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A qualitative study of mild to moderate psychological distress during pregnancy
International Journal of Nursing Studies 46 (2009) 669–677
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International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
A qualitative study of mild to moderate psychological distress during pregnancy Christine M. Furber a,*, Debbie Garrod b, Eileen Maloney b, Karina Lovell a, Linda McGowan a a b
School of Nursing, Midwifery & Social Work, The University of Manchester, Manchester, United Kingdom Stockport NHS Foundation Trust, Poplar Grove, Hazel Grove, Stockport SK2 7JE, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 3 August 2008 Received in revised form 26 October 2008 Accepted 6 December 2008
Background: Psychological distress is common in the antenatal period. In England, psychological distress is classified as mild, moderate or severe but only those who suffer severe psychological distress are referred to the specialist mental health services. Those who suffer mild to moderate psychological distress are managed by the primary care services. However, little is know about the psychosocial experiences of pregnant women who suffer from mild–moderate psychological distress. Objective: This study explored the experiences of pregnant women who self-reported mild to moderate psychological distress during antenatal care. Design: A qualitative study. Data were collected using digitally recorded, face-to-face, semi-structured interviews. Data were analysed using framework analysis. Setting: A large teaching maternity hospital in North West England. Participants: Twenty-four pregnant women who self-reported mild to moderate psychological distress to their midwife during routine antenatal care. Results: Three main themes emerged: the causes of, impact of, and ways of controlling self-reported mild to moderate psychological distress. A range of experiences caused psychological distress including past life and childbearing experiences, and current pregnancy concerns. Mild to moderate psychological distress took over the lives of these pregnant women. The strategies used to control mild to moderate psychological distress included both positive and negative coping elements. Conclusions: Psychological distress that is categorised as mild to moderate can be extremely debilitating for pregnant women. Identification of these women in clinical practice is crucial so that effective interventions can be targeted appropriately. Screening criteria that has the efficacy to identify depression and anxiety is needed. We recommend that a multidisciplinary approach to the management of care is developed to address the range of experiences that pregnant women who suffer mild to moderate prenatal psychological distress may have. ß 2008 Elsevier Ltd. All rights reserved.
Keywords: Pregnancy Antenatal care Mental health Framework analysis
What is already known about the topic? * Corresponding author at: School of Nursing, Midwifery & Social Work, The University of Manchester, University Place, Oxford Road, Manchester M13 9PL, United Kingdom. Tel.: +44 161 306 7719. E-mail address: [email protected] (C.M. Furber). 0020-7489/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2008.12.003
Psychological distress in pregnancy has been associated with significant risks for the future health of the mother and baby.
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Despite having national guidelines for managing psychological distress in pregnancy in England, the extent and impact of mild to moderate psychological distress in pregnancy is under researched. Mild to moderate psychological distress is usually managed by primary health care services in England. What this paper adds: Reveals the debilitating effects of mild to moderate psychological distress on the lives of pregnant women. Identifies several psychosocial factors that may trigger psychological distress in pregnancy. Guidelines on screening of mental health in pregnancy need to take account of the level of anxiety that pregnant women may experience. Pregnancy has often been described as a period of emotional well being (Altschuler et al., 1998), but for many women, pregnancy can be a distressing event that significantly affects the quality of life (Jomeen, 2004). Many factors have been associated with antenatal psychological distress including adjustments required because of the pregnancy, changes to relationships with significant others, and dissatisfaction with body image (Lavender, 2007). In England, psychological distress during childbearing is generally clinically defined as depression and/or anxiety and classified as mild, moderate, or severe (National Institute for Health and Clinical Excellence [NICE], 2006). ‘Mild to moderate’ psychological distress is usually managed by primary health care services, with those who have more severe distress being referred to specialist mental health services (NICE, 2006). Estimates of the prevalence of antenatal psychological distress are well documented, but display considerable variation. Rates in industrialised countries are between 8% and 24% of women during pregnancy (Rubertsson et al., 2003; van Bussell et al., 2006), whereas a meta-analysis of 59 studies suggested that the prevalence of postpartum depression is 13% (O’Hara and Swain, 1996). Traditionally, health services have focussed support on the postpartum period (Henshaw and Elliott, 2005); however, developing literature is beginning to focus on the risks associated with antenatal psychological distress. Antenatal depression has been associated with preterm birth and low birth weight (Field et al., 2004), a more complicated birth (Andersson et al., 2004), impaired maternal-fetal attachment (Lindgren, 2001), and may have negative effects on the behavioural development of the child (Deave et al., 2008). Furthermore, antenatal depression and anxiety may predict future postpartum depression (Robertson et al., 2004; van Bussell et al., 2006). The triennium reviews of maternal deaths in the UK have also identified that severe mental health problems may lead to maternal suicide (Lewis, 2007). Little is known about women’s subjective experiences when suffering from antenatal psychological distress. In one study, depressed pregnant women described their experiences of depression in terms of irrational emotions, inability to function, invasive thoughts, anxiety, and social
withdrawal (Bennett et al., 2007). Other studies have concentrated on the concerns that pregnant women may have, for example, practical issues such as finances (Ohman et al., 2003; Jomeen and Martin, 2005), and coping with another baby (Borthwick et al., 2004; Jomeen and Martin, 2005) have been reported. Women have also expressed worry over their own health (miscarriage), the baby’s health, and the quality of support provided by the maternity services (Ohman et al., 2003). The assessment of psychological distress during pregnancy is much debated. A number of validated screening instruments for depression exist (Sanders, 2006), including the Edinburgh Postnatal Depression Scale (EPDS) that has been validated for antenatal use (Murray and Cox, 1990). In some industrialised countries, structured antenatal screening protocols have been developed using questionnaires or structured interviews assessing psychosocial variables (Reid et al., 1998; Austin, 2004) to screen for anxiety and depression. In the UK, screening using the EPDS in the antenatal period is not recommended (NICE, 2008). Concern over the efficacy of the instrument (Shakespeare, 2001) has led to a recommendation from the Department of Health (DoH) in England that all pregnant women are provided with the opportunity to discuss mental health issues, rather than be screened. Midwives were advised to enquire about family history and personal experience of serious mental illness early in the antenatal period (DoH, 2004; NICE, 2008). In early 2007, the National Institute for Health and Clinical Excellence (NICE, 2007) recommended that pregnant women are screened for depression by being asked the following two questions at the first antenatal contact: 1. ‘‘In the past month, have you often been bothered by feeling down, depressed, or hopeless?’’ 2. ‘‘In the past month, have you often been bothered by having little interest or pleasure in doing things?’’ If a positive response is made to either, a further question is asked: 3. ‘‘Is this something you feel you need or want help with? If considered appropriate, it is recommended that treatment should be initiated within 1 month. Because of the costs, both emotionally and financially, of psychological distress on the individual affected, their family, and wider society, there is a need for interventions that are specifically focussed on the causes, and impact of, psychological distress. Given the paucity of research exploring the experiences of pregnant women who suffer from psychological distress, the purpose of this study is to add to, and inform, the emergent literature base. The main aim of this study was to explore the experiences of pregnant women who self-report mild to moderate psychological distress during antenatal care. 1. Methods A qualitative approach using an interpretive framework (Parahoo, 1997) was used. A past service user (a woman
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who suffered from antenatal depression and is now recovered) provided advice at each stage of the study, including analysis and interpretation of data. Permission to conduct the study was obtained from the Local Research Ethics Committee (reference 06/Q1401/59) and the National Health Service Trust Research Governance committee. 1.1. Sample A purposive sampling strategy was used to recruit participants who would provide rich information about the study focus (Ritchie et al., 2003). The size of the sample was determined by the principles of data saturation, thus data collection ended when no new information emerged from the interviews (Ritchie et al., 2003). 1.2. Selection and recruitment of participants The study setting was a large teaching hospital in the North of England with 3640 births during the year of data collection (Estcourt, 2008). During the period of data collection, pregnant women were asked about their ‘mental health’ by midwives (DoH, 2004). Those identified as suffering from severe mental health problems were referred to specialist mental health services. For those with mild/moderate mental health problems, a service was provided by a Specialist Midwife (EM) who provides emotional and practical support for women. All pregnant women over 16 years who self-reported psychological distress during routine antenatal care and were referred to EM (and not receiving support from specialist mental health services) from October 2006 to March 2007 were invited to participate. EM mailed information about the study to 65 women who met the inclusion criteria. Women were asked to return a form stating whether or not they wanted to take part in the study to the principal investigator (CF). Those who replied were telephoned by CF or DG and an appointment made for interview. Those who did not respond within 1 month were sent a reminder letter. 1.3. Data collection Data were collected during digitally recorded semistructured interviews by CF (15 interviews) and DG (9 interviews). Written consent was obtained before each interview, and all women were reminded that they could withdraw at any time. Two interviews took place in the hospital and 22 in the woman’s own home and lasted between 45 and 75 min. An interview guide was determined by the study team (available from CF), including discussions with midwives (EM, DG and CF), a health psychologist (LMcG), a specialist in mental health (KL), a service user (a mother who had suffered from antenatal psychological distress during a previous pregnancy), and the relevant literature (e.g. Borthwick et al., 2004; Jomeen, 2004). Key areas explored were perceived causes and triggers of distress, how such distress impacted on their lives, and what coping strategies were utilised.
