with increased maternal mortality but are unaware of the leading causes of death, namely cardiovascular disease and mental health conditions. Future Perinatal Quality Collaborative work should focus on campaigns that raise public awareness about cardiovascular disease and mental health-related birthing risks and the importance of monitoring early warning signs after delivery.

Path analysis of influencing factors for maternal antenatal depression in the third trimester

Maternal antenatal depression (AD) is a nonpsychotic depressive episode during pregnancy that can harm both the pregnant woman and the fetus. This study aimed to investigate the intrinsic interrelationships between AD and its influencing factors by constructing a path model. This survey-based cross-sectional study included 1071 pregnant women who underwent pregnancy examinations in three hospitals in Nantong City, China, between February and June 2023. General information and information regarding maternal AD, pregnancy stress, prenatal anxiety, social support, marital satisfaction, sleep quality, and resilience were collected. Multiple linear regression analysis using SPSS 25.0 was employed to determine the factors influencing pregnancy depression, and Amos25.0 was used to construct a structural equation model. AD incidence was 19.4% (208/1071). The independent risk factors affecting AD in pregnant women have been integrated into the established path analysis model. The model demonstrated a good fit (χ2/DF = 1.238, comparative fit index = 0.999, goodness-of-fit index = 0.998, normed fit index = 0.996, adjusted goodness-of-fit index = 0.990, incremental fit index = 0.999, and root mean square error of approximation = 0.015). While prenatal anxiety (0.230) and hyperthyroidism (0.048) only had direct effects on AD, mental resilience was the biggest factor affecting AD, followed by pregnancy stress, marital satisfaction, prenatal anxiety, sleep quality, social support, and hyperthyroidism. Improved mental resilience, social support, sleep quality, and marital satisfaction; reduced pregnancy stress and prenatal anxiety; and effective hyperthyroidism treatment might reduce AD. This study underscored the significance of delivering actionable strategies and tangible assistance to pregnant women to reduce AD.

Case report: Psychotherapy for enhancing psychological adjustment to dysphoric milk ejection reflex

Given its endless benefits, breastfeeding is widely acknowledged as the optimal choice for both maternal and infant health. Nevertheless, breastfeeding mothers often encounter various challenges that may hinder their ability to fully embrace this experience. This report delves into a compelling case of Dysphoric Milk Ejection Reflex (D-MER), a largely underexamined mental health issue among lactating mothers. D-MER is characterized by intense aversion right before milk let down, which can significantly impede a mother's willingness to breastfeed. The primary aim of this case report is to provide a comprehensive psychological understanding of D-MER, emphasizing aspects of attachment, the transition into motherhood, and the sociocultural sexualization of the female body. We also offer an overview of the psychotherapeutic journey, highlighting key insights and progress achieved over a span of six months. Therapy adopted an integrative approach combining narrative techniques and skills training such as mindfulness to facilitate a comprehensive therapeutic experience. This case underscores the psychological dimensions of the breastfeeding experience, complementing the well-established biochemical and physiological aspects of D-MER. It also emphasizes the need for further research into the psychological facets of both successful and less successful breastfeeding experiences.

Impact of pregnancy/childbirth on dispositional optimism in the context of risk of depression, mental health status and satisfaction with life

Introduction

Life optimism is an inseparable element accompanying every human being. It takes different values depending on the life situation. The present study aimed to measure the level of dispositional optimism in postpartum and pregnant women, compared to women who are not pregnant and have never given birth in Poland, Greece, Turkey, Belarus, and Russia, depending on the level of life satisfaction, risk of depression and mental health.

Materials and methods

A case-control study was carried out among 2017 women, including 584 pregnant women, 528 postpartum women, and 906 women who had never been pregnant and had never given birth (control group) from Poland, Greece, Turkey, Belarus, and Russia.The study used the LOT-R Life Orientation Test, the Beck Depression Scale (BDI), the Satisfaction With Life Scale (SWLS), the GHQ- 28, and the Edinburgh Postnatal Depression Scale (EPDS) - only in the postpartum group.

