Maternal health agency in women with a low socioeconomic status: a qualitative study.

BACKGROUND: Health agency refers to one's capacity to form health-related goals, experience control, and possess the means to pursue them. Low socioeconomic status (SES) is linked to impaired health agency and increased risk of adverse pregnancy outcomes, potentially due to a reduced tendency to seek care. Better healthcare availability may not improve their pregnancy outcomes, and therefore improved understanding of maternal health agency is paramount. METHODS: Semi-structured interviews were conducted with 15 participants who either had children or desired to have them. Low SES was determined by neighborhood median income and educational attainment. A thematic content analyses was conducted. RESULTS: Two themes emerged: 1) Origin and development of personal goals, and 2) Awareness and competence. Participant's goals stemmed from cultural norms, personal narratives, and intuition. Integrated goals were those participants valued highly, were aware of, and strived for. Four subthemes were identified in goal-awareness and competence. Internal conflict due to discrepancies between goals and behavior resulted in the need to balance the burdens and benefits of behavior change. CONCLUSION: Maternal health agency is a modifiable outcome dependent on goal-awareness and various factors. Impaired agency seemed to stem from lack of goal-awareness rather than an inability to meet established pillars.

Attachment security and disorganization in infants of mothers with severe psychiatric disorder: Exploring the role of comorbid personality disorder.

The aim of this preliminary study was to explore infant-mother attachment quality in a Dutch clinical sample of mothers with severe psychiatric disorder, with or without comorbid personality disorder. Thirty-two mothers were recruited through specialized secondary and tertiary outpatient clinics and mental health institutions. Maternal psychiatric and personality diagnoses were verified with structured clinical interviews during pregnancy. Maternal concurrent level of psychiatric symptoms was assessed by self-report and infant-mother attachment quality by observation in the Strange Situation Procedure at 14 months postpartum. In the full sample, almost half of the infants were classified as disorganized. All infants of mothers with a comorbid personality disorder were classified as either insecure or disorganized. Infants of mothers with a comorbid personality disorder had a significantly higher disorganization score than infants of mothers with a psychiatric disorder only. Continuous attachment security scores did not differ significantly between groups. In the full sample, continuous infant attachment security and disorganization score were not significantly correlated with the level of maternal concurrent psychiatric symptoms. Our exploratory findings suggest a specific link between maternal psychiatric and comorbid personality disorder and attachment disorganization. Moreover, chronicity of symptoms appears more relevant for attachment behaviors than the severity of concurrent psychiatric symptoms. Maternal personality disorder may have a strong formative impact on infant attachment security and disorganization, which warrants further research to inform clinical practice, in order to reduce the risk of intergenerational transmission of maternal psychopathology.

A systematic review of midwives' training needs in perinatal mental health and related interventions.

Background: Midwives may be key stakeholders to improve perinatal mental healthcare (PMHC). Three systematic reviews considered midwives' educational needs in perinatal mental health (PMH) or related interventions with a focus on depression or anxiety. This systematic review aims to review: 1) midwives' educational/training needs in PMH; 2) the training programs in PMH and their effectiveness in improving PMHC. Methods: We searched six electronic databases using a search strategy designed by a biomedical information specialist. Inclusion criteria were: (1) focus on midwives; (2) reporting on training needs in PMH, perinatal mental health problems or related conditions or training programs; (3) using quantitative, qualitative or mixed-methods design. We used the Mixed Methods Appraisal Tool for study quality. Results: Of 4969 articles screened, 66 papers met eligibility criteria (47 on knowledge, skills or attitudes and 19 on training programs). Study quality was low to moderate in most studies. We found that midwives' understanding of their role in PMHC (e.g. finding meaning in opening discussions about PMH; perception that screening, referral and support is part of their routine clinical duties) is determinant. Training programs had positive effects on proximal outcomes (e.g. knowledge) and contrasted effects on distal outcomes (e.g. number of referrals). Conclusions: This review generated novel insights to inform initial and continuous education curriculums on PMH (e.g. focus on midwives' understanding on their role in PMHC or content on person-centered care). Registration details: The protocol is registered on PROSPERO (CRD42021285926).