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1.4. Data analysis The tapes were transcribed verbatim. Data were analysed using the five stages of framework analysis: familiarisation, identification of a theoretical framework, indexing, charting, and mapping and interpretation (Ritchie and Spencer, 1994). An initial coding framework was developed and transcripts were checked against the framework to ensure that there were no significant omissions. Codes in each interview were examined across individual transcripts as well as across the entire data set and allocated to the framework. Using constant comparison methods (Glaser and Strauss, 1967) broader categories linked codes across interviews. Data were interpreted and analysed within the framework to distil key categories and sub-categories. Direct quotes were given an ID number and other characteristics have been removed to ensure anonymity. Data were managed using the computer software package nVivo 7. All authors were involved in the familiarisation process, developing the theoretical framework, and indexing phases. CF completed charting using a combination of nVivo and MS Word. CF and LMc concluded the mapping and interpretation phases. The service user was involved in the familiarisation phase and reviewed the final theoretical framework. The team approach employed throughout the analytical process assisted in data validation and helped to maintain rigor. 2. Results Of the 65 women invited to participate, 24 were interviewed. The characteristics of the participants are detailed in Table 1. To summarise, the youngest participant was 24 years and the oldest 39. All women had singleton pregnancies. Eight women were primigravidae and 16 were multigravidae. Fifteen women were interviewed during semester 3, 8 during semester 2, and 1 in semester 1. Nineteen women lived with their partner, 2 had partners living elsewhere, 2 were single, and 1 was separated from her partner. At the time of interview, 2 women were studying full-time, 4 worked full-time, 5 worked part-time, 1 was on maternity leave, and 12 were not working. Twelve women reported suffering from physical problems during the pregnancy such as hyperemesis gravidarum, vaginal bleeding, and back pain. Ten women had suffered a previous miscarriage or preterm birth. Three main themes emerged from the data related to women’s experiences of psychological distress during pregnancy. These were: The causes of psychological distress. The impact of psychological distress. Ways of controlling psychological distress. 2.1. The causes of psychological distress The perceived causes of distress varied. Almost all participants had experienced psychological distress prior to their current pregnancy.
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Table 1 Illustrate characteristics of participants. Participant
Age
Occupational status at interview
Number of pregnancies (n)
Number of living children (n)
Previous preterm birth/miscarriage (n)
Gestation at interview in weeks
Marital status
1 2
28 33
Not working Works PT
4 3
3 2
1 1
20 18
3 4 5 6 7 8 9 10 11
25 31 35 27 35 24 30 35 23
Works FT Works PT Studying FT Works FT Works PT Works FT Maternity leave Not working Not working
1 3 5 1 3 1 2 1 3
0 2 3 0 1 0 0 0 1
0 0 1 0 1 0 1 0 1
30 30 35 17 19 28 33 18 13
12 13 14 15 16 17 18 19 20 21 22 23 24
30 34 39 25 36 33 28 31 37 37 34 34 39
Not working Not working Not working Not working Works PT Works PT Studying FT Not working Not working Not working Not working Works FT Not working
4 2 5 3 2 3 3 5 4 2 2 1 1
3 1 1 0 1 2 1 2 3 1 1 0 0
0 0 3 2 0 0 1 2 0 0 0 0 0
31 34 28 35 7 18 28 38 33 38 39 20 32
Married Partner lives elsewhere Married Married Single Partner Married Partner Partner Partner Partner lives elsewhere Partner Separated Married Partner Married Partner Married Married Single Married Married Married Married
PT = part time. FT = full time.
2.1.1. Past experiences causing distress Some participants attributed past adverse life events as a trigger for their current distress, and included bereavement and childhood sexual abuse. I have had depression before, it started when my Nan died suddenly when I was 20. It was completely unexpected and it just basically knocked me for six. It really, really did knock me for six. I was in quite a mess for a few years really, on antidepressants for probably about 2 years. I was very close to her because my mum and dad aren’t together, and I grew up spending a lot of time with my mum’s Nan, and my mum’s mum and dad. Erm, and when she, because of how she died, it just knocked me for six. So I have suffered with it before (P19, 38 weeks pregnant). I keep getting stressed about, . . .. cos I was raped when I was a child for 10 years from the age of 4 to 14 off my step father. Erm with being pregnant with a girl it’s starting to worry me. Me and James [partner] discuss everything so he knows how I feel (P15, 35 weeks pregnant). Others described suffering from distress related to their work, but being pregnant meant that they could not use the same coping strategies as they had previously: One of the reasons I fell into depression was I used to work very, very hard and used going out drinking as an escape from it. So my release was getting away from it. Once I’d had a couple of glasses of wine you’re in that state of mind, nothing really matters. I’ve not being able to do that when I
was pregnant. I didn’t have anything to get away from it (P6, 17 weeks pregnant). Distress was also related to past childbearing experiences, including miscarriages and difficult births: At first, [I was] really anxious because I’d lost the other [pregnancy]. So I was really anxious up to 11 weeks, and for a few weeks after that (P7, 19 weeks pregnant). My labour was quite long last time and very, very. . . not traumatic. I never said it was a bad labour, it wasn’t a bad labour, it was just a very long drawn out messy labour and I really don’t want that. I don’t want to have to have a section, and the baby’s been breech, then it hasn’t, then it has, then it hasn’t, and I’m like . . . I’m going to have to have a section. I’m not going to have a section you know and it’s like I don’t want to have a section cos then I can’t drive and I can’t pick him up and you know and it’s just all the things going through my mind, it’s just made me quite low, really quite worried that everything will be alright. So it’s just how I sort of feel really (P22, 39 weeks pregnant). In response to being asked how she felt when she found out she was pregnant, this woman replied: Frightened to death, frightened to death. When I had [my last baby] they told me that, well from what I can remember, they told me not to have any more because I had a massive haemorrhage. I’m lucky to be alive basically.
