Adult attachment style as a risk factor for maternal postnatal depression: a systematic review

COVID-19-Related worries mediate the association between attachment orientation and elevated depression levels at 21-month postpartum

BACKGROUND

The study's aims were to examine whether the COVID-19 pandemic was associated with increases in depression levels of 21 months postpartum women who were initially sampled before the pandemic and whether COVID-19-related worries mediated the association between women's attachment orientations and this hypothesized increase.

METHODS

Participants comprised 185 postpartum women sampled in the maternity ward of a tertiary healthcare center in Israel followed from childbirth to 21 months postpartum in four-time points. . We analyzed demographic and obstetric information and the Experiences in Close Relationships (ECR) scale at T1; changes in the Edinburgh Postnatal Depression Scale (EPDS) levels at all timepoints (T1-4); and COVID-19-related worries at T4.

RESULTS

Results showed a significant increase in depression levels at T4 compared to T2 and T3, and an increase in the prevalence of women at the lower clinical EPDS threshold. COVID-19-related worries mediated the association between anxious attachment and depression (indirect effect: B = .21, p < .05, 95% CI = (.015, .47), R2=0.12).

DISCUSSION

The evident effect of COVID-19 on postpartum depression is associated with variability between people. Thus, early assessment of women's attachment orientations might provide a strategy for identifying and treating women at risk.

Early Parenting Interactions and First-Time Mothers' Postnatal Depression and Parental Competence

Objectives: Schema Therapy, an approach that integrates cognitive-behavioural and attachment principles, helps us understand the impact of early interactions with caregivers on adult mental health. These early interactions can be assessed through Schema Therapy-informed tools; however, these tools have yet to be used with a postnatal population, which represents a period of vulnerability for new mothers. Therefore, the present study aimed to evaluate the impact of positive and negative early parenting interactions on a first-time mother's mental health and her sense of competence during the postnatal period, using recently revised and newly developed Schema Therapy-informed tools. Design: This is a cross-sectional study. Method: First-time mothers (N = 220) participated in an online survey within 12 months post-birth. Participants completed the Positive Parenting Schema Inventory (PPSI), Young Parenting Inventory-Revised (YPI-R2), Edinburgh Postnatal Depression Scale (EPDS), and Parenting Sense of Competence (PSOC) scale. The data were analysed using hierarchical multiple regression and mediational analysis. Results: Negative early interactions with mothers and fathers led to greater postnatal depressive symptomology, while positive early interactions with mothers led to fewer postnatal depressive symptoms. Mediation analyses revealed that postnatal depressive symptoms mediated early parenting interactions and participants' sense of parenting competence as a new mother. Conclusions: The protective effects of positive early interactions with caregivers can help first-time mothers' postnatal emotional adjustment and their sense of competence through diminished postnatal depressive symptoms. However, the enduring effects of negative early interactions with caregivers can contribute to a first-time mother's risk of developing postnatal depression and negatively affect her sense of parental competence.

Risk psychosocial factors associated with postpartum depression trajectories from birth to six months

PURPOSE

The purpose of this study was to assess the trajectory of women's depressive symptoms during the first six months postpartum, identify risk factors (sociodemographic, obstetric and personality) associated with classes, and examine associations between classes and postpartum PTSD at two months and bonding at six months.

METHODS

The final sample included 212 women who gave birth in the maternity wards of a large tertiary health center that were approached at 1-3 days, two months, and six months postpartum and completed a demographic questionnaire and measures of neuroticism (BFI) and postpartum depression (EPDS), postpartum PTSD (City Birth Trauma Scale) and bonding (PBQ). Obstetric data were taken from the medical files.

RESULTS

Cluster analysis revealed three distinctive clusters: "stable-low" (64.2%), "transient-decreasing" (25.9%), and "stable-high" (9.9%). Neuroticism, general-related PTSD symptoms, and bonding were associated with differences between all trajectories. Birth-related PTSD symptoms were associated with differences between both stable-high and transient-decreasing trajectories and the stable-low trajectory. No obstetric or demographic variables were associated with differences between trajectories.

CONCLUSION

We suggest that screening women for vulnerabilities such as high levels of neuroticism and offering treatment can alleviate the possible deleterious effects of high-symptom depression trajectories that may be associated with their vulnerability.

High care and low overprotection from both paternal and maternal parents predict a secure attachment style with a partner among perinatal Japanese women

This study aimed to determine how paternal and maternal parenting before adolescence affects adult attachment to a partner during the perinatal period, using three different models of attachment. We used the Parental Bonding Instrument (PBI) and the Relationship Questionnaire (RQ) to examine perceived parenting practices and adult attachment styles, respectively. The participants included 4586 Japanese women who were pregnant or who had given birth, up until one month after childbirth. We performed structural equation modeling analysis between PBI and RQ scores with three different category models, including the four-category model (secure, fearful, preoccupied, and dismissive attachment) as Model 1, the two-category model (model of the self and others) as Model 2, and the single-category model (total attachment style) as Model 3. Models 1 and 2 showed a good fit. Both path models showed a significant association between adult attachment style and perceived paternal and maternal parenting before adolescence, where high care and low overprotection from both paternal and maternal parents predicted adult attachment. Our findings indicate that attachment styles are best described using the four-category and two-category models, and suggest that both paternal and maternal overprotection and care influence adult attachment with a partner during the perinatal period.

