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Perinatal stress and anxiety from conception to two years postpartum have important adverse outcomes for women and infants. This study examined (i) women’s perception of sources and experiences of perinatal stress and anxiety, (ii) women’s attitudes to and experiences of available supports, and (iii) women’s preferences for perinatal stress and anxiety supports in Ireland.
Methods:
An online mixed-methods cross-sectional survey was conducted with 700 women in Ireland. Participants were pregnant women (n = 214) or mothers of children ≤ 2 years old (n = 486). Participants completed closed-ended questionnaires on sociodemographic, birth and child factors, and on stress, anxiety, perceived social support, and resilience. Participants completed open-ended questions about experiences of stress and anxiety and the supports available for stress and anxiety during pregnancy and/or postpartum. Quantitative data were analysed descriptively and using correlations; qualitative data were analysed using thematic analysis.
Results:
Quantitative data indicated significant relationships between perinatal stress and/or anxiety and women’s perceived social support, resilience, having a previous mental health disorder diagnosis (both p < 0.001), and experiencing a high-risk pregnancy or pregnancy complications (p < 0.01). Themes developed in qualitative analyses included: ‘perceived responsibilities’; ‘self-care’; ‘care for maternal health and well-being’; ‘social support’; and ‘access to support and information’.
Conclusions:
Women’s stress and anxiety are impacted by multiple diverse factors related to the individual, to interpersonal relationships, to perinatal health and mental health outcomes, and to available services and supports. Development of support-based individual-level interventions and increased peer support, coupled with improvements to service provision is needed to provide better perinatal care for women in Ireland.
Maternity outcomes for women from certain ethnic groups are notably poor, partly owing to their not receiving treatment from services.
Aims
To explore barriers to access among Black and south Asian women with perinatal mental health problems who did not access perinatal mental health services and suggestions for improvements, and to map findings on to the perinatal care pathway.
Method
Semi-structured interviews were conducted in 2020 and 2021 in the UK. Data were analysed using the framework method.
Results
Twenty-three women were interviewed, and various barriers were identified, including limited awareness of services, fear of child removal, stigma and unresponsiveness of perinatal mental health services. Whereas most barriers were related to access, fear of child removal, remote appointments and mask-wearing during COVID-19 affected the whole pathway. Recommendations include service promotion, screening and enhanced cultural understanding.
Conclusions
Women in this study, an underrepresented population in published literature, face societal, cultural, organisational and individual barriers that affect different aspects of the perinatal pathway.
Functional neurological disorder (FND) most often presents in women of childbearing age, but little is known about its course and outcomes during pregnancy, labour and postpartum (the perinatal period). We searched MEDLINE, PsycInfo and Embase combining search terms for FND and the perinatal period. We extracted data on patient demographics, subtype of FND, timing of symptom onset, comorbidities, medications, type of delivery, investigations, treatment, pregnancy outcomes and FND symptoms at follow-up.
Results
We included 36 studies (34 case reports and 2 case series) describing 43 patients. Six subtypes of FND were identified: functional (dissociative) seizures, motor weakness, movement disorder, dissociative amnesia, speech disorders and visual symptoms. New onset of perinatal FND was more common in the third trimester and onwards. Some women with functional seizures were exposed to unnecessary anti-seizure prescriptions and intensive care admissions.
Clinical implications
Prospective studies are urgently needed to explore how FND interacts with women's health in the perinatal period.
Edited by
Rachel Thomasson, Manchester Centre for Clinical Neurosciences,Elspeth Guthrie, Leeds Institute of Health Sciences,Allan House, Leeds Institute of Health Sciences
Perinatal mental illnesses are common and carry significant morbidity for the mother and infant, the family and wider society. Suicide remains a leading cause of maternal death. Pregnancy, childbirth and the transition into parenthood presents a unique life stage where a combination of physical, biological and psychological stressors can leave many women vulnerable to developing perinatal mental illness. This is a time where individuals often reflect on their own experiences of parenting and early life trauma can be reactivated. In addition, there is now consistent evidence that perinatal mental illness is not confined to maternal mental health problems. Approximately 10% of fathers experience postnatal depression and a recent study by the National Childbirth Trust has shown that 38% of all first-time fathers are concerned about their mental health.
The perinatal period is a time in a family’s life when they are in contact with many health professionals.
