Week 7 RF-Measurement and screening of perinatal mental health

Question 1

Why is Perinatal health important?

Answer 1

■ Common mental health disorders have steadily increased in prevalence
among women, whilst remaining largely stable in men (McManus et al., 2016).

■ Depression and anxiety are commonly experienced at childbearing age (Baxter
et al., 2014).

■ From pregnancy through to the first postpartum year, a woman is at
heightened risk for experiencing a mental health disorder and/or relapse of
symptoms (Epifanio et al., 2015).

Question 2

Why is Perinatal health important regarding Infant social and emotional development?

Answer 2

-Maternal sensitivity: How promptly
and appropriately a mother displays
to their infant (Bornstein, 1989; 2013).

Responsive parenting:
– Reduces infant crying and unsettledness (Bell & Ainsworth, 1972).
– Increases infant responsiveness & social interaction (Bigelow & Power, 2014)
– Fosters healthy relationships,
behaviours, and socio-emotional skills (Leerkes, 2009).

• Maternal emotional distress is associated with lower levels of responsiveness/sensitivity (Miller & O’Hara, 2019).

Question 3

What is tokophobia (fear of childbirth)?

Answer 3

Primary tokophobia – A clinically-relevant fear of childbirth despite no previous experience of pregnancy and can often arise during as adolescence or early adulthood (Symonides, et al., 2016).

Secondary tokophobia – Fear of childbirth that develops as a result of a previous negative pregnancy or childbirth related experience such as, termination of pregnancy, miscarriage, traumatic
obstetric event or stillbirth (Bakshi, et al., 2008).
 Rigorous (i.e., strictly adhered to) contraceptive use (Bhatia & Jhanjee, 2012).
 Pregnancy termination to prevent pregnancy/avoid childbirth (Klabbers, et al., 2016).

Question 4

What measurements are used for tokophobia?

Answer 4

 Prevalence estimates of tokophobia
range from 1.9% to 30% (Slade et al., 2020). Variation may be due to problematic
measurement tools.

 Evaluation of self-report measures of
fear of childbirth to examine content
overlap - level of overall overlap was
weak (Martin et al., 2020).

 Poor reliability and validity in pre-
existing measures limits our ability to
identify and treat Tokophobia.

Question 5

What is The Fear of Childbirth Scale
(FCQ)?

Answer 5

Novel measure (Slade et al., 2022)

Good face and content validity:
-Includes both physical and emotional fears
related to childbirth
-Positive wording and balance of ‘worries’ and ‘feeling confident’ favourably viewed by survey completers
-Easy to read and acceptable for a range of
reading abilities

 Measure is brief (20 items) and easy to
complete
-Captures state, not trait anxieties

 Measure requires further testing:
-Reliability (internal and test-retest)
-Validity testing (predictive validity)
-Sensitivity and specificity, for clinical use

Question 6

‘Fear becomes fact’, what is the cycle of birthing negativity?

Answer 6

1. Women approach birth with negative expectations.
2. Women’s natural birthing ability inhibited by fear.
3. Women distrustful of birth and accepting of medical intervention.
4. Women have a negative, high intervention experience.
5. These negative experiences are shared in the media and by word of mouth. (then leads to 1. again).

Question 7

What is The Postpartum Specific Anxiety Scale (PSAS)?

Answer 7

-Some items in general measures of anxiety may be naturally elevated postnatally e.g., ‘I feel rested’ in the State Trait Anxiety Inventory (STAI).

Can lead to misdiagnosis of clinically-relevant anxiety:
- Important to consider context to improve
construct validity of measurement tools

-The PSAS (Fallon et al., 2016) is a 51-item scale that measures maternal and infant focused anxieties during the first year following birth.

Question 8

What are the 4 sub-scales in The Postpartum Specific Anxiety Scale (PSAS)?

Answer 8

1. ‘Competence and Attachment Anxieties (15 items)’
   “I have felt that my baby would be better cared for my someone else”
2. ‘Infant Safety and Welfare Anxieties (11 items)’
   “I have worried that my baby will stop breathing while sleeping”
3. ‘Practical Infant Care Anxieties (7 items)’
   “I have worried about my baby’s milk intake”
4. ‘Psychosocial Adjustment Anxieties (18 items)’ “I have felt resentment towards my partner”

Question 9

What evidence is there for The Postpartum Specific Anxiety Scale (PSAS) being well received?

Answer 9

oPsychometric evidence suggests that the PSAS is an acceptable, valid, and reliable research tool to assess postpartum-specific
anxieties.

– Good predictive validity: Explains more variance in infant feeding method, food responsiveness, enjoyment, and satiety signalling; and perceived infant temperament and sleep behaviour, than the STAI (Davies et al., 2022; Fallon et al., 2018).

– Good face and content validity: Perceived to be easy to understand, and appropriate, by postpartum women (Fallon et al., 2016)

– Good convergent validity with the Edinburgh Postnatal Depression Scale (EPDS) and the STAI.

– Excellent test-retest reliability in the first 6 months postpartum.

Question 10

Give an example of a Clinical case study for the PSAS

Answer 10

Malory scored “4 – Almost always” on the
following PSAS items (mostly relating to infant safety and welfare):
■ I have worried about accidentally harming my baby

■ I have worried that I will become too ill
to care for my baby.

■ I have not taken part in an everyday
activity with my baby because I fear they may come to harm.

■ I have worried about my baby’s health
even after reassurance from others

■ I have worried that my baby will stop
breathing while sleeping.

■ I have had difficulty sleeping even when
I have had the chance to.

■ I have repeatedly checked on my
sleeping baby

-PSAS helped to identify that the sleep problem stemmed from anxiety that the baby might die during sleep.