Coping as a Mediator between Attachment and Depressive Symptomatology Either in Pregnancy or in the Early Postpartum Period: A Structural Equation Modelling Approach

Peripartum depression (PPD) is a major complication of pregnancy, and numerous risk factors have been associated with its onset, including dysfunctional coping strategies and insecure attachment styles, both during pregnancy and postpartum. The aim of our study was to investigate the role of coping strategies in mediating the relationship between women's attachment style and depressive symptomatology in pregnancy and one week after giving birth in a large sample of women (N = 1664). Our hypothesis was that the relationship between anxious and avoidant attachment and depressive symptomatology would be mediated by use of maladaptive coping strategies. The assessment instruments were Edinburgh Postnatal Depression Scale (EPDS), Brief Coping Orientation for Problem Experiences (COPE), and Experiences in Close Relationship Scale (ECR). The results indicated that the effect of insecure attachment styles (anxious and avoidant attachment) on antepartum depressive symptomatology was partially mediated by dysfunctional coping styles. Anxious attachment also has an indirect significant effect on postpartum depressive symptomatology through emotional coping; however, avoidant attachment does not seem to be significantly related to postpartum depressive symptoms. Our findings revealed that not only is it important to consider attachment in understanding peripartum depressive symptomatology, but also that coping plays an important role in these relationships. These findings would help a preventive coping-based intervention strategy to enhance the capacity of women with insecure attachment styles to use more adaptive coping during and after pregnancy.

Mother-child interactions among children with visual impairment: Addressing maternal attachment style, depression-anxiety symptoms, and child's behavioral problems

OBJECTIVE

The birth of a visually impaired child leads to stress, disappointment, and medical challenges for the family due to the economic and financial costs, unmet expectations of other family members, and social embarrassment-isolation of the family from society. In these families, mothers are exposed to the stressors more often than other family members, because, in most families, they are the primary caregivers. In this study, we examined the relationship between maternal attachment styles, maternal depression and anxiety levels, and behavioral problems of children with visual impairment.

METHODS

This is a case-control study. In the study group, there were 35 children with visual impairment, and in the control group, there were 31 healthy children. All mothers completed adult attachment style dimensions scales, beck depression, and anxiety inventories, and the aberrant behaviour checklist.

RESULTS

Our results demonstrated that children with visual impairment have higher levels of behavior problems including irritability, stereotypic behavior, and inappropriate speech when compared with healthy controls. Contrary to our expectations depression and anxiety, scores of mothers were similar, also, there was not a difference in terms of maternal attachment types. Interestingly, there was a positive relationship between secure attachment and depression among mothers of the visual impairment group. In other words, securely attached mothers were more depressive. On the other hand, there was a positive relationship between anxious/ambivalent attachment and the child's irritability.

CONCLUSION

The relationship between maternal depression and secure attachment could be a consequence of higher maternal sensitivity due to a child's impairment and should be evaluated in future studies.

Attachment-based psychosocial programme for under-privileged school children with adverse life experiences in Istanbul, Turkey

Children experiencing educational neglect are likely to experience the harm associated with adverse life experiences and a range of emotional and psychological challenges. Using attachment theory and psychosocial frameworks, we devised and implemented an intervention designed to ameliorate the deleterious effects of challenging behaviours in an elementary school situated in a deprived neighbourhood of Istanbul, Turkey. For a period of eight months, 160 pupils received a psychosocial intervention once a week. Children’s patterns of behaviour, emotions, movements, interactivity, socialisation and interpersonal communications were observed during this period. Core activities of the intervention included library visits, reading, writing and listening games, maths games, drawing, animal animation, leaf making, ball games, parachuting games, colouring, hula-hoop and driver-car role plays. At the end of the intervention, one group of children made significant improvements in behavioural changes while no improvements were observed for another group. Although further research is required to generalize beyond the reference group, the findings suggest that a robust collaboration between inter-agency community partnership and universities can play a crucial role in responding to the needs of marginalized children with psychological and emotional problems.

Maternal adult attachment and maternal-fetal attachment in the context of romantic relationship quality after premature birth-A cross sectional study

OBJECTIVE

The primary outcome of the study was to evaluate the maternal adult attachment and maternal-fetal attachment (MFA) in the context of romantic relationship quality among mothers of preterm born children. Associations between MFA, maternal adult attachment, maternal perceived stress, depressive symptoms, social support in the neonatal period were also examined as secondary outcomes.

MATERIALS AND METHODS

The study had a cross-sectional design and involved 260 of women after premature birth, who participated in the study in the early neonatal period. The following self-reported methods were used: Socio-demographic questionnaire, Attachment Styles Questionnaire (ASQ), Maternal-Fetal Attachment Scale (MFAS), The Perceived Stress Questionnaire (PSQ), The Dyadic Adjustment Scale (DAS), The Edinburgh Postnatal Depression Scale (EPDS), The Social Support Questionnaire (SSQ).

RESULTS

The results showed that a secure attachment style is associated with a higher intensity of the MFA and consequently, a higher quality of the romantic relationship. Regression analysis presented that the higher the secure attachment score, the lower the perceived level of stress and depressive symptoms, which in turn lead to a higher quality of the partner relationship.

CONCLUSION

Maternal secure attachment positively impacts the romantic relationship quality and the maternal-fetal attachment. The findings also draw attention to the role of the secure attachment style as a protective factor while coping with stress and depressive symptoms.

The relationship between postpartum depression and social support during the COVID-19 pandemic: A cross-sectional study

AIM

This study aims to examine the prevalence of postpartum depression and its relationship with social support adjusted for self-perceived impact of COVID-19 in parturient women admitted to a perinatal medical center in Japan.

METHODS

This cross-sectional study included 513 women who underwent a 1-month postpartum checkup between August 3 and November 27, 2020. Postpartum depression was measured using the Edinburgh Postnatal Depression Scale. Social support was measured using the Multidimensional Scale of Perceived Social Support and the score was dichotomized using the Youden index. Nineteen demographic and obstetric characteristics were also assessed.

