A Moderated Mediation Model of Maternal Perinatal Stress, Anxiety, Infant Perceptions and Breastfeeding

The Impact of Social Determinants of Maternal Mental Health in Marginalized Mothers

Background: A deeper understanding of the key determinants of maternal mental health is important for improving care for women, especially women who are at an economic disadvantage. Objectives: To explore the associations of select social determinants: access, social support, and stress, with the onset of antepartum depression in low-income mothers. Participants: The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing, population-based surveillance system with selected data from 2016 to 2019, establishing a randomly selected sample of women with a recent live birth at most 4 months postdelivery, between 1,300 and 3,400 women per state (n ∼ 162,558). Methods: In this cross-sectional study, the phase 8 PRAMS was adapted to measure social support, access, stress, and their relationships with the onset of antepartum depression in low-income mothers. To assess low-income marginalization, a threshold was established based on income levels within 130% of the federal poverty level; antepartum (n ∼ 41,289). Results: The defined access, social support, and stress factors showed a statistically significant association with the onset of antepartum depression among low-income mothers. Of women in this sample, 22.6% indicated antepartum depression (p < 0.001; R2 = 0.066). Negative social support indicators were associated with an increased likelihood of antepartum depression; 3.71 increased odds of depression for abuse during pregnancy, and 0.79 decreased odds with positive acknowledgment of paternity. Access indicator terms showed an association with the decreased likelihood of antepartum depression through breastfeeding information support (Info from Baby Doc, odds ratio [OR] = 0.86), prenatal care utilization (12+ visits, OR = 0.82), and specific insurance type (insurance by job, OR = 0.82). All instances of stressful life events showed an increased likelihood of depression during pregnancy (for majority of stressful life events: OR >1.12). Conclusions: Economically marginalized mothers face unmet social and health care needs leading to poorer outcomes during pregnancy. These findings provide additional support for improved policy and public health efforts, such as assessment, education, and interventions, to decrease prevalence and improve treatment for antepartum depression among marginalized mothers.

Trauma History Questionnaire: validation with novel samples of incarcerated women and perinatal women

Trauma exposure is associated with numerous negative outcomes, many of which are amplified within at-risk populations. Two under-researched and at-risk populations, incarcerated women and perinatal women, both report high rates of trauma, psychopathology, and PTSD compared to the general population. One common measure of trauma exposure in various populations, including incarcerated women and perinatal women, is the Trauma History Questionnaire (THQ). However, no known studies have validated the THQ within these two unique, understudied populations. Using data from two studies of incarcerated women and one study of perinatal women, researchers explored indices of THQ construct, predictive, and convergent validity. The study also included between-sample comparisons, highlighting differences in trauma incidence between the included samples. Analyses supported statistically significant relations between THQ scores and Severity of Violence Against Women Scale (SVAWS), depressive symptoms, PTSD, and psychological distress. Prenatal women's THQ scores were also predictive of later postpartum depressive symptoms. Significantly higher THQ scores were found within the incarcerated samples compared to the perinatal sample. The study results provide further information about trauma within incarcerated and perinatal populations, as well as increase understanding of the utility of trauma assessments within these vulnerable groups.

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.

The association between pregnancy-related anxiety and behavioral development in 18-month-old children: The mediating effects of parenting styles and breastfeeding methods

BACKGROUND

Pregnancy-related anxiety (PRA) is a distinct type of anxiety from general anxiety, affects many pregnant women, and is correlated with poor behavioral development in children. However, the mediation paths were unclear.

METHODS

A total of 2032 mother-infant pairs from the Ma'anshan Birth Cohort were included in the current study. Maternal PRA was assessed in the second and third trimesters. Children's behavioral development was evaluated at the age of 18 months. In addition, information on parenting styles and breastfeeding methods was obtained at postpartum. Multivariate regression and structural equation modeling were used to examine the associations between maternal PRA and children's behavioral development.

