Pregnancy and the postpartum period are usually characterized by deep alterations in sleep. The complex interaction of bodily changes, breastfeeding practices, and the random wake-sleep patterns of newborn babies promote significant sleep disruption and deprivation in women at this stage.
In a review of the main findings about sleep, pregnancy, and the postpartum period, Lee (1998) asserts that the main variables underlying sleep alteration are hormonal changes, physical symptoms, and infant sleep.
With regard to hormonal alterations, it has been argued that the high progesterone levels that are essential to the pregnancy process affects drowsiness and are responsible for the increased sleepiness and earlier sleep onset during the first trimester of pregnancy. Additionally, it has been argued that progesterone has an inhibitory effect on smooth muscles, which is related to increased urinary frequency at this early stage (Lee, 1998).
From a different perspective, physical symptoms during pregnancy have been widely acknowledged as a disturbing factor (Kamysheva et al, 2010). The most common somatic complaints during this stage include:
- nausea, vomiting
- heartburn and other discomforts associated to eating
- increased urination
- tender breast
- headache
- vaginal discharge
- shortness of breath, and
- backache
Finally, infant sleep has been pointed out as a significant factor underlying sleep disruption during the postpartum period due to the random sleep-wake patterns that are commonly observed in newborn babies, breastfeeding practices, and baby’s temperament (Dennis & Ross, 2005; Hiscock & Wave, 2001; Horiuchi & Nishihara, 1999; Meltzer & Mindell, 2007).
Interestingly, research has pointed out an association between sleep and mood, and has provided significant evidence to support the bidirectional influence between sleep alteration and depression (Breslau et al, 1996; Kahn-Greene et al, 2007).
In line with this argument, some evidence supporting the significant association between sleep and depressed mood during pregnancy (Jomeen & Martin, 2007; Skouteris et al, 2008) and the postpartum (Goyal, Gay and Lee, 2007) has been reported. Therefore it has been suggested that poor sleep quality might increase the vulnerability to PPD (Okun, Hanusa & Hall, 2009).
Wednesday, 4 August 2010
The role of the subjective experience of pregnancy and childbirth in the development of postnatal distress
As previously commented, a strong body of research has focused on unraveling risk factors for the development of postnatal distress, due to the negative effect this phenomenon exerts on maternal and infant well-being. The most significant findings have been yielded by the psychosocial and physiological realms, and significant and well-validated explanatory models have been proposed.
The first approach has highlighted the role of six main risk factors such as antenatal depression, antenatal anxiety, previous history of depression, social support, life events, and self-esteem; whereas the latter highlights the influence of hormonal variables, progesterone levels being the most significant.
Notwithstanding the validity of these findings, feminist scholars have argued that postnatal distress cannot be explained exclusively by objective facts and risk factors, which they claim to be strongly influenced by the cultural discourse. In line with this argument, these scholars declare that the personal or subjective experiences women have during pregnancy, childbirth, and the postpartum are to be considered a central piece of the postnatal distress’ puzzle.
Accordingly, qualitative researchers have suggested that perceptions and expectations of events related to the pregnancy process are important variables to be studied. From a phenomenological perspective, Hart (1981) argues that “the experience of motherhood is integrated into a system of existent meanings, thus, the experiences are not processed as detached information in a pure cognitive level, but incorporated into a woman’s values and beliefs, an into her particular way to experience the world she lives in” (p.285).
So, postnatal distress and postnatal depression can be understood as one of the various meanings that can be constructed regarding the experience of pregnancy and childbirth.
The first approach has highlighted the role of six main risk factors such as antenatal depression, antenatal anxiety, previous history of depression, social support, life events, and self-esteem; whereas the latter highlights the influence of hormonal variables, progesterone levels being the most significant.
Notwithstanding the validity of these findings, feminist scholars have argued that postnatal distress cannot be explained exclusively by objective facts and risk factors, which they claim to be strongly influenced by the cultural discourse. In line with this argument, these scholars declare that the personal or subjective experiences women have during pregnancy, childbirth, and the postpartum are to be considered a central piece of the postnatal distress’ puzzle.
Accordingly, qualitative researchers have suggested that perceptions and expectations of events related to the pregnancy process are important variables to be studied. From a phenomenological perspective, Hart (1981) argues that “the experience of motherhood is integrated into a system of existent meanings, thus, the experiences are not processed as detached information in a pure cognitive level, but incorporated into a woman’s values and beliefs, an into her particular way to experience the world she lives in” (p.285).