RESULTS

Postpartum depression was observed in 35 (7.6%) of 461 women: 25 (26.6%) and 10 (2.7%) in the low- and high-support groups, respectively. Women in the low-support group were significantly more likely to have postpartum depression than those in the high-support group (odds ratio [OR], 11.7; 95% confidence interval [CI], 5.4-27.3; p < 0.001). Furthermore, no interaction was observed between social support and the impact of COVID-19 for postpartum depression (p = 0.32).

CONCLUSIONS

The prevalence of postpartum depression in the study institution was lower than that reported by previous studies in Japan. Moreover, social support was an important predictive factor for postpartum depression during the COVID-19 pandemic.

Postnatal Major Depressive Disorder in Australia: Inequalities and Costs of Healthcare to Individuals, Governments and Insurers

BACKGROUND

Perinatal mental health has pervasive impacts on the wellbeing of both the mother and child, affecting quality of life, bonding and attachment and cognitive development.

OBJECTIVES

The aim of this study was to (i) quantify the costs to government healthcare funders, private health insurers and individuals through out-of-pocket fees, of women with postnatal major depressive disorder (MDD); and (ii) identify any socioeconomic inequalities in health service use and costs amongst these women.

METHODS

A whole-of-population linked administrative dataset containing the clinical records and health service use for all births in the state of Queensland, Australia between 01 July 2012 and 30 June 2015 was used (n = 189,081). Postnatal MDD was classified according to ICD-10 code, with women hospitalised for MDD in the 12 months after birth classified as having 'postnatal MDD' (n = 728). Health service use and costs from birth to 12 months post-birth were included. Total costs included cost to government funders and private health insurers and out-of-pocket fees. Total costs and costs to different funders were compared for women with postnatal MDD and for women without an inpatient event for postnatal MDD, with unadjusted means presented. A generalised linear model was used to compare the difference in total costs, adjusting for key confounders. Costs to different funders and number of different services accessed were then compared for women with postnatal MDD by socioeconomic status, with unadjusted means presented.

RESULTS

The total costs from birth to 12 months post-birth were 636% higher for women with postnatal MDD than women without an inpatient event for postnatal MDD, after accounting for differences in private hospital use, mode of birth, clinical characteristics and socioeconomic status. Amongst women with postnatal MDD, the cost of all services accessed was higher for women of highest socioeconomic status than for women of lowest socioeconomic status (A$15,787.66 vs A$11,916.94). The cost of services for women of highest socioeconomic status was higher for private health insurers (A$8941.25 vs A$2555.26), but lower for public hospital funders (A$2423.39 vs A$6582.09) relative to women of lowest socioeconomic status. Outside of public hospitals, costs to government funders was higher for women of highest socioeconomic status (A$2766.80 vs A$1952.00). Women of highest socioeconomic status accessed more inpatient (8.2 vs 3.1) and specialist services (13.4 vs 5.5) and a higher proportion had access to psychiatric specialist care (39.7% vs 13.6%) and antidepressants (97.6% vs 93.8%).

CONCLUSION

MDD is costly to all funders of healthcare. Amongst women with MDD, there are large differences in the types of services accessed and costs to different funders based on socioeconomic status. There may be significant financial and structural barriers preventing equal access to care for women with postnatal MDD.

The association of attachment style, postpartum PTSD and depression with bonding- A longitudinal path analysis model, from childbirth to six months

BACKGROUND

There is substantial evidence that postpartum depression (PPD) is associated with a poor mother-infant bond, however, fewer studies have examined the role of other postpartum psychopathologies such as birth-related PTSD or relevant trait variables such as adult attachment styles in the quality of the mother-infant bond.

METHODS

210 postpartum women were sampled in a maternity ward of a tertiary health care center. Participants completed questionnaires at three-time points. Demographics questionnaire and the Adult Attachment style scale were administrated at 1-4 days postpartum, the City Birth Trauma Scale and the Edinburgh Postpartum Depression Scale two months postpartum and the Postpartum Bonding questionnaire at six months postpartum.

RESULTS

The associations between adult attachment styles and postpartum bonding were fully mediated by postpartum psychopathology. Avoidant attachment had indirect effects on bonding through general PTSD symptoms (Beta=0.05, p=.019) and PPD (Beta=0.06, p=.010). Anxious attachment also had indirect effects on bonding through general PTSD symptoms (Beta=0.04, p=.044) and PPD (Beta=0.10, p=.001). In contrast, birth-related PTSD symptoms were not associated with bonding. The model presented a good fit.

LIMITATIONS

Women sampled from one health-care center and self-report measures used.

CONCLUSIONS

Our results suggest that although birth-related PTSD symptoms may cause difficulties, importantly they may not be associated with bonding difficulties six months postpartum. Therefore, women could be reassured that their birth-related PTSD symptoms, may not impact on bonding. Consequently, if interventions are specifically aimed at improving the mother-infant bond, the general-related PTSD, PPD symptoms and insecure attachment styles should be the focus of treatment.

Psychosocial factors associated with postpartum psychological distress during the Covid-19 pandemic: a cross-sectional study

BACKGROUND

Trauma, natural and man-made catastrophic events can be predictors of postpartum psychological distress. In a public health response due to coronavirus disease 2019 outbreak, the Italian government imposed a lockdown from March 9 to May 3. This extraordinary situation may have been challenging for maternal psychological health. The aim of this study was to investigate the prevalence of depressive and post-traumatic stress symptoms in women giving birth during the Covid-19 pandemic and its associations with quarantine measures, obstetrical factors, and relational attachment style.