RESULTS

Significant intercorrelations were found between maternal PRA, the potential mediators (parenting styles and breastfeeding methods), and 18-month-old children's ASQ scores. Parenting styles played an intermediary role in the relationship between maternal PRA and children's behavioral development (β = 0.030, 95 % confidence interval: 0.017-0.051), and the mediating effect accounted for 29.1 % of the total effect. However, breastfeeding methods did not mediate the link between PRA and children's behavior.

LIMITATIONS

Depression and postpartum anxiety were not controlled for in our analysis, which left us unable to estimate the independent impact of PRA on children's behavior.

CONCLUSIONS

Parenting rather than breastfeeding is the mediating factor of behavioral problems in children caused by PRA.

The relationship of psychological well-being and cognitive emotions with breastfeeding self-efficacy in mothers in the postpartum period

To determine the relationship of psychological well-being and cognitive emotion regulation and breastfeeding self-efficacy in mothers in the postpartum period. The research was designed as cross-sectional and correlational and carried out between 1 November 2021 and 1 January 2022 in the pediatric outpatient clinic of a Medical Faculty Hospital of a province in the Central Anatolian Region of Turkey. Responses from a total of 325 mothers who were in postpartum 1-6 months were analyzed. Data were collected using a Personal Information Form, the Scales of Psychological Well-Being (SPWB), the Cognitive Emotion Regulation Questionnaire (CERQ), and the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF). The following factors were found to be important associated risk factors that negatively affected breastfeeding self-efficacy in 29% of the mothers (F = 14.536, p < .001): mothers' poor mental health, using self-blaming maladaptive cognitive coping strategy, inability to use positive reappraisal coping strategy, and feeding the baby only formula or both breast milk and formula. Weak and positive correlations were found between psychological well-being of mothers and adaptive cognitive coping subdimensions, and negative and weak correlations were found between psychological well-being of the mothers and maladaptive cognitive coping subdimensions (p < .001). Breastfeeding self-efficacy of mothers in a well psychological state, who can use adaptive cognitive coping strategies, and who exclusively breastfeed their babies is positively affected.

Maternal Stress and Neonatal Nutrition during the COVID-19 Era

Objective

COVID-19 pandemic has put a tremendous amount of stress on people, which can negatively affect nursing. Previous studies showed that perceived stress and cortisol levels in the postpartum period correlate with the LATCH scores, which is a simple tool to assess the pattern of nursing. Likewise, greater prenatal anxiety was associated with a shorter breastfeeding duration. We aimed to evaluate whether pregnant women were under extra stress due to the COVID-19 pandemic and if this stress affected their breastfeeding patterns and anthropometric measures of the neonates.

Methods

Pregnant women giving birth to healthy neonates were included. Coronavirus Anxiety Scale (CAS) and Beck Anxiety Inventory (BAI) were used to assess the anxiety levels of the mothers, and LATCH breastfeeding assessment tool was used to assess the nursing. The results of these scales and anthropometric measures of the neonates were recorded.

Results

Only one mother showed coronavirus-specific anxiety. Therefore, further analysis was done based on the Beck Anxiety (BA) levels of the mothers. CAS and BA scores were positively correlated (p<0.001, r=0.444), indicating that coronavirus-specific anxiety increased with increasing general anxiety. None of the variables changed depending on the anxiety levels of the mothers, except for the % weight gain at day five (p=0.020, r=-0.248). Even though anxiety seemed to show a small effect on weight loss during the first neonatal days, percent weight gain results did not seem to correlate with the anxiety levels in later stages (first month of life). Furthermore, LATCH scores of the infants on day one were positively correlated with BA scores of the mothers (p=0.045, r=0.175).

Conclusion

COVID-19 seemed to have no additional effect on the stress levels of the mothers. The more the mothers have anxiety, the more they may stress about the well-being of their infants, which can improve their nursing pattern.

Can Maternal Prenatal Self-Reported and Physiological Distress Predict Postnatal Caregiving Practices?

