Psychological Difficulties, Pregnancy, Childbirth, and Beyond Childbirth is a significant life event for women, and within society generally there is an expectation that childbirth will be a very rewarding and happy time. Although many women view birth and the postpartum period as a satisfying and joyful experience, this is not the case for all women. In reality, women report both positive and negative experiences associated with childbirth. While childbirth is a naturally occurring phenomenon and represents a normal human event, it is also commonly a stressful event that requires changes and adaptations, and is associated with a substantial risk for psychological distress. Indeed, similar to other significant life stressors, childbirth and the postpartum period represent an emotionally vulnerable time for women. This period is associated with increased physical health problems that include exhaustion, back and bowel problems, urinary and breast problems, prolonged bleeding, and sexual difficulties. Often, the physical health problems are accompanied by hospital readmission and the frequent utilisation of health care services. Childbirth and the postpartum period are also associated with increased distress and mental illness that can be severe enough to warrant hospitalisation. In fact, the likelihood of being admitted to a psychiatric hospital is higher for the first 12 months postpartum than any other point in a woman s life. Unfortunately, a mother s needs for assistance are often not met. There are a number of psychological conditions that can occur during pregnancy and postpartum. Mood disorders and anxiety disorders are among the more common conditions experienced in relation to pregnancy and childbirth. Postpartum depression (PPD) is a negative emotional outcome of childbirth that has received the majority of research attention. This research attention is understandable given that PPD is widely accepted as the most common mental health issue for women following childbirth. Yet, while the focus of research has been predominantly on PPD, there are other mental disorders associated with the postpartum period. Childbirth and the surrounding circumstances can be a stressful time for some women, and the related stress can manifest through anxiety symptoms. The postpartum period can be associated with developing or worsening anxiety symptoms, which may or may not have begun to develop during the pregnancy itself. Anxiety symptoms may relate to the birth event, such as fear of childbirth and obstetric factors, pain, hospital care, and the wellbeing and life of the baby; or they may be more indicative of anxiety disorders, such as Generalized or Social Anxiety. Anxiety during pregnancy and postpartum can be severe, distressing and debilitating to women, and anxiety disorders can impact negatively on adjustment during pregnancy, postpartum outcomes, a mother s overall functioning, attachment to her infant, and infant outcome. Research into postpartum anxiety indicates that a number of anxiety disorders can occur postpartum, for example Panic Disorder (PD), Generalized Anxiety Disorder (GAD), and may present with or without depression. An anxiety disorder that has recently been investigated in relation to childbirth is Posttraumatic Stress Disorder (PTSD) and partial PTSD (i.e., subsyndromal PTSD). Research has indicated that childbirth can be a traumatic event for a significant number of women, even after the birth of a healthy baby or following what is considered a normal birth. Research also 1
indicates that childbirth can lead to trauma symptoms. This may not be surprising, given that childbirth can be a dangerous event for mothers and infants. Hence, while most women experience some degree of stress, challenge, and adjustment associated with pregnancy and childbirth, research indicates that childbirth can be a traumatic event for some women and can lead to the development of PTSD and partial PTSD. Unfortunately, a delay in receiving appropriate treatment for concerns can be associated with prolonged difficulties postpartum, marital difficulties, reduced work attendance, adverse infant outcomes, and in extreme cases, mortality for women and their children. Psychological