Early Abusive Relationships-Influence of Different Maltreatment Types on Postpartum Psychopathology and Mother-Infant Bonding in a Clinical Sample.

Postpartum psychopathology is a well-documented risk factor for impaired mother-infant bonding and thus child development. Increasingly, the focus of research in this area lies on maternal adverse childhood experiences that mothers bring into the relationship with their own baby, especially regarding the possible intergenerational transmission of traumatic experiences. Several studies showed that there is no direct link between child maltreatment and mother-infant bonding as one part of mother-child relationship, but that this link is mediated by postpartum psychopathology. To date, few studies examined differential effects between sexual, physical, and emotional abuse, and physical and emotional neglect, especially in a clinical sample. The aim of this study is to investigate whether the relationship between child maltreatment, psychopathology, and mother-infant bonding can be found for different forms of child maltreatment in patients of a mother-baby unit. Our sample consisted of 330 mothers of a mother-baby-unit in a psychosomatic clinic, who filled out self-report measures at time of admission. Mothers reported on maternal child maltreatment history with the Childhood Trauma Questionnaire, on current psychopathology with the Brief Symptom Inventory, and on mother-infant bonding with the Postpartum Bonding Questionnaire. Mediation analyses were performed with psychopathology as mediator, child maltreatment history as independent, and mother-infant bonding as dependent variable. There was no total effect of child maltreatment on mother-infant bonding. However, there were significant indirect effects of child maltreatment in general (ab = 0.09) and of the various forms of child maltreatment on mother-infant bonding via psychopathology (0.16 ≤ ab ≤ 0.34). The strongest effect was found for emotional abuse. After controlling for psychopathology, the direct effect of physical abuse on mother-infant bonding presented as a negative significant effect. This indicates that the more severe the physical abuse experienced, the better the self-reported bonding. A similar, but non-significant trend was found for sexual abuse. Our findings highlight the importance of assessing neglect forms of child maltreatment as well as abuse in women during the perinatal period. It further supports initial findings that different forms of child maltreatment can have differential effects on mother-infant bonding as one aspect of the mother-child relationship. Further research should include observational data to compare with self-report measures.

Subjective Birth Experience Predicts Mother-Infant Bonding Difficulties in Women With Mental Disorders.

Background: The subjective experience of giving birth to a child varies considerably depending on psychological, medical, situational, relational, and other individual characteristics. In turn, it may have an impact on postpartum maternal mental health and family relationships, such as mother-infant bonding. The objective of the study was to evaluate the relevance of the subjective birth experience (SBE) for mother-infant bonding difficulties (BD) in women with mental disorders. Methods: This study used data from N = 141 mothers who were treated for postpartum mental disorders in the mother-baby day unit of the Psychosomatic University Clinic in Dresden, Germany. Patients' mental status at admission and discharge was routinely examined using a diagnostic interview (SCID I) and standard psychometric questionnaires (e.g., EPDS, BSI, PBQ). Both, the SBE (assessed by Salmon's Item List, SIL) as well as medical complications (MC) were assessed retrospectively by self-report. The predictive value of SBE, MC, as well as psychopathological symptoms for mother-infant BD were evaluated using logistic regression analyses. Results: About half of this clinical sample (47.2%) reported a negative SBE; 56.8% of all mothers presented with severe mother-infant BD toward the baby. Mothers with BD showed not only significantly more depressiveness (EPDS: M = 16.6 ± 5.6 vs. 14.4 ± 6.2*), anxiety (STAI: M = 57.2 ± 10.6 vs. 51.4 ± 10.6***), and general psychopathology (BSI-GSI: M = 1.4 ± 0.7 vs. 1.1 ± 0.6**) compared to women without BD, but also a significantly more negative SBE (SIL: M = 79.3 ± 16.2 vs. 61.3 ± 22.9***). Moreover, the SBE was the most powerful predictor for BD in univariate and multiple logistic regression analyses [OR = 0.96*** (95% CI 0.94-0.98) vs. OR = 0.96** (95% CI 0.93-0.98)], even when univariate significant predictors (e.g., current psychopathology and MC during birth) were controlled. Conclusions: A negative SBE is strongly associated with mother-infant bonding in patients with postpartum mental disorders. It needs to get targeted within postpartum treatment, preferably in settings including both mother and child, to improve distorted mother-infant bonding processes and prevent long-term risks for the newborn. Furthermore, the results highlight the importance of focusing on the specific needs of vulnerable women prior to and during birth (e.g., emotional safety, good communication, and support) as well as individual factors that might be predictive for a negative SBE.