METHODS

Women who gave birth in a high-volume obstetric/gynaecological medical centre located in an epidemic area during the Covid-19 pandemic (March 8 to June 15) were asked to complete an online survey about their childbirth experience and the perceived effect of the pandemic. The Edinburgh Postnatal Depression Scale (EPDS), the Impact of Event Scale-Revised (IES-R), and the Relationship Questionnaire (RQ) were administered to assess levels of postpartum depressive and post-traumatic stress symptoms (PTSS) and relational style of attachment, respectively. Multivariate analysis was applied to identify associations between quarantine measures, childbirth experience, attachment style, and EPDS and IES-R scores.

RESULTS

The survey was completed by 163 women (response rate 60.8%). The prevalence of depressive symptoms was 44.2% (EPDS cut-off score ≥ 11) and the PTSS rate was 42.9% (IES-R cut-off score ≥ 24). Dismissive and fearful avoidant attachment styles were significantly associated with the risk of depression and PTSS, respectively. Perceived pain during birth was a risk factor for postpartum depression. Perceived support provided by healthcare staff was a protective factor against depression and PTSS. Another protective factor against PTSS was quiet on the ward due to the absence of hospital visitors.

CONCLUSION

This study reports a high prevalence of postpartum depressive and PTSS in women who gave birth during the Covid-19 pandemic. Postnatal psychological distress seemed to be associated more with the prenatal experience and other individual factors than with the pandemic hospital restrictions. Early detection during pregnancy of an insecure attachment style is fundamental to provide targeted preventive and therapeutic psychological interventions.

The associations between insecure attachment, rooming-in, and postpartum depression: A 2 months' longitudinal study

Postpartum depression (PPD) is the most common complication of childbearing, and recent studies have attempted to examine risk factors associated with it. The main study hypothesis was that a protective situational factor at a sensitive time period (full rooming-in postpartum) would moderate the associations between insecure attachment dimensions and PPD. Three hundred twelve women, in either full or partial rooming-in, participated in a longitudinal study at the maternity ward of a tertiary healthcare center. A Demographic questionnaire and the Experiences in Close Relationships Scale were administered at 1-4 days postpartum, and the Edinburgh Postnatal Depression scale at 2 months postpartum. PPD was significantly associated with both anxious and avoidant attachment dimensions, but not with rooming-in conditions. In addition, women in partial rooming-in showed a positive correlation between insecure attachment dimensions and PPD, whereas no such correlation was found for full rooming-in women. A situational factor such as full rooming-in, which occurs at a critical time point for the mother-infant relationship, can moderate the association between maternal avoidant or anxious attachment dimensions and the mother's PPD levels. Postpartum practices, such as rooming-in, can be personalized and thus beneficial in moderating personal risk factors for PPD.

Maternal-fetal bonding among pregnant women at psychosocial risk: The roles of adult attachment style, prenatal parental reflective functioning, and depressive symptoms

Pregnancy offers a unique period for initiating preventive parenting interventions. Disturbances in maternal-fetal bonding may indicate suboptimal parenting and a need for intervention. However, more knowledge is needed on the development of maternal-fetal bonding among at-risk groups. The study aim was to examine psychosocial correlates of maternal-fetal bonding among pregnant women identified to be at risk socially and regarding their mental health. The sample consisted of 78 at-risk pregnant women participating in a perinatal intervention study: Godt på Vej Sammen [A Good Start to Life—an Early Cross-sectorial Intervention]. This study was cross-sectional reporting on the baseline characteristics of the participants. In the beginning of the second trimester, participants completed questionnaires assessing maternal-fetal bonding (the Maternal Antenatal Attachment Scale [MAAS]), prenatal parental reflective functioning, adult attachment style, and depressive symptoms. We compared the distribution of MAAS styles with norms from a recent Dutch community sample. In addition, we tested associations between psychosocial variables and the quality and intensity of MAAS scores in regression models and performed Chi-square analyses to assess the association of MAAS styles with psychosocial variables. First, compared to women from a community sample, approximately half of the women in our sample presented lower and suboptimal MAAS scores. Second, insecure avoidant adult attachment style was negatively associated with MAAS intensity, and depressive symptoms were negatively associated with MAAS quality. Third, prenatal parental reflective functioning positively correlated with both quality and intensity of MAAS. Fourth, we found no association between insecure anxious adult attachment style and MAAS scores. Fifth, women with a negative disinterested MAAS style demonstrated the highest avoidant attachment scores, while women with a positively preoccupied MAAS style demonstrated the highest prenatal parental reflective functioning scores. The results suggest that there is a need to differentiate among at-risk pregnant woman and that prenatal screening using the MAAS may help identify those who need preventive parenting interventions and what those interventions should focus on. A main limitation of the study is the lack of a representative group of at-risk pregnant women which limits the generalizability of the study results to all risk groups.

Personal and Family Resources Related to Depressive and Anxiety Symptoms in Women during Puerperium