So, postnatal distress and postnatal depression can be understood as one of the various meanings that can be constructed regarding the experience of pregnancy and childbirth.
Psychosocial risk factors for postnatal distress
The question about the risk factors associated to the development of postnatal distress has not only been addressed from a biological point of view, but from a psychosocial approach as well.
This perspective inquires about the relevance of a number of demographic, obstetric, and psychological factors that may underlie this phenomenon. The extensive discussion offered by current literature about these factors has led to the development of a well validated model that considers the six most significant risk factors for the onset of postnatal distress, namely
- Antenatal depression
- Antenatal anxiety
- Social support (being support from the partner specially significant)
- Negative life events
- Low self-esteem
- Previous history of depression
(Beck, 1996, 2001; O’Hara, 1991; O’Hara & Swain, 1996; Robertson et al, 2004).
Other variables have been suggested as contributing factors, such as an increased level of daily hassles, socioeconomic variables, parity, and psychological aspects (such as specific personality traits). Nevertheless, current research supports the notion that the above listed factors play a major role in the onset and maintenance of postnatal distress.
These findings have been used to design - and promote the use of - procedures to identify women who may be at risk for developing postnatal depression, and who may need special care, assistance, and/or treatment.
This perspective inquires about the relevance of a number of demographic, obstetric, and psychological factors that may underlie this phenomenon. The extensive discussion offered by current literature about these factors has led to the development of a well validated model that considers the six most significant risk factors for the onset of postnatal distress, namely
- Antenatal depression
- Antenatal anxiety
- Social support (being support from the partner specially significant)
- Negative life events
- Low self-esteem
- Previous history of depression
(Beck, 1996, 2001; O’Hara, 1991; O’Hara & Swain, 1996; Robertson et al, 2004).
Other variables have been suggested as contributing factors, such as an increased level of daily hassles, socioeconomic variables, parity, and psychological aspects (such as specific personality traits). Nevertheless, current research supports the notion that the above listed factors play a major role in the onset and maintenance of postnatal distress.
These findings have been used to design - and promote the use of - procedures to identify women who may be at risk for developing postnatal depression, and who may need special care, assistance, and/or treatment.
Biological factors for postnatal distress
Since both anxiety and depressive symptoms – the most characteristic signs of distress - have been found to have a negative effect on the mother’s wellbeing and the newborn’s development (Beck, 1998), a large body of research from different perspectives has focused on building explanatory models and describing risk factors that may explain the development of this phenomenon.
From a biochemical perspective, the intense physiological and hormonal changes observed across pregnancy and the postpartum period have been pointed out as a possible cause for the onset of postnatal distress. This hypothesis is based on the findings about the interaction between ovarian hormones - such as progesterone and estrogen – and central nervous system neurotransmitters related to mood disorders (i.e. serotonin and GABA).
Studies have usually focused on hormones such as progesteron, estrogene, cortisol, and prolactine. During pregnancy these hormones increase their levels progressively to reach levels that are hundred times higher than those found in non-pregnant women. This high concentration decreases intensively after delivery and the withdrawal of the placenta - with the exception of prolactine, which remains high in lactating women - therefore it has been hypothesized that depressed mood in the early postpartum period might be related to the sudden drop of hormonal levels (Harris, 2010).
Several studies have been conducted on this topic, and although hormonal fluctuation has provided a suitable explanation for the aetiology of PPD in some cases, it has failed to do so in many others; which raise questions about individual differences in the responses to both increase and reduction of hormonal levels. In effect several authors (Bloch, 2000; Harris et al, 2010, Kammerer et al, 2009; Klier et al, 2007) have suggested that women who develop postnatal depression may have certain vulnerability and/or high responsiveness to hormonal changes, which would put them at higher risk for developing mood disorders.
The mixed and inconclusive nature of current findings on this topic highlights the complex dynamics within the endocrine system and its intricate relation to the neural structures involved in mood regulation and mood disorders; and raises the question about the role of other factors - such as psychosocial aspects - that may play a role in this phenomenon.
From a biochemical perspective, the intense physiological and hormonal changes observed across pregnancy and the postpartum period have been pointed out as a possible cause for the onset of postnatal distress. This hypothesis is based on the findings about the interaction between ovarian hormones - such as progesterone and estrogen – and central nervous system neurotransmitters related to mood disorders (i.e. serotonin and GABA).
