Pregnancy, Childbirth, and Psychology - How It All Fits Together

PREGNANCY, CHILDBIRTH, AND PSYCHOLOGY – HOW IT ALL FITS

TOGETHER

BY JOSLYN PANKA SOLOMON

INTRODUCTION

When I first “chose” this topic, I hadn’t really chosen a topic, but a broad range of things I was interested in. As I did my research, things narrowed down. Some things I wanted to study more but couldn’t find sufficient knowledge on. Some things I found a ton of research on and found entrancing. Overall, it began as a lot of notes, which lead to scraps of paper floating around my dining room table. A rough concept map, a less-rough layout, and here I am. I found myself immersed in the psychological aspects of childbirth. Parents-to-be often ask tons of questions – should I get an epidural? Is being induced bad? What is post-partum depression, and can dad suffer too? Much of pregnancy, labor and childbirth are personal choices, and that is what is so fantastic about this day and age, but just as any other aspect of life, our choices can and do have consequences. I wanted to examine them and be able to confidently say “This is what oxytocin does – what would you prefer to do?”

WHY I CHOSE TO STUDY CHILDBIRTH PSYCHOLOGICALLY

I am currently in pre-nursing school to become an RN, but my career goal is to become a Certified Nurse Midwife. Two years ago I delivered my son with a CNM, and it was an incredible experience. I fell in love with the way these professionals support, encourage have faith in, and build the self-esteem of women. I knew I had found my calling. I also knew that I had a long road ahead, and a lot of knowledge to gain. This project gave me a great opportunity to do research related to my future career field and learn about a topic that I love – childbirth!

My babies!

THE BIOPSYCHOSOCIAL MODEL OF CHILDBIRTH

Who knew having a baby was so complicated? Of course that’s a joke, but childbirth is very involved in a biological, psychological, and social nature. In this project, I will address all three:

Biological – Our hormones play a giant role in pregnancy, childbirth, and our post-partum lives. How do hormones and body processes affect us during these major times in our lives?

Psychological – Mentally there is a lot going on as we become parents. Not just trying to figure out how to assemble the crib that only came with directions in Spanish, but how do our moods affect our babies? How do our moods affect others? How does stress and anxiety change the ball game? What is post-partum depression, anyway?

Socially – How do relationships work once the baby is here? All of a sudden things change – our partner is a parent, we are a parent, we have a child. Our parents are Grandparents, which means by some law of nature that there will suddenly be candy and toys and more than any child should ever have of things that they REALLY don’t need. How does this change influence us, and how do we influence each other?

EXPECTATIONS OF PREGNANCY AND BIRTH

All women have their own expectations of birth. They may have come from family, friends, books, movies, or their health practitioner. It may be a combination of these influences. Yet research has shown that a woman’s expectations, whether they are met, exceeded, or not met at all, can have very important effects on the mental health of mom, baby, and the entire family.

THE PERFECT PREGNANCY AND BIRTHAccording to Figueiredo and Costa (2009), pregnancy itself involves a lot of development for the parents-to-be. Initially the parents accept the pregnancy, but then begin picturing how the child will be, or how they will be as parents. This is the beginning of the relationship, even if the relationship is more speculative than real. As the pregnancy progresses,

the reality of the child becomes more apparent, and bonding increases. Movements and hearing the heartbeat are often keys that unlock doors to a larger bond and less anxiety. It is noted that “several empirical evidences have demonstrated that parents anxiety diminishes after ultrasound exams, while parental attachment improves”. Now, instead of an speculation, the parents perceive an actual individual.

TRAUMATIC BIRTH EXPERIENCESIn research, there are many instances that are considered traumatic in birth. Some of these may range from episiotomies, tearing, emergency c-section, a stall or delay in labor, a long labor, and an unexpectedly painful labor. While many people have heard stories of such events, the result of such events on mental health is not discussed as often. Buckley (2003) states that women who experience a spontaneous vaginal birth show a great improvement in mood and self-esteem. However, studies have shown that women who have a forceps or vacuum assisted delivery have an unaltered mood and self-esteem. This lack of mood change can inhibit bonding and increase the risk of PTSD.