Introduction: This study investigated the relationship between personal and family resources (i.e., social support, family functioning, self-efficacy in care, sense of coherence and perceived burden of care) and depressive and anxiety symptoms in women during the puerperium, adjusting for stressors. Methods: This is a quantitative research design, carried out through a descriptive, cross-sectional correlation study. This study includes 212 women over the age of 19 who gave birth from March to September 2019 in Maternal and Child Hospital of Jaén (Spain). Women were selected during the immediate postpartum period. The variables analysed were postpartum depressive symptoms (Edinburgh scale), anxiety symptoms (STAI state anxiety questionnaire), perceived social support (Duke-UNC-11), family functioning (family APGAR), self-efficacy in care (Lawton), sense of coherence (SOC-13), perceived burden (Caregiver Strain Index) and stressful life events (Holmes and Rahe). The main analysis consisted of a multiple linear regression. Results: The regression model of depressive symptoms found a positive association with perceived burden (β = 0.230, p = 0.015) and negative associations with self-efficacy in care (β = -0.348, p < 0.001), social support (β = -0.161, p < 0.001) and sense of coherence (β = -0.081, p = 0.001). The regression model of anxiety symptoms obtained a positive association with perceived burden (β = 1.052, p < 0.001) and negative associations with self-efficacy in care (β = -0.329, p = 0.041), social support (β = -0.234, p = 0.001) and sense of coherence (β = -0.262, p < 0.001). Discussion: Firstly, depressive and anxiety symptoms in the puerperium period may be more prevalent than in other periods of a woman's life. Secondly, perceived social support, self-efficacy in caring for the newborn and sense of coherence may be protective factors for depressive and anxiety symptoms in the puerperium period. Finally, perceived burden in caring for the newborn may be a risk factor for these symptoms.

Association between Lack of Social Support from Partner or Others and Postpartum Depression among Japanese Mothers: A Population-Based Cross-Sectional Study

Lack of social support is a known risk factor for postpartum depression (PPD). However, the association between lack of social support from a partner or others and PPD remains unknown. We examined this association among Japanese mothers. We distributed an original questionnaire to mothers participating in a three- or four-month health check-up program over October to November 2012 in Aichi Prefecture, Japan. Of the 9707 eligible mothers, 6590 responded to the questionnaire (response rate: 68%). Social support from a partner or others was assessed based on whether the mother can consult with her partner or others (i.e., parents, relatives, and friends who are close by or far) on childcare. PPD was assessed with the Edinburgh Postnatal Depression Scale. The data were analyzed using multiple logistic regression analysis for four categories: no social support from either a partner/others, social support from a partner only, social support from others only, and social support from both, adjusted for possible covariates. Mothers who have no social support from either a partner/others, have social support from a partner only, and have social support from others only were 7.22 (95% confidence interval [CI], 1.76–29.6), 2.34 (95% CI, 1.37–3.98), and 3.13 (95% CI, 2.11–4.63) times more likely to show PPD, respectively, in comparison with mothers who have social support from both, after adjustment of possible covariates. Mothers with no social support from a partner, but have social support from others, showed significant risk for PPD, which may be invisible. Further prevention effort is needed to detect PPD cases, with a focus on mothers without support from their partner.

An early intervention to promote maternal sensitivity in the perinatal period for women with psychosocial vulnerabilities: study protocol of a randomized controlled trial

BACKGROUND

Maternal mental well-being and social circumstances during pregnancy and early childhood impact the child's well-being and development. Supportive and sensitive parenting is one of the strongest predictors of positive emotional, social and behavioral outcomes for the child. Knowledge is needed about how to detect and support vulnerable families already during pregnancy and in the postnatal period. The aim of this study is to assemble and evaluate an interdisciplinary cross-sectoral intervention to promote maternal sensitivity among women with psychological or social vulnerabilities.

METHODS/DESIGN

This randomized controlled trial tests the efficacy of an intervention program in the perinatal period compared to care as usual in enhancing maternal sensitivity in a group of psychologically or socially vulnerable women in the Capital Region of Denmark. The intervention consists of four components: 1) detecting symptoms of mental illness in vulnerable pregnant women and initiating treatment if indicated, 2) strengthening parenting skills using the Circle of Security Parenting program, 3) supporting breastfeeding, and 4) sharing knowledge and organizing treatment pathways for families across sectors. Seventy-six families will be randomly assigned to the intervention or care-as-usual. Data will be obtained at study inclusion at 3-5 months of pregnancy, eight weeks after childbirth, and nine months after childbirth. The primary outcome is maternal sensitivity. Secondary outcomes include infant's socio-emotional development, parents' mentalization, parental stress, depressive symptoms, and parental wellbeing. Qualitative data will provide insight into the implementation process.

DISCUSSION

This paper presents the rational and background for developing the intervention. Furthermore, the design and protocol of the randomized controlled trial. It is hypothesized that the intervention will be associated with positive changes in primary and secondary outcomes. If effective, the intervention will provide insights into prenatal risk profiles among an identified group of psychosocial vulnerable women important for early screening and point to effective preventive interventions that can support women in the perinatal period, increase maternal sensitivity and promote positive child development -starting before the child is born.

TRIAL REGISTRATION

ClinicalTrials.gov: ID: NCT03190707. Registered June 16, 2017.

Comparison of screening accuracy of the Patient Health Questionnaire-2 using two case-identification methods during pregnancy and postpartum

Background

Variation exists regarding perinatal depression screening. A two-step screening method has been recommended. According to a maternity-focused core outcome set developed by the International Consortium for Health Outcomes Measurement, women who score 3 or more on the PHQ-2 then complete the Edinburgh Postnatal Depression Scale (EPDS). Limited evidence exists regarding the screening accuracy of the PHQ-2 in childbearing women. An alternative case-identification method may be more sensitive for perinatal women. We aimed to [1] evaluate the screening accuracy of the PHQ-2 during the perinatal period using two case-identification methods, and [2] measure the variability of accuracy over four time-points during pregnancy and postpartum.

Methods

A prospective, longitudinal cohort study was conducted with 309 consecutive women who completed the PHQ-2 and EPDS during pregnancy (booking, 36-weeks) and postpartum (6-, 26-weeks). EPDS was the reference standard using cut-off scores for ‘at least probable minor depression’ during pregnancy (≥ 13) and postpartum (≥ 10) and for ‘probable major depression’ during pregnancy (≥ 15) and postpartum (≥ 13). PHQ-2 was analysed using two methods: [1] scored (cut-points ≥ 2 and ≥ 3), [2] dichotomous yes/no (positive response to either question) against EPDS cut-points for at least probable minor and probable major depression. Receiver operating characteristic analyses determined accuracy.