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So they said it was to do with the placenta breaking up, and they said it’s something that could happen again, and that they’d recommend not to have any more children (P12, 31 weeks pregnant). Experiences occurring after the last birth also triggered distress: I’m very anxious and very worried, to be honest. Only because this little man here [pointing to toddler], when he was born, he got bronchiolitis. I now worry that the baby’s going to get the same thing, so it’s very, very worrying, constantly worrying. I’m worrying of it recurring again (P1, 20 weeks pregnant). I’m anxious about getting postpartum depression again, I’m anxious about giving birth. I’m anxious purely and simply about having two children to look after (P16, 7 weeks pregnant). 2.1.2. Current pregnancy experiences causing distress For a few women, their distress initially emerged in the current pregnancy, for example, participant 21 suffered severe hyperemesis gravidarum during most of her pregnancy requiring long admissions to hospital for intravenous rehydration and was desperate for some relief from the constant vomiting: I didn’t know if I could do this for another day let alone 40 weeks of it. I’m at 10 weeks or whatever it was and I’ve got 30 weeks where I could be like this. I did ask in the hospital for information about termination and what they would do. I was, I really don’t know whether I can do the rest of the pregnancy. If I don’t continue with this pregnancy that I’m in now, our hopes for a second child have just gone (P21, 38 weeks pregnant). Participant 5 was concerned about her baby being separated from her in the hospital: I’ve had a very anxious pregnancy this time. I’ve been really worried about losing it, and I’ve been worried about not bonding with it. I’m having lots of nightmares about people coming to take my baby away, or that she’s getting switched in labour (P5, 35 weeks pregnant). Participant 2 suffered from polycystic ovaries and knew this was a risk of miscarriage (Homberg, 2006). She had also experienced a previous traumatic birth: With polycystic ovaries you’ve got 25% chance of carrying it. It’s just thoughts of my baby not being here. Then the anxiety of delivering because I’ve had two blood transfusions and it was BAD. So I’m panicking about that (P2, 18 weeks pregnant). 2.2. The impact of psychological distress Psychological distress appeared to be all-encompassing and had considerable impact on their lives. When asked about the behaviours that they thought were precipitated by their distress, women found this difficult to talk about, and became tearful. Impact included changes in eating habits, decreased energy, frequent
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crying, altered lifestyle and work patterns which led to women feeling down. I can’t face food at all. I can’t face it. I’ll be hungry and then when it’s in front of me, I just can’t face it. I’ve not eaten properly for about 2 weeks, but I did late yesterday. I ate a full meal yesterday (P17, 18 weeks pregnant). I’ve found work really hard. I found it really difficult to go back because (a) I feel ill (b) because the next day I feel like I’ve used all my energy on just doing something normal. Before I was pregnant it would have been nothing (P4, 30 weeks pregnant). I’m constantly worrying, constantly hygienic, clean hands. Don’t do this, don’t do that, don’t touch, don’t eat that. All that, and that’s like going round and round all the time (P2, 18 weeks pregnant). Feelings of panic were often expressed: I’d worked myself up into that much of a panic at having to walk into the room [where Parent Education was held] that I very nearly didn’t go in. I very nearly stayed in my car and drove home again (P3, 30 weeks pregnant). Crying alone was frequently mentioned: I was in tears two or three times day. Really big, on my own as well. Crying when there was nobody here. I’d go out in the car just to get away and cry (P6, 17 weeks pregnant). I cry a lot during the night. I wake up in the night, things like that (P20, 33 weeks pregnant). The pervasiveness of the distress forced some women to disengage from the pregnancy, and life in general at times. Five women explained how they refused to acknowledge that the pregnancy exists, for example: They listened to the heartbeat and I said ‘I can’t . . .’, because at that moment I didn’t want to bond (P21, 38 weeks pregnant). Several women interviewed expressed that their levels of anxiety impacted on social life or leaving their homes. Four interviews were conducted in daylight hours and with the curtains closed. I can’t go out and socialise when I’m feeling like this. At the minute I can’t go out. I went to my friend’s party. I had to come back cos I just felt anxious all the time (P1, 20 weeks pregnant). I just think that people are looking at me half the time. I don’t seem to be able to socialise like I used to (P11, 13 weeks pregnant). When I started to feel fed up, I wasn’t going out at all. My partner was coming home from work to even pick the kids
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up because I didn’t want to go out (P17, 18 weeks pregnant). Some participants indicated that their distress had a negative impact on their relationship, and caused further stress. My partner keeps saying ‘For God’s sake, I wish we’d never got pregnant. I wish you’d have got rid of him’. He doesn’t understand. He’s just ‘What’s up? You in a mood?’ and I find that a bit hard (P12, 31 weeks pregnant). Real deep depression was just feeling I couldn’t do anything. I think the worst part was that my husband never understood that I was depressed. I was really shouting for help and he was ‘Oh, it’s not so bad’. He thought I had a bit of a problem sometimes (P18, 28 weeks pregnant). 2.3. Ways of controlling distress A range of different methods were used to cope with the distress. Some coping strategies had a positive effect and enabled them to regain control. 2.3.1. Positive coping strategies. Most women interviewed described activities that enabled them to have some time to themselves, often alone. These included: having a bath, staying in bed, reading, writing, seeing people, taking time out of work, yoga, singing, swimming, walking, and shopping. Sometimes I’ll spend times on my own. If I’m feeling a bit down in the dumps I must admit going shopping (P19, 38 weeks pregnant). Just having 3 h in bed quiet on my own was better than any yoga class (P22, 39 weeks pregnant). Going swimming has been quite helpful (P8, 28 weeks pregnant). Several participants explained how their partner facilitated opportunities to have time alone, or helped with childcare and household chores to relieve stress. My husband has been an absolute star because basically for four to five months he was running the house, working full time, doing everything with the children. He works nights, he was coming home getting the kids to school, going to sleep for two hours, getting up and getting the youngest child from nursery, going back to sleep, he was an absolute legend. Thank God (P4, 30 weeks pregnant).
their experiences when asked how they felt at the end of the interview. Some women described activities that alleviated their symptoms. Participant 10 established strict routines in her day-to-day life: I’ve sort of compartmentalised everything. I’ve found that the more regimented and routined I am, the better it is at dealing with it (P10, 18 weeks pregnant). Participant 14 had experienced depression earlier in her life, and had subsequently studied holistic therapies and learnt strategies that helped: I was determined that I wasn’t going to let this get me down. Somebody suggested a book, it’s called ‘You can heal your life’. It really did open my eyes to different things. It made me realise a lot of things. Everything went from there really. I was intrigued to find out more, I enrolled myself into college to get my self-confidence back and to get used to being out of the house. I pushed myself to do it. I did body massage; I went on to do sports massage then Hands on Healing, and a holistic nutrition course. It was the best thing I have ever done (P14, 28 weeks pregnant). Another woman developed the confidence to say ‘no’ to work colleagues: I’ve been saying ‘No’ to people as well. Gradually I’ve started to realise that I have to (P6, 17 weeks pregnant). Many women had an overwhelming desire to seek information about their pregnancy and to seek to understand their feelings by using the Internet, books and other media sources. Participant 17 had several episodes of bleeding during her pregnancy: When I had the bleeding I can’t remember what I looked up. I just typed it into Google and it brought up this message board of other women that have been through the same, which was more helpful (P17, 18 weeks pregnant). 2.3.2. Negative coping strategies. Other coping strategies adopted were repetitive, and caused further distress. Five of the women interviewed described how they frequently cleaned the house: Sometimes I was hoovering the house a million times a day (P11, 13 weeks pregnant). Recently I’ve gone compulsive, and I mean to the point of making myself sick at cleaning. Constant. I never sit down, I’ll wipe anything, and I’ll go and wipe it again (P12, 31 weeks pregnant).
He knows that there’s more chance of me getting depressed again . . . so he takes her (daughter with a previous partner) to school and picks her up. She likes to go to the park playing football with him (P11, 13 weeks pregnant).
Not everyone found that sourcing information eased their distress. For some, this precipitated further distress, for example:
Talking about feelings helped. All of the women interviewed stated that they felt pleased to talk about
The worst thing . . .. Don’t do it, don’t do all the books. There is too much information. I panic (P2, 18 weeks pregnant).