BABY BLUES

The “baby blues” is very common among new parents – as many as 80% of new parents will experience the baby blues (Boston Women’s Health Book Collective, 2005). Sometimes parents may feel disconnected or stressed or sad, and that is completely normal. The baby blues are nothing to be worried about. Both mom and dad are susceptible – mom typically experiences this about 4 days postpartum, which is easily explained by hormonal changes (Edhborg, Matthiesen, Lundh, Wisdtrom, 2005). Yet studies have found that dad experiences the baby blues the day after birth. Why the difference? Researchers believe that for fathers the blues is more of an early reaction to the tension and exhaustion from the birth rather than hormonal factors. I’m sure to the female partner, exhaustion of the father seems quite funny!

POST-PARTUM DEPRESSIONThe baby blues often goes away on its own, and the family returns to its blissful new-family state. Yet sometimes baby blues can lead to post-partum depression – a serious condition that affects 10-15% of new moms (Boston Women’s Health Book Collective 2005). According to the book “Our Bodies, Ourselves”, post-partum depression problems with feelings or moods that seem to last and do not go away. PPD can inhibit bonding as well as leave a new mother distraught and sad, much like any other depression may do. It was found that depression often resulted in fewer positive thoughts about the baby rather than more negative or not clear thoughts (Figueiredo, Costa, 2009). It was also found that oftentimes if a mother was suffering from depression, the father may very well suffer from depression, too (Edhborg, Matthiesen, Lundh, Wistrom, 2005).

WHAT CAN BE DONE ABOUT POST-PARTUM DEPRESSION?

It is recommended that healthcare professionals screen not just the mother, but the father for depression (Rice, Harold, Boivin, van den Bree, Hay, Thapar, 2010). If the mother is depressed but the father is not, studies have found that the father can often diminish the negative consequences of the mother’s depression for the infant. This makes it important to ensure that dad is “up for the challenge” of taking care of mom and baby and that help be offered to the family if needed.

POST TRAUMATIC STRESS DISORDER FROM CHILDBIRTH?

PTSD is not extremely common in childbirth, but still a risk of a new mother. PTSD, or post traumatic stress disorder, is defined as “an anxiety disorder characterized by haunting memories, nightmares, social withdrawal, jumpy anxiety, and/or insomnia that lingers for four weeks or more after a traumatic experience” (Myers, 2011) According to Alder, Stadlmayr, Tschudin and Bitzer in 2006, only in the last decade has childbirth began to be recognized as a potential trigger for PTSD and post-traumatic symptoms.

WHAT FACTORS CAN LEAD TO PTSD FROM CHILDBIRTH?

As previously mentioned, many factors can contribute to PTSD in a new mother. One study found that “a lack of emotional support from the partner is shown to be associated with the development of PTSD from month 1 to month 4 after childbirth” (Alder, Stadlmayr, Tschundin, Bitzer, (2006). Traumatic birth events were also a leading cause, and a study done by Alcorn, O’Donovan, Patrick, Creedy and Devilly in 2010 showed that all women that met full PTSD criteria at 4-6 weeks postpartum had said to have experienced at least one traumatic event during labor and delivery. By 24 weeks postpartum, 4.4% of women suffering from PTSD claimed they had not experienced a traumatic event during labor. This shows that traumatic events during labor and PTSD are not exclusive.

THE PARTNER AND

BIRTH TRAUMA

We have already established that a partner can also suffer depression postpartum. Childbirth can have significant negative effects on a relationship. Often a mother who has experienced a traumatic birth feels that there was not enough support from the partner during the childbirth (Alder, Stadlmayr, Tschundin, Bitzer, 2006). This can lead to relationship problems and even sexual difficulties (Figueiredo and Costa, 2009).Research also shows that a woman shows psychological maladjustment after such an experience and it can have major effects on the couple’s relationship and the development of the offspring through adolescence.The partner of a mother who experienced a poor birth or is suffering after a birth has the ability to help. It may seem small and insignificant, but simply talking with the mother may help – mothers report talking to be quite helpful in recovery (Highsmith, 2006).

CALM THAT MAMA DOWN!Pregnant women are bombarded with things not to do. Avoid deli meats and hot dogs, do not drink caffeine, avoid medications. Yet many women do not even realize how their stress and anxiety levels can have a huge impact on their health and the health – and personality – of their babies, too! One very useful study used both mothers of their own child and mothers of children that were not genetically paired to the mother (IVF) for studies on anxiety and stress during pregnancy and the resulting factors. This study by Rice, Harold, Boivin, van den Bree, Hay and Thapar (2010) was used to determineexpand on the knowledge that high levels of anxiety during pregnancy led to children with more emotional and disruptive behavior problems. The study found that in both genetic and non-genetic mother and child pairs, there was a significant correlations between late prenatal stress and preterm birth and lower birth weight in babies overall. The study also found that there were significant associations between the stress a pregnant mother experienced and the child’s overall anxiety levels. A child born of a mother, related or unrelated, show an association between the stress levels of the mother and child antisocial behavior, as well. The good news? There is NO association between prenatal stress and offspring ADHD in the group of mothers that were unrelated to the child. However, there was an association between stress, related mothers and child ADHD, but this points to genetic factors rather than stress experienced in the womb.