Results

Probable major depression: Over four timepoints PHQ-2 ≥ 3 revealed lowest sensitivity (36–79%) but highest specificity (94–98%). An alternative case-identification method revealed high sensitivity (93–100%), but lowest specificity (58–71%). Minor depression: PHQ-2 ≥ 3 revealed the lowest sensitivity (19–50%) but highest specificity (95–98%). An alternative case-identification method revealed the highest sensitivity (81–100%) and moderate specificity (60–74%).

Conclusions

Recommended method of case-identification (PHQ-2 ≥ 3) missed an unacceptable number of women at-risk of depression. As a clinical decision-making tool, an alternative, dichotomous method maximized case-identification and is recommended. Further, the literature identified inconsistent reporting of the PHQ-2 and the alternative case-identification method hindering the ability to synthesise data. The future use and reporting of consistent question wording and response format will improve outcome reporting and synthesis. Further research in larger and diverse maternity populations is recommended.

Epigenetic signatures of attachment insecurity and childhood adversity provide evidence for role transition in the pathogenesis of perinatal depression

Early life adversity and insecure attachment style are known risk factors for perinatal depression. The biological pathways linking these experiences, however, have not yet been elucidated. We hypothesized that overlap in patterns of DNA methylation in association with each of these phenomena could identify genes and pathways of importance. Specifically, we wished to distinguish between allostatic-load and role-transition hypotheses of perinatal depression. We conducted a large-scale analysis of methylation patterns across 5 × 106 individual CG dinucleotides in 54 women participating in a longitudinal prospective study of perinatal depression, using clustering-based criteria for significance to control for multiple comparisons. We identified 1580 regions in which methylation density was associated with childhood adversity, 3 in which methylation density was associated with insecure attachment style, and 6 in which methylation density was associated with perinatal depression. Shorter telomeres were observed in association with childhood trauma but not with perinatal depression or attachment insecurity. A detailed analysis of methylation density in the oxytocin receptor gene revealed similar patterns of DNA methylation in association with perinatal depression and with insecure attachment style, while childhood trauma was associated with a distinct methylation pattern in this gene. Clinically, attachment style was strongly associated with depression only in pregnancy and the early postpartum, whereas the association of childhood adversity with depression was time-invariant. We concluded that the broad DNA methylation signature and reduced telomere length associated with childhood adversity could indicate increased allostatic load across multiple body systems, whereas perinatal depression and attachment insecurity may be narrower phenotypes with more limited DNA methylation signatures outside the CNS, and no apparent association with telomere length or, by extension, allostatic load. In contrast, the finding of matching DNA methylation patterns within the oxytocin receptor gene for perinatal depression and attachment insecurity is consistent with the theory that the perinatal period is a time of activation of existing attachment schemas for the purpose of structuring the mother-child relationship, and that such activation may occur in part through specific patterns of methylation of the oxytocin receptor gene.

A Sociodemographic variables questionnaire (Q-SV) for research on family caregivers of children with chronic disease

Background

Chronic diseases in childhood can affect the physical and mental health of patients and their families. The literature on pediatric chronic diseases has found important associations between the sociodemographic variables of children and their caregivers and negative health consequences in families.

Methods

In this study, we aimed to design and validate a questionnaire on sociodemographic variables that would be useful for research on pediatric chronic diseases; and investigate the relationship between sociodemographic variables and psychosocial variables among family caregivers. First, we created a questionnaire that consists of 20 demographic, medical, and family-related items based on a literature review and expert evaluations. This questionnaire was then validated by 335 expert reviewers in the field of Social Work, who work daily with the families of patients with chronic diseases in 10 National Institutes of Health of Mexico. The validation was based on three empirical criteria created specifically for this study, and the reviewers evaluated the usefulness, relevance, and permanence of the items. In a second cross-sectional, correlational and comparative study, a total of 446 family caregivers of children with chronic diseases were interviewed, and they completed the Sociodemographic Variables Questionnaire for research on family caregivers of children with chronic sociodemographic diseases and four psychosocial measurement instruments for evaluating anxiety, depression, caregiver burden and quality of life.

Results

Based on the results of the first study, we created the Sociodemographic Variables Questionnaire (Q-SV) for research on family caregivers of children with chronic diseases, and it includes 17 items that assess demographic, medical, and family characteristics. The results of the second study showed that the 17 sociodemographic variables obtained in the validation by expert judges are useful for measuring and evaluating the relationship between psychosocial variables in families of children with chronic diseases.

Conclusions

Psychosocial and sociodemographic factors are relevant for the development of research processes for families that care for children with chronic diseases.

Contextual-relationship and stress-related factors of postpartum depression symptoms in nulliparas: a prospective study from Ljubljana, Slovenia

Background

For a significant proportion of women, postpartum depression (PPD) is the first mood episode in their lives, yet its aetiology still remains unclear. Insecure attachment in close adult relationships is considered to be a risk factor for depressive symptoms. This study aimed to gain further insight into the risk factors for postpartum depression symptoms (PPDS) of nulliparas in Slovenia and to examine vulnerability to developing depressive symptoms, with an emphasis on contextual and stress-related characteristics.

Methods

The sample consisted of 156 nulliparas in the third trimester of pregnancy enrolled in a childbirth preparation program. The following instruments were applied: Experiences in Close Relationships-Revised, the Edinburgh Postpartum Depression Scale (EPDS), the Zung Anxiety Scale and a question battery designed by the research team including questions about emotional support and work-related stress. Logistic regression was used to test the association between demographic, social, environmental, personality and attachment variables and PPD of nulliparas (EPDS ≥10), controlling for baseline (prepartum) depression score. A multivariable linear regression model was built with the postpartum EPDS continuous score as a dependent variable.