Results

Women from the control group showed an average level of optimism, obtaining an average of 16 points in Belarus, 13.4 points in Poland, 13.3 points in Greece, 13.5 points in Turkey, and Russia - 16.3 points. Pregnant women from Belarus had a high level of optimism (17 points), and in other countries, an average level of optimism was in Poland - 14.5 points, Greece - 14.0 points, Turkey - 14.3 points, and Russia - 16.5 points. Women after childbirth had a high level of optimism in Belarus (17.4 points) and Russia (17.2 points), and in other countries had the average level of optimism. In these countries, the lowest level of optimism was found in non-pregnant women. No significant correlation between age and life optimism was found in any group. In Poland, life optimism increased with age in women who had never been pregnant, and in Turkey, in women who were pregnant and after childbirth.

Conclusion

Pregnant women from Belarus had a higher level of optimism than other countries. Non-pregnant women had an average level of optimism. Future studies should include larger groups of women and consider other factors that may additionally contribute to dispositional optimism.

Anxiety and depression in pregnancy: associated variables during the COVID-19 pandemic period

OBJECTIVE

To assess the association between age, parity, nationality, educational level, employment and partner support with depression and anxiety during pregnancy. To determine the impact of the evolution of the COVID-19 pandemic on the anxiety and depression levels of the participants.

METHOD

Cross-sectional descriptive correlational study carried out in the Osakidetza/Basque Health Service, Primary Care, Bizkaia (Spain). A total of 295 pregnant women between 8 and 41 weeks participated. The association between age, parity, nationality, educational level, employment, partner support and COVID-19 incidence rates during the study period and depression (measured with the Edinburgh Postnatal Depression Scale) and anxiety (measured with the State-Anxiety Inventory/STAI-S subscale) scores during pregnancy was measured. A logistic regression model was constructed and odds ratios and their 95% confidence intervals were estimated.

RESULTS

The mean score was 18.75 points for anxiety (SD=8.69) and 6.45 points for depression (SD=4.32). Women expecting their second or later child had higher scores for depression (OR 2.51[95%IC: 1.26-5.01)) and anxiety (OR 1.98 [95%IC: 1.01-3.89]). Having completed university studies was associated with lower scores in depression (OR 0.28 [95%IC: 0.11-0.77]) and in anxiety (OR 0,2 [95%IC: 0.08-0.54]). A good relationship with the partner was associated with lower levels of anxiety (OR 0.45 [95%IC: 0.24-0.81]). The mean anxiety and depression scores are related to the incidence of COVID-19 cases; the anxiety score was significantly higher in periods of higher incidence.

CONCLUSIONS

Greater emotional care for pregnant women with low educational level, multiparous and with weak support from their partner, would reduce anxiety and depression in pregnancy. Health emergency situations affect mental health during gestation.

Mental Health Awareness and Promotion during the First 1000 Days of Life: An Expert Consensus

The first 1000 days of life constitute a critical phase that will determine the optimum growth and development of a child. An important factor in this phase of life is the perinatal mental health of mothers and children. Mental health awareness is an important public health issue with significant impacts on mothers, spouses, and families, as well as the long-term emotional and cognitive development of children as well. However, the awareness and promotion of mental health within the realms of reproductive health, maternal health, and infant health, i.e., the first 1000 days of life, do not receive high prioritization in Indonesia. Nonetheless, Indonesia, with its existing primary healthcare system, has the potential to raise awareness of and promote the importance of perinatal mental health for its citizens. This experts' consensus proposes several strategies to maximize the usefulness of primary healthcare facilities in Indonesia, including Community Health Centers and Integrated Healthcare Posts, to support perinatal mental health awareness and promotion during the first 1000 days of life. The success of this program, in return, will improve the health status of women and children in Indonesia.

