What's New: Stress in Pregnancy & Motherhood Readiness
(From a presentation by Kathryn E. Barnard on May 12, 2003)

There is a need to reorient the health care delivery system to several psychological issues during pregnancy that have important implications for the outcome of pregnancy and the assumption of the parenting role. The two issues I have in mind are the anxiety/depression of the mother, and her preparation for taking on the mothering role.

For the past twenty years, data from animal models and more recently the human are documenting the impact stress has on the regulatory systems of the pregnant organism. Studies have identified that anxiety and stress have a role in altering the duration of pregnancy and the well being of the fetal brain. Wadhwa, et al. (2001) propose that maternal stress may be mediated through biological and or behavioral mechanisms through the neuroendocrine and or immune/inflammatory pathway. They propose that placental corticotropin releasing hormone (CRH) may play a key role.

Hobel, Dunkel-Schetter, Roesch, Castro and Arora (1999) demonstrated empirically that maternal plasma corticotropin releasing hormone was related to stress levels reported by women during their 20th week of pregnancy. Those stress and CRH levels at 20 weeks were also related to later measures of reported stress and CRH during the pregnancy and to the occurrence of preterm delivery.

Another study measuring both anxiety and depression found that, in combination with the mother's history of being underweight or of prior preterm labors, antenatal measures of anxiety and depression were associated with preterm labor. Dayan, et al. (2002)

Monk (2001) reports that fetal heart rate patterns are associated with maternal anxiety and depressive symptoms. He suggests that these fetal heart rate markers are linked to differences in the neurobiological substrate of the fetus's emerging emotional regulation system. Another group from Sweden (Sjostrum, et al. 1997) reported less fetal cerebral blood flow in instances of increased maternal anxiety.

A study done in the area of Avon, England, reports that maternal antenatal anxiety measured from a paper pencil questionnaire correlated with children's behavioral and emotional problems when the children were age four (O'Connor, et al. 2002). Teixeria, Fish & Glover, 1999, report a study of mothers at 32 weeks gestation to see if there was any correlation between anxiety and uterine blood flow. The results showed that, in the high anxiety mothers, there was with impaired blood flow through the uterine arteries. The reduced uterine blood flow could be a mechanism for lower birth weight, preterm births and infants with elevated cortisol seen in highly anxious women. However, another study done earlier in pregnancy, at 20 weeks (Hughes, Ormerod, Jones and Thilaganathan, 2002), found no association with maternal anxiety at this early point in the pregnancy.

There has been little attention to the mental health status of pregnant women in obstetrical care. Very few providers do screening, assessment or consider any treatment. Kelly (2001) reported 23% of pregnant women receiving prenatal care in California demonstrated depressive and anxiety disorders. In studies of poor pregnant women in Early Head Start, the rate of maternal depression ranges from 30-70%. This empirical data substantiate that mood state and the neuroendocrine and immune systems may play a critical role in reproductive outcome and fetal development. At the very least we need to challenge the health care system to begin monitoring anxiety and depression in pregnant women and to begin helping women deal with the unbalanced function of their autonomic nervous system.

There is plenty of data to show how exercise, massage and meditation can regulate the HPT and autonomic nervous system. This down regulation of the system is critical in regulating the biological response to stress, especially in the natural acceleration during pregnancy (Clapp, 2001, Brown, et al 2001).

The second issue I want to address is the psychological preparation to mother. At least 40 years ago, Reva Rubin, a nurse specializing in maternity care doing doctoral work at the University of Chicago, carefully observed women during their pregnancy, labor and delivery and during the early postpartum period. She integrated those observations into a theory about the development of maternal identity. There are four maternal tasks the mother deals with during pregnancy. These are (1) seeking safe passage; (2) ensuring the acceptance of the child by others; (3) binding in or bonding with the fetus; and (4) learning to give of oneself. Josten, a student of Rubin's, evaluated the course of pregnancy in the population studied by Egelund and Stroufe. From prenatal chart reviews, she found that the mothers rated as providing excellent mothering had higher scores on their perception of the complexities of the mothering role; acceptance of the child by significant others; and physical well being during pregnancy. On the other hand the mothers rated as providing inadequate care had more negative scores on maternal tasks.

Josten's findings have been replicated in a recent population we followed from Early Head Start. Women with unresolved stress and trauma had a trajectory of increasingly inadequate mothering with their infants and toddlers. We need to reform our Health Care system. Currently the Federal government provides money to provide prenatal care and maternity support services from pregnancy confirmation through the second month postpartum. Cases can be followed beyond two months post partum for case management but direct services cannot be reimbursed. We have found in Washington State that the peak of anxiety and depression in the First Steps program is at two months.