Reducing behavior problems in children born after an unintended pregnancy: the generation R study.

OBJECTIVES: To examine differences in behavior problems between children from intended versus unintended pregnancies, and to estimate how much the difference in problem behavior would be reduced if postnatal depression was eliminated and social support was increased within 6 months after birth. METHODS: Data from the Generation R Study were used, a population-based birth cohort in Rotterdam, the Netherlands (N = 9621). Differences in child internalizing and externalizing behavior at ages 1.5, 3, 6, 9 and 13 years between pregnancy intention groups were estimated using linear regression. Associations of postnatal depression and social support with internalizing and externalizing problems were also estimated using linear regression. Child behavior outcomes where compared before and after modelling a situation in which none of the mothers experienced a postnatal depression and all mother experienced high social support. RESULTS: Most pregnancies (72.9%) were planned, 14.8% were unplanned and wanted, 10.8% were unplanned with initially ambivalent feelings and 1.5% with prolonged ambivalent feelings. Children from unplanned pregnancies had more internalizing and externalizing problems at all ages as compared to children from a planned pregnancy, especially when ambivalent feelings were present. Hypothetically eliminating on postnatal depression reduced the differences in internalizing and externalizing problems by 0.02 to 0.16 standard deviation. Hypothetically increasing social support did not significantly reduce the difference in internalizing and externalizing problems. CONCLUSIONS: Children from an unplanned pregnancy have more behavior problems, in particular when mothers had prolonged ambivalent feelings. Eliminating postnatal depression may help to reduce the inequality in child behavior related to pregnancy intention.

Paternal peripartum depression: emerging issues and questions on prevention, diagnosis and treatment. A consensus report from the cost action Riseup-PPD.

INTRODUCTION: Paternal peripartum depression (P-PPD) is a serious and understudied public health problem associated with impaired family functioning and child development. The lack of recognition of P-PPD may result in limited access to both information and professional help. OBJECTIVE: The aim of the study was to review studies on paternal peripartum depression and to identify issues and questions where future research and theory formation are needed. METHODS: A literature search for systematic reviews, meta-analyses and primary studies was conducted using PubMed, Web of Science, Embase, Scopus, Medline, PsychInfo and Informit databases. Key results within the retrieved articles were summarised and integrated to address the review objectives. RESULTS: Based on the literature, the knowledge related to prevalence, screening, risk factorsunique to fathers, management strategies and outcomes of P-PPD is lacking. Currently, there is no consensual understanding of the definition of P-PPD and recommendations for dealing with P-PPD. Limited data were available regarding the barriers preventing fathers from accessing support systems. CONCLUSION: Emerging issues that need to be addressed in future research include: P-PPD definition and pathogenetic pathways; prevention strategies and assessment tools; self-help seeking and engagement with interventions; the cost-effectiveness of P-PPD management; needs of health professionals; effect on child development, and public awareness. Future studies and clinical practice should account the complexities that may arise from the father's perceptions of health care services. Results from this review highlights the critical issues on how to plan, provide and resource health services, to meet the health needs of fathers.

Traumatic Childbirth Experience and Childbirth-Related Post-Traumatic Stress Disorder (PTSD): A Contemporary Overview.

With this manuscript we provide an overview of the prevalence, symptoms, risk factors, screening, support, and treatment for women with a traumatic childbirth experience or childbirth-related PTSD. This overview is based on both recent literature and the authors' clinical experiences from the fields of obstetrics, psychiatry and medical psychology to provide up-to-date knowledge about recognizing, preventing and treating CB-PTSD from a clinical perspective. We pay substantial attention to prevention as there are many things health care professionals can do or not do to contribute to a positive childbirth experience, and save women, their infants and families from a sub-optimal start due to childbirth-related trauma.

Intergenerational impact of childhood trauma on hair cortisol concentrations in mothers and their young infants.