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Participant 1 had deliberately restricted her access to the computer as she was aware that sourcing information made her more distressed: My partner’s put a lock on the computer for me because I find myself looking at these things. I’ve said to him ‘It’s no good, it’s making me worse’. So I don’t use the computer whilst he’s not with me (P1, 20 weeks pregnant). 3. Discussion This study explored the experience of self-reported antenatal psychological distress and the impact this has on women’s lives. Our results have highlighted several psychosocial factors that may initiate significant psychological distress in pregnancy and suggest how debilitating psychological distress that is insufficient to warrant referral to the mental health services can be. These accounts illustrate how mild to moderate psychological distress has the capacity to dominate, and take charge of women’s lives. The causes of distress disclosed by these women are in common with others (Ohman et al., 2003; Borthwick et al., 2004; Jomeen, 2004). The psychological period of adjustment to motherhood requiring the need to behave differently, and less selfishly (Bailey, 1999; Borthwick et al., 2004) was reiterated when the women in this study described their feelings of loss when social activities were curtailed. In particular, these results have provided further insight into the intense negative feelings that may be experienced with antenatal psychological distress. Worry and anxiety were frequently disclosed by these women. Experiencing anxiety in subsequent pregnancies after past fetal loss is not unusual (Ohman et al., 2003), and disengagement from the developing unborn child after such an event, or if the pregnancy is not progressing well, is common (Armstrong and Hutti, 1998; Hart and McMahon, 2006). Anxiety over the health of family members, such as other children as participant 1 described has also been reported (Melender, 2002). Distress related to previous births, in a later pregnancy, is not unknown in Western populations (Melender, 2002; Eriksson et al., 2006; Nilsson and Lundgren, 2009). Some of the feelings described in this study (participants 2 and 12) concur with those of Swedish women cared for by ‘fear of childbirth’ teams. These teams of midwives, obstetricians, and psychologists were developed to provide care to women traumatized by past birth experiences (Eriksson et al., 2006; Nilsson and Lundgren, 2009). The impact related to psychological distress that these women described are commonly experienced during depression (Melender, 2002; Bennett et al., 2007). Withdrawal from normal life activities often occurs (Borthwick et al., 2004; Bennett et al., 2007). Crying alone is not unusual, for example (Borthwick et al., 2004). Other distressed pregnant women have described behaviour that enables them to focus on something else, be busy, and ‘evade’ their fear (Eriksson et al., 2006), which may explain these women’s cleaning behaviour as a controlling mechanism. Although too much information may pre-
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cipitate further distress (Eriksson et al., 2006), as participants 1 and 2 found, confronting distress by seeking out information is a coping mechanism used by other distressed women (Eriksson et al., 2006; Bennett et al., 2007; Raymond, 2009). Although several women described partners who understood their feelings and actively supported them, the ‘emotional loneliness’ that has been cited in other studies of antenatal depression (Bennett et al., 2007, Raymond, 2009) was apparent in those who did not have supportive partners (participants 12 and 18). Strain in relationships has been associated with maternal stress in pregnancy (Bergman et al., 2007). There is a dearth of literature exploring the experiences of partners of depressed pregnant women. However, the incidence of depression is higher in partners of mothers with postnatal depression than the normal rate of the general population (Davey et al., 2006). This suggests that partners of pregnant depressed women may also be at risk of depression. Further research is required to increase understanding of the partner’s experiences of antenatal depression, the impact this has on them, and their role as partner and (future) father. None of the women interviewed in this study had been clinically diagnosed as agoraphobic, however agoraphobic type behaviour (defined as ‘fear of leaving the safe environment of the home . . . or being in a public place’ [Royal College of Psychiatrists, 2007]), was evident. This behaviour warrants further study as research related to agoraphobia and pregnancy is limited (NICE, 2006). Agoraphobic behaviour is frequently associated with panic attacks (Bandelow et al., 2006; Ramnero and Ost, 2007), which were often described by these women. 3.1. Implications for practice Given the risks identified with prenatal psychological distress, our results suggest that accurate assessment of a pregnant women’s psychological state is essential in order to understand fully the nature of the distress experienced (Hart and McMahon, 2006). Only with specific information about the cause of the distress can suitable targeted management strategies be devised. Antenatal history taking should include sensitive questioning about past pregnancies and births in order to identify any factors that may lead to increased distress in the current pregnancy. The data in this study were collected before the NICE recommendations were announced (NICE, 2007). These women were identified after being asked about their ‘mental health’ by midwives (DoH, 2004; NICE, 2008), and were encouraged to discuss this. The NICE questions (developed in the US) focus on major depression (Whooley et al., 1997), but worry and anxiety were frequently mentioned in this study. We believe that applying the NICE questions to these women’s experiences indicates that some women with psychological distress may be missed as they may not associate their current feelings with ‘feeling down, depressed, or hopeless’. Depression and anxiety are often comorbid (Da Costa et al., 2000; Hirschfield, 2001; Preisig et al., 2001) but may present with clinical variations (Hirschfield, 2001; Matthey et al., 2003). For example, the criteria for a depressive
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diagnosis may be met, but anxiety may be subsyndromal, or the criteria for an anxiety diagnosis may be met, and depression be subsyndromal (Hirschfield, 2001). Using these questions, those who predominantly suffer worry and anxiety may not respond positively, and may remain undetected. Furthermore, the ‘help’ question may inhibit women from responding positively if they have not had the opportunity to discuss treatment options (Coyne and Mitchell, 2007), or if they are controlling their distress without professional help. The questions have been designed for quick use (less than 2 min) in primary care (Whooley et al., 1997; Mitchell and Coyne, 2007), therefore the health professional asking them may not use the opportunity to explore mental health in detail. A meta analysis which reviewed the use of a few short questions for depression screening suggests that these 2 questions only perform well in ruling out a diagnosis (Mitchell and Coyne, 2007). On the basis of our findings we strongly recommend that health professionals who use these questions in antenatal care should allow sufficient time to explore the presence of anxiety, and to discuss treatment options if appropriate. Our data also suggests that interventions are needed to alleviate the symptoms of psychological distress. Many of the women stated at the end of the interview that talking had helped to lessen their distress, therefore developing forums for distressed pregnant women to discuss their concerns should be considered. The format should take account of some women’s reluctance to join groups away from home, especially Parent Education. For some, one-to-one sessions may be most appropriate. A qualitative systematic review of the literature related to postpartum depression has highlighted that emotional and practical support from partners and family are desired by depressed mothers (Dennis and Chung-Lee, 2006). In light of the positive support provided by some partners of the women in this study, consideration should be made for the provision of support groups for partners that provide them with the opportunity to discuss their feelings, and ways that they can help (Dennis and Chung-Lee, 2006; Davey et al., 2006). The education of health professionals who care for childbearing women should be reviewed, and enhanced if appropriate, to include information about the causes and impact of mild to moderate psychological distress so that suitable healthcare can be developed. Furthermore, a multidisciplinary approach to the management of care (including psychologists and counsellors, for example) is vital to address the range of experiences of distressed pregnant women. Psychological distress should also be monitored in pregnancy, especially as it is a predictor of postpartum depression (Da Costa et al., 2000; Robertson et al., 2004). We acknowledge the limitations in the study. This is a small study in one geographical area in England so these results may not be generalisable to other populations. For example, most of the participants were aged over 30 years so the results are not applicable to younger
pregnant women. We recognize that selection bias may have been introduced as those who participated were also being supported by EM, so they may have felt obliged to take part. However, we believe that the positive relationship that EM had with these women gave them the confidence to participate. No women withdrew from the study which suggests that they were comfortable taking part. A major strength is the contemporaneous exploration of psychological distress during the pregnancy. Other similar studies are retrospective (Borthwick et al., 2004; Eriksson et al., 2006; Bennett et al., 2007), and may be limited by recall bias (Robertson et al., 2004) as they relied on the woman’s memory of their prenatal experiences explored after the birth. Furthermore, the team approach, involving midwives with different remits (clinical, academic, and service development) and the inclusion of the service user, provided a robust framework for developing the study, and monitoring the research process. 3.2. Conclusions To the best of our knowledge, this is one of the first studies to explore in-depth, mild to moderate psychological distress, contemporaneously during pregnancy. Our results highlight the range of psychosocial factors involved in psychological distress and the impact that these may have on prenatal women’s experiences. Furthermore, our results indicate that screening for prenatal psychological distress warrants further consideration in order to identify those at risk. Although these women’s experiences are categorised as mild to moderate psychological distress (NICE, 2006), clinical staff should take these experiences seriously because of their potential impact on the developing fetus and child, and woman’s later postpartum psychological experiences. Women in this study who reported mild to moderate psychological distress were not in receipt of mental health services’ support, yet the perception of the effect such distress had on their day-to-day quality of life, was highly apparent. It is imperative that future research should focus on helping women to develop, or enhance, their own coping mechanisms, and the provision of more formal support systems. Acknowledgements The Queen’s Nursing Institute for funding the study. The authors would like to thank the user for her contribution to the study. Thanks are also extended to all of the women who participated. Conflict of interest None declared. Funding This study was funded by the Queen’s Nursing Institute, London, England. Ethical approval Ethical approval was given by Stockport Research Ethics Committee in July 2006. REC reference number: 06/Q1401/ 59.