Planned Place of Birth-Impact of Psychopathological Risk Factors on the Choice of Birthplace and Its Postpartum Effect on Psychological Adaption: An Exploratory Study.

The choice of birthplace may have an important impact on a woman's health. In this longitudinal study, we investigated the psychopathological risk factors that drive women's choice of birthplace, since their influence is currently not well understood. The research was conducted in 2011/12 and we analyzed data of 177 women (obstetric unit, n = 121; free standing midwifery unit, n = 42; homebirth, n = 14). We focused antepartally (M = 34.3 ± 3.3) on sociodemographic and risk factors of psychopathology, such as prenatal distress (Prenatal Distress Questionnaire), depressiveness (Edinburgh Postnatal Depression Scale), birth anxiety (Birth Anxiety Scale), childhood trauma (Childhood Trauma Questionnaire), and postpartally (M = 6.65 ± 2.6) on birth experience (Salmon's Item List), as well as psychological adaption, such as postpartum depressive symptoms (Edinburgh Postnatal Depression Scale) and birth anxiety felt during birth (modified Birth Anxiety Scale). Women with fear of childbirth and the beginning of birth were likely to plan a hospital birth. In contrast, women with fear of touching and palpation by doctors and midwives, as well as women with childhood trauma, were more likely to plan an out-of-hospital birth. Furthermore, women with planned out-of-hospital births experienced a greater relief of their birth anxiety during the birth process than women with planned hospital birth. Our results especially show that women with previous mental illnesses, as well as traumatic experiences, seem to have special needs during childbirth, such as a safe environment and supportive care.

[Improvement of Mental Health and Bonding in Women with Mental Disorders in the Postpartum Period - Evaluation of an Interaction-Centered Treatment of a Mother-Baby Day Clinic]. / Verbesserung der psychischen Gesundheit und Bindung bei postpartal psychisch erkrankten Frauen ­ Evaluation einer interaktionszentrierten Therapie in einer Mutter-Kind-Tagesklinik.

OBJECTIVE: Women with postpartum mental disorders often have a delayed bonding to their child with negative consequences for the child's development. In several countries it has been demonstrated that a specific mother-child treatment has positive effects on maternal psychopathology and mother-child bonding. Data for German-speaking countries are rare, partly due to the lack of adequately financed mother-baby units. The objectives of this study were to characterize the patients and to evaluate the treatment in a psychosomatic-psychotherapeutic mother-child day clinic. METHODS: A total of 270 patients were examined at admission and discharge from the mother-child day clinic. The evaluation included main and secondary diagnoses according to ICD-10, duration of treatment, medication, information on the child, and psychometric questionnaires on maternal psychopathology, mother-child bonding, and parental sense of competence. RESULTS: Of the women examined, 75% had more than one, on average 2.3 mental diagnoses. The most frequent main diagnoses were affective disorders (38.5%), neurotic, stress and somatoform disorders (30.7%) and personality and behavioral disorders (20.4%). About 56% reported impaired mother-child bonding. The average duration of therapy was 32 treatment days. Between admission and discharge, a highly significant improvement in symptoms was observed with a high effect size [F=288.557 (df=1), p<0.001, Eta²=0.549]. At discharge, 86.6% of patients showed no signs of mother-child bonding disorder. DISCUSSION: The results indicate high potential effects of an interaction-centered treatment on maternal mental health and mother-child bonding. CONCLUSIONS: The joint treatment of mother and child should be a fixed and financed component of the mental health system in order to prevent chronification and negative developmental consequences for the child.

Maladaptive personality styles in a clinical sample of women with postpartum depression.

