Maternal self-esteem after successful treatment for infertility

Transcription

1 INFERTILITY Maternal self-esteem after successful treatment for infertility Sara Jane Cox, Ph.D., C.Psychol., a Cris Glazebrook, Ph.D., b Charlotte Sheard, b George Ndukwe, F.R.C.O.G., c and Margaret Oates, F.R.C.Psych. b a Institute of Work, Health and Organisations, University of Nottingham; b Department of Psychiatry, Queens Medical Centre; and c Centres for Assisted Reproduction (CARE), The Park Hospital, Nottingham, Nottinghamshire, United Kingdom Objective: To [1] investigate self-esteem during pregnancy after previous infertility and [2] establish the relationship among self-esteem, anxiety during pregnancy, and parenting self-efficacy. Design: Limited prospective study. Setting: A regional infertility clinic and antenatal clinic. Patient(s): Seventy women who had conceived through assisted reproductive technology and 111 women who had conceived naturally. Intervention(s): Measures of self-esteem, anxiety, and parenting self-efficacy. Main Outcome Measure(s): Self-esteem, anxiety, and parenting self-efficacy. Result(s): Women who had conceived through IVF treatment did not differ in terms of self-esteem during pregnancy from those who had conceived naturally. All of the women in the present study displayed levels of self-esteem that were within the normal range. Self-esteem increased as pregnancy progressed. Self-esteem was negatively correlated with anxiety during pregnancy. As self-esteem increased, anxiety decreased. Self-esteem at the start of pregnancy (18 weeks) and anxiety in the early stages of parenthood (6 weeks postpartum) predicted parenting self-efficacy. Conclusion(s): Self-esteem in the early stages of pregnancy, for both women who conceived through IVF and women who conceived naturally, is related to self-reported levels of parenting efficacy. Coaching and mentoring through antenatal clinics in the early stages of pregnancy should be tailored to incorporate advice regarding self-esteem in addition to management of pregnancy and psychological well-being. (Fertil Steril 2006;85: by American Society for Reproductive Medicine.) Key Words: Self-esteem, anxiety, parenting self-efficacy, IVF The decline in fertility since the 1970s has been paralleled by the advances made in reproductive technology since the birth of the first IVF baby, Louise Brown, in Britain in There now exists, for the infertile couple, a wide spectrum of medical interventions to aid in the pursuit of a family. However, these advances in science have raised questions concerning the wider psychological and social implications of such interventions for both the new parents and the children resulting from assisted reproductive technology (ART). Received March 1, 2005; revised and accepted July 7, Supported by a grant from National Health Service Executive Trent (Research and Development). The views expressed here are the authors and do not necessarily reflect those of any other person or organization. Reprint requests: Sara J. Cox, Ph.D., C.Psychol., Institute of Work, Health and Organisations, University of Nottingham, William Lee Buildings 8, Science & Technology Park, University Boulevard, Nottingham, Nottinghamshire NG7 2RQ, United Kingdom (FAX: ; sara.cox@ nottingham.ac.uk). This article is concerned with the relationship among history of infertility, self-esteem during pregnancy, and parenting self-efficacy. The correlates of low self-esteem are well documented. These include dependency, the need for approval, helplessness, and masked hostility; depression, anxiety, and submissiveness; poor general health; apathy, feelings of powerlessness, isolation, withdrawal, passivity, and compliance; the tendency to downgrade or denigrate others or to project one s own failings onto others; and a tendency to accept unfavorable assessments as accurate (1). Individuals with low self-esteem and high levels of anxiety also appear to be more vulnerable when facing stressful situations than do those with high self-esteem and low levels of anxiety (1). Existing literature has established a relationship between infertility and low levels of self-esteem (2 5). Despite the known detrimental effects of infertility on self-esteem, less research exists that explores the relationship between history of infertility and self-esteem during pregnancy. The majority of psychosocial studies have dealt with psychological well- 84 Fertility and Sterility Vol. 85, No. 1, January /06/$32.00 Copyright 2006 American Society for Reproductive Medicine, Published by Elsevier Inc. doi: /j.fertnstert