In the late 1980's, through a research partnership with an Early Head Start program in King County, we instituted a protocol utilizing the theories of Rubin. We found that the mothers were receptive to talking about their pregnancy and their role as a mother. Many of them had not identified a maternal role model, having rejected their own mother as such a model. From this work, Solchany (2001) developed a book that addresses mental health theory and practice and intervention protocols during pregnancy, specifically as they relate to maternal role attainment. This book, Promoting Maternal Mental Health During Pregnancy, is quickly becoming a classic in the field for nurses, midwifes and other human resource providers involved in pregnancy services.

We do know that the assignment of a birth doula influences intrapartum outcomes and this is thought to be related to the anxiety-reducing support a doula provides during labor and delivery.

(Please see references below for additional reading on these topics.)

Related References:

Barnard, K.E. and Solchany J.E. (2002) Mothering in Handbook of Parenting Ed. M.H. Bornstein. Mahwah, NJ. Erlbaum Associates

Brown, M.A., Goldstein-Shirley, J., Robinson, J. & Casey, S. (2001)
The Effects of a Multi-Modal Intervention Trial of Light, Exercise, and Vitamins on Women's Mood. Women & Health, Vol. 34(3) 2001.

Copper, R.L., Goldenberg, R.L., Das, A., Elder, N., Swain, M., Norman, G., Ramsey, R. Cotroneo, P., Collins, V.A., Johnson, F., Jones, P., Meier, A.M. (1996)The preterm prediction study: maternal stress is associated with spontaneous preterm birth at less than thirty-five weeks gestation. National Institutes of Child Health and Human Development Maternal-Fetal Medicine Units Network. Am J Obstet Gynecol. Nov; 175(5): 1286-92.

Dayan, J., Creveuil, C., Herlicoviez, M., Herbel, C., Baranger, E., Savoye C. & Thouin, A. (2002) Role of anxiety and depression in the onset of spontaneous preterm labor. Am J Epidemiol. Feb 15;155(4): 302-4.

Glover, V. (1999) Maternal stress or anxiety during pregnancy and the development of the baby. Pract Midwife May; 2(5):20-2.

Hobel, C.M., Dunkel-Schetter, C., Roesch, S.C, Castro, L.C. & Arora, C.P. (1999) Hormonal Pathways of Preterm Birth: Maternal plasma corticotropin-releasing hormone associated with stress at 20 weeks' gestation in pregnancies ending in preterm delivery. American journal of Obstetrics and Gynecology, Vol 180, N 1.

Kelly, RH, Russo, J. & Katon, W. (2001) Somatic complaints among pregnant women cared for in obstetrics: normal pregnancy or depressive and anxiety symptom amplification revisited. Gen Hosp Psychiatry. May-June; 23(3): 107-13.

Kent, A., Hughes, P., Ormerod, L. Jones, G. & Thilaganathan, B. (2002) Uterine artery resistance and anxiety in the second trimester of pregnancy. Ultrasound Obstet Gynecol Feb; 19(2): 177-9.

O'Connor, TG, Heron, J., Golding, J., Beveridge, M. & Glover, V. (2002)
Maternal antenatal anxiety and children's behavioral/emotional problems at 4 years. Report from the Avon Longitudinal Study of Parents and Children. Br J Psychiatry June; 180:478-9.

Monk, C. (2001) Stress and mood disorders during pregnancy: implications for child development. Psychiatry Q Winter;72(4):347-57.

Rubin, R. (1984) Maternal Identity and maternal experience. New York: Springer

Sjostrom, K., Valentin, L., Thelin, T. & Marsal K. (1997) Maternal anxiety in late pregnancy and fetal heodynamics. Eur J Obstet Gynecol Reprod Biol. Aug; 74(2): 149-55.

Solchany, J. (2001) Promoting Maternal Mental Health During Pregnancy. Seattle. University of Washington. NCAST Publications. www.ncast.org

Solchany, J., Sligar, K. & Barnard, K.E. (2002) Attachment promoting interventions in pregnancy. The parent-child communication coaching program. In J.M>M. Duran (Ed.) Infant and early childhood mental health, models of clinical intervention. Washington D.C: American Psychiatric Press.

Teixeria, J.M., Fisk, N.M. & Glover, V. (1999) Association between maternal anxiety in pregnancy and increased uterine artery resistance index: cohort based study. BMJ. May 8; 318(7193) 1288-9.

Wadhwa, P.D., Culhane, J.F, Rauh, V., Barve, S.S., Hogan, V., Sandman, C.A., Hobel, C.J., Chicz-DeMent, A., Dunkel-Schetter, C., Garite, T.Jl and Glynn, L. (2001) Paediatric and Perinatal Epidemiology 2001, 15 (Suppl.2) 17-29.

Archives
Copyright © 2003 Stepping Up, Seattle, Washington, USA