BACKGROUND: Personality traits are associated with the onset and course of postpartum depression. The impact of maladaptive personality traits on mother-child bonding and parenting is less studied. Therefore, the aims of this study are to investigate: a) the frequency of maladaptive personality styles in women with postpartum depression; b) the association between personality styles and the course of maternal psychopathology; and c) the association between personality styles and mother-child bonding and parenting competence. METHODS: We examined n = 123 patients of a mother-baby unit with the Personality Style and Disorder Inventory (PSSI) at admission and instruments assessed maternal psychopathological symptoms (BSI), mother-child bonding (PBQ), and parenting sense of competence (PSOC) at admission and discharge. RESULTS: Maladaptive personality styles were frequent. Women with postpartum depression had higher scores on the schizoid, avoidant, obsessive-compulsive, negativistic, dependent, borderline, depressive, and self-forgetting PSSI scales than women of the general population. The presence of maladaptive personality styles was associated with higher psychopathology, impaired mother-child bonding, and lower parenting sense of competence at admission. From admission to discharge, women showed significant improvements on psychopathology, bonding and parenting irrespective of the presence of maladaptive personality styles. However, mothers with maladaptive personality styles still had higher psychopathology and impaired mother-child bonding at discharge compared to mothers with normal PSSI scores. LIMITATIONS: Data is based upon a clinical sample of women hospitalized in a mother-child unit. Results are not representative for all women with postpartum depression. CONCLUSIONS: Our results underline the need for early identification of maladaptive personality styles and for the adequate treatment and monitoring of women with postpartum depression. It can be anticipated that women suffering from maladaptive personality styles will need ongoing care to prevent long-term negative outcomes.

Course of mental health and mother-infant bonding in hospitalized women with threatened preterm birth.

PURPOSE: Pregnancy complications (PC) with signs of threatened preterm birth are often associated with lengthy hospital stays, which have been shown to be accompanied by anxiety, depressive symptoms, and increased stress level. It remains unclear, whether the perinatal course of mental health of these women differs from women without PC and whether there may be differences in the postpartum mother-infant bonding. METHODS: In a naturalistic longitudinal study with two measurements (24-36th weeks of gestation and 6 weeks postpartum), we investigated depression (EPDS), anxiety (STAI-T), stress (PSS), and postpartum mother-infant bonding (PBQ) in women with threatened preterm birth (N = 75) and women without PC (N = 70). For data evaluation, we used means of frequency analysis, analysis of variance with repeated measurements, and t-tests for independent samples. RESULTS: The patient group showed significantly higher rates of depression, anxiety, and stress during inpatient treatment in pregnancy, as well as 6 weeks postpartum compared to the control group. While depression and anxiety decreased over time in both groups, stress remained at the same level 6 weeks postpartum as in pregnancy. We found no significant differences in mother-infant bonding between the two groups at all considered PBQ scales. CONCLUSION: It is recommended to pay attention to the psychological burden of all obstetric patients as a routine to capture a psychosomatic treatment indication. A general bonding problem in women with threatened preterm birth was not found. Nevertheless, increased maternal stress, anxiety, and depressiveness levels during pregnancy may have a negative impact on the development of the fetus.

Mothers With Postpartum Psychiatric Disorders: Proposal for an Adapted Method to Assess Maternal Sensitivity in Interaction With the Child.

About 15% of mothers suffer from postpartum psychiatric disorders, such as depression, anxiety, or psychosis. Numerous studies have shown maternal caregiving behavior to be negatively affected under these circumstances. The current study sets out to shed light on specific caregiving behaviors of affected mothers in the context of parental mental illness at an early stage. There are several methods to assess maternal caregiving behavior in terms of sensitivity. However, all of them have limitations regarding the peculiarities of mothers with postpartum disorders, that is, changes in affect regulation, and the early onset of the disorder postpartum. With the current study, we provide an adapted method to assess maternal sensitivity based on methods recently approved in attachment research. Two groups of mothers, who were either healthy or had different postpartum disorders, were recorded on video during interactions with their infants. Behaviors were rated regarding responsiveness, promptness, appropriateness, intrusiveness, and positive and negative affect. A first analysis revealed an increased number of deficits on all subscales in mothers with postpartum psychiatric disorders as compared to healthy mothers. Depressive mothers with a single diagnosis had lower scores in responsiveness, promptness, and appropriateness and higher scores on intrusiveness as compared to those in healthy mothers. Here, maternal behavior appears more parent-centered, whereas affect seemed to be relatively unharmed. Moreover, as compared to healthy mothers, mothers with comorbid depression and anxiety symptomatology achieved lower scores on responsiveness, appropriateness, and positive affect and higher scores on intrusiveness and negative affect. It is suggested, that increased deficits are related to the severity of illness in mothers with comorbidities. Results on promptness indicate that these mothers are still capable of maintaining higher vigilance to infant cues. Variance in maternal behavior was relatively high in clinical mothers, showing that some of them are well capable of behaving in a sensitive manner toward their child. One strength of our adapted method is that particular aspects of sensitive parent-child interactions are assessed separately. This may shed light on specific behavior patterns of different postpartum psychiatric disorders, which may in turn relate to specific child outcomes. The manual is open for usage, while reliability testing is required.