Background: Alterations in stress regulation and function of the hypothalamic-pituitary-adrenal (HPA) axis during infancy may be a risk factor for the development of psychopathology later in life. Maternal childhood trauma, depression, anxiety and stressful life events are individually associated with HPA axis dysregulation. Less is known about their interdependent influence on maternal and infant stress regulation in at risk populations. In a sample of mothers with a history of depressive-, and/or anxiety disorders and their infants we explored if a history of maternal childhood trauma, current depressive and anxiety symptomatology, and recent life events were associated with maternal and infant long-term cortisol levels three months postpartum. Methods: Data were available of 89 mothers and 49 infants. All mothers fulfilled criteria for a lifetime depressive or anxiety disorder. Diagnosis was established with a diagnostic interview. Current depressive symptomatology was assessed with the Edinburgh Postnatal Depression Scale (EPDS), current anxiety with the State-Trait Anxiety Inventory (STAI), maternal childhood trauma with the Childhood Trauma Questionnaire (CTQ) and recent life events with the Everyday Problem Checklist (EPC). Maternal and infant hair cortisol concentrations (HCC) were quantified with liquid chromatography with tandem mass spectrometry (LC-MS/MS) three months after birth. Total scores of the CTQ and subscales, EPDS, STAI, and EPC were regressed on maternal and infant HCC using regression analyses. Differences in HCC regarding trauma history were tested with t-tests. Potential confounders were identified and adjusted for. Results: In regression analyses, a positive curvilinear relationship was found between CTQ total score and maternal HCC (n = 83, B = 0.076, SE 0.033, p = .021), but not for current depression (n = 88, B = -0.001, SE 0.011, p = .931), current anxiety (n = 88, B = 0.002, SE 0.004, p = .650) or recent life events (n = 89, B = 0.018, SE 0.032, p = .568). Analyses were adjusted for confounders. A negative linear relationship was found between maternal CTQ score and infant HCC (n = 49, ß = -0.264, B = -0.006, SE 0.003, p = .052), but not for current maternal depression (n = 45, ß = -0.182, B = -0.011, SE 0.008, p = .164), current maternal anxiety (n = 45, ß = -0.209, B = -0.005, SE 0.003, p = .113) or recent life events (n = 46, ß = -0.128, B = -0.022, SE 0.023, p = .325). Analyses were adjusted for relevant infant hair characteristics. Specifically, maternal emotional and physical neglect were related to HCC in both mothers and infants. Conclusions: Results suggest that maternal childhood trauma is more prominent in altering maternal and infant long-term cortisol levels than perinatal depressive and anxiety symptomatology or recent life stressors in mothers with a history of depressive and/or anxiety disorders, and their infants. As infants of mothers with psychopathology are at increased risk for later psychiatric disease, future studies should investigate the interplay of possible risk factors for transgenerational transmission, intra-uterine programming of the HPA axis, including (epi-)genetic phenomena, of the HPA axis, and the influence of parenting impairment.

Examining the evidence on complementary and alternative therapies to treat peripartum depression in pregnant or postpartum women: study protocol for an umbrella review of systematic reviews and meta-analyses.