Results

28/156 (17,9%) were evaluated as being at risk for depression (EPDS≥10) in the last trimester and 25/156 (16%) at six weeks postpartum. The results of the logistic regression model controlled for prepartum depression score showed that increased risk for developing PPDS was associated with anxiety level postpartum, intimate-partner-attachment anxiety postpartum, and elevated stress due to loss of employment or an unsuccessful search for employment in the previous year. The results of the multivariable regression model, however, showed the association with education and postpartum anxiety with PPDS continuous score; EPDS after giving birth was higher for more educated and more anxious primiparas.

Conclusions

Our findings demonstrate the importance of anxiety symptoms and higher education level in assessments of nulliparas’ mental health. The results of our study show and confirm the results of previous research that anxiety symptoms in the immediate postpartum period are likely to be associated with depressive symptoms in nulliparas. The results also suggest that higher level of education of first-time mothers might not be a protective factor, especially for nulliparas with the university level of education. Further studies on larger samples should be considered.

Individual and Contextual Factors of Nulliparas' Levels of Depression, Anxiety and Fear of Childbirth in the Last Trimester of Pregnancy: Intimate Partner Attachment a Key Factor?

Background

Depression, anxiety and fear of childbirth have numerous consequences for women and their developing offspring. Insecure attachment in close adult relationships is considered to be a risk factor for depressive symptoms. This study aims to gain further insight into the risk factors for depressive and anxiety symptoms in nulliparous women during the third trimester of pregnancy regarding the main contextual relations, with an emphasis on partner attachment.

Methods

A group of 325 nulliparas in the third trimester of pregnancy was enrolled in a childbirth preparation program. The following instruments were applied: Experiences in Close Relationships-Revised, the Edinburgh Depression Scale, the Zung Anxiety Scale, and a questionnaire regarding fear of childbirth. Three separate multiple linear regression models were built to explore the associations between demographic, social and attachment variables and mental health functioning.

Results

Highly educated nulliparas and those with a higher level of co-workers’ emotional support experienced a lower level of anxiety when other predictors in the model were held constant. Of all the predictors in the model, only attachment anxiety and co-workers’ support were statistically significantly associated with the level of depression. Attachment anxiety was significantly associated with all three mental health indicators (level of depression, anxiety and fear of childbirth).

Conclusions

The results suggest that intimate attachment anxiety could be a key contextual factor for mood and anxiety mental health functioning during the third trimester of pregnancy, accessible to change. Our results could facilitate the formulation of interventions for reducing antenatal depressive symptoms.

Factors associated with anxiety in family caregivers of children with chronic diseases

BACKGROUND

Currently, information on factors associated with anxiety in family caregivers of children with chronic diseases is unavailable, indicating a significant gap in the literature. Therefore, this study aims to identify the psychosocial and sociodemographic variables associated with anxiety in family caregivers of children with chronic diseases.

METHODS

In 2018, a nonprobability sample of 446 family caregivers was recruited at the National Institute of Health in Mexico City. The participants completed a sociodemographic variable questionnaire, clinical questions, and 18 psychosocial assessment scales, including a scale to assess family caregiver anxiety.

RESULTS

Family caregiver anxiety was correlated with almost all psychosocial variables and one out of three clinical variables but with none of the sociodemographic variables. Furthermore, a multiple linear regression model with five psychosocial variables was established to predict family caregiver anxiety.

CONCLUSIONS

Some psychosocial variables have effects on caregiver anxiety that are relevant for interventions. Clinical interventions should be implemented based on the psychosocial variables associated with family caregiver anxiety.

Validity and reliability of the Beck Depression Inventory II (BDI-II) in family caregivers of children with chronic diseases

BACKGROUND

Information on the psychometric properties of the Beck Depression Inventory II (BDI-II) in family caregivers of children with chronic diseases is currently unavailable, indicating a significant gap in the literature. Therefore, we investigated 1) which of the five evaluated measurement models had the best fit, 2) the scale's reliability, and 3) the scale's convergent validity.

METHODS

In 2018, a cross-sectional ex post facto study with non-probability convenience sampling was conducted in 446 family caregivers of children with chronic diseases at the National Institute of Health in Mexico City; the family caregivers responded to the BDI-II and a battery of instruments measuring anxiety, caregiver burden, parental stress, well-being, and quality of life. A confirmatory factor analysis was conducted to determine the fit of the five models. Cronbach's alpha and composite reliability were calculated to assess the scale's reliability, and Spearman´s rank correlation was used to investigate the scale's convergent validity.

RESULTS

This study provided evidence that the two-factor somatic-affective and cognitive model had the best fit. The BDI-II demonstrated adequate reliability and evidence of convergent validity, as the BDI-II factors were positively correlated with anxiety, caregiver burden, and parental stress and negatively correlated with well-being and quality of life.

CONCLUSIONS

The findings reveal that the BDI-II is a valid, reliable, and culturally relevant instrument to measure depression in family caregivers of children with chronic diseases.

The role of emotion regulation difficulties in the relationship between attachment representations and depressive and anxiety symptoms in the postpartum period

BACKGROUND

Insecure attachment representations have been established as a vulnerability factor for postpartum depressive symptoms. However, there is a lack of studies on the effects of attachment (in)security on postpartum anxiety symptoms, and on the mechanisms through which attachment representations may affect women's postpartum adjustment, namely, emotion regulation difficulties.