The Impact of Parental Role Distributions, Work Participation, and Stress Factors on Family Health-Related Outcomes: Study Protocol of the Prospective Multi-Method Cohort "Dresden Study on Parenting, Work, and Mental Health" (DREAM).

The Dresden Study on Parenting, Work, and Mental Health ("DResdner Studie zu Elternschaft, Arbeit, und Mentaler Gesundheit", DREAM) aims to prospectively investigate the relationship between parental work participation, role distribution, stress factors, and their effects on perinatal outcomes and long-term family mental and somatic health in a community sample targeting N = 4,000 individuals, i.e., 2,000 couples, expecting a child and residing in Dresden, Germany (interim sample of N = 1,410 participants, recruitment ongoing). Various questionnaires are completed at four measurement points from pregnancy to 2 years postpartum (prolongation into middle childhood planned). Applying a multi-method approach, long-term endocrinological data (analyses of hair cortisol concentrations and other endogenous hormones, "DREAMHAIR") and qualitative interview data (regarding gender role attitudes and distribution of domestic work, child care, and paid employment; "DREAMTALK") are obtained. In this study protocol, the theoretical background, methods, and preliminary results considering sociodemographic characteristics during pregnancy and birth-related factors at 8 weeks postpartum are presented. Additionally, there is a focus on our endocrinological sub-study DREAMHAIR. In this sub-study currently comprising N = 152 participants, i.e., 88 families (recruitment ongoing), we want to gain knowledge on the transgenerational processes of stress regulation and psychopathology in the whole family by analyzing hair cortisol concentrations in both parents and children during the course from pregnancy (or after birth regarding children) to at least 2 years postpartum. By comparing data of the community sample to a clinical sample of mothers with postpartum mental disorders, their children, and their partners during the period between admission and discharge from a mother-baby unit and post-treatment ("DREAMMBU"), the course of mothers' psychopathology, parent-infant interaction, and infant regulation disorders with special regard to long-term endocrine correlates will be examined. With previous studies neglecting the fathers or partners involved, a major advantage of DREAM is the use of a multi-method and multi-level approach by examining the whole family in a longitudinal design. Therefore, the DREAM study will contribute to a better understanding of the role of social, work, and stress factors for mental and somatic health and its long-term endocrine correlates in the natural course of becoming a family.

Mother-child bonding is associated with the maternal perception of the child's body odor.

Mothers can recognize the odor of their baby and typically adore this odor. In line with this observation, infant body odors activate reward-related brain areas in the mothers. In some mother-child-dyads however, the mutual bond is impaired and mothers have trouble engaging in interaction with their child. We aimed to examine how mothers with bonding difficulties perceive their child's body odor. In total, 75 mothers of babies aged 0-12 months were examined: Twenty-five of those were recruited in a psychosomatic day hospital ward, which is specialized for mother-child bonding disorders. Fifty age-matched healthy women and their babies served as controls. Body odor samples of each baby were collected from bodysuits in a highly standardized procedure. Thereafter, each mother rated the samples of her own and two other infants in a blind and randomized design. In addition, general olfactory function in terms of threshold and identification ability was tested and the mother reported the bonding to her baby in a standardized questionnaire. Healthy mothers showed a clear preference of their own compared to odors of other infant's, while mothers with bonding difficulties did not. Furthermore, the degree of preference was negatively correlated to self-reported bonding difficulties. Mothers with bonding difficulties could not identify their own infant's odor above chance, while control mothers could. Both groups did not differ in general olfactory function. We assume that reduced close body contact and interaction time associated with bonding difficulties may lead to reduced exposure and hinder the recognition of the infantile body odor. Within a vicious cycle, a reduced hedonic experience smelling their own baby may prevent women from deliberately approaching the baby. Thus, the positive and bond-building consequences of bodily and sensory interaction cannot unfold. As the baby's odor is normally perceived as very pleasant and rewarding, the conscious perception of the infantile body odor may be an additive therapeutic approach for mothers with bonding difficulties.