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Contents lists available at ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
A qualitative study of mild to moderate psychological distress during pregnancy Christine M. Furber a,*, Debbie Garrod b, Eileen Maloney b, Karina Lovell a, Linda McGowan a a b
School of Nursing, Midwifery & Social Work, The University of Manchester, Manchester, United Kingdom Stockport NHS Foundation Trust, Poplar Grove, Hazel Grove, Stockport SK2 7JE, United Kingdom
A R T I C L E I N F O
A B S T R A C T
Article history: Received 3 August 2008 Received in revised form 26 October 2008 Accepted 6 December 2008
Background: Psychological distress is common in the antenatal period. In England, psychological distress is classified as mild, moderate or severe but only those who suffer severe psychological distress are referred to the specialist mental health services. Those who suffer mild to moderate psychological distress are managed by the primary care services. However, little is know about the psychosocial experiences of pregnant women who suffer from mild–moderate psychological distress. Objective: This study explored the experiences of pregnant women who self-reported mild to moderate psychological distress during antenatal care. Design: A qualitative study. Data were collected using digitally recorded, face-to-face, semi-structured interviews. Data were analysed using framework analysis. Setting: A large teaching maternity hospital in North West England. Participants: Twenty-four pregnant women who self-reported mild to moderate psychological distress to their midwife during routine antenatal care. Results: Three main themes emerged: the causes of, impact of, and ways of controlling self-reported mild to moderate psychological distress. A range of experiences caused psychological distress including past life and childbearing experiences, and current pregnancy concerns. Mild to moderate psychological distress took over the lives of these pregnant women. The strategies used to control mild to moderate psychological distress included both positive and negative coping elements. Conclusions: Psychological distress that is categorised as mild to moderate can be extremely debilitating for pregnant women. Identification of these women in clinical practice is crucial so that effective interventions can be targeted appropriately. Screening criteria that has the efficacy to identify depression and anxiety is needed. We recommend that a multidisciplinary approach to the management of care is developed to address the range of experiences that pregnant women who suffer mild to moderate prenatal psychological distress may have. ß 2008 Elsevier Ltd. All rights reserved.
Keywords: Pregnancy Antenatal care Mental health Framework analysis
What is already known about the topic? * Corresponding author at: School of Nursing, Midwifery & Social Work, The University of Manchester, University Place, Oxford Road, Manchester M13 9PL, United Kingdom. Tel.: +44 161 306 7719. E-mail address: [email protected] (C.M. Furber). 0020-7489/$ – see front matter ß 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2008.12.003
Psychological distress in pregnancy has been associated with significant risks for the future health of the mother and baby.
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Despite having national guidelines for managing psychological distress in pregnancy in England, the extent and impact of mild to moderate psychological distress in pregnancy is under researched. Mild to moderate psychological distress is usually managed by primary health care services in England. What this paper adds: Reveals the debilitating effects of mild to moderate psychological distress on the lives of pregnant women. Identifies several psychosocial factors that may trigger psychological distress in pregnancy. Guidelines on screening of mental health in pregnancy need to take account of the level of anxiety that pregnant women may experience. Pregnancy has often been described as a period of emotional well being (Altschuler et al., 1998), but for many women, pregnancy can be a distressing event that significantly affects the quality of life (Jomeen, 2004). Many factors have been associated with antenatal psychological distress including adjustments required because of the pregnancy, changes to relationships with significant others, and dissatisfaction with body image (Lavender, 2007). In England, psychological distress during childbearing is generally clinically defined as depression and/or anxiety and classified as mild, moderate, or severe (National Institute for Health and Clinical Excellence [NICE], 2006). ‘Mild to moderate’ psychological distress is usually managed by primary health care services, with those who have more severe distress being referred to specialist mental health services (NICE, 2006). Estimates of the prevalence of antenatal psychological distress are well documented, but display considerable variation. Rates in industrialised countries are between 8% and 24% of women during pregnancy (Rubertsson et al., 2003; van Bussell et al., 2006), whereas a meta-analysis of 59 studies suggested that the prevalence of postpartum depression is 13% (O’Hara and Swain, 1996). Traditionally, health services have focussed support on the postpartum period (Henshaw and Elliott, 2005); however, developing literature is beginning to focus on the risks associated with antenatal psychological distress. Antenatal depression has been associated with preterm birth and low birth weight (Field et al., 2004), a more complicated birth (Andersson et al., 2004), impaired maternal-fetal attachment (Lindgren, 2001), and may have negative effects on the behavioural development of the child (Deave et al., 2008). Furthermore, antenatal depression and anxiety may predict future postpartum depression (Robertson et al., 2004; van Bussell et al., 2006). The triennium reviews of maternal deaths in the UK have also identified that severe mental health problems may lead to maternal suicide (Lewis, 2007). Little is known about women’s subjective experiences when suffering from antenatal psychological distress. In one study, depressed pregnant women described their experiences of depression in terms of irrational emotions, inability to function, invasive thoughts, anxiety, and social
withdrawal (Bennett et al., 2007). Other studies have concentrated on the concerns that pregnant women may have, for example, practical issues such as finances (Ohman et al., 2003; Jomeen and Martin, 2005), and coping with another baby (Borthwick et al., 2004; Jomeen and Martin, 2005) have been reported. Women have also expressed worry over their own health (miscarriage), the baby’s health, and the quality of support provided by the maternity services (Ohman et al., 2003). The assessment of psychological distress during pregnancy is much debated. A number of validated screening instruments for depression exist (Sanders, 2006), including the Edinburgh Postnatal Depression Scale (EPDS) that has been validated for antenatal use (Murray and Cox, 1990). In some industrialised countries, structured antenatal screening protocols have been developed using questionnaires or structured interviews assessing psychosocial variables (Reid et al., 1998; Austin, 2004) to screen for anxiety and depression. In the UK, screening using the EPDS in the antenatal period is not recommended (NICE, 2008). Concern over the efficacy of the instrument (Shakespeare, 2001) has led to a recommendation from the Department of Health (DoH) in England that all pregnant women are provided with the opportunity to discuss mental health issues, rather than be screened. Midwives were advised to enquire about family history and personal experience of serious mental illness early in the antenatal period (DoH, 2004; NICE, 2008). In early 2007, the National Institute for Health and Clinical Excellence (NICE, 2007) recommended that pregnant women are screened for depression by being asked the following two questions at the first antenatal contact: 1. ‘‘In the past month, have you often been bothered by feeling down, depressed, or hopeless?’’ 2. ‘‘In the past month, have you often been bothered by having little interest or pleasure in doing things?’’ If a positive response is made to either, a further question is asked: 3. ‘‘Is this something you feel you need or want help with? If considered appropriate, it is recommended that treatment should be initiated within 1 month. Because of the costs, both emotionally and financially, of psychological distress on the individual affected, their family, and wider society, there is a need for interventions that are specifically focussed on the causes, and impact of, psychological distress. Given the paucity of research exploring the experiences of pregnant women who suffer from psychological distress, the purpose of this study is to add to, and inform, the emergent literature base. The main aim of this study was to explore the experiences of pregnant women who self-report mild to moderate psychological distress during antenatal care. 1. Methods A qualitative approach using an interpretive framework (Parahoo, 1997) was used. A past service user (a woman
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who suffered from antenatal depression and is now recovered) provided advice at each stage of the study, including analysis and interpretation of data. Permission to conduct the study was obtained from the Local Research Ethics Committee (reference 06/Q1401/59) and the National Health Service Trust Research Governance committee. 1.1. Sample A purposive sampling strategy was used to recruit participants who would provide rich information about the study focus (Ritchie et al., 2003). The size of the sample was determined by the principles of data saturation, thus data collection ended when no new information emerged from the interviews (Ritchie et al., 2003). 1.2. Selection and recruitment of participants The study setting was a large teaching hospital in the North of England with 3640 births during the year of data collection (Estcourt, 2008). During the period of data collection, pregnant women were asked about their ‘mental health’ by midwives (DoH, 2004). Those identified as suffering from severe mental health problems were referred to specialist mental health services. For those with mild/moderate mental health problems, a service was provided by a Specialist Midwife (EM) who provides emotional and practical support for women. All pregnant women over 16 years who self-reported psychological distress during routine antenatal care and were referred to EM (and not receiving support from specialist mental health services) from October 2006 to March 2007 were invited to participate. EM mailed information about the study to 65 women who met the inclusion criteria. Women were asked to return a form stating whether or not they wanted to take part in the study to the principal investigator (CF). Those who replied were telephoned by CF or DG and an appointment made for interview. Those who did not respond within 1 month were sent a reminder letter. 1.3. Data collection Data were collected during digitally recorded semistructured interviews by CF (15 interviews) and DG (9 interviews). Written consent was obtained before each interview, and all women were reminded that they could withdraw at any time. Two interviews took place in the hospital and 22 in the woman’s own home and lasted between 45 and 75 min. An interview guide was determined by the study team (available from CF), including discussions with midwives (EM, DG and CF), a health psychologist (LMcG), a specialist in mental health (KL), a service user (a mother who had suffered from antenatal psychological distress during a previous pregnancy), and the relevant literature (e.g. Borthwick et al., 2004; Jomeen, 2004). Key areas explored were perceived causes and triggers of distress, how such distress impacted on their lives, and what coping strategies were utilised.