The identification and measurement of postpartum anxiety in England: A Delphi survey

Postpartum anxiety has negative consequences for both mother and infant, so effective identification and measurement is vital to enable intervention. Despite NICE recommendations to prioritise the measurement of postpartum anxiety in mothers, current clinical measurement in England remains both fragmented and flawed. The Postpartum Specific Anxiety Scale [PSAS] offers an alternative, as it measures maternal-focused anxieties which can enable specifically targeted interventions. However, it is only currently used as a research tool and may require modification for clinical use. To inform modification of the PSAS, nineteen stakeholders from a variety of organisations participated in a two-round Delphi consensus survey to measure its clinical relevance and potential for effective identification of clinical anxiety. Descriptive analyses revealed all subscales of the PSAS scored highly across all domains, excluding Practical Infant Care Anxieties. Analyses also indicated good consensus between stakeholders across specific items, suggesting that the some items on the PSAS are relevant and effective at identifying clinical postpartum anxiety. Participants also expressed a need for a shorter version of the PSAS for clinical use, and that additional items may need including. Future research must now adapt the existing PSAS based on the results of this study and pilot the adapted measure in a clinical population.

The effect of perceived social support on postpartum stress: the mediating roles of marital satisfaction and maternal postnatal attachment

BACKGROUND

Multiple factors may be responsible for the development of postpartum stress, including perceived social support, marital satisfaction, and maternal postnatal attachment. However, the underlying mediation mechanisms remain unclear. This study examined the complex relationships between perceived social support and postpartum stress among Chinese women.

METHODS

A convenience sample comprising 406 postpartum women was recruited from six hospitals in Nantong, Jiangsu Province, China. The participants completed general survey questionnaires and were evaluated using the Maternal Postpartum Stress Scale, the Perceived Social Support Scale, the Maternal Postnatal Attachment Scale, and the Marital Satisfaction Scale. Furthermore, we evaluated the relationship between postpartum stress and the various influencing factors by performing a multiple linear regression analysis. The potential mediating roles of marital satisfaction and maternal and infant attachment in the association between perceived social support and postpartum stress were explored by performing a mediation analysis.

RESULTS

According to the multivariate regression analysis, perceived social support, marital satisfaction, and maternal postnatal attachment contributed to postpartum stress levels (P < 0.05). The mediation analysis revealed that marital satisfaction and maternal postnatal attachment played parallel mediating roles in the association between perceived social support and postpartum stress, and the mediating effect of marital satisfaction was - 0.1125 (95% confidence interval [CI]: -0.1784 to -0.0520), accounting for 33.20% of the total effect, and the mediating effect of maternal postnatal attachment was - 0.0847 (95% CI: -0.1304 to -0.0438), accounting for 25.00% of the total effect.

CONCLUSION

Our study revealed that perceived social support could influence postpartum stress not only through direct effect (41.80% of the total effect), but also through the indirect effect (mediation effect) of marital satisfaction and maternal postnatal attachment (58.20% of the total effect), suggesting that improving postpartum women's social support, enhancing maternal and infant attachment, and improving their marital satisfaction could help lower postpartum stress.

Contextualizing the experiences of Black pregnant women during the COVID-19 pandemic: 'It's been a lonely ride'

The emergence of the COVID-19 pandemic significantly changed the prenatal care experience, specifically regarding medical appointments and social opportunities. It is critical to capture this change through the narratives of pregnant people, particularly those of marginalized populations, whose voices may often be underrepresented in the literature. This mixed-methods paper summarizes the experiences of 40 pregnant Black/African American (AA) women during the COVID-19 pandemic. A cross-sectional, online survey was administered between 2020 and 2021 to assess prenatal health and the impacts of the COVID-19 pandemic on patients' pregnancy experience. Coping behaviors during the pandemic were self-reported using the COPE-IS. Univariate analyses were conducted. An additional analysis of participants (n = 4) was explored through a week-long qualitative exercise using a photo documentation procedure. Photo-Elicitation Interviews (PEI) were conducted to capture and center their pandemic pregnancy experiences. Sources of stress during the pandemic varied, with the most common being financial concerns (n = 19, 47.5%). Over half of the sample (n = 18, 54.5%) self-reported increases in their positive coping behaviors during the pandemic, such as communicating with friends and family, talking to healthcare providers, listening to music, and engaging in spiritual practices-such as prayer. The four PEI study participants reflected on the impacts of social distancing on their prenatal experience and mentioned hospital and provider-related weariness due to their race. The findings of this study suggest that during the COVID-19 pandemic, Black/AA pregnant women in Charlotte, NC used social support, mindfulness practices, self-advocacy, and health literacy to navigate challenges present during their prenatal health experience. This paper highlights the personal, social, and structural experiences of pregnant women during a public health crisis so that responsive and effective programs or policies can be planned in the future.