treatments have been shown to be effective in the treatment of depression and anxiety and can assist women with emotional concerns in pregnancy and postpartum. If a woman or her partner is experiencing emotional concerns during the perinatal period or beyond, it is important to seek assistance from a health care professional whom has training and experience in the treatment of mental health care problems during this period. Seeking advice in the first instance from a General Practitioner for an appropriate referral would be recommended and other resources such as the Australian Psychological Society Website (for example, the find a psychologist link) and the Beyond Blue Website would be helpful. It is important for women and their families to know that assistance is available and that they do not have to suffer in silence. Dr Kristie Alcorn, PhD, MAPS CCLIN Clinical Psychologist Special interest and developed expertise in the treatment of difficult birth events; psychological concerns in pregnancy and postpartum; and parental and couple functioning in pregnancy and postbirth. 2
References Affonso, D. D., De, A. K., Horowitz, J. A., & Mayberry, L. J. (2000). An international study exploring levels of postpartum depressive symptomatology. Journal of Psychosomatic Research, 49, 207-216. Ansara, D., Cohen, M., Gallop, R., Kung, R., & Schei, B. (2005). Predictors of women's physical health problems after childbirth. Journal of Psychosomatic Obstetrics and Gynecology, 26, 115-125. Bailham, D., & Joseph, S. (2003). Post-traumatic stress following childbirth: A review of the emerging literature and directions for research and practice. Psychology, Health and Medicine, 8, 159-168. Beck, C., & Gable, R. K. (2001). Further validation of the Postpartum Depression Screening Scale. Nursing Research, 50, 155-164. Born, L., Zinga, D., & Steiner, M. (2004). Challenges in identifying and diagnosing postpartum disorders. Primary Psychiatry, 11(3), 29-36. Brandon, S. (1982). Depression after childbirth. British Medical Journal, 284, 613-614. Brockington, I. F., Cernik, K. F., Schofield, E. M., Downing, A. R., Francis, A. F., & Keelan, C. (1981). Puerperal psychosis. Phenomena and diagnosis. Archives of General Psychiatry, 38, 829-833. Brown, S., & Lumley, J. (1998). Maternal health after childbirth: Results of an Australian population based survey. British Journal of Obstetrics and Gynaecology, 105, 156-161. Czarnocka, J., & Slade, P. (2000). Prevalence and predictors of post-traumatic stress symptoms following childbirth. British Journal of Clinical Psychology, 39(Pt 1), 35-51. Dennis, C. L., Janssen, P. A., & Singer, J. (2004). Identifying women at-risk for postpartum depression in the immediate postpartum period. Acta Psychiatrica Scandinavica, 110, 338-346. Eriksson, C., Westman, G., & Hamberg, K. (2005). Experiential factors associated with childbirthrelated fear in Swedish women and men: A population based study. Journal of Psychosomatic Obstetrics and Gynecology, 26, 63-72. Glazener, C. M., Abdalla, M., Stroud, P., Naji, S., Templeton, A., & Russell, I. T. (1995). Postnatal maternal morbidity: extent, causes, prevention and treatment. British Journal of Obstetrics and Gynaecology, 102, 282-287. Green, J., & Kafetsios, K. (1997). Positive experiences of early motherhood: Predictive variables from a longitudinal study. Journal of Reproductive and Infant Psychology, 15, 141-157. Horan-Smith, J., & Gullone, E. (1998). Screening an Australian community sample for risk of postnatal depression. Australian Psychologist, 33, 138-142. Johnson, R. C., & Slade, P. (2003). Obstetric complications and anxiety during pregnancy: Is there a relationship? Journal of Psychosomatic Obstetrics and Gynecology, 24, 1-14. 3