2 being during pregnancy rather than with self-concept and self-esteem. However, self-esteem is a fundamental aspect of well-being and as such requires further investigation. It is not known whether any damage to self-esteem related to previous infertility persists into pregnancy and whether the effects of such damage may extend into parenthood. The picture that emerges from the few studies that have been conducted is unclear. McMahon (6) states that the little evidence that does exist shows that previous infertility does negatively impact on self-esteem during pregnancy. That investigator argues that this is not related to later maternal competence during parenthood. This is supported by studies such as those of McMahon et al. (7), Cohen et al. (8), and Gibson et al. (3), which found that couples conceiving through IVF have lower levels of self-esteem than do those conceiving naturally in the immediate postpartum period but that this effect disappears over time. Other research, however, has found that couples conceiving through IVF show no difference in self-esteem at the start of pregnancy from those conceiving naturally and show greater increases throughout pregnancy and into the postpartum period (9). The present article investigates self-esteem during pregnancy in mothers who conceived through IVF treatment (single births) and in a matched control group of mothers who conceived naturally. The relationship between selfesteem and anxiety during pregnancy and parenting selfefficacy postpartum is examined. MATERIALS AND METHODS Design The study was longitudinal in design. Self-esteem and anxiety were measured by postal questionnaire at two points during pregnancy (18 weeks and 28 weeks), and participants were interviewed at 6 weeks postpartum (interview data will be reported in a separate publication). Measures of parenting self-efficacy and anxiety were taken at the time of interview as well. Women who had successfully conceived after IVF were recruited through a United Kingdom research and treatment unit. A matched control group of expectant mothers who had not received treatment for infertility were recruited through an associated antenatal clinic. The study received full ethical approval from the relevant ethics committees. The data reported here are derived from a larger study examining the psychological sequelae of IVF treatment. Participants In Vitro Fertilization Group. This group included women conceiving after IVF treatment at one research and treatment unit in a United Kingdom hospital. The inclusion criteria for admission to this study were that women should be resident in the United Kingdom, be in a stable relationship, have reached the 18th week of pregnancy (date of first scan), and be expecting their first child. Naturally Conceived Group. Women were recruited to the comparison group through antenatal booking clinics in the same hospital. The inclusion criteria for admission to the study were that women should be in a stable relationship; speak English; be older than 24 years of age (the estimated age of the youngest participant in the IVF group); be expecting their first child; and be 18 weeks pregnant, having conceived without any form of medical or surgical treatment for infertility (date of first scan). All women meeting the inclusion criteria were invited to take part in the study. Measures The Self-Concept Questionnaire. The Self-Concept Questionnaire (10) consists of 30 items and was designed to provide an easily comprehensible and quick-to-complete measure of self-esteem. It provides a broad view of the concept of self-esteem without overemphasizing any single aspect. The original reliability of the scale was found to be 0.89 (Cronbach s alpha) (11), and a test retest value of 0.87 was found. The original validity of the scale was tested both by comparing it with Rosenberg s (12) self-report measure of self-esteem (correlation 0.80) and with clinician ratings of self-esteem (correlation 0.70). The normative data for the self-concept questionnaire provide a mean of 139 (SD, 20.5) for females (10). The Hospital Anxiety and Depression Scale. The Hospital Anxiety and Depression Scale (HADS) (13) is a self-assessment mood scale that is designed specifically for use in nonpsychiatric hospital departments. Each of its two subscales consists of seven items. Scores on the HADS are banded in terms of noncases (0 7), doubtful cases (8 10), and cases (11 21). The two subscales hold high reliability and validity. We report on the anxiety subscale in the following analysis. The Parenting Self-Efficacy Scale. The Parenting Self- Efficacy Scale was taken from the Parenting Sense of Competence Scale (14). The items formed the skill knowledge subscale. The scale was designed to assess parental perceptions of the degree to which they had acquired the skills and understanding to be a good parent (15). The scale comprises seven items. Items were scored from 0 (strongly disagree) to 5 (strongly agree). The range of possible scores is The scale held high internal reliability (.80). Procedure A letter explaining the study and a consent form were sent to all women who met the inclusion criteria. All women who returned the consent form were included in the study. Assessment included three stages. Fertility and Sterility 85