INTRODUCTION: Complementary and alternative therapies (CATs) refer to a diverse range of approaches that can be used as add-on or an alternative to conventional therapies. While a number of individual studies and systematic reviews (SRs) or meta-analyses (MAs) have investigated the effectiveness of specific types of CATs to treat depressive symptoms at specific moments of the perinatal period, an overarching synthesis of the literature is currently lacking. We will conduct an umbrella review of SRs and MAs to assess to which extent CATs are associated with depressive symptoms reduction during pregnancy or after childbirth. METHODS AND ANALYSIS: We will search a broad set of electronic databases (MEDLINE via Ovid, Embase.com, CINAHL via EBSCOhost, PsycINFO via Ovid, AMED and Google Scholar). We will include SRs with or without MAs meeting the following criteria: (1) the review should focus mostly on individual studies reporting a randomised controlled design; (2) diagnosis should be made during pregnancy or during the post partum using a clinical interview according to DSM or ICD criteria; (3) the reviewed intervention should start during pregnancy or in the first postpartum year and meet the criteria for being considered as CAT. The main outcome will be depressive symptoms reduction during pregnancy or after childbirth. Secondary outcomes will include the remission of depression according to DSM criteria and intervention acceptability. Overlap between reviews will be described, quantified and discussed. We will rate the quality of the included SRs or MAs using the AMSTAR-2 tool. MAs will be performed by using the data from the individual RCT studies included in the SRs or MAs. Sensitivity analyses restricted to studies with a low-moderate risk of bias will be realised. Publication bias will be examined visually by using a funnel plot, and formally using the Egger's test and test of excess significance. ETHICS AND DISSEMINATION: We intend to publish the results of the umbrella review in an international peer-reviewed journal. Oral presentations in congresses and internal diffusion through the Rise up-PPD European COST Action network are also planned. PROSPERO REGISTRATION NUMBER: CRD42021229260.

Clustering of characteristics associated with unplanned pregnancies: the generation R study.

BACKGROUND: Unplanned or unintended pregnancies form a major public health concern because they are associated with unfavorable birth outcomes as well as social adversity, stress and depression among parents-to-be. Several risk factors for unplanned pregnancies in women have previously been identified, but studies usually take a unidimensional approach by focusing on only one or few factors, disregarding the possibility that predictors might cluster. Furthermore, data on predictors in men are largely overlooked. The purpose of this study is to determine predictors of unplanned versus planned pregnancy, to determine predictors of ambivalent feelings regarding pregnancy, and to investigate how characteristics of men and women with an unplanned pregnancy cluster together. METHODS: This study was embedded in Generation R, a multiethnic population-based prospective cohort from fetal life onwards. Pregnancy intention was reported by 7702 women and 5367 partners. Information on demographic, mental, physical, social, and sexual characteristics was obtained. Logistic regression, multinomial regression and cluster analyses were performed to determine characteristics that were associated with an unplanned pregnancy, with ambivalent feelings regarding the unplanned pregnancy and the co-occurrence of characteristics in women and men with unplanned pregnancy. RESULTS: Twenty nine percent of the pregnancies were unplanned. Logistic regression analyses showed that 42 of 44 studied predictors were significantly associated with unplanned pregnancy. The most important predictors were young age, migration background, lower educational level, lower household income, financial difficulties, being single, lower cognitive ability, drug use prior to pregnancy, having multiple sexual partners in the year prior to the pregnancy, younger age of first sexual contact and a history of abortion. Multinomial regression analyses showed that a Turkish or Moroccan background, Islamic religion, little financial opportunities, being married, having ≥3 children, high educational level, more mental health and social problems and older age of first sexual contact were associated with prolonged ambivalent feelings regarding pregnancy. Different combinations of characteristics were observed in the four clusters of women and men with unplanned pregnancy. CONCLUSIONS: Many predictors are related with unplanned pregnancies, ambivalent feelings toward the pregnancy, and we identified very heterogeneous groups of women and men with unplanned pregnancies. This calls for heterogeneous measures to prevent unplanned pregnancies.

Childbirth related PTSD and its association with infant outcome: A systematic review.