ANXIETY AND LABOR

Does anxiety affect labor and delivery? Most certainly! High levels of anxiety often leads to increased adrenaline, which is shown to lead to longer labors and even adverse fetal heart patterns (Buckley 2003). Often slower labors lead to more interventions, such as c-sections or assisted vaginal births with forceps or vacuum. Use of epidural analgesia is increased, as well.

ANXIETY AND DEPRESSIONAnxiety and depression are common among pregnant women and new mamas alike. In fact, one study states that roughly 29% of pregnant women are anxious or depressed and 16.5% of postpartum women are anxious or depressed (Figueiredo and Costa, 2009). High levels of anxiety predict depression 3 months before and 3 months after childbirth. Some have claimed that depression is often triggered by higher cortisol levels during pregnancy and the postpartum period, but other studies have found that cortisol levels and depression or anxiety did not have any correlation whatsoever. Anxiety is devastating as it has been found to be associated with pregnancy complications, emergency c-sections, postnatal depression and impaired bonding between mother and baby.

HOW DOES BONDING ESTABLISH?While bonding occurs throughout the pregnancy, labor and delivery prove to be a very significant time for bonding. During labor, contractions begin with the influence of oxytocin, a hormone created in the hypothalmus (Marieb, 2010). This hormone is often referred to as the “love-hormone”, responsible for bonding in mating and in parent-child relationships.

OXYTOCIN AND BIRTH

While in labor, a woman’s body naturally produces oxytocin. A positive feedback system is created – oxytocin stimulates uterine contraction, which stimulates more oxytocin to be released, and the cycle continues (Marieb, 2010). Lots of factors can interrupt or disturb this cycle, and often we hear of people receiving Pitocin to start or augment labor (Pitocin is synthetic oxytocin). How does oxytocin affect us? Why should we care if it is used to start or augment labor? Can it have long term effects?

WHAT DOES OXYTOCIN HAVE TO DO WITH ANYTHING?

We know oxytocin is responsible for bonding. But what happens when it is reduced? It is suggested that epidural analgesia may counteract or delay a mother’s adaption process to motherhood. It is not hopeless, however - some studies show that in sheep and heifers, if epidurals are used for pain relief but synthetic oxytocin is delivered postpartum, bonding and mothering instincts are restored (Jonas, Nissen, Ransjo-Arvidson, Matthiesen, Uvnas-Moberg, 2008). It is even believed that breastfeeding might make up for the less optimal maternal ability to adapt immediately after birth by increasing a mother’s oxytocin production.

THE EPIDURAL AND OXYTOCINIn Sweden in 2004, 44% of first time moms had epidural analgesia during their labors. (Jonas, et al., 2008). Epidurals are somewhat common in the obstetrics world, with strong feelings from people on either side of the issue. Some people absolutely refuse epidurals, while others find absolutely no reason to “suffer” and request them right away when in labor. Yet we are finding that epidural analgesia can have an effect on oxytocin levels in a mother. Jonas and colleagues state; “Administration of EDA (epidural analgesia) during labor in sheep and heifers has been demonstrated to decrease release of oxytocin into the circulation and into the cerebrospinal fluid”. EDA has also been reported to result in a lower score in socialization and a higher score in tension and anxiety in the mother.

SYNTHETIC OXYTOCIN AND LABORIf synthetic oxytocin is given in labor, it not only has the physical effect of stimulating contractions, but it can have various mental effects on mom, too. While synthetic oxytocin stimulates contractions, it cannot cross the blood brain barrier (Buckley, 2003). Sensors for hormones are located throughout the body, so oxytocin sensors will detect sufficient levels of oxytocin and send the message to the brain that there is enough oxytocin – no need to produce more! This is not of importance until after birth, when the synthetic oxytocin infusion is stopped. Since oxytocin is responsible for bonding and our brain has determined that we have enough, production is stopped or slowed significantly and mothers are found to have less mothering instincts and a hard time bonding to their new baby (Edhborg, Matthiesen, Lundh, Widstrom 2005). It has also been noted that the more oxytocin that is infused during birth, the lower the mother’s ability to inhibit aggression is (Jonas, Nissen, Ransjo-Arvidson,Matthiesen, Uvnas-Moberg, 2008).