Studies have usually focused on hormones such as progesteron, estrogene, cortisol, and prolactine. During pregnancy these hormones increase their levels progressively to reach levels that are hundred times higher than those found in non-pregnant women. This high concentration decreases intensively after delivery and the withdrawal of the placenta - with the exception of prolactine, which remains high in lactating women - therefore it has been hypothesized that depressed mood in the early postpartum period might be related to the sudden drop of hormonal levels (Harris, 2010).
Several studies have been conducted on this topic, and although hormonal fluctuation has provided a suitable explanation for the aetiology of PPD in some cases, it has failed to do so in many others; which raise questions about individual differences in the responses to both increase and reduction of hormonal levels. In effect several authors (Bloch, 2000; Harris et al, 2010, Kammerer et al, 2009; Klier et al, 2007) have suggested that women who develop postnatal depression may have certain vulnerability and/or high responsiveness to hormonal changes, which would put them at higher risk for developing mood disorders.
The mixed and inconclusive nature of current findings on this topic highlights the complex dynamics within the endocrine system and its intricate relation to the neural structures involved in mood regulation and mood disorders; and raises the question about the role of other factors - such as psychosocial aspects - that may play a role in this phenomenon.
On postnatal distress
Having a baby is usually considered as a joyful experience, however, the adaptation to a newborn can be demanding and challenging, and the process of adjustment may lead to unexpected outcomes. As in every critical situation, mood changes and general signs of distress, anxiety and/or depression might be experienced during the postpartum period. However it is important to notice that postnatal levels of distress are highly related to antenatal distress, therefore, it has been argued that there is a continuum of perinatal distress that first develops during pregnancy and extends into the postpartum period.
The most common disorders that might be experienced in the postpartum are Postpartum Blues (PPB) and Postpartum depression (PPD).
PPB, known as well as maternity blues and baby blues, refers to a type of mood lability which may be accompanied by sadness, fatigue, and irritability. It commencement is usually set within 48 hours after delivery, and in most cases remits after twelve or fourteen days without treatment (Beck, 2003; Benett & Indman, 2003).
It is experienced by 30%~75% of new mothers, and is therefore the most common condition during the postpartum period, yet it may be an unsettling experience for mothers(Chaudron, 2006).
Postpartum Depression (PPD) has been described as a depressive episode experienced up to a year after childbirth, showing a highest point prevalence at two months postpartum and 6 months postpartum (Beck, 2006). The diagnostic criteria include the presence of symptoms such as: insomnia or hypersonmnia, psychomotor agitation or retardation, fatigue, changes in appetite, feelings of worthlessness or guilt, decreased concentration, and suicidality; additionally depressed mood and/or loss of interest or pleasure must be experienced.
This disorder is present in approximately 13% of women, and usually requires both pharmacological and psychological treatment (Beck, 2006). It has shown to have negative consequences for the mother’s well-being and the development of children in the cognitive, emotional and social realms (Beck, 2006), therefore many efforts have been oriented to define risk factors and develop screening
The similarity between Postpartum blues' symptoms and Postnatal depression has led to confusion and misuse of both terms (Beck, 2006; Chaudron, 2006)¸however these disorders vary not only in terms of severity and intensity, but also in terms of quality since PPB symptoms are experienced along with a predominant mood of happiness which lacks some depression characteristics like reduced interest in living or inability to enjoy things (Wisner et al, 2003).
References
Beck, C. (2006). Postpartum depression, it isn´t just the blues. AJN.106, 40-49
Bennett SS, Indman P. Beyond the blues. Prenatal and postpartum depression. San Jose, CA: Moodswings Press; 2003
Chaudron, L. (2006) Critical issues in perinatal psychiatric emergency care. Psychiatric times. 23, 36 - 51
The most common disorders that might be experienced in the postpartum are Postpartum Blues (PPB) and Postpartum depression (PPD).
PPB, known as well as maternity blues and baby blues, refers to a type of mood lability which may be accompanied by sadness, fatigue, and irritability. It commencement is usually set within 48 hours after delivery, and in most cases remits after twelve or fourteen days without treatment (Beck, 2003; Benett & Indman, 2003).
It is experienced by 30%~75% of new mothers, and is therefore the most common condition during the postpartum period, yet it may be an unsettling experience for mothers(Chaudron, 2006).
Postpartum Depression (PPD) has been described as a depressive episode experienced up to a year after childbirth, showing a highest point prevalence at two months postpartum and 6 months postpartum (Beck, 2006). The diagnostic criteria include the presence of symptoms such as: insomnia or hypersonmnia, psychomotor agitation or retardation, fatigue, changes in appetite, feelings of worthlessness or guilt, decreased concentration, and suicidality; additionally depressed mood and/or loss of interest or pleasure must be experienced.