INTRODUCTION: Maternal postnatal mental health problems may negatively impact child development. Postpartum research has mainly focused on the impact of maternal depression and anxiety due to their high prevalence (13-25 % and 10-18 %, respectively). However, maternal childbirth-related PTSD (CB-PTSD) could be another important risk factor in child development (estimated prevalence: 4.7 %). OBJECTIVE: We investigated whether maternal CB-PTSD (symptoms) are associated with a negative mother-child relationship and/or child developmental outcome for children aged 0-5 years. Furthermore, we examined whether maternal trauma-focused therapy can positively impact mother and child outcomes. METHODS: We performed a systematic review by searching three databases (Embase, Medline, PsycInfo). Search terms involved: 'birth or delivery modes', 'PTSD psychological trauma', and 'child development or child behavior'. Two independent reviewers evaluated all eligible papers. RESULTS: Thirty-five papers (30 samples) were included and qualitatively reported. Results suggest a negative association of maternal CB-PTSD (symptoms) with mother-infant attachment and child behavior. However, confounding factors may explain this association. The evidence on associations with breastfeeding, sleeping, socio-emotional development, and weight gain is insufficient. Research investigating the effect of maternal trauma-focused therapy on a child's outcome is scarce, contradictory, and of low quality. CONCLUSION: This systematic review suggests that maternal CB-PTSD may be associated with an increased number of problems in mother-infant attachment and child behavior, but other domains remain scarcely investigated and methodologic issues are present (cross-sectional study design, influence of confounding variables, sample representativeness, diversity in assessment tools). Our results support a multidisciplinary approach to providing early prevention and screening of the maternal mental health state.

Clinical practice guidelines with recommendations for peripartum depression: A European systematic review.

OBJECTIVE: This study aims to systematically review all Clinical Practice Guidelines (CPGs) with recommendations for peripartum depression in European countries. METHODS: A systematic review according to the PRISMA statement was conducted. CPGs focussing on peripartum depression or with at least one specific recommendation for peripartum depression from European countries were selected. Searching was conducted in electronic databases (MEDLINE and PsycINFO), and by contacting professional societies and international experts until November 24th, 2021. Characteristics of the included CPGs and their recommendations were extracted. A methodological quality assessment was conducted using the AGREE-II tool. RESULTS: A total of 239 records were identified after duplicate removal. Of these, 54 were examined for full-text inspection. The final selection yielded 14 CPGs from 11 European countries in 10 languages. Of them, 11 provided recommendations on pharmacological treatments, 10 on psychological treatment (e.g., cognitive-behavioural therapy), 10 on screening, 8 on diagnosis, 6 on other treatments (e.g., physical exercise), 5 on prevention, and 5 other recommendations (e.g., provide information). Regarding the overall methodological quality, only five (35.7%) guidelines were rated as of adequate quality, reaching a score ≥ 70% in the overall assessment of the AGREE-II instrument. Of the six AGREE-II domains, applicability scored the lowest and clarity of presentation scored the highest. CONCLUSION: The absence of CPGs in most European countries, the discrepancy in recommendations and the low methodological quality of the guidelines may lead to disparities and inequalities in peripartum depression management in Europe. The COST Action Riseup-PPD highlights key considerations for future guideline developers.

[Mental problems, psychosocial problems and substance use during pregnancy: a structured multidisciplinary approach reduces the child's risk]. / Psychische en psychosociale problemen of middelengebruik bij zwangeren.

AIM: To demonstrate the results of routine screening and treatment for psychiatric problems, psychosocial problems and substance use (PPS) among pregnant women in the Netherlands. This approach is advocated by the national program 'The first 1000 days', which focuses on a healthy start for (unborn) children in vulnerable situations. DESIGN: Secondary data analysis of a routine care dataset obtained from midwifery practices and hospitals throughout the Netherlands. All practices and hospitals applied systematic screening with Mind2Care. METHOD: Each Mind2Care screening results in either a negative result (no risk), an alert and/or a treatment advice based on local care pathways. Anonymous data on detected risk factors and subsequent alerts/advices from 22.141 pregnant women were analyzed. RESULTS: Of all women, 24% had at least one PPS risk factor. Accumulation of risks was present in 10% of women. Thirty-one percent of all pregnant women received at least one specific advice (15% alerts, 24% treatment advices, including overlap). CONCLUSION: One in four pregnant women has psychiatric problems, psychosocial problems and/or substance use for which guideline care is available. Implementation of Mind2Care is demanding to the obstetrical system, and requires multidisciplinary care processes of medical and social caregivers. Despite the lack of a scientific evidence on the added value of systematic detection and treatment of PPS-risks in all pregnancies, this programmatic approach is increasingly acknowledged on the national attention level as the way forward to a healthy start for every child, even if born under vulnerable conditions.