3 Stage 1 (18 Weeks of Pregnancy). Women were sent the Self-Concept Questionnaire and the HADS. Demographic data also were collected, including age, length of cohabitation, weeks to conceive, occupation, educational level, and number of children in the family. Stage 2 (28 Weeks of Pregnancy). The Self-Concept Questionnaire and the HADS were sent again to all women. Stage 3 (6 Weeks Postpartum). The HADS and the Parenting Self-Efficacy Scale were sent to all women. Telephone interviews also were conducted with participants. RESULTS Naturally Conceiving Group In the naturally conceiving (NC) group, 166 women (42% response rate) consented to take part in the study, and of these, 146 (88%) returned data. Those women who had already had children (n 14) were excluded from the present study. As expected with longitudinal data, the number of participants decreased over time. One hundred eleven women returned complete stage 1 data, 92 women returned complete stage 1 and stage 2 data, and 77 women returned complete stage 1 and stage 3 data. The mean age of the women was 29.3 years (SD, 3.1). Social class was assigned according to the Standard Occupational Classification on the basis of the participant s occupation. The majority of the women (86%) were in social class I (professional occupations), social class II (semiprofessional), or IIINM (skilled clerical occupations) (16). The women had been in a stable relationship with their current partner for a mean of 4.2 years (SD, 3.1) and had been trying to conceive for a mean of 3.6 months (SD, 7.0). In Vitro Fertilization Group In the IVF group, 225 women (45% response rate) consented to take part in the study, and of these 184 (82%) returned data. Those women who had already had children (n 26) and those who had a multiple birth (n 52) were excluded from the present study. Seventy women returned complete stage 1 data; 52 women returned complete stage 1 and stage 2 data, and 51 women returned complete stage 1 and stage 3 data. The mean age of the women was 33.6 years (SD, 3.2). They had been in a stable relationship with their current partner for a mean of 8.0 years (SD, 4.3) and had been trying to conceive for a mean of 44.0 months (SD, 29.3). Most women were in white-collar jobs (87%; Standard Occupational Classification I, II, or IIINM). Comparison Between IVF and NC Group Response rates were similar in the two groups. Female partners in the IVF group were older than in the NC group [T (t test) 8.8, df 177, P.001], had been in a stable relationship with their present partner for longer (T 6.4, TABLE 1 Demographic characteristics of women in NC group and IVF group. Parameter NC IVF group group (n 111) (n 70) Age (y) Mean SD Social class Nonmanual Manual 8 3 Time in current relationship (y) Mean SD Time before conception (mo) Mean SD df 111, P.001), and, not surprisingly, had taken longer to conceive (T 10.6, df 65, P.001; Table 1). In Vitro Fertilization Treatment Type and Outcome. More than half of the women (55.7%) were receiving treatment as a result of male infertility. The most common form of treatment received was ICSI, and nearly half of the women (37.1%) had conceived on their first treatment cycle, with a range of up to 7 cycles. The fertility history of a random sample of 100 women who had declined to take part in the study was obtained anonymously and compared with the study sample. The two samples did not differ in terms of age, diagnosis of infertility, number of cycles, or type of treatment (IVF or ICSI). Self-Esteem During Pregnancy. A repeated-measures analysis of variance was performed, with self-esteem at 18 weeks of pregnancy and 28 weeks of pregnancy as the withinsubject variable and with group (NC and IVF) as the independent factor. Age was not linearly related to self-esteem and so was not entered as a covariate. Self-esteem scores significantly increased between 18 weeks and 28 weeks for both groups [F (1, 142) 15.0, P.001; Table 2]. There was, however, no significant effect of group or of interaction. Within the IVF group, self-esteem did not differ significantly between those who had malefactor infertility and those who had female-factor infertility. When comparing self-esteem scores with normative data (females 139; SD, 20.5) (11), the majority of both groups scored equal to or above average at 18 weeks (NC 63.1%, IVF 70.0%). The same was true at 28 weeks (NC 65.2%, IVF 75.0%). All scores were within the normal 86 Cox et al. Self-esteem after successful infertility treatment Vol. 85, No. 1, January 2006

4 TABLE 2 Mean self-esteem scores at two time points by group. Time point in pregnancy NC group (n 111) IVF group (n 70) 18 wk Mean SD wk Mean SD range. When comparing self-esteem scores with clinical normative data (psychotherapy referral group 100; SD, 24.1), only one woman in the control group scored below 100. Self-Esteem, Anxiety, and Parenting Self-Efficacy. Selfesteem at 18 weeks was correlated with anxiety during pregnancy (18 weeks and 28 weeks) and at 6 weeks postpartum for both groups (see Table 3). The same was true of self-esteem at 28 weeks for both groups. Self-esteem at 18 weeks, self-esteem at 28 weeks, and anxiety at 6 weeks postpartum were correlated with parenting self-efficacy for both groups. Self-esteem at 18 weeks, anxiety at 6 weeks postpartum, and group were entered in a multiple linear regression, with parenting self-efficacy as the dependent variable. Collinearity checks