Chapter 6. Monitoring women’s emotional wellbeing in the antenatal period

Trigger scenario B9780443103544000064/fx1.jpg is missing

Simone, a community based midwife, rings Joanna’s doorbell. This is Joanna’s first pregnancy and she is now 28 weeks pregnant. Joanna eventually opens the door. ‘Hello,’ Simone says. At which point Joanna bursts into tears. ‘I am so scared,’ she sobs. B9780443103544000064/fx2.jpg is missing

Introduction

The onset of pregnancy will be a time of great joy for many women and their families. It will normally be a fulfilment of something that has been hoped for and wanted and a positive event in a woman’s life. For other women a pregnancy may bring more negative emotions, especially in situations where it is unexpected or unplanned. However, most women will find that there will be a mixture of emotions over the course of the pregnancy, as it is a powerful, life-changing experience that affects the woman and those who are close to her. In an holistic approach to care it is important to think about the time of pregnancy in a complete way. How a woman will react in pregnancy will depend on many factors including her experiences before she became pregnant. Care will entail recognition of what is a natural emotional reaction to pregnancy in contrast to recognizing when reactions are pathological.

The World Health Organization web pages (WHO 2008a) state that:

Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.

This means that part of a midwifery role will be to help women try to achieve this state. John Swinton (2001:35) has identified seven elements that define mental health:

▪ Absence of illness

▪ Appropriate social behaviour

▪ Freedom from worry and guilt

▪ Personal competence and control

▪ Self-acceptance and self-actualization

▪ Unification and organization of personality

▪ Open-mindedness and flexibility.

Activity

Think about yourself, and about how you feel in relation to the seven elements above. Decide which issues are relevant to you.

Consider the list above and relate it to the pregnant women in your care. Decide which issues are relevant to them at this time.

Emotional and mental wellbeing should be considered in an holistic way, recognizing the continuum between the body, mind and spirit (Davis-Floyd 2001). This means that what affects the physical part of a person will affect the other parts and vice versa.

The aim of this chapter is to consider emotional wellbeing in relation to pregnancy and to enable a midwife to provide women with support as they experience different emotions.

Background

Pregnancy is a time of change and adjustment. The changes that take place are physical, in that the fetus will be growing inside a woman and affecting her bodily processes. Amy Mullin (2002:38) writes that ‘At no other time will an otherwise healthy adult undergo such widespread, rapid and undesired change in the shape and size of her body’. The changes will also be psychological, as she goes through adaptation into being a mother of this child (Rubin 1984, Raphael-Leff 1991, Mercer 1995). The profound nature of this change leads women to consider the experience as meaningful and spiritual (Carver & Ward 2007, Jesse et al 2007). It is important to recognize how the physical changes that take place in pregnancy can affect the emotional moods of women, and how psychological changes may also present with physical symptoms.

Hormonal influences

Activity

Remind yourself of the menstrual cycle and the changes in hormonal function in pregnancy. Think about how your mood changes throughout your menstrual cycle.

During pregnancy there are changes in circulating hormones in order to maintain the developing fetus. In the early weeks of pregnancy human chorionic gonadotrophin (HCG) is produced prior to the development of the placenta. During the pregnancy the levels of oestrogens and progesterone rise with a subsequent effect on other normally produced hormones. Though a significant amount of research has been carried out on the effects of these hormones on mood, specifically in relation to the menstrual cycle and premenstrual syndrome, it has been shown that the levels of progesterone may have an effect in some women (Buckwalter et al 1999) but that the effect may be more indirect, in that they are combined with effects of stress, lack of social support and anxiety (Ross et al 2004). There is evidence to show that stress in pregnancy has some effect on the immune system and consequently may impact on the growth and development of the fetus (Coussons-Read et al 2003).

Physical changes

Physical changes take place in women during pregnancy, such as expanding waist lines, increase in hip and thigh and breast size. In addition she may also experience changes to her eyesight, skin pigments, blood pressure and breathing (Mullin 2002:39). A woman may experience symptoms in the course of the pregnancy of nausea or vomiting, fatigue, backache, heartburn, oedema or urinary or bowel changes that may have an influence on her feelings about herself. Certainly poor sleep quality in early pregnancy has been linked with antenatal depression (Jomeen & Martin 2007). Physical illness in pregnancy, such as anaemia or hyperemesis gravidarum may lead to fatigue and less ability to adjust mentally (Cantwell &Cox 2003). An underactive thyroid gland may also lead to anxiety and depression (Timms 2007).