Johnston-Robledo, I., & Barnack, J. (2004). Psychological issues in childbirth: Potential roles for psychotherapists. Women and Therapy, 27, 133-150. Lee, D. T. S., Yip, A. S. K., Chan, S. S. M., Tsui, M. H. Y., Wong, W. S., & Chung, T. K. H. (2003). Postdelivery screening for postpartum depression. Psychosomatic Medicine, 65, 357-361. Lee, D. T. S., Yip, A. S. K., Chiu, H. F. K., Leung, T. Y. S., & Chung, T. K. H. (2001). Screening for postnatal depression: Are specific instruments mandatory? Journal of Affective Disorders, 63, 233-238. Matthey, S. (2004b). Detection and treatment of postnatal depression (perinatal depression or anxiety). Current Opinion in Psychiatry, 17, 21-29. Melender, H. (2002). Experiences of fears associated with pregnancy and childbirth: A study of 329 pregnant women [Electronic version]. Birth, 29, 101-111. Milgrom, J., & Beatrice, G. (2003). Coping with the stress of motherhood: Cognitive and defence style of women with postnatal depression. Stress and Health: Journal of the International Society for the Investigation of Stress, 19, 281-287. Nystedt, A., Hogberg, U., & Lundman, B. (2005). The negative birth experience of prolonged labour: a case-referent study [Electronic version]. Journal of Clinical Nursing, 14, 579-586. Reynolds, J. L. (1997). Post-traumatic stress disorder after childbirth: the phenomenon of traumatic birth. Canadian Medical Association Journal, 156, 831-835. Ryding, E., Wiren, E., Johansson, G., Ceder, B., & Dahlstrom, A. M. (2004). Group counseling for mothers after emergency cesarean section: A randomized controlled trial of intervention [Electronic version]. Birth, 31, 247-253. Saisto, T., & Halmesmaki, E. (2003). Fear of childbirth: A neglected dilemma [Electronic version]. Acta Obstetricia et Gynecologica Scandinavica, 82, 201-208. Saisto, T., Salmela-Aro, K., Nurmi, J. E., Kononen, T., & Halmesmaki, E. (2001). A randomized controlled trial of intervention in fear of childbirth [Electronic version]. Obstetrics and Gynecology, 98(5, Pt. 1), 820-826. Seimyr, L., Edhborg, M., Lundh, W., & Sjogren, B. (2004). In the shadow of maternal depressed mood: Experiences of parenthood during the first year after childbirth. Journal of Psychosomatic Obstetrics and Gynecology, 25, 23-34. Shear, M. K., & Mammen, O. (1995). Anxiety disorders in pregnant and postpartum women. Psychopharmacology Bulletin, 31, 693-703. Sjogren, B. (1997). Reasons for anxiety about childbirth in 100 pregnant women. Journal of Psychosomatic Obstetrics and Gynecology, 18, 266-272. Skari, H., Skreden, M., Malt, U. F., Dalholt, M., Ostensen, A. B., Egeland, T., et al. (2002). Comparative levels of psychological distress, stress symptoms, depression and anxiety after childbirth: A 4
prospective population-based study of mothers and fathers [Electronic version]. BJOG: An International Journal of Obstetrics and Gynaecology, 109, 1154-1163. Slade, P., Escott, D., Spiby, H., Henderson, B., & Fraser, R. B. (2000). Antenatal predictors and use of coping strategies in labour. Psychology and Health, 15, 555-569. Soet, J. E., Brack, G. A., & Dilorio, C. (2003). Prevalence and predictors of women's experience of psychological trauma during childbirth. Birth, 30, 36-46. Stuart, S., Couser, G., Schilder, K., O'Hara, M., & Gorman, L. (1998). Postpartum anxiety and depression: Onset and comorbidity in a community sample. The Journal of Nervous and Mental Disease, 186, 420-424. Stuart, S., O'Hara, M., & Blehar, M. C. (1998). Mental disorders associated with childbearing: Report of the biennial meeting of the Marce Society. Psychopharmacology Bulletin, 34, 333-338. Thompson, J. F., Roberts, C. L., Currie, M., & Ellwood, D. A. (2002). Prevalence and persistence of health problems after childbirth: Associations with parity and method of birth. Birth, 29, 83-94. Waldenstrom, U. (2003). Women's memory of childbirth at two months and one year after the birth [Electronic version]. Birth, 30, 248-254. Waldenstrom, U., Hildingsson, I., Rubertsson, C., & Radestad, I. (2004). A negative birth experience: Prevalence and risk factors in a national sample [Electronic version]. Birth, 31, 17-27. Wenzel, A., Haugen, E. N., Jackson, L. C., & Brendle, J. R. (2005). Anxiety symptoms and disorders at eight weeks postpartum. Journal of Anxiety Disorders, 19, 295-311. Wessely, S. (1998). Commentary: Reducing distress after normal childbirth [Electronic version]. Birth, 25, 220-221. Wijma, K. (2003). Why focus on fear of childbirth? Journal of Psychosomatic Obstetrics and Gynecology, 24, 141-143. Zar, M., Wijma, K., & Wijma, B. (2001). Pre- and postpartum fear of childbirth in nulliparous and parous women. Scandinavian Journal of Behaviour Therapy, 30, 75-84. 5