[Traumatic Birth: Recognition and Prevention]. / Traumatische Geburtsverläufe: Erkennen und Vermeiden.

A history of sexual as well as physical or emotional abuse may represent a high-risk factor for difficult pregnancies and birth processes, potentially yielding the development of postpartum posttraumatic stress disorder as well as impaired mother-child attachment. However, birth itself may also be experienced as primarily traumatic, i. e., without having had prior trauma experiences. Difficult and traumatic births may affect midwives and obstetricians, too. This article provides an overview of the prevalence and risk factors of traumatic childbirth as well as the course, consequences, and intervention possibilities.

The influence of postpartum PTSD on breastfeeding: A longitudinal population-based study.

BACKGROUND: In most Western countries, breastfeeding rates are lower than what is recommended by the World Health Organization. Depression has been shown to influence breastfeeding outcomes; however, there is very little research on the role of postpartum posttraumatic stress disorder (PTSD). This study examined to what extent maternal postpartum PTSD predicted breastfeeding initiation, exclusive breastfeeding during the first 6 months, and continuation up to 1 and 2 years. METHODS: The study is part of the large, population-based Akershus Birth Cohort. Data from the hospital's birth record and questionnaire data from 8 weeks and 2 years postpartum were used (n = 1480). All breastfeeding variables significantly correlated with postpartum PTSD were entered into stepwise logistic regression analyses. RESULTS: Although most mothers (97.1%) initiated breastfeeding, considerably fewer adhered to the World Health Organization's breastfeeding guidelines about exclusive breastfeeding during the first 6 months (13.4%) or continued breastfeeding for 12 or 24 months postpartum (37.7% and 4.2%, respectively). Even after adjustment for important confounding variables, maternal postpartum PTSD was significantly associated with not initiating breastfeeding (aOR 5.98 [95% CI 1.79-19.97]). Postpartum PTSD was also significantly related to not continuing breastfeeding up to 12 months, although this association did not hold after adjusting for confounding variables. CONCLUSION: Identifying women at risk of not initiating breastfeeding is crucial to prevent a negative influence on infant development and the development of the mother-infant bond. Early screening and treatment of women at risk of developing postpartum PTSD might be a way forward.

Early intervention in pregnant women with elevated anxiety and depressive symptoms: efficacy of a cognitive-behavioral group program.

To examine whether a cognitive-behavioral group program among pregnant women with elevated levels of anxiety or depression may reduce anxious and depressive symptoms and has a positive impact on risk factors for anxiety disorders and depression. A total of 753 participants were recruited. After completion of the clinical standardized interview, 160 participants were randomized to an intervention group or a control condition. Psychometric assessments took place at T1 (preintervention), T2 (antenatal follow-up), and T3 (3 months postpartum). Analyses included women who took part in all 3 assessments (intervention group, N = 21; control group, N = 53). The subjective program evaluation by the participants was highly positive, but with the exception of a short-term effect on the quality of an intimate partnership (F1/67 = 4.056; P < .05], intervention effects on anxiety or depressive symptoms were not found. However, there was an intervention effect 3 months postpartum for participants with high depressive symptoms at T1 (Edinburgh Postnatal Depression Scale score of ≥10) (F1/69 = 5.410; P < .05). The results argue against a general efficacy of a cognitive-behavioral group program for pregnant women with rather low levels of anxiety and depression. For women with higher depressive symptoms during pregnancy, a cognitive-behavioral group program may have a positive impact on the course of depressive symptoms during the postpartum period.