Understanding and preferences regarding risk communication during pregnancy: a survey to facilitate provider communication with patients

BACKGROUND

Clear communication of medical risk helps to ensure proper patient understanding of healthcare options and supports informed decision-making. Communication involving visual and written risk typically conveys risk more effectively than conversations alone between a patient and a clinician. However, perception of risk is context-dependent, and the efficacy of and preferences for commonly-used risk communication formats are not well-understood during pregnancy, which is a time of complex decision-making. We sought to address this knowledge gap.

OBJECTIVE

This study aimed to assess pregnant and recently pregnant people's understanding and preferences for different risk communication formats.

STUDY DESIGN

We conducted an open online REDCap survey of pregnant and recently pregnant people over a 1-month period in 2022. Study participants were aged 16 to 49 years, pregnant or recently pregnant, and able to provide informed consent in English. Data collected included demographics, measurements of accuracy of understanding including both gist accuracy (general understanding) and verbatim accuracy (numeric quantification), and preferences for risk communication formats including icon arrays, pie charts, bar graphs, and text. Descriptive analyses of the proportion of correctly answered questions were calculated.

RESULTS

A total of 247 participants completed ≥1 item on accuracy and risk communication preferences, and 230 provided complete responses. Gist (general) understanding was accurate between 74% and 89% of the time for most graphical formats. Verbatim understanding (exact numeric quantification) was approximately 90% accurate for most formats. Respondents preferred that figures be used over circles to display risk in icon arrays, both for themselves and for infants, although figures generated more worry. However, participants substantially preferred pie charts over bar graphs (59%-70% vs 19%-25%). Respondents preferred risk to be expressed with a lower denominator of 200 rather than a higher denominator of 1000 (79% vs 13%, although the lower denominator generated more worry), and in terms of chance of survival rather than chance of death (50% vs 33%).

CONCLUSION

In a survey of pregnant and recently pregnant people, most respondents preferred pie charts over other graph formats, and lower rather than higher denominators in text. Presentations of survival rather than death estimates were also preferred. Approximately 75% to 90% of respondents accurately understood risk presented with visual and written communication. For the remaining participants, for whom accurate understanding was challenging, new strategies need to be developed.

The Level of Stress and Anxiety in Pregnant Women Depending on Social Support and Physical Activity

Social support and physical activity are mentioned among the numerous factors affecting the emotional state of pregnant women. Therefore, the aim of the study was to assess the level of perceived stress and anxiety in pregnant women depending on social support and their physical activity both before and during pregnancy and find the factors that affected the level of perceived stress.

METHODS

A total of 373 pregnant women were qualified for the study. The Perceived Stress Scale (PSS-10), the State-Trait Anxiety Inventory (STAI), and a self-administered questionnaire were used.

RESULTS

In the study group, a high level of stress and anxiety were noted. A comparative analysis showed that physically active women before pregnancy, women attending childbirth classes and remaining in a relationship, were characterized by a lower level of stress and anxiety compared to physically inactive women, women who did not participate in childbirth classes and were single. A multiple linear regression analysis showed that participation in childbirth classes, physical activity before pregnancy, the level of anxiety as a trait, and women's age had the most significant impact on the stress level of surveyed women.

CONCLUSIONS

Further research among pregnant women and women in the postpartum period is needed to confirm the benefits of physical activity and to identify as many factors as possible that may affect the emotional state of pregnant women.