were run, and tolerance values were found to be acceptable (17). Self-esteem at 18 weeks (t 2.2, P.03), TABLE 4 Anxiety and parenting self-efficacy by group. Variable NC group (n 111) IVF group (n 70) Anxiety at points during pregnancy 18 wk Mean SD wk Mean SD Anxiety at 6 wk postpartum Mean SD Parenting self-efficacy at 6 wk postpartum Mean SD and anxiety at 6 weeks postpartum (t 4.3, P.001) explained 20.1% of the variance in parenting self-efficacy (adjusted R 2 ; F(3, 122) 13.7, P.001). There was no effect of group. There were no significant differences between the IVF group and the NC group in terms of anxiety during pregnancy and in the postpartum period and in terms of parenting TABLE 3 Correlations between self-esteem, anxiety, and parenting self-efficacy by group. Self- Esteem (28) Anxiety (18) Anxiety (28) Anxiety (6P) Parenting selfefficacy (6P) IVF NC IVF NC IVF NC IVF NC IVF NC Self-esteem (18) a 0.40 Self-esteem (28) a 0.33 Anxiety (18) b 0.15 b Anxiety (28) a 0.18 b Anxiety (6P) Parenting self-efficacy (6P) Note: Numbers in parentheses indicate time of assessment: 28 at week 28 of pregnancy; 18 at wk 18 of pregnancy; 6P at wk 6 postportum. For IVF group, n 50, for NC group, n 80. a 0.05 b Not significant. Fertility and Sterility 87

5 self-efficacy postpartum (see Table 4). Anxiety at all three time points was low and indicative of non-caseness on the HADS (13). Parenting self-efficacy was high for both groups. Anxiety significantly decreased between 18 weeks of pregnancy and 28 weeks of pregnancy for the IVF group (T 3.7, df 53, P.001) and between 28 weeks of pregnancy and 6 weeks postpartum for the NC group (T 2.0, df 81, P.05). DISCUSSION Empirical research in this area holds important implications for clinical practice. It is important that knowledge regarding the psychological concomitants of IVF treatment is both extended and then translated into appropriate support for couples undergoing this process, both during pregnancy and in the immediate postpartum period. Remarkably, despite a documented effect in the literature that would suggest that IVF women have lower levels of self-esteem than do women who have conceived naturally (see Bernstein [15]), the IVF women in the present sample did not differ discernibly in terms of self-esteem from those who had conceived naturally. When their data were compared with existing normative data for self-esteem, the women in the present sample, both IVF and control, were within the normal range. When their data were compared with normative data obtained from a clinical sample (psychotherapy referral group), the women in the present sample had high levels of self-esteem. There may have been a positive effect conferred on these women by pregnancy, as illustrated by this quote from one participant in the IVF group: Having a house, job and most materialistic things people want in life, there was still a large hole in my life that has now been filled by having my baby. Both my husband and I feel whole. It is the best thing that has happened to us and especially more so as we have tried for a baby for so long. IVF mother Indeed, self-esteem significantly increased throughout pregnancy in both groups of women, similar to the case in the findings of Klock and Greenfeld (9). As predicted from the literature, self-esteem was linked to anxiety during pregnancy for both groups of women. As self-esteem increased during pregnancy, there was a decrease in anxiety. However, it is not possible to determine the direction of causality for this relationship. When investigating the relationship between self-esteem during pregnancy and parenting competence (i.e., parenting self-efficacy), self-esteem at the start of pregnancy and anxiety in the early days of being a parent were strong predictors of parenting self-efficacy for both groups of women. Interestingly, anxiety during pregnancy was not found to be related to parenting self-efficacy. This holds implications for the guidance and coaching that are given to women in the early stages of pregnancy, both women who have conceived naturally and who have conceived through IVF. Unfortunately, because of the length of the study period and the moderate response rate for the study, it is hard to ascertain whether women in the IVF group were those who had come through the experience of infertility with a relatively intact self-concept or whether pregnancy had significantly increased their self-esteem. Further research from the point of start of treatment through to pregnancy and the postpartum period is needed to clarify this issue. The findings certainly do not provide support for theories existing in the current literature that suggest that infertility can quite severely damage self-concept and self-esteem. Methodological issues include the need to use a cohort of IVF couples from the time of arrival at the clinic through to the 1st postpartum year to provide benchmark measurements. There is the possibility that the distinctive characteristic of our IVF sample may have influenced levels of self esteem. The main characteristics of this group were that infertility