Psychological interventions have demonstrated effectiveness in treating perinatal depression (PND), but understanding for whom, how and under what conditions they improve symptoms in low- and middle-income countries (LMICs) is largely unknown. This review aims to synthesise current knowledge about predictors, moderators and mediators of psychological therapies to treat PND in LMICs. Five databases were searched for studies quantitatively examining the effects of at least one mediator, moderator or predictor of therapies for PND in LMICs. The review sampled seven publications evaluating findings from randomised trials conducted in Asia and sub-Saharan Africa. The small number of included studies limited generalisability of findings. Analyses of trials with acceptable quality suggest that patient activation in Pakistan and social support in both India and Pakistan may mediate psychotherapy effectiveness, higher baseline depression severity may moderate treatment response in South Africa, and shorter depression duration at baseline may moderate intervention response in India. This review highlights current gaps in evidence quality and the need for future trials exploring PND psychotherapy effectiveness in LMICs to follow reporting guidelines to facilitate appropriate predictor, moderator and mediator analyses.
Common mental health problems (particularly depression and anxiety) are common among adolescents during the perinatal period. Previous research has identified the distinctive needs of this group and called for contextually appropriate psychosocial interventions. The current study conducted in Malawi aimed to explore risk and protective factors for common mental health problems, and barriers to accessing mental health care, among perinatal adolescents, to develop a contextually relevant intervention for preventing and treating perinatal depression and anxiety. An exploratory qualitative study was conducted in antenatal and postnatal clinics in Zomba district, Malawi in January–March 2022. In-depth individual interviews were completed with perinatal adolescents aged ≤19 (n = 14); their family members (n = 4); and healthcare workers (n = 8). Interview data were subjected to thematic framework analysis. Data were organised around two themes: “psychosocial risk and protective factors” (potential causes of common mental health problems among adolescents); and “health care services” (maternal and mental health services available, and adolescents’ experiences of using these services). Interventions need to go beyond targeting symptoms of depression and anxiety to addressing the wider contextual risk factors and barriers to care at the different socioecological levels.
During early life-sensitive periods (i.e., fetal, infancy), the developing stress response system adaptively calibrates to match environmental conditions, whether harsh or supportive. Recent evidence suggests that puberty is another window when the stress system is open to recalibration if environmental conditions have shifted significantly. Whether additional periods of recalibration exist in adulthood remains to be established. The present paper draws parallels between childhood (re)calibration periods and the perinatal period to hypothesize that this phase may be an additional window of stress recalibration in adult life. Specifically, the perinatal period (defined here to include pregnancy, lactation, and early parenthood) is also a developmental switch point characterized by heightened neural plasticity and marked changes in stress system function. After discussing these similarities, lines of empirical evidence needed to substantiate the perinatal stress recalibration hypothesis are proposed, and existing research support is reviewed. Complexities and challenges related to delineating the boundaries of perinatal stress recalibration and empirically testing this hypothesis are discussed, as well as possibilities for future multidisciplinary research. In the theme of this special issue, perinatal stress recalibration may be a mechanism of multilevel, multisystem risk, and resilience, both intra-individually and intergenerationally, with implications for optimizing interventions.
Anxiety is common during the perinatal period and despite effective treatments being available, many women with perinatal anxiety disorders experience barriers when accessing treatment.
Aims:
The aims of the current study were to explore women’s perceived barriers to treatment uptake; cognitive behavioural therapy (CBT) treatment delivery preferences; and the utility of the Health Belief Model (HBM) in predicting intention to seek psychological help for women with perinatal anxiety symptoms.
Method:
This study employed a cross-sectional design consisting of women with self-reported anxiety in the perinatal period. A total of 216 women (Mage=28.53 years; SD=4.97) participated in the study by completing a battery of online self-report measures.
Results:
The results indicated that the most salient barriers to accessing care were: (1) the cost of treatment, (2) wanting to solve the problem on their own, and (3) thinking the problem would go away without treatment. Group-delivered CBT was the least acceptable treatment method, while face-to-face individual CBT was the most acceptable treatment method. The HBM variables predicted approximately 35% of the variance in help-seeking intention.
Discussion:
This study has important implications for the delivery of psychological care in the perinatal period and may be used to improve treatment uptake.
Severe anxiety affects a huge number of women in pregnancy and the postnatal period, making a challenging time even more difficult. You may be suffering from uncontrollable worries about pregnancy and birth, distressing intrusive thoughts of accidental or deliberate harm to the baby, or fears connected to traumatic experiences. This practical self-help guide provides an active route out of feeling anxious. Step-by-step, the book teaches you to apply cognitive behaviour therapy (CBT) techniques in the particular context of pregnancy and becoming a new parent in order to overcome maternal anxiety in all its forms. Working through the book you will gain understanding of your anxiety and how factors from the past and present may be playing a role in how you feel. Together with practical exercises and worksheets to move through at your own pace, you will gain the tools you need to help you move forward and enjoy parenthood.