This disorder is present in approximately 13% of women, and usually requires both pharmacological and psychological treatment (Beck, 2006). It has shown to have negative consequences for the mother’s well-being and the development of children in the cognitive, emotional and social realms (Beck, 2006), therefore many efforts have been oriented to define risk factors and develop screening
The similarity between Postpartum blues' symptoms and Postnatal depression has led to confusion and misuse of both terms (Beck, 2006; Chaudron, 2006)¸however these disorders vary not only in terms of severity and intensity, but also in terms of quality since PPB symptoms are experienced along with a predominant mood of happiness which lacks some depression characteristics like reduced interest in living or inability to enjoy things (Wisner et al, 2003).
References
Beck, C. (2006). Postpartum depression, it isn´t just the blues. AJN.106, 40-49
Bennett SS, Indman P. Beyond the blues. Prenatal and postpartum depression. San Jose, CA: Moodswings Press; 2003
Chaudron, L. (2006) Critical issues in perinatal psychiatric emergency care. Psychiatric times. 23, 36 - 51
Reflexions on pregnancy, childbirth, and the postpartum period
Pregnancy, childbirth, and the postpartum trigger enormous changes in a woman’s life, which are experienced differently due to the particular characteristics, expectations, and the personal history of every woman.
Logically, one of the core aspects promoting the changes is the presence of the baby, which becomes increasingly real to the expectant mother as pregnancy progresses. This interaction between the mother and the unborn child supports the development of thoughts and ideas about the forthcoming child and about the woman as a mother (Viziello et al, 1993).
It has been argued that the whole pregnancy period can be seen as a process where the expectant mother is slowly undergoing the changes and facing the several issues that will prepare her for mothering, and the particular challenges of every trimester of have been described (Smith, 1999).
The first trimester - from conception until the end of the third month - is characterized by physiologic changes in the body, being a time of uncertainty and adjustment to the new state. At this stage “the nature of change can itself be an issue” (Smith, 1999, p.286).
During the second trimester, the pregnant woman can feel the movements of her baby, a fact that helps her acquire a more realistic perception of the infant while seeing him/her as independent from her own body (Caplan, 1959 in Trad, 1990). Withdrawing from the world has been described as another important feature in this stage. The pregnant woman would draw her attention from the public world to focus herself in her own experiences and the familial domain. The focus on relationships with her own family, and other pregnant women or mothers, may help the mother-to-be to smooth the transition into motherhood as well as reinforces her network for social support.
During the third trimester women may experience varied feelings related to the forthcoming birth, possible fears about delivery and childcare, and mixed ideas about mothering the baby, due to the proximity of childbirth (Caplan, 1959 in Trad, 1990). Attention is shifted outwards again, and the self-containing state slowly comes to an end giving way to a different and more realistic relationship to the newborn. Finally, after childbirth, women face the challenge to adjust themselves to the newborn; personal projects begin slowly to re-gain importance as the baby grows up and a new balance based in the changes in perceptions and priorities related to the new – or reinforced - state of motherhood is to be made (Smith, 1999).
References
Smith, J. (1999). Identitiy development during the transition to motherhood: an interpretative phenomenological analysis. Journal of reproductive and infant physiology.17, 281-299
Trad, P. (1990). Emergence and resolution of ambivalence in expectant mothers. American Journal of Psychotherapy. 4, 577-589.
Vizziello, G., Antonioli, M., Cocci, V. & Invernizzi, R. (1993). From pregnancy to motherhood: The structure of representative and narrative change. Infant Mental Health Journal. 14, 4-13.
Logically, one of the core aspects promoting the changes is the presence of the baby, which becomes increasingly real to the expectant mother as pregnancy progresses. This interaction between the mother and the unborn child supports the development of thoughts and ideas about the forthcoming child and about the woman as a mother (Viziello et al, 1993).
It has been argued that the whole pregnancy period can be seen as a process where the expectant mother is slowly undergoing the changes and facing the several issues that will prepare her for mothering, and the particular challenges of every trimester of have been described (Smith, 1999).
The first trimester - from conception until the end of the third month - is characterized by physiologic changes in the body, being a time of uncertainty and adjustment to the new state. At this stage “the nature of change can itself be an issue” (Smith, 1999, p.286).
During the second trimester, the pregnant woman can feel the movements of her baby, a fact that helps her acquire a more realistic perception of the infant while seeing him/her as independent from her own body (Caplan, 1959 in Trad, 1990). Withdrawing from the world has been described as another important feature in this stage. The pregnant woman would draw her attention from the public world to focus herself in her own experiences and the familial domain. The focus on relationships with her own family, and other pregnant women or mothers, may help the mother-to-be to smooth the transition into motherhood as well as reinforces her network for social support.