■ This helped the clinical psychologist focus on the real problem.

■ Therapy targeted towards alleviating fears about cot death and infant welfare at night (i.e., more tailored compared to a general measure).

Question 11

What is a limitation with The Postpartum Specific Anxiety Scale (PSAS)?

Answer 11

oHowever, the PSAS-51 is rather time-consuming to complete

o Not pragmatic for use in clinical settings

o PSAS-RSF was developed to address this issue (12 item version of the PSAS; Davies et al., 2021).

Variations of the PSAS have been developed for use in different populations:
o Translated for use in five different countries, and for use in global crises e.g., COVID-19 (Silverio et al., 2021) – to ensure
meaning is retained in forward-backward translations of included items.

-Could consider teenage mums as some of their struggles and anxieties may differ.

Question 12

What are some gaps in the literature?

Answer 12

 Variation in prevalence of postpartum distress across psychometric measurement tools warrants the need to develop and validate more robust tools.

 At present, why fear of childbirth develops in some women but not others still remains unclear.

 Significant gaps in knowledge base surrounding the aetiology that underpins fear of childbirth.

 Need to better understand risks and protective factors.

 Evaluation of current pathways of care and interventions needed in treatment of
childbearing-specific anxiety.

Question 13

What is Guilt and shame within the context of infant feeding?

Answer 13

■ Guilt and shame are predictive of
postnatal depression and anxiety (Caldwell
et al., 2021).

■ Thought to be considered as
transdiagnostic phenomena: “Underlying the development and/or maintenance of numerous psychological symptoms and disorders, including depression and anxiety” (Dalgleish et al., 2020).

 Not yet been assessed in context of
infant feeding

 “Breast is best” promotion can be
aggressive, biased, and insensitive to
individual circumstances (Fallon et al., 2019)

 Resulting ideal-actual discrepancy can
lead to guilt and shame for those who
cannot, or do not, breastfeed (Murphy, 1999).

Question 14

What was found when guilt was measured quantitatively and qualitatively?

Answer 14

Quantitative:
-Feelings of guilt increased with increased percentage formula feeding use
-Guilt was exacerbated when antenatal intentions to breastfeed went unmet (i.e., was planning to and then didn’t).

Qualitative:
-Formula feeding guilt – healthcare
professionals, having unmet ‘breast is best’ ideals
-Breastfeeding guilt – peers and
family

Question 15

What was found when shame was measured quantitatively and qualitatively?

Answer 15

Quantitative:
No available literature

Qualitative:
-Breastfeeding and formula feeding –perceived biological failing
– In front of the ‘judgemental other’
– Medicalisation/objectification of infant
feeding (i.e., actively silenced)
– Avoidance behaviour

Question 16

What are the Limits of pre-existing
literature?

Answer 16

Quantitative:
-Missing information regarding statistical
analyses
-Examination investigated via binary
response options, ‘Yes/No’ (Fallon et al., 2016; Komninou et al., 2016)

Qualitative:
-Guilt and shame are sometimes grouped in
thematic analysis, e.g., “Stress, shame, and
guilt”
-Used interchangeably in some research
papers

Question 17

What are the Limits of pre-existing
literature overall?

Answer 17

-Only 2 of the 20 papers which investigated guilt, shame, and/or infant feeding defined shame (Hanell, 2017; Thomson et al., 2015).

o Only 1 of 20 papers defined guilt (Thomson et al., 2015).

Poor sample variability (compromises generalisability):
- Largely White, highly educated, partnered,
primiparous women of high socioeconomic status

oMissing information about participant demographics
- Demographic factors play a role in infant feeding outcomes and experiences
- Not reporting this information could introduce confounders

Question 18

What are examples in Theoretically mapping guilt and shame: A concept analysis

Answer 18

Antecedent=% (the triggers causing the concepts to occur)
Consequences=*
Attributes=& (key characteristics of that concept)

Shame:“I ended up suffering from quite severe postnatal depression (%), I have always wondered whether that was something to do with it, if I could have breastfed would it have happened (*).” (Thomson et al., 2015, pg.41).

Question 19

What are the recommendations and next steps?

Answer 19

Infant-feeding specific definitions generated should be used in future infant
feeding research to improve construct validity and research homogeneity

• Can act as a springboard for generating definitions for other periods/special
  populations e.g., antenatal, middle- and low-income settings, pre-term infants,
  teenage parenthood etc. (Jackson et al., 2021)

Longitudinal research needed to ecologically validate theorised antecedents,
attributes, and consequences

• Majority of pre-existing literature is cross-sectional in nature (Jackson et al., 2021)
• Need to establish directionality Longitudinal research needed to ecologically validate theorised antecedents, attributes, and consequences.

Question 20

What are Issues with pre-existing
measures of guilt and shame?

Answer 20

Guilt and Shame Proneness Scale (Cohen et al., 2011):
* Poor transferability to different cultures e.g., “not making the honor society”
* Use of abstracted scenarios lack ecological validity
* Reductionist – Taps in to trait,
but not state affect.

Event Related Guilt and Shame Scale (Orth et al., 2006):
* Lack of context specificity – designed for measuring affect after relationship breakdown.
* Short – easy to distribute (pragmatic applications).

Question 21

What is A novel measure of postpartum
guilt and shame?

Answer 21

Initial 54-item measure developed for postpartum guilt and shame (Jackson
et al., in prep):
oFalling short of one’s expectations of self:
“I have felt guilty because I have not done what has been best for my baby”

o The failing body:
“I have felt ashamed of my weight”

o Self-other parenting comparisons:
“It has felt like other mothers have had less emotional issues than me.”

o Dissociation from the maternal identity:
“I have felt ashamed because at times I have not wanted to be a mother”