Prevalence and risk factors of birth-related posttraumatic stress among parents: A comparative systematic review and meta-analysis.

This systematic review and meta-analysis aimed to determine mean estimates of prevalence rates for fulfilling all diagnostic criteria of posttraumatic stress disorder (PTSD) or at least showing significant levels of posttraumatic stress (PTSS) in relation to the traumatic event of childbirth. For the first time, both mothers and fathers were included in the synthesis. Studies were identified through systematic database search and manual searches, irrespective of language. Meta-analyses of 154 studies (N = 54,711) applied a random-effects model to four data sets, resulting in pooled prevalence rates of 4.7% for PTSD and 12.3% for PTSS in mothers. Lower rates of 1.2% for PTSD and 1.3% for PTSS were found among fathers. Subgroup analyses showed elevated rates in targeted samples (those with a potential risk status) most distinctly for maternal PTSS. The significant amount of heterogeneity between studies could not be explained to a satisfactory degree through meta-regression. Given the substantial percentage of affected parents, the adoption of adequate prevention and intervention strategies is needed. As this field of research is evolving, attention should be broadened to the whole family system, which may directly and indirectly be affected by birth-related PTSD. Further studies on paternal PTSD/PTSS are particularly warranted.

Treatment of Peripartum Depression with Antidepressants and Other Psychotropic Medications: A Synthesis of Clinical Practice Guidelines in Europe.

This study examined (1) the availability and content of national CPGs for treatment of peripartum depression, including comorbid anxiety, with antidepressants and other psychotropics across Europe and (2) antidepressant and other psychotropic utilization data as an indicator of prescribers' compliance to the guidelines. We conducted a search using Medline and the Guidelines International Network database, combined with direct e-mail contact with national Riseup-PPD COST ACTION members and researchers within psychiatry. Of the 48 European countries examined, we screened 41 records and included 14 of them for full-text evaluation. After exclusion of ineligible and duplicate records, we included 12 CPGs. Multiple CPGs recommend antidepressant initiation or continuation based on maternal disease severity, non-response to first-line non-pharmacological interventions, and after risk-benefit assessment. Advice on treatment of comorbid anxiety is largely missing or unspecific. Antidepressant dispensing data suggest general prescribers' compliance with the preferred substances of the CPG, although country-specific differences were noted. To conclude, there is an urgent need for harmonized, up-to-date CPGs for pharmacological management of peripartum depression and comorbid anxiety in Europe. The recommendations need to be informed by the latest available evidence so that healthcare providers and women can make informed, evidence-based decisions about treatment choices.

The Dutch Infant Caregiving Assessment Scales: Psychometric properties in mothers with and without a severe psychiatric disorder.

OBJECTIVES: This study examines the psychometric properties of the Dutch adaptation of the Infant Caregiving Assessment Scales (INCAS). This standardized observation procedure is the first to assess both emotional and instrumental caregiving skills of mothers with a severe psychiatric disorder, during the postpartum period. METHODS: Mothers with and without a severe psychiatric disorder (N = 123) were observed at home at the infant age of 6 weeks during daily caregiving; changing a diaper, bathing, dressing, and feeding. Recordings of observations were coded independently by trained coders, blind for group membership. Subsequently, the component structure, internal consistency, interrater reliability, and concurrent validity of the INCAS were examined. RESULTS: Principal component analysis largely confirmed the two a priori defined caregiving domains. The internal consistencies of the emotional and instrumental domains were deemed excellent and good, respectively. The interrater reliability was substantial for the emotional domain and moderate for the instrumental domain. Furthermore, evidence for good concurrent validity of the emotional domain was found. Lastly, significant correlations were found between specific instrumental caregiving skills and maternal neuropsychological functioning. CONCLUSION: Psychometric findings support the INCAS as a comprehensive and reliable instrument for standardized assessment of caregiving by mothers with a severe psychiatric disorder.