Maternal prenatal distress is associated with child outcomes, including health, neurocognitive, and socio-emotional development. Knowledge on underlying mechanisms is limited, yet relevant for prevention and intervention. This study investigated whether maternal prenatal distress predicts specific caregiving practices that are known for their effects on child outcomes. Caregiving practices studied were maternal caregiving quality and the initiation and course of breastfeeding and room-sharing. We hypothesized that more maternal prenatal distress would be associated with altered caregiving practices. Participants were 174 healthy mother-child dyads. During the 37^th week of pregnancy maternal self-reported distress was assessed using questionnaires, and physiological stress by collecting saliva cortisol. Maternal caregiving quality was observed in postnatal week 5 during infant bathing. Weekly diaries on breastfeeding and daily diaries on room-sharing were completed during the first 6 postnatal months. In a regression analysis, no associations between maternal prenatal distress and caregiving quality were found. Multilevel analyses indicated that maternal prenatal evening cortisol was positively related to the initiation of breastfeeding and room-sharing. Replications are warranted, but these results suggest that breastfeeding and room-sharing initiation may be part of a mechanism underlying links between maternal prenatal physiological stress and child outcomes. As other prenatal cortisol markers and self-reported distress were not found to be related to the caregiving practices, it is likely that alternative mechanisms (co-)exist in explaining links between maternal prenatal distress and child outcomes. Future replication research including child outcomes and (other) potential mechanisms will inform prevention and intervention programs fostering healthy pregnancies and child development.

Maternal Psychological Distress and Lactation and Breastfeeding Outcomes: a Narrative Review

PURPOSE

Despite recommendations from the World Health Organization and the American Academy of Pediatrics to exclusively breastfeed infants for their first 6 months of life, 75% of women do not meet exclusive breastfeeding guidelines, and 60% do not meet their own breastfeeding goals. Numerous observational studies have linked maternal psychological distress (eg, perceived stress, anxiety, and depression) with nonoptimal breastfeeding outcomes, such as decreased proportion and duration of exclusive breastfeeding. The physiological mechanisms underlying these associations, however, remain unclear.

METHODS

For this narrative review, we evaluated the evidence of relationships between maternal psychological distress and lactation and breastfeeding outcomes in pregnancy and post partum and the possible physiological mechanisms that facilitate these relationships. We searched PubMed using the following terms: stress, anxiety, depression, breastfeeding, and lactation. Additional search by hand was conducted to ensure a thorough review of the literature.

FINDINGS

Among the studies examined, methods used to assess maternal psychological distress were not uniform, with some studies examining perceived distress via a variety of validated tools and others measuring biological measures of distress, such as cortisol. Evidence supports a role for psychological distress in multiple breastfeeding outcomes, including delayed secretory activation and decreased duration of exclusive breastfeeding. One physiological mechanism proposed to explain these relationships is that psychological distress may impair the release of oxytocin, a hormone that plays a critical role in milk ejection during lactation. Continued impairment of milk ejection may lead to decreased milk production because of incomplete emptying of the breast during each feed. Maternal distress may also yield elevated levels of serum cortisol and decreased insulin sensitivity, which are associated with decreased milk production. The relationship between psychological distress and breastfeeding is likely to be bidirectional, however, in that breastfeeding appears to reduce maternal distress, again possibly via effects on the pleasure or reward pathway and calming effects of oxytocin on the mother. This finding suggests that interventions to support lactation and breastfeeding goals in women who score high on measures of psychological distress would be beneficial for both maternal and infant well-being.

IMPLICATIONS

Evidence to date suggests that maternal psychological distress may impair lactation and breastfeeding outcomes, but stronger study designs and rigorous assessment methods are needed. A better understanding of the physiological mechanisms leading to impaired lactation may assist in the development of early interventions for mothers experiencing distress. In addition, stress-reducing programs and policies should be investigated for their potential to improve breastfeeding outcomes.

Anxiety and its influence on maternal breastfeeding self-efficacy

Objective:

to identify the levels of anxiety and breastfeeding self-efficacy in puerperal women at the intervals of 60, 120, and 180 days postpartum; and to verify the influence of anxiety on breastfeeding self-efficacy among these puerperal women.

