Risk Factors of Depression and Anxiety during Pregnancy: Maternal Antenatal Attachment

ABSTRACT Background: : Perinatal depression is one of the most common complications of childbearing. Approximately 10 to 15% of women experience a clinically significant major depressive episode during pregnancy or the early postpartum period (Bennett, Einarson, Taddio, Koren, & Einarson, 2004b; Epperson, 1999; Gavin, Gayner, Lohr, Meltzer-Brody, Gartlehner, & Swinson, 2005; O’Hara & Swain, 1996). These prevalence estimates predominantly reflect rates of depressive symptoms in developed countries; there is evidence that rates of depression vary more widely in non-developed countries (Halbreich & Karkun, 2006). In addition to the distress and impairment experienced by depressed women, depression during this time period is associated with further adverse outcomes for both mother and child. Women who experience perinatal depressive episodes are at increased risk for subsequent episodes of both postpartum and non-postpartum depression (Cooper & Murray, 1995). Anxiety symptoms are frequently reported by pregnant women and are often considered as part of the normal psychic experiences of pregnancy, especially if they are focused on the baby's health or on maternal competencies. The emotional image of the baby inside is what is called the mother fetus relationship. Cranley (1981) describes the nature of mother’s experiences as ‘physical and kinesthetic awareness of the fetus’, and an ‘intellectual knowledge of her child’. Nowadays, the concept of prenatal attachment is more accurately defined (Righetti, 2003) and it generally refers to the maternal–fetal relationship, which normally develops during the pregnancy; it represents the earlier internalized representation of the fetus that both parents typically acquire and elaborate. Pregnancy can also represent a crisis period for many women, with manifest effect on antenatal attachment. Condon and Corkindale (1997) explore the hypothesis that feelings of anxiety or depression and lack of social support would be an interference issue in the development of maternal antenatal attachment. Women characterized by low attachment are associated with high levels of depression and anxiety, weak external social support, and high control and criticism in the partner relationship. Aims: The aims of this thesis were: 1)to assess association between antenatal attachment and demographic characteristics. 2) to investigate the role of maternal attachment (as MAAS) on the development of depression (EPDS>12) , anxiety symptoms (STAI-Y >40) and risk factors (PDPI-R) during pregnancy. 3) to assess the specific role of antenatal attachment as risk factor for depression (EPDS>12), as anxiety symptoms (STAI>40) during pregnancy. . Methods: A sample of pregnant (N= 456) women was recruited as part of a larger study conducted at Pisa in the framework of the Perinatal Research and Screening Unit Study (PND-ReScU). The Perinatal Depression-Research and Screening Unit (PND-ReScU) is based on an ongoing collaboration between the Department of Obstetrics and Gynecology and the Department of Psychiatry, Neurobiology, Pharmacology, and Biotechnologies of the Azienda Ospedaliera Universitaria Pisana. The primary aim of the PND-ReScU is to evaluate the effectiveness of screening for early identification and the intervention strategies to reduce mood disorders in the perinatal period. Furthermore, PND-ReScU aims at defining a battery of instruments that can be easily administered in a primary prevention setting. Women were recruited for the study during pregnancy, at the time of delivery of the pregnancy book, or in the immediate post-partum period (during hospitalization). Instruments: Symptoms of maternal depression were assessed using the 10-item Edinburgh Postnatal Depression Scale (Cox et al., 1987). The Post-partum Depression Predictors Inventory-Revised (PDPI-R) (Beck, 2002) was used to identify the risk factors for PPD. Prenatal maternal attachment were assessed using the Maternal Antenatal Attachment Scale (MAAS). Maternal and paternal antenatal attachment scales (MAAS; Condon, 1993). Anxiety symptoms were assessed using STAI-Y ( state trait anxiety Inventory form Y-1.) Statistical analysis: Data are presented as means (standard deviations), or percentages. Chi-square tests were used to compare percentages and ANOVA were used to compare mean scores. Using analysis of variance (ANOVA) was able to compare two or more groups of data comparing the internal variability in these groups with the variability between groups. To check the intensity and direction of the relationships between depression, anxiety, attachment to the fetus and risk factors, was performed Pearson bivariate correlation. Analyses were conducted using SPSS, version 15. Results: Our sample is composed by 456 women: among them, 393 (86.2%) of Italian nationality and 401 (87.9%) experiencing a spontaneous pregnancy. Moreover, 61.6% of the sample is composed of women in their first pregnancy. At T0, we can observe that 4.8% of women have an high score on EPDS (EPDS ≥13) while at T1 At the percentage of the output decreases to .9%. At T2 decreases further to 4%. while the T3 is increased up to 1.1%.T0, the prevalence of anxiety is 18%, while we can observe that the percentage decrease at the next T: T1 (6.1%), T2 (4.4%), T3 (3.9%). the average of the MAAS total scores at T2 was 76.95 ± 6.3, while at T3, the average is 78.54 ± 6.29. Considering the MAAS Preoccupation subscales at T2 the average is 28.12 ± 4.2 and 29.33 ± 4.21 at T3. Considering the Quality of Attachment subscale MAAS, at T2, the average is 47.2 ± 3.29, while the T3 is 47.71 ± 2.98. Association between depression during pregnancy, good antenatal attachment , anxiety symptoms and risk factors is reported in tab 2,3,4,5. In our sample we don’t find any association between antenatal maternal attachment and demographic characteristics except for women in their first pregnancy in which we discover higher MAAS scores than other women in sample. Correlation between antenatal attachment, anxiety, depression and risk factors during pregnancy is reported in tab.7 Conclusions: Many of the physiological sensations that occur during pregnancy closely resemble anxiety symptoms; thus, these disorders may be masked in pregnant women. For this reason it is essential that treatment providers in obstetric offices, primary care settings, and mental health clinics be attuned to the signs of anxiety disorders (Weisberg and Paquette, 2002). Carrying out antenatal screening of established risk factors and accurate evaluation of attachment during pregnancy may help to plan adequate treatment in order to prevent possible postpartum distress outcomes. Further studies are needed to replicate our findings and to clarify the role of pre/post natal attachment during pregnancy and its link with Post-Partum Depression in order to identify a specific subgroup of women warranting special attentio