Dysphoric milk ejection reflex (D-MER) and its implications for mental health nursing

Dysphoric milk ejection reflect (D-MER) is a dysphoria which women may experience within seconds of commencing breastfeeding. It is only recently gaining recognition in the academic literature and may have important implications for breastfeeding continuation, differential diagnosis and perinatal mental health. This perspective piece introduces the topic, sets out the physiological processes underpinning the experience and outlines why increased awareness of D-MER is important for the profession of mental health nursing.

Parental stress during pregnancy and maternity

OBJECTIVE

To identify factors related to parental stress of women during pregnancy and the child's first month of life.

METHOD

Prospective longitudinal study in two stages. Analysis of home interviews with 121 participants, Gestational Stress Scale, and Parental Stress Scale. Fisher's exact test, Spearman's correlation, and linear and logistic multivariate regression were applied, with p < 0.05.

RESULTS

Most of the participants were between 18 and 35 years old, had 11 to 13 years of education, had no paid work, had a partner, usually the child's father, planned pregnancy, were multiparous, and underwent prenatal care. During pregnancy, 67.8% had stress. In the first month after the child's birth, most had low parental stress (52.1%). High parental stress correlated with some gestational stress. Planning pregnancy decreased parental stress.

CONCLUSION

Gestational and parental stress in the child's first month of life were correlated and pregnancy planning was a factor that reduced stress levels. Timely actions to reduce parental stress are essential for parenting and the child's overall health.

Effects of maternal pre-pregnancy body mass index and gestational weight gain on antenatal mental disorders in China: a prospective study

BACKGROUND

Maternal obesity is the most common medical condition among women of reproductive age worldwide. The pre-pregnancy body mass index and gestational weight gain have been suggested to be associated with maternal mental disorders. This study aimed to investigate the effects of the pre-pregnancy body mass index and gestational weight gain on antenatal depression, stress, and anxiety.

METHODS

In total, 4,890 pregnant women were enrolled in the present study, which is based on an ongoing prospective cohort study. We used self-reported pre-pregnancy weights and the last weights measured prior to delivery (using professional instruments) to calculate the pre-pregnancy body mass index and gestational weight gain. The questionnaires used included the Center for Epidemiologic Studies Depression Scale (CES-D), Self-Rating Anxiety Scale (SAS), and 10-item version of the Perceived Stress Scale (PSS-10). We used Pearson product-moment correlation and multivariable logistic regression models to examine the impact of the pre-pregnancy body mass index and gestational weight gain on different maternal mental disorders.

RESULTS

After adjusting for conception, annual household income, occupation, education, smoking status, and drinking status, excessive gestational weight gain during pregnancy was associated with a greater chance of anxiety symptoms in the entire sample (adjusted model: odds ratio = 1.479, 95% confidence interval = 1.128, 1.938) and especially in women with a normal body mass index (adjusted model: odds ratio = 1.668, 95% confidence interval = 1.209, 2.302). However, the relationship between the maternal pre-pregnancy body mass index and mental health was not significant.

CONCLUSION

Pregnant women with a normal pre-pregnancy body mass index had a greater chance of experiencing anxiety symptoms before delivery if gestational weight gain was excessive; however, its effects on depression or stress symptoms were not observed. The maternal pre-pregnancy body mass index may not be independently associated with maternal mental disorders.

Comparing prenatal and postpartum stress among women with previous adverse pregnancy outcomes and normal obstetric histories: A longitudinal cohort study

OBJECTIVE

The aim of this study was to compare subjectively and objectively measured stress during pregnancy and the three months postpartum in women with previous adverse pregnancy outcomes and women with normal obstetric histories.

METHODS

We recruited two cohorts in southwestern Finland for this longitudinal study: (1) pregnant women (n = 32) with histories of preterm births or late miscarriages January-December 2019 and (2) pregnant women (n = 30) with histories of full-term births October 2019-March 2020. We continuously measured heart rate variability (HRV) using a smartwatch from 12 to 15 weeks of pregnancy until three months postpartum, and subjective stress was assessed with a smartphone application.