Activity

Ask someone who has a baby (or consider this if you have) how they felt about the changes that were taking place in their body.

Find out more about hyperemesis gravidarum, anaemia and underactive thyroid gland.

Body image

Changing identity during pregnancy also entails dealing with a changing body image (Mercer 1995:39). A woman’s view of her body image prior to pregnancy will be related to her cultural views and the society in which she lives. For some women being pregnant and growing in size will make her feel better about herself (Price 1988:31). For others they may feel more negative about these changes (Stewart 2004:33, Lavender 2006). Current fashion promotes being thin as the ideal and such portrayal has been shown to be influential on pregnant women (Sumner et al 1993). Poor body image is linked to poor self-esteem and this may then be expressed through excessive dieting or purging of the body (Lavender 2006). There is gathering evidence that poor nutritional status may have an influence on psychological wellbeing (Serci 2008). It has been shown that women may not be consuming enough of the appropriate nutrients in pregnancy (Thomas et al 2006). Exploration of a woman’s diet in pregnancy should be made, especially if she has a low mood status.

Sexuality

The physical changes of the woman are also linked to her views of her sexual self. Jane Price (1988:31) writes: ‘Pregnancy is a clear label both that the person is a woman and that she is sexually active.’

Her changing physical shape means that she is recognized by others as a sexual being (Mullin 2002:39). Pregnancy leads to changes of status in society with recognition that where she has previously been a daughter she is becoming a mother. This may be a complex state, particularly for some women who may feel uncomfortable about displaying their sexual selves and may choose to hide being pregnant for as long as possible. For others, being pregnant may heighten their sexual feelings (Raphael-Leff 1991:383).

Mary Stewart (2004:33) writes: ‘women’s bodies are likely to be touched more during and immediately after pregnancy than at any other time.’

A woman’s concepts of her body and acceptance of being touched by ‘strangers’ will be linked to her emotional wellbeing in pregnancy.

Activity

Think about how you feel about being touched by strangers. Having reflected on this, think about how you could make your practice better to enable the women you look after to feel better about this.

More intensive aversion to being touched may be felt by women who are currently, or have been, in an abusive relationship. It could have a detrimental affect on women’s mental health, and they will need specialist support, alongside careful midwifery care (Hobbins 2004, Baird 2007, Tiwari et al 2008).

Psychological changes

Significant changes take place psychologically in women and their partners over the course of pregnancy. Complex processes take place in relationships between partners and their wider family, as they adjust to the impending addition of a new family member (Raphael-Leff 1991, Mullin 2002:40). A woman’s expectations and previous experiences of pregnancy will have a significant effect on how she copes and adapts to the changes that take place. These may be influenced by many factors, including how she has been brought up, the society and culture in which she resides and the social support she receives.

The process of adaptation often begins before pregnancy when couples make the decision to have a child. The reasons for this will be individual to the people involved, and sometimes will be subconscious (Bergum 1989, Raphael-Leff 1991). For women who were not expecting pregnancy the process of adaptation may take longer as they have to come to terms with the news (Marck 1994). Women who are experiencing a complicated pregnancy or have had a previous pregnancy loss may take a longer time to build a relationship with their unborn child, until the risk or threat to the pregnancy has passed, or they have passed the anniversary of the loss (Lever Hense 1994, McGeary 1994).

Current maternity provision in the UK includes opportunity for ‘choice’. Women and their partners may have to make choices relating to place of birth, choice of caregiver and antenatal screening methods. Suggestion has been made that the introduction of screening may psychologically cause greater anxiety (Marteau 1989). Lorraine Sherr (1995) sums up as follows in relation to antenatal screening:

▪ May cause anxiety

▪ Delay in feedback may cause ‘adverse emotional consequences’

▪ Poor communication skills may raise anxiety

▪ Anxiety may remain even after the outcomes have been negative or positive

▪ Medical practitioners are poor at identifying the nature of anxiety in women

▪ The widespread programmes make it difficult to respond to individual need and concern.

Activity

Think about your current experience of giving information about antenatal screening tests. In the light of the above information, work out whether there are ways this could be improved.

A recent study of the psychological effect of choice of place of birth has not shown that a particular type of care is of psychological benefit (Jomeen & Martin 2008).

Mercer’s (1995:52) review of research relating to maternal identity has identified how women use fantasy and dreams during the process of change. It is suggested this is related to women mentally ‘rehearsing’ their future role as mother. Women may also experience grief and loss as they may lose some part of their identity through changing roles (Mercer 1995:59).