Pregnancy-related anxiety and fears of childbirth are very common indeed. This chapter focuses on anxiety about pregnancy and birth. It covers the range of fears that mothers can experience during pregnancy, including the health of your baby, your bond with your baby, what birth will be like, your appearance during pregnancy or after birth, your parenting abilities and / or how life might change after birth. It provides tips to understand why you migtht be feeling particularly anxious at this time, and techniques to tackle the factors that keep anxiety going, so that you can enjoy more of your pregnancy wihtout interference from anxiety.
Becoming a parent is a process that begins psychologically at the start of the journey to pregnancy and continues beyond birth. This chapter covers what to expect emotionally as you adjust to life after birth. We provide practical tips on finding your own way as a parent and tips on how to manage worries about being an ‘anxious parent’. There is a practical guide to navigating anxiety about bonding with your baby and tips to increase feelings of closeness as this relationship develops.
Panic attacks are frightening experiences. During a panic, you experience strong physical sensations that feel very serious and threatening at the time. This can leave you fearful of having further panic attacks. This chapter outlines how to understand and beat panic attacks at this time. Pregnancy is a time of lots of physical change and lots of focus on those changes, which can be difficult if you have become worried about physical sensations. It can be difficult managing panic attacks if you are caring for young children. We guide you through the cognitive understanding of panic attacks, that they are driven by understandable but incorrect interpretations of physical sensations. We will help you to apply this theory to your individual situation, to recognise which sensations are particularly frightening, and outline experiments to target behaviours such as avoidance, focus on sensations and other factors that keep the fear going.
This chapter provides an understanding of the ways that past trauma can affect women in pregnancy and postnatally. It provides guidance on how to recognise and understand the symptoms of post traumatic stress and information on why a traumatic event can continue to affect a person deeply, even if it was a long time ago, other circumstances have moved on or it is not considered ‘traumatic’ by others. The focus is on maternity and birth-related traumas, although the principles apply to other types of trauma. Evidence-based techniques will help you understand and work through your reactions to trauma and will help you put intrusive memories into the past so that you can untangle the past and present. This chapter covers working with self-blame and tackling other consequences of trauma such as feelings of disconnection as well as practical tips on talking to loved ones and professionals in order to get the right support at this time.
This chapter provides an overview of what anxiety problems are, and why the perinatal period features all the key ingredients that can lead to problemmatic anxiety. Nurturing and caring for a baby is not easy for anyone and involves large emotional and physical demands, managing uncertainty and avoiding harm. All in the context of disturbed sleep and a major life change. The cognitive-behavioural model of anxiety states that it is not just the situation we find ourselves in, but the particular meaning we give to our experiences that drive and make sense of our emotions and other responses. In pregnancy and the postnatal period these meanings may be influenced by a complicated and sometimes traumatic journey to pregnancy and birth, beliefs about the importance of thoughts or physical sensations, and how we respond to the responsibility of being pregnant or in charge of a baby, as well as other personal and historical factors. There are many common factors across anxiety problems. In the rest of the book we explain how to apply this basic understanding to overcome particular forms of maternal anxiety.
This chapter revisits the key ideas of the book on breaking free from maternal anxiety and provides a framework to capture the information and techniques that have been most useful to take you forward into the future as a parent and any future pregnancies. There are additional resources including a template for a birth plan to help work through fears and identify the best strategies for support. Also included are practical tips on improving sleep and mood as well as further resources, reading and peer support tailored to a range of issues in pregnancy and the postnatal period.
Unwanted intrusive thoughts, images, urges and doubts of harm coming to the infant are very common experiences for parents. These include intrusive thoughts of both accidental harm and deliberate harm coming to the baby, but can be about other topics too. When the thoughts and efforts to deal with them are very distressing and impairing, the problem is known as obsessive compulsive disorder (OCD). This chapter explains why this is such a common problem at this time, and how our interpretation, what we make of intrusive thoughts, is key to understanding why they persist and are particularly distressing for some parents. In this chapter we explain how to make sense of the thoughts and behaviours that keep the problem going and apply this to your particular experience. We guide you through experiments and exposure exercises to test out these ideas and challenge them so that they no longer interfere in your life, and you can enjoy pregnancy and the postnatal period.