RESULTS

We recruited the women in both cohorts at a median of 14.2 weeks of pregnancy. The women with previous adverse pregnancy outcomes delivered earlier and more often through Caesarean section compared with the women with normal obstetric histories. We found differences in subjective stress between the cohorts in pregnancy weeks 29 and 34. The cohort of women with previous adverse pregnancy outcomes had a higher root mean square of successive differences between normal heartbeats (RMSSD), a well-known HRV parameter, compared with the other cohort in pregnancy weeks 26 (64.9 vs 55.0, p = 0.04) and 32 (63.0 vs 52.3, p = 0.04). Subjective stress did not correlate with HRV parameters.

CONCLUSIONS

Women with previous adverse pregnancy outcomes do not suffer from stress in subsequent pregnancies more than women with normal obstetric histories. Healthcare professionals need to be aware that interindividual variation in stress during pregnancy is considerable.

Healthcare professionals' experiences and perceptions of providing support for mental health during the period from pregnancy to two years postpartum

OBJECTIVE

Mental health issues in the perinatal period are common, and can have negative consequences for maternal and child health. Healthcare professionals (HCPs) who provide women with perinatal care are well-placed to detect mental health issues and provide support. This study therefore examines HCPs' experiences and perceptions of providing mental health support during the perinatal period, including during the COVID-19 pandemic.

DESIGN

An exploratory realist qualitative study was conducted.

SETTING

Republic of Ireland PARTICIPANTS: A purposive sampling strategy was employed to recruit HCPs (e.g., general practitioners, midwives, public health nurses, practice nurses, doulas, and breastfeeding counsellors), via professional bodies in Ireland. An invitation to participate was also circulated via Twitter. A total of 18 HCPs participated in semi-structured interviews conducted between 18/8/2020 and 24/5/2021.

MEASUREMENTS AND FINDINGS

Semi-structured interviews were conducted according to a topic guide designed by a multidisciplinary team. Data were analysed using thematic analysis. Four themes were developed: 'Supporting women in healthcare settings,' 'Skills and capacity to provide adequate care,' 'Structural barriers to care provision,' and 'The impact of the COVID-19 pandemic on stress support.'

KEY CONCLUSIONS

HCPs reported providing emotional support and advocacy, but highlighted challenges, including limited capacity to address women's concerns, clinical culture and hierarchy, insufficient organisational investment, and social inequities in support access. Some HCPs felt these barriers could lead to additional psychological harm. HCPs also reported that the pandemic had introduced novel stressors and changed the nature of the mental health support they provided.

IMPLICATIONS FOR PRACTICE

Interventions incorporating education and physical resources for HCPs, increased investment in specialist perinatal mental health services, increased investment in holistic supports, and changes to address cultural challenges in care environments, may facilitate - or enhance - support for women.

Emotional difficulties, coping strategies, and help-seeking patterns among Czech perinatal women

OBJECTIVE

To understand both, women´s perception of emotional difficulties in perinatal period and their related coping strategies. Further, we mapped and analysed help-seeking patterns utilized by these women to overcome their emotional difficulties. This study serve as an important piece of information for women-centred innovations in perinatal mental health care in Czechia, and more broadly in the region of Central and Eastern Europe.

DESIGN

A qualitative study with an exploratory and descriptive approach using thematic analysis.

SETTING

Online survey consisting of open-ended questions mapping women´s perception of emotional difficulties in perinatal period and their related coping strategies and help-seeking patterns.

PARTICIPANTS

Two hundred women self-reporting emotional difficulties in perinatal period, from whom 108 (54 %) stated that they had sought professional help with their emotional difficulties.

FINDINGS

Two themes were identified in the analysis of women´s perception of emotional difficulties including Experience of symptoms of mental disorders, and Mother-child relationship. Three themes were identified in the analysis of women´s coping with these difficulties (Personal resources, External resources, and No coping strategy used). Four themes were identified in the analysis of help seeking patterns utilized by study participants (Mental health specialists, Physicians of the first line of contact, Midwifes, and Peer consultants).