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1.4. Data analysis The tapes were transcribed verbatim. Data were analysed using the five stages of framework analysis: familiarisation, identification of a theoretical framework, indexing, charting, and mapping and interpretation (Ritchie and Spencer, 1994). An initial coding framework was developed and transcripts were checked against the framework to ensure that there were no significant omissions. Codes in each interview were examined across individual transcripts as well as across the entire data set and allocated to the framework. Using constant comparison methods (Glaser and Strauss, 1967) broader categories linked codes across interviews. Data were interpreted and analysed within the framework to distil key categories and sub-categories. Direct quotes were given an ID number and other characteristics have been removed to ensure anonymity. Data were managed using the computer software package nVivo 7. All authors were involved in the familiarisation process, developing the theoretical framework, and indexing phases. CF completed charting using a combination of nVivo and MS Word. CF and LMc concluded the mapping and interpretation phases. The service user was involved in the familiarisation phase and reviewed the final theoretical framework. The team approach employed throughout the analytical process assisted in data validation and helped to maintain rigor. 2. Results Of the 65 women invited to participate, 24 were interviewed. The characteristics of the participants are detailed in Table 1. To summarise, the youngest participant was 24 years and the oldest 39. All women had singleton pregnancies. Eight women were primigravidae and 16 were multigravidae. Fifteen women were interviewed during semester 3, 8 during semester 2, and 1 in semester 1. Nineteen women lived with their partner, 2 had partners living elsewhere, 2 were single, and 1 was separated from her partner. At the time of interview, 2 women were studying full-time, 4 worked full-time, 5 worked part-time, 1 was on maternity leave, and 12 were not working. Twelve women reported suffering from physical problems during the pregnancy such as hyperemesis gravidarum, vaginal bleeding, and back pain. Ten women had suffered a previous miscarriage or preterm birth. Three main themes emerged from the data related to women’s experiences of psychological distress during pregnancy. These were: The causes of psychological distress. The impact of psychological distress. Ways of controlling psychological distress. 2.1. The causes of psychological distress The perceived causes of distress varied. Almost all participants had experienced psychological distress prior to their current pregnancy.
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Table 1 Illustrate characteristics of participants. Participant
Age
Occupational status at interview
Number of pregnancies (n)
Number of living children (n)
Previous preterm birth/miscarriage (n)
Gestation at interview in weeks
Marital status
1 2
28 33
Not working Works PT
4 3
3 2
1 1
20 18
3 4 5 6 7 8 9 10 11
25 31 35 27 35 24 30 35 23
Works FT Works PT Studying FT Works FT Works PT Works FT Maternity leave Not working Not working
1 3 5 1 3 1 2 1 3
0 2 3 0 1 0 0 0 1
0 0 1 0 1 0 1 0 1
30 30 35 17 19 28 33 18 13
12 13 14 15 16 17 18 19 20 21 22 23 24
30 34 39 25 36 33 28 31 37 37 34 34 39
Not working Not working Not working Not working Works PT Works PT Studying FT Not working Not working Not working Not working Works FT Not working
4 2 5 3 2 3 3 5 4 2 2 1 1
3 1 1 0 1 2 1 2 3 1 1 0 0
0 0 3 2 0 0 1 2 0 0 0 0 0
31 34 28 35 7 18 28 38 33 38 39 20 32
Married Partner lives elsewhere Married Married Single Partner Married Partner Partner Partner Partner lives elsewhere Partner Separated Married Partner Married Partner Married Married Single Married Married Married Married
PT = part time. FT = full time.
2.1.1. Past experiences causing distress Some participants attributed past adverse life events as a trigger for their current distress, and included bereavement and childhood sexual abuse. I have had depression before, it started when my Nan died suddenly when I was 20. It was completely unexpected and it just basically knocked me for six. It really, really did knock me for six. I was in quite a mess for a few years really, on antidepressants for probably about 2 years. I was very close to her because my mum and dad aren’t together, and I grew up spending a lot of time with my mum’s Nan, and my mum’s mum and dad. Erm, and when she, because of how she died, it just knocked me for six. So I have suffered with it before (P19, 38 weeks pregnant). I keep getting stressed about, . . .. cos I was raped when I was a child for 10 years from the age of 4 to 14 off my step father. Erm with being pregnant with a girl it’s starting to worry me. Me and James [partner] discuss everything so he knows how I feel (P15, 35 weeks pregnant). Others described suffering from distress related to their work, but being pregnant meant that they could not use the same coping strategies as they had previously: One of the reasons I fell into depression was I used to work very, very hard and used going out drinking as an escape from it. So my release was getting away from it. Once I’d had a couple of glasses of wine you’re in that state of mind, nothing really matters. I’ve not being able to do that when I
was pregnant. I didn’t have anything to get away from it (P6, 17 weeks pregnant). Distress was also related to past childbearing experiences, including miscarriages and difficult births: At first, [I was] really anxious because I’d lost the other [pregnancy]. So I was really anxious up to 11 weeks, and for a few weeks after that (P7, 19 weeks pregnant). My labour was quite long last time and very, very. . . not traumatic. I never said it was a bad labour, it wasn’t a bad labour, it was just a very long drawn out messy labour and I really don’t want that. I don’t want to have to have a section, and the baby’s been breech, then it hasn’t, then it has, then it hasn’t, and I’m like . . . I’m going to have to have a section. I’m not going to have a section you know and it’s like I don’t want to have a section cos then I can’t drive and I can’t pick him up and you know and it’s just all the things going through my mind, it’s just made me quite low, really quite worried that everything will be alright. So it’s just how I sort of feel really (P22, 39 weeks pregnant). In response to being asked how she felt when she found out she was pregnant, this woman replied: Frightened to death, frightened to death. When I had [my last baby] they told me that, well from what I can remember, they told me not to have any more because I had a massive haemorrhage. I’m lucky to be alive basically.