We can relate the change from non-mother to mother as a form of loss where women may have to reinterpret the ways in which they view themselves in accordance with their new role as a mother and caregiver, and revaluate their former self, as well as adjust to their new identity which is now on view to the wider society.

(Atkinson 2006)

This may be in relation to loss of status in leaving employment. It is common that women will express feelings of ambivalence, of ‘not being ready’ to have a baby during pregnancy, even if they have made a choice to become pregnant (Bergum 1989, Raphal Leff 1991:240).

Many women will experience anxiety at some point over pregnancy, however Lorraine Sherr (1995:137) suggests that anxiety may be a ‘protective positive emotion’ as a result of stressors. Problems may only arise should the anxiety be out of proportion to the stressors. Fears and anxieties relating to the wellbeing of the growing fetus are common. In Melender’s (2002) survey of 329 pregnant women in Finland 78% of the respondents admitted to having some fear in relation to childbirth. The fears created different levels of stress and anxiety, which were more marked in those women experiencing their first pregnancy. The authors conclude by recommending that midwives should discuss a woman’s fears in greater depth. A pathological condition of intense fear of childbirth has been defined and labelled tokophobia (Hofberg & Ward 2004) though Denis Walsh (2002) has challenged whether this is actually a ‘normal’ reaction to a traumatic event.

Hofberg and Ward (2003) state there are different types of tokophobia:

▪ Primary – when women have not had a baby before

▪ Secondary – where women have had previous traumatic deliveries

▪ Secondary to depressive illness in pregnancy.

Activity

Think about the three types of tokophobia mentioned. For each situation, decide how you as a midwife would support women.

Spirituality

Within an holistic philosophy of care, it is essential to consider the relevance of spirituality to the woman (Hall 2001). Pregnancy and childbirth is considered to be a powerful and meaningful event, which is a rite of passage into motherhood (Balin 1988, Wallas La Chance 1991, Ayers-Gould 2000). Spiritual and religious beliefs may become more significant during pregnancy, with these providing a source of coping with stressful situations (Carver & Ward 2007, Jesse et al 2007, Price et al 2007). The Royal College of Psychiatrists recognizes the significance of thinking about the spiritual dimension in relation to mental wellbeing (Royal College of Psychiatrists 2007). Spiritual care could lead to:

▪ Improved self-control, self-esteem and confidence

▪ Faster and easier recovery, achieved through both promoting the healthy grieving of loss and maximizing personal potential

▪ Improved relationships – with self, others and with God/creation/nature

▪ A new sense of meaning, resulting in reawakening of hope and peace of mind, enabling people to accept and live with problems not yet resolved.

This signifies that aiming to provide a spiritual focus to care may help women with emotional needs during pregnancy. The midwife may establish women’s spiritual need by asking appropriate questions in the antenatal period (Hall, in press) and staying alert to signs of distress.

Antenatal depression

It has been suggested that pregnancy improves the condition of some women with psychiatric disorders. However, until recently, understanding of mental illness has been more focused on the postnatal period of childbirth than before birth. It has been identified that from 7.4–10.7% of women may have a type of antenatal depression in the first trimester of pregnancy with a potential 12.8% in the second trimester (Dennis et al 2007); whether this is as a result of pregnancy or has been present before pregnancy and gone undiagnosed is difficult to establish. Further, certain pre-existing psychiatric disorders may become worse in pregnancy (Hadwin 2007, Weeks 2007).

In Raymonds’ (2007) study of some women’s experience of antenatal depression it was identified that some found it hard to reveal their feelings and that it was common to feel ‘emotional isolation’. The authors concluded this could have been helped through provision of continuity of carer. They further established that the partner may also have a need for support. The women identified helpful support mechanisms: massage, social groups, practical skill development and exercise plus access to web-based support groups.

In a Swedish study, Rubertsson et al (2005) showed that for those women who had signs of depression in the antenatal and postnatal period factors associated with this were:

▪ A difficult social situation, such as being unemployed, not having Swedish as a first language and an unplanned or unwanted pregnancy

▪ Lack of social support, mostly from a partner but also from others

▪ Having experienced two or more stressful life events in the year prior to pregnancy

▪ Physical health issues during pregnancy and afterwards.

Rodriguez et al (2001) demonstrated that there may be a link between pregnancy symptoms experienced and psychological stress. The authors recommend that practitioners help to reduce stress in pregnancy. Difficult social situations that need to be considered include domestic violence, which may have a significant effect on the emotional wellbeing of the pregnant woman (Baird 2007).