KEY CONCLUSIONS

Emotional difficulties of perinatal women stemmed in both, general symptoms of mental disorders and specific concerns connected to mother-child relationship. Therefore, the perinatal mental health services should cover both topics, preferably by a multidisciplinary team. Women search information about perinatal mental health, so thus, easy to reach valid resources are needed. Finally, Czech perinatal women experiencing emotional difficulties utilize various help-seeking patterns. Some of them naturalistically utilize integrated stepped care even when it is not systematically established.

Estresse parental na gestação e maternidade

RESUMO Objetivo: Identificar fatores relacionados ao estresse parental de mulheres na gestação e primeiro mês de vida da criança. Método: Estudo longitudinal prospectivo em duas etapas. Análise de entrevistas em domicílio com 121 participantes, Escala de Estresse Gestacional e de Estresse Parental. Aplicados teste exato de Fisher, correlação de Spearman e regressão multivariada linear e logística, com p < 0,05. Resultados: A maior parcela das participantes tinha entre 18 e 35 anos, 11 a 13 anos de estudo, sem trabalho remunerado, com companheiro, geralmente o pai da criança, gestação planejada, multípara e realização do pré-natal. Na gestação, 67,8% apresentaram estresse. No primeiro mês após o nascimento do filho, a maioria teve baixo estresse parental (52,1%). Estresse parental alto apresentou correlação com algum estresse gestacional. Planejar a gestação diminuiu o estresse parental. Conclusão: Estresse gestacional e parental no primeiro mês de vida da criança foram correlacionados e o planejamento da gestação constituiu fator de diminuição dos níveis de estresse. Ações oportunas para reduzir o estresse parental são fundamentais para a parentalidade e saúde integral da criança.

The Fourth Trimester: a Time for Enhancing Transitions in Cardiovascular Care

Purpose of Review

The "fourth trimester" concept, defined as the first 12 weeks after delivery (and beyond), is a critical window of time for clinicians to intervene to optimize women's cardiovascular health after pregnancy. A timely and comprehensive postpartum cardiovascular assessment should be performed in all women following delivery in order to (1) follow up medical conditions present prior to conception, (2) evaluate symptoms and signs of common postpartum complications, and (3) identify risk factors and prevent future adverse cardiovascular outcomes. In this review, we aim to discuss major maternal cardiovascular risk factors such as hypertensive disorders of pregnancy, gestational diabetes mellitus, postpartum weight retention, and postpartum depression, as well as lactation as a potential protective risk modifying factor. Additionally, we will review effectiveness of outpatient interventions to enhance transitions in cardiovascular care during the fourth trimester.

Recent Findings

A seamless hand-off from obstetric to primary care, and potentially cardiology, is needed for early detection and management of hypertension, weight, glycemic control, stress and mood, and long-term cardiovascular risk. Additionally, the use of telemedicine, blood pressure self-monitoring, remote activity monitoring, and behavioral health coaches are potentially feasible modalities to augment clinic-based care for cardiovascular risk factors and weight management, but additional studies are needed to study their long-term effectiveness.

Summary

Development of a comprehensive postpartum care plan with careful consideration of each patient's risk profile and access to resources is critical to improve maternal morbidity and mortality, reduce health disparities, and achieve long-term cardiovascular health for women. Supporting postpartum well-being of women during this transition period requires a multidisciplinary approach, especially primary care engagement, and planning should start before delivery.

The Impact of the COVID-19 Pandemic on Perinatal Loss Experienced by the Parental Couple: Protocol for a Mixed Methods Study in Italy

Background

At the beginning of 2020, mothers and fathers who experienced perinatal events (from conception to pregnancy and postpartum period) found themselves facing problems related to the emergency caused by the COVID-19 pandemic and the associated difficulties for health care centers in providing care. In the unexpected and negative event of perinatal loss (ie, miscarriage, stillbirth, and neonatal death) more complications occurred. Perinatal loss is a painful and traumatic life experience that causes grief and can cause affective disorders in the parental couple—the baby dies and the couple’s plans for a family are abruptly interrupted. During the COVID-19 pandemic, limited access to perinatal bereavement care, due to the lockdown measures imposed on medical health care centers and the social distancing rules to prevent contagion, was an additional risk factor for parental mental health, such as facing a prolonged and complicated grief.