During the third trimester women may experience varied feelings related to the forthcoming birth, possible fears about delivery and childcare, and mixed ideas about mothering the baby, due to the proximity of childbirth (Caplan, 1959 in Trad, 1990). Attention is shifted outwards again, and the self-containing state slowly comes to an end giving way to a different and more realistic relationship to the newborn. Finally, after childbirth, women face the challenge to adjust themselves to the newborn; personal projects begin slowly to re-gain importance as the baby grows up and a new balance based in the changes in perceptions and priorities related to the new – or reinforced - state of motherhood is to be made (Smith, 1999).
References
Smith, J. (1999). Identitiy development during the transition to motherhood: an interpretative phenomenological analysis. Journal of reproductive and infant physiology.17, 281-299
Trad, P. (1990). Emergence and resolution of ambivalence in expectant mothers. American Journal of Psychotherapy. 4, 577-589.
Vizziello, G., Antonioli, M., Cocci, V. & Invernizzi, R. (1993). From pregnancy to motherhood: The structure of representative and narrative change. Infant Mental Health Journal. 14, 4-13.
This research project
What is this?
This study is being conducted by Soledad Coo Calcagni, psychologist and PhD Candidate at the Psychology Department of the University of Melbourne - Australia, under the supervision of Prof. Jeannette Milgrom, and Prof. John Trinder.
Our purpose is to assess the personal or subjective perception women have about their own experience of pregnancy and childbirth to increase our comprehension of the factors that promote a positive postnatal adjustment.
Why is this study important?
What happens during pregnancy and childbirth may have a significant influence on the mother's and her baby's wellbeing, therefore, several studies have been conducted to gain a deeper understanding of this period and to identify risk factors that may lead to negative outcomes - such as anxiety or depression. Surprisingly, the role of the personal or subjective experience of women has been usually disregarded. This project intends to explore this important aspect and its influence on postnatal adjustment.
What will we ask you to do?
Participants will be required to complete a set of questionnaires at three different times, namely during the third trimester of pregnancy (26-38 weeks), one week after delivery, and 10 weeks after childbirth.
Questionnaires include items on mood, sleep, and expectations about pregnancy and the forthcoming baby, as well as some questions about demographic variables (i.e. country of birth, education, marital status, etc.)
Questionnaires will be posted to every woman's personal address, and a pre-paid envelope will be enclosed to mail the survey back.
How can I participate?
If you are pregnant and would like to participate please contact me - Soledad - through this blog or by emailing me at s.coocalcagni@pgrad.unimelb.edu.au and I will come back to you as soon as possible to ask you your mailing address and expected due date in order to send you the questionnaire, participant information, and consent form.
By reading this blog you will find out more about this study and its core issues.
This study is being conducted by Soledad Coo Calcagni, psychologist and PhD Candidate at the Psychology Department of the University of Melbourne - Australia, under the supervision of Prof. Jeannette Milgrom, and Prof. John Trinder.
Our purpose is to assess the personal or subjective perception women have about their own experience of pregnancy and childbirth to increase our comprehension of the factors that promote a positive postnatal adjustment.
Why is this study important?
What happens during pregnancy and childbirth may have a significant influence on the mother's and her baby's wellbeing, therefore, several studies have been conducted to gain a deeper understanding of this period and to identify risk factors that may lead to negative outcomes - such as anxiety or depression. Surprisingly, the role of the personal or subjective experience of women has been usually disregarded. This project intends to explore this important aspect and its influence on postnatal adjustment.
What will we ask you to do?
Participants will be required to complete a set of questionnaires at three different times, namely during the third trimester of pregnancy (26-38 weeks), one week after delivery, and 10 weeks after childbirth.
Questionnaires include items on mood, sleep, and expectations about pregnancy and the forthcoming baby, as well as some questions about demographic variables (i.e. country of birth, education, marital status, etc.)
Questionnaires will be posted to every woman's personal address, and a pre-paid envelope will be enclosed to mail the survey back.
How can I participate?
If you are pregnant and would like to participate please contact me - Soledad - through this blog or by emailing me at s.coocalcagni@pgrad.unimelb.edu.au and I will come back to you as soon as possible to ask you your mailing address and expected due date in order to send you the questionnaire, participant information, and consent form.
By reading this blog you will find out more about this study and its core issues.
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