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So they said it was to do with the placenta breaking up, and they said it’s something that could happen again, and that they’d recommend not to have any more children (P12, 31 weeks pregnant). Experiences occurring after the last birth also triggered distress: I’m very anxious and very worried, to be honest. Only because this little man here [pointing to toddler], when he was born, he got bronchiolitis. I now worry that the baby’s going to get the same thing, so it’s very, very worrying, constantly worrying. I’m worrying of it recurring again (P1, 20 weeks pregnant). I’m anxious about getting postpartum depression again, I’m anxious about giving birth. I’m anxious purely and simply about having two children to look after (P16, 7 weeks pregnant). 2.1.2. Current pregnancy experiences causing distress For a few women, their distress initially emerged in the current pregnancy, for example, participant 21 suffered severe hyperemesis gravidarum during most of her pregnancy requiring long admissions to hospital for intravenous rehydration and was desperate for some relief from the constant vomiting: I didn’t know if I could do this for another day let alone 40 weeks of it. I’m at 10 weeks or whatever it was and I’ve got 30 weeks where I could be like this. I did ask in the hospital for information about termination and what they would do. I was, I really don’t know whether I can do the rest of the pregnancy. If I don’t continue with this pregnancy that I’m in now, our hopes for a second child have just gone (P21, 38 weeks pregnant). Participant 5 was concerned about her baby being separated from her in the hospital: I’ve had a very anxious pregnancy this time. I’ve been really worried about losing it, and I’ve been worried about not bonding with it. I’m having lots of nightmares about people coming to take my baby away, or that she’s getting switched in labour (P5, 35 weeks pregnant). Participant 2 suffered from polycystic ovaries and knew this was a risk of miscarriage (Homberg, 2006). She had also experienced a previous traumatic birth: With polycystic ovaries you’ve got 25% chance of carrying it. It’s just thoughts of my baby not being here. Then the anxiety of delivering because I’ve had two blood transfusions and it was BAD. So I’m panicking about that (P2, 18 weeks pregnant). 2.2. The impact of psychological distress Psychological distress appeared to be all-encompassing and had considerable impact on their lives. When asked about the behaviours that they thought were precipitated by their distress, women found this difficult to talk about, and became tearful. Impact included changes in eating habits, decreased energy, frequent
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crying, altered lifestyle and work patterns which led to women feeling down. I can’t face food at all. I can’t face it. I’ll be hungry and then when it’s in front of me, I just can’t face it. I’ve not eaten properly for about 2 weeks, but I did late yesterday. I ate a full meal yesterday (P17, 18 weeks pregnant). I’ve found work really hard. I found it really difficult to go back because (a) I feel ill (b) because the next day I feel like I’ve used all my energy on just doing something normal. Before I was pregnant it would have been nothing (P4, 30 weeks pregnant). I’m constantly worrying, constantly hygienic, clean hands. Don’t do this, don’t do that, don’t touch, don’t eat that. All that, and that’s like going round and round all the time (P2, 18 weeks pregnant). Feelings of panic were often expressed: I’d worked myself up into that much of a panic at having to walk into the room [where Parent Education was held] that I very nearly didn’t go in. I very nearly stayed in my car and drove home again (P3, 30 weeks pregnant). Crying alone was frequently mentioned: I was in tears two or three times day. Really big, on my own as well. Crying when there was nobody here. I’d go out in the car just to get away and cry (P6, 17 weeks pregnant). I cry a lot during the night. I wake up in the night, things like that (P20, 33 weeks pregnant). The pervasiveness of the distress forced some women to disengage from the pregnancy, and life in general at times. Five women explained how they refused to acknowledge that the pregnancy exists, for example: They listened to the heartbeat and I said ‘I can’t . . .’, because at that moment I didn’t want to bond (P21, 38 weeks pregnant). Several women interviewed expressed that their levels of anxiety impacted on social life or leaving their homes. Four interviews were conducted in daylight hours and with the curtains closed. I can’t go out and socialise when I’m feeling like this. At the minute I can’t go out. I went to my friend’s party. I had to come back cos I just felt anxious all the time (P1, 20 weeks pregnant). I just think that people are looking at me half the time. I don’t seem to be able to socialise like I used to (P11, 13 weeks pregnant). When I started to feel fed up, I wasn’t going out at all. My partner was coming home from work to even pick the kids
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up because I didn’t want to go out (P17, 18 weeks pregnant). Some participants indicated that their distress had a negative impact on their relationship, and caused further stress. My partner keeps saying ‘For God’s sake, I wish we’d never got pregnant. I wish you’d have got rid of him’. He doesn’t understand. He’s just ‘What’s up? You in a mood?’ and I find that a bit hard (P12, 31 weeks pregnant). Real deep depression was just feeling I couldn’t do anything. I think the worst part was that my husband never understood that I was depressed. I was really shouting for help and he was ‘Oh, it’s not so bad’. He thought I had a bit of a problem sometimes (P18, 28 weeks pregnant). 2.3. Ways of controlling distress A range of different methods were used to cope with the distress. Some coping strategies had a positive effect and enabled them to regain control. 2.3.1. Positive coping strategies. Most women interviewed described activities that enabled them to have some time to themselves, often alone. These included: having a bath, staying in bed, reading, writing, seeing people, taking time out of work, yoga, singing, swimming, walking, and shopping. Sometimes I’ll spend times on my own. If I’m feeling a bit down in the dumps I must admit going shopping (P19, 38 weeks pregnant). Just having 3 h in bed quiet on my own was better than any yoga class (P22, 39 weeks pregnant). Going swimming has been quite helpful (P8, 28 weeks pregnant). Several participants explained how their partner facilitated opportunities to have time alone, or helped with childcare and household chores to relieve stress. My husband has been an absolute star because basically for four to five months he was running the house, working full time, doing everything with the children. He works nights, he was coming home getting the kids to school, going to sleep for two hours, getting up and getting the youngest child from nursery, going back to sleep, he was an absolute legend. Thank God (P4, 30 weeks pregnant).
their experiences when asked how they felt at the end of the interview. Some women described activities that alleviated their symptoms. Participant 10 established strict routines in her day-to-day life: I’ve sort of compartmentalised everything. I’ve found that the more regimented and routined I am, the better it is at dealing with it (P10, 18 weeks pregnant). Participant 14 had experienced depression earlier in her life, and had subsequently studied holistic therapies and learnt strategies that helped: I was determined that I wasn’t going to let this get me down. Somebody suggested a book, it’s called ‘You can heal your life’. It really did open my eyes to different things. It made me realise a lot of things. Everything went from there really. I was intrigued to find out more, I enrolled myself into college to get my self-confidence back and to get used to being out of the house. I pushed myself to do it. I did body massage; I went on to do sports massage then Hands on Healing, and a holistic nutrition course. It was the best thing I have ever done (P14, 28 weeks pregnant). Another woman developed the confidence to say ‘no’ to work colleagues: I’ve been saying ‘No’ to people as well. Gradually I’ve started to realise that I have to (P6, 17 weeks pregnant). Many women had an overwhelming desire to seek information about their pregnancy and to seek to understand their feelings by using the Internet, books and other media sources. Participant 17 had several episodes of bleeding during her pregnancy: When I had the bleeding I can’t remember what I looked up. I just typed it into Google and it brought up this message board of other women that have been through the same, which was more helpful (P17, 18 weeks pregnant). 2.3.2. Negative coping strategies. Other coping strategies adopted were repetitive, and caused further distress. Five of the women interviewed described how they frequently cleaned the house: Sometimes I was hoovering the house a million times a day (P11, 13 weeks pregnant). Recently I’ve gone compulsive, and I mean to the point of making myself sick at cleaning. Constant. I never sit down, I’ll wipe anything, and I’ll go and wipe it again (P12, 31 weeks pregnant).
He knows that there’s more chance of me getting depressed again . . . so he takes her (daughter with a previous partner) to school and picks her up. She likes to go to the park playing football with him (P11, 13 weeks pregnant).
Not everyone found that sourcing information eased their distress. For some, this precipitated further distress, for example:
Talking about feelings helped. All of the women interviewed stated that they felt pleased to talk about
The worst thing . . .. Don’t do it, don’t do all the books. There is too much information. I panic (P2, 18 weeks pregnant).