Objective

The main aims of this study are as follows: to investigate the impact of COVID-19 on mothers and fathers who experienced perinatal loss during the pandemic, comparing their perceptions; to evaluate their change over time between the first survey administration after bereavement and the second survey after 6 months; to examine the correlations between bereavement and anxiety, depression, couple satisfaction, spirituality, and sociodemographic variables; to investigate which psychosocial factors may negatively affect the mourning process; and to identify the potential predictors of the development of complicated grief.

Methods

This longitudinal observational multicenter study is structured according to a mixed methods design, with a quantitative and qualitative section. It will include a sample of parents (mothers and fathers) who experienced perinatal loss during the COVID-19 pandemic from March 2020. There are two phases—a baseline and a follow-up after 6 months.

Results

This protocol was approved by the Ethics Committee of Psychological Research, University of Padova, and by the Institutional Ethics Board of the Spedali Civili of Brescia, Italy. We expect to collect data from 34 or more couples, as determined by our sample size calculation.

Conclusions

This study will contribute to the understanding of the psychological processes related to perinatal loss and bereavement care during the COVID-19 pandemic. It will provide information useful to prevent the risk of complicated grief and psychopathologies among bereaved parents and to promote perinatal mental health.

International Registered Report Identifier (IRRID)

DERR1-10.2196/38866

Preferences and Barriers to Counseling for and Treatment of Intimate Partner Violence, Depression, Anxiety, and Posttraumatic Stress Disorder Among Postpartum Women: Study Protocol of the Cross-Sectional Study INVITE

The cross-sectional study INVITE (INtimate partner VIolence care and Treatment prEferences in postpartum women) aims to examine treatment and counseling preferences and barriers in relation to the experience of intimate partner violence (IPV), depression and anxiety, and (childbirth-related) posttraumatic stress disorder (PTSD) among postpartum women in Dresden, Germany. Currently, the INVITE study consists of an interim sample of N = 1,787 participants with n = 891 completed interviews. Recruitment is ongoing, targeting a community sample of at least N = 4,000 women who complete various quantitative questionnaires via telephone interviews at 3-4 months postpartum. The differences in rates of IPV, postpartum depression and anxiety, and/or (childbirth-related) PTSD as well as treatment and counseling preferences and barriers between affected and non-affected women will be assessed. Further, predisposing variables, past and present stress exposure, enabling resources, as well as past and present health will be examined as predictors of service preferences and barriers. In this study protocol, the theoretical background, methods, as well as preliminary results regarding sociodemographic characteristics and birth-related factors of the interim sample are presented and discussed in terms of their socio-political relevance. Simultaneously assessing IPV, postpartum depression and anxiety, and (childbirth-related) PTSD will facilitate exploring comorbidities and concomitant special needs of affected women. Results of the INVITE study will therefore set the ground for well-aimed development and improvement of treatment and counseling services for the respective target groups by informing health care professionals and policy makers about specific preferences and barriers to treatment. This will yield the possibility to tailor services to the needs of postpartum women.

Adult Health and Early Life Adversity: Behind the Curtains of Maternal Care Research

The quality of one's adult health and the chances of maintaining cognitive ability in aging stem directly from the quality of care one receives as an infant. Formal studies of maternal care can be traced back at least a century. Revelations of behavioral outcomes after maternal deprivation in primates were followed by discoveries of systemic and brain growth factors mediated by the caregiver-offspring relationship in rodents. More recently, much of the genetic/epigenetic bases of maternal care has been defined and positively linked to adult health and cognitive ability in senescence. The history of this field is both tragic and fascinating. The early primate work, while informative, was abusive. The initial rodent work was ridiculed before its importance was recognized. The final lesson learned is that infant/toddler care matters a lot. Today, we have a better understanding of the biology underlying maternal care and its transmission across generations as well as a scientific basis for massaging premature infants and hugging our children.