Pregnancy and the postnatal period can be a source of many worries – the health of you and the baby, safety, bonding, financial and partner stress are normal topics of worry. However, for some, the experience of worrying is time consuming, uncontrollable and jumps from topic to topic, causing stress and anxiety. Generalised anxiety (the experience of overwhelming worry) is one of the most common perinatal anxiety problems. This chapter will help you identify and recognise the processes involved in keeping worry going, such as getting drawn into ‘what if’ questions, thinking the worst and finding uncertainty difficult to cope with. Techniques are described to help you disengage from worry, deal with uncertainty, think through and challenge beliefs about worry and support yourself to gain control over your anxiety.
Being pregnant and having a new baby attracts lots of attention and usually involves meeting a range of new people from professionals to other parents. This can be difficult if you experience social anxiety; the postnatal period can be a particularly challenging time as fears of being judged for how you are going about things are very common. Furthermore, it is easy to fall into self-criticism and self-judgements that we are not doing things well enough and that other parents are doing things better than we are. This chapter will help you understand the particular processes that keep social anxiety going and will help you develop alternative strategies that you can use to change your experience of social situations. The chapter will also help you understand the difference between high standards and unhelpful perfectionism, and what you can do to live more comfortably in your own skin as a parent and support yourself through this challenging time to become the parent you want to be.
Insomnia symptoms are common during the postpartum period, yet interventions remain scarce. This trial aimed to simultaneously examine the efficacy of cognitive behavioural therapy (CBT) and light dark therapy (LDT), targeting different mechanisms, against treatment-as-usual (TAU), in reducing maternal postpartum insomnia symptoms.
Methods
This three-arm randomised controlled trial recruited from the general community in Australia. Nulliparous females 4–12 months postpartum with self-reported insomnia symptoms [Insomnia Severity Index (ISI) scores >7] were included; severe medical/psychiatric conditions were excluded. Participants were randomised 1:1:1 to CBT, LDT, or TAU stratified by ISI (< or ⩾14) and infant age (< or ⩾8 months). Participants and principal investigators were unblinded. Six-week interventions were delivered via digital materials and telephone. The primary outcome was insomnia symptoms (ISI), assessed pre-, midpoint-, post- (primary endpoint), and one-month post-intervention. Analyses were intention-to-treat using latent growth models.
Results
114 participants (CBT = 39, LDT = 36, TAU = 39; Mage = 32.20 ± 4.62 years) were randomised. There were significantly greater reductions in ISI scores in CBT and LDT (effect sizes −2.01 and −1.52 respectively, p < 0.001) from baseline to post-intervention compared to TAU; improvements were maintained at follow-up. Similar effects were observed for self-reported sleep disturbance. There were greater reductions in fatigue in CBT (effect size = 0.85, p < 0.001) but not LDT (p = 0.11) compared to TAU. Changes in sleepiness, depression, and anxiety were non-significant compared to TAU (all p > 0.08). Four participants (11%) in the LDT group reported headaches, dizziness, or nausea; no others reported adverse events.
Conclusions
Therapist-assisted CBT and LDT were feasible during the first postpartum year; data at post-intervention and 1-month follow-up support their safety and efficacy in reducing postpartum insomnia symptoms.
Community Perinatal Mental Health Services (CPMHS) have been established in the UK, however, there is limited research around their real-world effectiveness. Post-Partum Psychosis (PPP), a severe episode of affective psychosis usually occurring soon after birth, has known risk factors. CPMHS offer assessment and interventions for women with risk factors for PPP, with a view to reducing the risk of its occurrence, as well as, where necessary, to proactively manage the illness to minimise the impact on the mother-infant dyad, as well as associated risks to self and/or others.
Objectives
To review the rate of PPP in women with established risk factors, who were referred and managed by our CPMHS between September 2019-September 2021. This rate will be compared with the known rates of PPP reported in the literature. Rates of non-psychotic relapse, acute hospitalisation, children social care supervision and mother-infant separation as a result of postnatal relapse will be (amongst others) secondary outcomes. Perinatal interventions offered to reduce the risk of PPP and contingency planning will also be reviewed.
Methods
This will be a retrospective case review study involving women referred and cared for by our CPMHS from October 2019 to October 2021, with known risk factors for PPP. Women identified as high risk for PPP receive consultant led-care in our service, therefore cases will be identified via the individual caseloads. Subsequently, electronic case notes will be reviewed to determine the primary and secondary outcomes, as well as the perinatal interventions that were offered.