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Participant 1 had deliberately restricted her access to the computer as she was aware that sourcing information made her more distressed: My partner’s put a lock on the computer for me because I find myself looking at these things. I’ve said to him ‘It’s no good, it’s making me worse’. So I don’t use the computer whilst he’s not with me (P1, 20 weeks pregnant). 3. Discussion This study explored the experience of self-reported antenatal psychological distress and the impact this has on women’s lives. Our results have highlighted several psychosocial factors that may initiate significant psychological distress in pregnancy and suggest how debilitating psychological distress that is insufficient to warrant referral to the mental health services can be. These accounts illustrate how mild to moderate psychological distress has the capacity to dominate, and take charge of women’s lives. The causes of distress disclosed by these women are in common with others (Ohman et al., 2003; Borthwick et al., 2004; Jomeen, 2004). The psychological period of adjustment to motherhood requiring the need to behave differently, and less selfishly (Bailey, 1999; Borthwick et al., 2004) was reiterated when the women in this study described their feelings of loss when social activities were curtailed. In particular, these results have provided further insight into the intense negative feelings that may be experienced with antenatal psychological distress. Worry and anxiety were frequently disclosed by these women. Experiencing anxiety in subsequent pregnancies after past fetal loss is not unusual (Ohman et al., 2003), and disengagement from the developing unborn child after such an event, or if the pregnancy is not progressing well, is common (Armstrong and Hutti, 1998; Hart and McMahon, 2006). Anxiety over the health of family members, such as other children as participant 1 described has also been reported (Melender, 2002). Distress related to previous births, in a later pregnancy, is not unknown in Western populations (Melender, 2002; Eriksson et al., 2006; Nilsson and Lundgren, 2009). Some of the feelings described in this study (participants 2 and 12) concur with those of Swedish women cared for by ‘fear of childbirth’ teams. These teams of midwives, obstetricians, and psychologists were developed to provide care to women traumatized by past birth experiences (Eriksson et al., 2006; Nilsson and Lundgren, 2009). The impact related to psychological distress that these women described are commonly experienced during depression (Melender, 2002; Bennett et al., 2007). Withdrawal from normal life activities often occurs (Borthwick et al., 2004; Bennett et al., 2007). Crying alone is not unusual, for example (Borthwick et al., 2004). Other distressed pregnant women have described behaviour that enables them to focus on something else, be busy, and ‘evade’ their fear (Eriksson et al., 2006), which may explain these women’s cleaning behaviour as a controlling mechanism. Although too much information may pre-
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cipitate further distress (Eriksson et al., 2006), as participants 1 and 2 found, confronting distress by seeking out information is a coping mechanism used by other distressed women (Eriksson et al., 2006; Bennett et al., 2007; Raymond, 2009). Although several women described partners who understood their feelings and actively supported them, the ‘emotional loneliness’ that has been cited in other studies of antenatal depression (Bennett et al., 2007, Raymond, 2009) was apparent in those who did not have supportive partners (participants 12 and 18). Strain in relationships has been associated with maternal stress in pregnancy (Bergman et al., 2007). There is a dearth of literature exploring the experiences of partners of depressed pregnant women. However, the incidence of depression is higher in partners of mothers with postnatal depression than the normal rate of the general population (Davey et al., 2006). This suggests that partners of pregnant depressed women may also be at risk of depression. Further research is required to increase understanding of the partner’s experiences of antenatal depression, the impact this has on them, and their role as partner and (future) father. None of the women interviewed in this study had been clinically diagnosed as agoraphobic, however agoraphobic type behaviour (defined as ‘fear of leaving the safe environment of the home . . . or being in a public place’ [Royal College of Psychiatrists, 2007]), was evident. This behaviour warrants further study as research related to agoraphobia and pregnancy is limited (NICE, 2006). Agoraphobic behaviour is frequently associated with panic attacks (Bandelow et al., 2006; Ramnero and Ost, 2007), which were often described by these women. 3.1. Implications for practice Given the risks identified with prenatal psychological distress, our results suggest that accurate assessment of a pregnant women’s psychological state is essential in order to understand fully the nature of the distress experienced (Hart and McMahon, 2006). Only with specific information about the cause of the distress can suitable targeted management strategies be devised. Antenatal history taking should include sensitive questioning about past pregnancies and births in order to identify any factors that may lead to increased distress in the current pregnancy. The data in this study were collected before the NICE recommendations were announced (NICE, 2007). These women were identified after being asked about their ‘mental health’ by midwives (DoH, 2004; NICE, 2008), and were encouraged to discuss this. The NICE questions (developed in the US) focus on major depression (Whooley et al., 1997), but worry and anxiety were frequently mentioned in this study. We believe that applying the NICE questions to these women’s experiences indicates that some women with psychological distress may be missed as they may not associate their current feelings with ‘feeling down, depressed, or hopeless’. Depression and anxiety are often comorbid (Da Costa et al., 2000; Hirschfield, 2001; Preisig et al., 2001) but may present with clinical variations (Hirschfield, 2001; Matthey et al., 2003). For example, the criteria for a depressive
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diagnosis may be met, but anxiety may be subsyndromal, or the criteria for an anxiety diagnosis may be met, and depression be subsyndromal (Hirschfield, 2001). Using these questions, those who predominantly suffer worry and anxiety may not respond positively, and may remain undetected. Furthermore, the ‘help’ question may inhibit women from responding positively if they have not had the opportunity to discuss treatment options (Coyne and Mitchell, 2007), or if they are controlling their distress without professional help. The questions have been designed for quick use (less than 2 min) in primary care (Whooley et al., 1997; Mitchell and Coyne, 2007), therefore the health professional asking them may not use the opportunity to explore mental health in detail. A meta analysis which reviewed the use of a few short questions for depression screening suggests that these 2 questions only perform well in ruling out a diagnosis (Mitchell and Coyne, 2007). On the basis of our findings we strongly recommend that health professionals who use these questions in antenatal care should allow sufficient time to explore the presence of anxiety, and to discuss treatment options if appropriate. Our data also suggests that interventions are needed to alleviate the symptoms of psychological distress. Many of the women stated at the end of the interview that talking had helped to lessen their distress, therefore developing forums for distressed pregnant women to discuss their concerns should be considered. The format should take account of some women’s reluctance to join groups away from home, especially Parent Education. For some, one-to-one sessions may be most appropriate. A qualitative systematic review of the literature related to postpartum depression has highlighted that emotional and practical support from partners and family are desired by depressed mothers (Dennis and Chung-Lee, 2006). In light of the positive support provided by some partners of the women in this study, consideration should be made for the provision of support groups for partners that provide them with the opportunity to discuss their feelings, and ways that they can help (Dennis and Chung-Lee, 2006; Davey et al., 2006). The education of health professionals who care for childbearing women should be reviewed, and enhanced if appropriate, to include information about the causes and impact of mild to moderate psychological distress so that suitable healthcare can be developed. Furthermore, a multidisciplinary approach to the management of care (including psychologists and counsellors, for example) is vital to address the range of experiences of distressed pregnant women. Psychological distress should also be monitored in pregnancy, especially as it is a predictor of postpartum depression (Da Costa et al., 2000; Robertson et al., 2004). We acknowledge the limitations in the study. This is a small study in one geographical area in England so these results may not be generalisable to other populations. For example, most of the participants were aged over 30 years so the results are not applicable to younger
pregnant women. We recognize that selection bias may have been introduced as those who participated were also being supported by EM, so they may have felt obliged to take part. However, we believe that the positive relationship that EM had with these women gave them the confidence to participate. No women withdrew from the study which suggests that they were comfortable taking part. A major strength is the contemporaneous exploration of psychological distress during the pregnancy. Other similar studies are retrospective (Borthwick et al., 2004; Eriksson et al., 2006; Bennett et al., 2007), and may be limited by recall bias (Robertson et al., 2004) as they relied on the woman’s memory of their prenatal experiences explored after the birth. Furthermore, the team approach, involving midwives with different remits (clinical, academic, and service development) and the inclusion of the service user, provided a robust framework for developing the study, and monitoring the research process. 3.2. Conclusions To the best of our knowledge, this is one of the first studies to explore in-depth, mild to moderate psychological distress, contemporaneously during pregnancy. Our results highlight the range of psychosocial factors involved in psychological distress and the impact that these may have on prenatal women’s experiences. Furthermore, our results indicate that screening for prenatal psychological distress warrants further consideration in order to identify those at risk. Although these women’s experiences are categorised as mild to moderate psychological distress (NICE, 2006), clinical staff should take these experiences seriously because of their potential impact on the developing fetus and child, and woman’s later postpartum psychological experiences. Women in this study who reported mild to moderate psychological distress were not in receipt of mental health services’ support, yet the perception of the effect such distress had on their day-to-day quality of life, was highly apparent. It is imperative that future research should focus on helping women to develop, or enhance, their own coping mechanisms, and the provision of more formal support systems. Acknowledgements The Queen’s Nursing Institute for funding the study. The authors would like to thank the user for her contribution to the study. Thanks are also extended to all of the women who participated. Conflict of interest None declared. Funding This study was funded by the Queen’s Nursing Institute, London, England. Ethical approval Ethical approval was given by Stockport Research Ethics Committee in July 2006. REC reference number: 06/Q1401/ 59.
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