METHODS

The sample included 450 women in the postpartum period (up to 12 months postpartum), who were recruited both online (advertisements on social media) and in person (study was presented by the researchers during the women's postpartum hospitalization).

RESULTS

Approximately one third of the women with clinically significant symptoms (33.3%) presented comorbid symptoms of anxiety and depression, and these women presented more insecure attachment representations and more emotion regulation difficulties (p < .001) than did women without comorbid symptoms (p < .001). The relationship between more insecure attachment representations and depressive and anxiety symptoms occurred both directly and indirectly through emotional regulation difficulties.

LIMITATIONS

The cross-sectional nature of the study, the use of self-report questionnaires that do not allow the establishment of clinical diagnosis and the self-selected bias in recruitment were study limitations.

CONCLUSIONS

The results underline the need for attention to anxiety symptomatology, which is a condition that co-occurs frequently in this period. Interventions that focus on promoting adaptive strategies of emotional regulation are relevant rather than more intensive interventions to change attachment representations.

Psychometric properties of the attachment style questionnaire in Swedish pregnant women: short and full versions

OBJECTIVES

(i) To evaluate the reliability and factor structure of the Attachment Style Questionnaire - Short Form (ASQ-SF) for use in pregnant women and (ii) to compare the reliability and factor structure of the short- and full version-ASQ among pregnant women.

BACKGROUND

Adult attachment insecurity is currently included as a major risk factor in studies of perinatal health. None of the self-report measures with a Swedish translation have been psychometrically evaluated in a pregnant cohort.

METHODS

A population-based cohort of 1631 pregnant women answered the ASQ in late pregnancy. Internal consistency (item-subscale correlations, Cronbach's α, and α if item deleted) was evaluated for the seven available subscales. Confirmatory factor analysis (CFA) was run to examine the factor structure of the short form compared with the full-version. Test-retest correlations were assessed in a subgroup (n = 48).

RESULTS

All mean item-subscale correlations for the ASQ-SF were > 0.30. Cronbach's α's for ASQ-SF dimensions were as follows: Avoidance (0.87); Anxiety (0.89); Discomfort with Closeness (0.85); Relationships as Secondary (0.54); Confidence (0.83); Need for Approval (0.76); and Preoccupation with Relationships (0.77). No item removal substantively increased subscale α's. The CFA demonstrated better model fit for the ASQ-SF than for the full-version ASQ, while other reliability measures were similar. Test-retest correlations ranged from 0.65 to 0.84.

CONCLUSION

The ASQ-SF showed similar psychometric properties in pregnant women as in the general population and had good reliability, but the optimal factor structure needs to be studied further. Results support the usage of the ASQ-SF in pregnant cohorts.

Maternal attachment style and psychiatric history as independent predictors of mood symptoms in the immediate postpartum period

BACKGROUND

There is evidence that both a past history of psychiatric illness and insecure attachment put women at risk for mood disturbances in the postpartum period. The aim of this study was to ascertain whether maternal insecure attachment is a risk factor for mood symptoms in the immediate postpartum period independently of the confounding effect of maternal psychiatric history.

METHODS

A convenience sample of 120 mothers was assessed prenatally with the Maternal History of Mood Disturbances (MHMD), the Relationship Questionnaire (RQ), and in the first week after delivery with the Profile of Mood States (POMS).

RESULTS

Mothers with higher scores on the preoccupied and fearful attachment scales had more severe postpartum anxiety and depression symptoms but only fearful attachment remained a significant predictor of postpartum anxiety when the significant effect of maternal history of mood disturbances was included in the model.

LIMITATIONS

Our diagnostic assessment focused on mood symptoms, not disorders, and we limited psychometric assessment to the immediate postpartum period and did not collect longitudinal data to ascertain whether the relationship between maternal insecure attachment and postpartum mood disturbances changed over time.

CONCLUSIONS

Our results show the necessity to assess prior psychiatric symptoms in studies of maternal attachment style and postpartum mood disturbances. The finding that a mother's recall of her own psychiatric history emerged as significant predictor of postpartum mood symptoms suggests that antenatal assessment based on maternal self-report can be used in those settings where structured diagnostic interviews are not feasible.

Antenatal interpersonal sensitivity is more strongly associated than perinatal depressive symptoms with postnatal mother-infant interaction quality

Maternal mental health has enduring effects on children's life chances and is a substantial cost driver for child health, education and social services. A key linking mechanism is the quality of mother-infant interaction. A body of work associates maternal depressive symptoms across the antenatal and postnatal (perinatal) period with less-than-optimal mother-infant interaction. Our study aims to build on previous research in the field through exploring the association of a maternal personality trait, interpersonal sensitivity, measured in early pregnancy, with subsequent mother-infant interaction quality. We analysed data from the Avon Longitudinal Study of Parents and Children (ALSPAC) to examine the association between antenatal interpersonal sensitivity and postnatal mother-infant interaction quality in the context of perinatal depressive symptoms. Interpersonal sensitivity was measured during early pregnancy and depressive symptoms in the antenatal year and across the first 21 months of the postnatal period. In a subsample of the ALSPAC, mother-infant interaction was measured at 12 months postnatal through a standard observation. For the subsample that had complete data at all time points (n = 706), hierarchical regression examined the contribution of interpersonal sensitivity to variance in mother-infant interaction quality. Perinatal depressive symptoms predicted little variance in mother-infant interaction. Antenatal interpersonal sensitivity explained a greater proportion of variance in mother-infant interaction quality. The personality trait, interpersonal sensitivity, measured in early pregnancy, is a more robust indicator of subsequent mother-infant-interaction quality than perinatal depressive symptoms, thus affording enhanced opportunity to identify vulnerable mother-infant relationships for targeted early intervention.