Understanding factors which can influence the experience of pregnancy and childbirth

In recent years there has been increasing interest in what women bring to pregnancy with them, and the research articles published in this edition of the journal reflect this. While pregnancy and birth are understood as natural processes, there is a wish to understand the antecedents and concurrent factors that contribute to perturbations in these processes. There is also recognition of the value of carrying out research in a wider framework in which a multitude of individual differences may have a part to play in outcomes for parents and babies. In some research studies this encompasses parents' personalities and prior experience, and in some instances their earlier relationships and even their own parenting.

Women's antenatal inpatient experiences are an aspect of maternity care that is rarely documented, although in a recent UK study nearly a quarter of women (24%) who had recently given birth reported having an overnight stay in hospital during pregnancy (mean duration 4.2 nights) that was not associated with the initiation of labour (Redshaw et al., 2007). Focusing on women who experienced admission to hospital during pregnancy due to concerns about their own health or that of their baby or both, Olive White and colleagues carried out a study in Northern Ireland of risk appraisal, coping and prenatal attachment. Concern about anxiety and depression among higher‐risk women, with possible long‐term consequences for them and their babies, led the authors to explore relationships between these factors and other aspects of psychosocial functioning during pregnancy. While social support apparently played no significant role, positive appraisal of their own and their baby's health was positively related to the quality and intensity of attachment to the baby during pregnancy. Interestingly, however, maternal perception of risk did not map on to health professionals' views about pregnancy risk. While the authors suggest that further research should be carried out on maternal perception of risk, they argue strongly about the importance of acknowledgement by those caring for women in a clinical context that there may be a mismatch between medically assessed risk and that perceived by the women themselves. This is especially critical if support and counselling are to be effective.

Just how prenatal attachment can be assessed is discussed in the paper by Anna Maria Della Vedova and colleagues' study of more than two hundred Italian women. Using a translated version of the Prenatal Attachment Inventory (Gau & Lee, 2003) the authors describe a five‐factor solution which accounted for 41% of the variance. Like other researchers in this area, Vedova et al. argue that underlying prenatal attachment is a complex web of interrelated constructs which are not so easily handled from a research perspective. Perhaps what is most important is the emphasis on prenatal maternal attachment reflecting the emotional nature of the relationship between pregnant mothers and their unborn babies.

Partner relationships during the transition to parenthood are the subject of the third paper, in which Barbara Figueiredo et al. describes a study looking at wellbeing and psychological adjustment of mothers and fathers during the second and third trimesters of pregnancy and following the birth. Using standard measures of anxiety and depressive symptoms, and a relationship questionnaire which was designed for the study of largely Hispanic and Black‐American couples, it was clear both men and women with positive partner relationships scored lower in terms of anxiety and depression. As might be expected, unhappiness about the pregnancy and not actually living together marked out less‐positive relationships. It was also evident that the quality of partner relationships declined across pregnancy and the postpartum period, and the author suggests that the measures used in the study could be employed in identifying couples at risk for poor pregnancy and early parenting outcomes. Like other researchers and health professionals working in this area, the role of partners at this time is recognised as key if primary prevention is to be supported (Lemola et al., 2007).

Studies of post traumatic stress disorder (PTSD) in women after childbirth suggest a range of rates for the disorder and for PTSD symptomatology, usually relying on data collection in the early months after childbirth (Ayers and Pickering, 2001; White et al., 2006). The study by Lesley Leeds and Isabel Hargreaves in this edition of the journal looks at women more than six months after the birth and reports relatively high rates of PTSD (at 3.9%) and depression (21.5%), although self‐selection and the low overall response rate may have contributed to these figures. The findings, in addition to links with depression and previous mental health problems which the authors discuss, suggest that fear for the baby during labour and the unexpectedness of procedures at this time effectively predicted scores on the measure of PTSD symptoms even after six months post‐partum in the group of women studied. The following paper also addresses the issue of PTSD symptoms, though focusing on individual perceptions of the events around childbirth. Also using a UK population, Zai Edworthy and colleagues looked at the role of pre‐existing cognitive schema as a risk factor. They discuss the debate about the ways in which such schema may be associated with PTSD: thus individuals holding more positive pre‐trauma beliefs may be more vulnerable when their beliefs are ‘shattered’ by traumatic events, while on the other hand, holding very rigid or very negative beliefs may also make individuals more susceptible as their beliefs are challenged or confirmed. Data were collected before birth at thirty‐four weeks of pregnancy and at six weeks after the birth using standard measures including a schema questionnaire (Schmidt et al., 1995). With a 1% of the study group showing significant levels of distress and 8% showing moderate distress, the incidence rates map on to those described by Ayers and Pickering (2001). In contrast to some studies, no significant associations were found with previous mental health or trauma experiences or type of delivery, though the findings do indicate that the way women assimilated and interpreted their birth experience had a significant impact on the development or otherwise of PTS symptoms. Based on the exploratory data from the study the authors suggest that it may be the incongruence between pre‐existing beliefs and trauma experiences that leads to post traumatic stress, and argue for larger scale studies on more representative groups and particularly vulnerable sub‐groups as the way forward.

Changes in perceptions of the childbirth experience are also the topic of the paper by Ana Conde and colleagues in Portugal. Their study explored change and continuity after the birth of a baby, by collecting data at three time points in the postpartum period, up to six months, using a specifically designed questionnaire. Over the first year after childbirth, a previous study by Waldenstrom (2003) showed that some perceptions change in what seem to be opposite directions, with the overall view becoming more negative, but the description of the associated pain as less severe. Conde et al. discuss the possible reasons for these changes in the context of their own study, in which type of delivery had a marked impact, suggesting that the changes they report may be seen as reflecting progressive change and the process of adjustment to motherhood over these early months. However, the role that the particularly high rate of caesarean section among the sample of women on which this study relies may have played in relation to the adjustment process, and the normalisation of this type of birth within the wider culture, needs further consideration.

The role of individual differences, variations between cultures in practices and healthcare systems need to be considered in undertaking and interpreting research studies which aim to try and understand some of the complex factors at work in how women experience care. The papers published in this edition of the journal illustrate this well. Small‐scale cross‐sectional studies can be effective in highlighting possible relationships and can explore a range of associations between the possible factors at work. However, longitudinal studies, on both short and longer time frames are needed. By making comparisons between groups and across time using standard measures, translated if necessary, and by developing new instruments, the kind of evidence base can be gradually built that is both theoretically sound and of relevance to the health professionals providing care. At the same time the methodological problems of self‐selection, use of a large numbers of standard and non‐standard measures, small sample size and consequent difficulties associated with generalisability require both acknowledgement and action as far as future research is concerned. Being able to describe non‐respondents allows us to more adequately interpret study findings and carrying out parallel studies with different groups or in different countries enables us to appreciate how medical and other healthcare interventions may be constructed differently by different populations or groups and thus impact in different ways.

Notes

1. One of the authors (MR) undertook this work at the National Perinatal Epidemiology Unit which receives funding from the Department of Health. The views expressed in the editorial are those of the authors and not necessarily those of the Department of Health.