[Protective factors for postpartum depression]. / Was halt Schwangere gesund? Protecktive Faktoren fur postpartale Depression.

OBJECTIVES: This article examines the associations between protective factors und the occurrence of postpartum depressive symptoms. METHODS: Using a prospective-longitudinal design 303 pregnant women were examined at 3 points in time (T1: 1st trimester, T2: 3rd trimester, T3: 3-5 months postpartum). The analyses are based on T1 and T3. RESULTS: Sense of coherence (SOC-L9, Schumacher et al. 2000) at 1st trimester was on average 51.7 (SD = 7.2) - significantly above the mean of a comparison sample. 37 women (15.4 %) had a score of 10 or more on the Edinburgh Postnatal Depression Scale (EPDS, Cox et al. 1987) 3 to 5 months postpartum. Pregnant women who stated that their pregnancy had been planned and desired, with a higher marital and overall life satisfaction as well as a higher sense of coherence, had a significantly lower risk for the development of postpartum depression. Using multiple regression it was found that only sense of coherence significantly predicted postpartum depression. CONCLUSIONS: The results suggest that a higher sense of coherence at first trimester is an important protective factor for the occurrence of postpartum depression.

Effects of an early intervention on perceived stress and diurnal cortisol in pregnant women with elevated stress, anxiety, and depressive symptomatology.

The goal of the present investigation was to examine effects of a cognitive-behavioral group intervention for pregnant women with subclinically elevated stress, anxiety and/or depression on perceived stress and salivary cortisol levels. Expectant mothers were recruited in gynaecologist practices. They participated in a screening, a standardized diagnostic interview (Munich-Composite Diagnostic Interview, M-CIDI), and were randomly assigned to an intervention (N = 21) and treatment as usual control group (N = 40). The intervention consisted of a manualized cognitive-behavioral group program for expectant mothers with subclinically elevated stress, depression, and/or anxiety symptoms. Stress questionnaire (prenatal distress (PDQ), perceived stress (PSS)) as well as diurnal salivary cortisol assessment took place at T1 (antenatal, preintervention), at T2 (antenatal, post-intervention) and T3 (3-month postpartum). Subjects that participated in the intervention exhibited a significant post-treatment change in morning cortisol (cortisol awakening response, CAR) in contrast to control subjects, F(8,51) = 2.300, p = 0.047. Intervention participants showed a smaller CAR subsequent to the intervention, displaying a lessened stress reaction. This effect was not observed in the control group. In contrast, we failed in discovering a significant difference between the research groups regarding the cortisol area under curve parameter (AUC) and the applied subjective stress questionnaires. Evaluation results were thus heterogeneous. Nevertheless, intervention effects on the CAR are promising. Our results suggest that a cognitive-behavioral intervention might lead to an improvement in the biological stress response of pregnant women with subclinically elevated stress, anxiety, or depressive symptoms.

A psychosomatic intervention in pregnant in-patient women with prenatal somatic risks.

PURPOSE: This study examined whether a short-term psychosomatic intervention during pregnancy had effects on characteristics of labour and delivery as well as on the long-term course of anxiety, depression and physical complaints in pregnant in-patient women. METHODS: All gynaecological and obstetric inpatients of a university hospital, who had either exhibited complications during their pregnancy or were considered high-risk pregnancies, were examined. Symptoms of anxiety and depression (HADS) and physical symptoms (GBB) were assessed by standardised questionnaires. Women with elevated scores on either the HADS or the GBB were randomly assigned to either a treatment group, which had received a psychosomatic intervention or an untreated control group. Of the n = 238 women who were assessed during their stay in our hospital, n = 135 were included in the follow-up 1-year later. RESULTS: More than one-third of the participants (38.7%) had elevated scores of anxiety, depression and/or physical symptoms. The psychosomatic intervention had a significant effect on anxiety scores (p = 0.006), but not on depression scores, physical complaints and characteristics of labour and delivery. CONCLUSIONS: Findings suggest that a short-term psychosomatic intervention can have a positive long-term effect on anxiety symptoms. Future studies are needed to show whether the reduction of anxiety symptoms in turn can lead to a reduction of postnatal complications and lower rates of disturbed mother-child interactions.