BREASTFEEDINGBreastfeeding is known to have amazing effects on mother and baby. Mothers who breastfeed have been shown to be more responsive to their infants and also seem to physically touch their infants more during feedings and playtime (Else-Quest, Hyde, Clark, 2003). Since breastfeeding also stimulates oxytocin, bonding through breastfeeding is certain. Mothers that breastfeed often report less negative affect parentally, less intruded upon, and report less infant dysregulation at 12 months of age. These results hint that negative factors are lessened, but there is no shown proven increase in positive factors. (Else-Quest, Hyde, Clark 2003) Mothers who breastfeed also tend to be less

anxious and more relaxed compared to non-lactating women (Jonas, Nissen, Ransjo-

Arvidson, Matthiesen, Uvnas-Moberg, 2008).

GO, OH KNOWLEDGEABLE ONE, AND TEACH!Okay, so maybe it’s not that dramatic. Yet now, whether you are an expecting parent, grandparent, aunt or uncle, you know a little bit more about popular childbirth options and their effect on a family. Now you can, like me, stare at the TV in disbelief while watching “One Born Every Minute” at women who go into the hospital not in labor, are induced with Pitocin and given an epidural, end up in emergency c-section and then told “This has absolutely no adverse effects”. This does NOT mean that all “medical interventions” in birth are bad. Like anything else medically, they need to be used wisely and the decision to do so should not be taken lightly. C-sections, epidurals, and Pitocin save babies, too! Now you can be prepared if someone you know experiences a birth that they feel was traumatic, or has a hard time adjusting to their new parental role. Just being a sounding board, as mentioned previously, can have amazing results!

REFERENCES:Alcorn, K.L., O’Donovan, A., Patrick, J.C., Creedy, D., Devilly, G.J. (2010). A prospective longitudinal study of the prevalence

of post-traumatic stress disorder resulting from childbirth events. Psychological Medicine, 40, 1849-1859.

Alder, J., Stadlmayr, W., Tschudin, S., Bitzer, J. (2006). Post-traumatic symptoms after childbirth: What should be offer? Journal of Psychosomatic Obstetrics and Gynecology, 27, 107-112.

Boston Women’s Health Book Collective, The. (2005). Our Bodies, Ourselves. New York, NY: Simon and Schuster.

Buckley, S.J., (2003). Undisturbed Birth: Nature’s Blueprint for Ease and Ecstasy. Journal of Prenatal and Perinatal Psychology and Health, 17, 261.

Edhborg, M., Matthiesen, A.S., Lundh, W., Widstrom, A.M. (2005). Some early indicators for depressive symptoms and bonding 2 months postpartum – a study of new mothers and fathers. Archives of Women’s Mental Health, 8, 221-231.

Else-Quest, N.M., Hyde, J.S., Clark, R. (2003). Breastfeeding, Bonding, and the Mother-Infant Relationship. Merril-Palmer Quarterly, 49, 495-514.

Figueiredo, B., Costa, R. (2009). Mother’s stress, mood and emotional involvement with the infant: 3 months before and 3 months after childbirth. Women’s Mental Health, 12, 143-153.

Highsmith, S. (2006). Primiparas’ Expectations of Childbrith: The Impact of Consciousness. Journal of Prenatal and Perinatal Psychology & Health, 21, 141-179.

Jonas,W., Nissen, E., Ransjo-Arvidson, A.B., Matthiesen, A.S., Uvnas-Moberg, K. (2008). Influence of oxytocin or epidural analgesia on personality profile in breastfeeding women: a comparative study. Women’s Mental Health, 11, 335-345.

Marieb, E.N. (2010). Human Anatomy and Physiology. San Francisco, CA: Pearson Education, Inc.

Myers, D.G. (2011). Exploring Psychology. New York, NY: Worth Publishers.

Rice, F., Harold, G.T., Boivin, J., van den Bree, M., Hay, D.F., Thapar, A. (2010). The links between prenatal stress and offspring development and psychopathology: disentangling environmental and inherited influences. Psychological Medicine, 40, 335-3450

 All images courtesy of Microsoft Power Point Clip Art except slide 3. Those are just my own super cute pictures of my super cute babies.