was more likely to be caused by male factors and that treatment with ICSI enabled a high percentage of women (44.9%) to conceive on their first treatment cycle. Therefore, the issue arises that the present study might unwittingly have recruited a fairly healthy IVF sample that is not necessarily representative of the wider group. There was, however, no evidence to suggest that the type of infertility experienced (female-factor or male-factor infertility) affected women s self-esteem during pregnancy, and there was no significant difference at either 18 or 28 weeks between those seeking treatment for female-factor infertility and those seeking treatment for male-factor infertility. Again, this may be related to the positive effects conferred on self-esteem and well-being by pregnancy. Further longitudinal comparisons with different cohorts of IVF couples would be needed to ascertain the truth in this. However, this does not detract from the importance of these findings, given recent evidence to suggest that the rate of male infertility is increasing and that many more men than women could be suffering from fertility problems (18). With research in this area, there is always the issue of potential differences between those who participate in the research and those who do not. This may be driven by differences in socioeconomic status, level of education, or psychological well-being, all of which could hold implications for self-esteem. The current study examined a random sample of nonresponders within the IVF group and found no significant differences between the current sample and the nonresponders in terms of age, type of infertility experienced, type of treatment (IVF or ICSI), or number of cycles. Confidentiality prevented the extraction of more detailed information about nonresponders. 88 Cox et al. Self-esteem after successful infertility treatment Vol. 85, No. 1, January 2006

6 The focus of the present limited prospective study was self-esteem during pregnancy and parenting efficacy. The present findings have shown the IVF women in the study to have normal self-concepts as measured by self-esteem and to be no different from those conceiving naturally. This is in keeping with research investigating other key psychological dimensions (e.g., anxiety and depression) that suggests that IVF treatment does not negatively affect psychological well-being during pregnancy. Indeed, appropriate guidance and coaching during pregnancy to build and maintain self-esteem also could help to improve and maintain positive feelings of parenting efficacy in the early stages of parenthood (19). REFERENCES 1. Robson P. Self-esteem: a psychiatric view. Br J Psychiatry 1988;153: Abbey A, Halman LJ, Andrews FM. Psychosocial, treatment and demographic predictors of the stress associated with infertility. Fertil Steril 1992;57: Gibson FL, Ungerer JA, Tennant CC, Saunders DM, McMahon C. Parental adjustment and attitudes to parenting after in vitro fertilization. Fertil Steril 2000;73: Pasch LA, Dunkel-Schetter C, Christensen A. Differences between husbands and wives approach to infertility affect marital communication and adjustment. Fertil Steril 2002;77: Stotland NL. Psychiatric issues related to infertility, reproductive technologies and abortion. Prim Care 2002;29: McMahon C. Does assisted reproduction make an impact on the identity of self-esteem of infertile women during the transition to parenthood? J Assist Reprod Genet 1999;16: McMahon C, Ungerer J, Tennant C, et al. Psychological adjustment and the quality of the mother-child relationship at four months postpartum after conception by in vitro fertilization. Fertil Steril 1997;68: Cohen J, McMahon C, Tennant C, Saunders D, Leslie G. Psychosocial outcomes for fathers after IVF conception: a controlled prospective investigation from pregnancy to four months postpartum. Reprod Technol 2000;10: Klock SC, Greenfeld DA. Psychological status of in vitro fertilization patients during pregnancy: a longitudinal study. Fertil Steril 2000;73: Robson P. Development of a new self-report questionnaire to measure self esteem. Psychol Med 1989;19: Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika 1951;16: Rosenberg M. The association between self-esteem and anxiety. J Psychiatr Res 1962;1: Zigmond A, Snaith R. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983;67: Gibaud-Wallston JA. Self-esteem and situational stress: factors related to sense of competence in new parents. Dissertation Abstr Int 1977;39: 379B. 15. Bernstein J. Parenting after infertility. J Perinat Neonatal Nurs 1990;4: OPCS. Standard occupational classification. Vol 3. London: HMSO, Coolican H. Research methods and statistics in psychology. 4th ed. London: Hodder & Stoughton, Nyboe Andersen A, Nygren KG, Gianaroli L, de Mouzon J, Felberbaum R. Assisted Reproductive Technology in Europe, Results generated from European registers by ESHRE. Copenhagen: European Society for Human Reproduction and Embryology Annual Conference, June Siegel S. Nonparametric statistics for the behavioural sciences. New York: McGraw-Hill, Fertility and Sterility 89