Method:

an analytical, longitudinal and prospective study, conducted with 186 puerperal women, and which used a sociodemographic and obstetric characterization questionnaire, the State-Trait Anxiety Inventory, and the Breastfeeding Self-Efficacy Scale - Short Form. The analyses were performed by means of descriptive statistics, and Fisher’s Exact Test was used.

Results:

most of the puerperal women presented low levels of trait anxiety (55.4%) and of state anxiety (66.2% at 60 days, 72.8% at 120 days, and 75.5% at 180 days), and a high level of self-efficacy (77.3% at 60 days, 75.3% at 120 days, and 72.1% at 180 days of puerperium). Low levels of trait anxiety and state anxiety were associated with high self-efficacy at 60 days (p=0.0142 and p=0.0159, respectively).

Conclusion:

it is necessary to pay greater attention to the mental health of puerperal women, considering that those who presented low levels of anxiety had higher levels of self-efficacy, a situation that can result in longer exclusive breastfeeding.

Perinatal Maternal Mental Health and Breastfeeding Are Associated with Infant and Toddler Sensory Profiles

Infants’ sensory processing may impact their development and daily functioning in multiple domains, as does the mental health of their mothers. Little research has been conducted exploring the novel construct of sensory processing in relation to maternal mental health and arguably one of the most important co-occupations during this sensitive time (i.e., breastfeeding), which may also be impacted by maternal mental health. Therefore, this study aims to explore associations between maternal mental health, the co-occupation of breastfeeding, and the sensory processing profiles of infants. Specifically, a sample of maternal-offspring dyads was examined from pre-gestation through the infant’s age of 18 months. Mothers completed well-validated and contemporary self-report questionnaires of mental health (i.e., depression and anxiety symptom severity) and sensory processing across time points. Findings yielded statistically significant relationships between maternal prenatal and postnatal anxiety and depression symptom severity and infants’ sensory processing profiles. Further connections were found between infants’ sensory processing profiles and both duration and frequency of breastfeeding. The study provides health care professionals with additional perspectives on how maternal mental health status and breastfeeding may be related to infants’ sensory processing profiles.

Exploring the Impact of Restricted Partners' Visiting Policies on Non-Infected Mothers' Mental Health and Breastfeeding Rates during the COVID-19 Pandemic

Changes in perinatal care occurring during the coronavirus disease 2019 (COVID-19) pandemic may negatively affect mothers' mental health and breastfeeding. This study, performed between April and May 2020, aimed to investigate the effect of restricted partners' visiting policies on non-infected mother's anxiety symptoms, the perceived postpartum support, and the breastfeeding outcomes at discharge. A cross-sectional study was conducted in a neonatal tertiary referral center in northern Italy during Italy's lockdown. We enrolled mothers with a negative nasopharyngeal swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), adequate oral and written comprehension of the Italian language, and absence of underlying maternal or neonatal clinical conditions. Maternal anxiety levels were assessed through the State-Trait Anxiety Inventory-Form Y (STAI-Y). Maternal perception of staff's support was evaluated by the Nurse Parent Support Tool (NPST). A STATE-A (concurrent emotional state after a specific situation) score ≥ 40 was considered indicative of clinically significant symptoms of anxiety. A total of 109 mothers completed the study. Mean STATE-A score was ≥40 in 42% of mothers, and median NPST score was 4.23. Mothers separated from their partner had a mean STATE-A score ≥ 40 in a higher percentage of cases than those who were not (51% vs. 30%, p = 0.03) and a lower perception of caregiver support. A NPST score ≤4.23, partner 's absence during the hospital stay and primiparity were independently associated with a STATE-A score ≥ 40. Breastfeeding rates at discharge were not influenced by maternal anxiety levels and partner's restricted policies. Instead, they were influenced by mode of delivery, a well-known risk factor, and pre-pandemic intention to breastfeed. Our study demonstrates the positive impact of a partner's presence on maternal mental health and perception of caregiver support.