Maternal self-confidence during the first four months postpartum and its association with anxiety and early infant regulatory problems

Infant Behavior and Development 49 (2017) 228–237

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Maternal self-confidence during the first four months postpartum and its association with anxiety and early infant regulatory problems

MARK

⁎

Lina Maria Matthiesa,1, Stephanie Wallwienera, ,1, Mitho Müllerb, Anne Dostera, Katharina Plewnioka, Sandra Fellera, Christof Sohna, Markus Wallwienera, Corinna Reckb a b

University of Heidelberg, Department of Obstetrics and Gynecology, Im Neuenheimer Feld 440, 69120 Heidelberg, Germany Ludwig Maximilian University, Department of Psychology, Leopoldstr. 13, 80802 Munich, Germany

AR TI CLE I NF O

AB S T R A CT

Keywords: Maternal self-confidence Anxiety Depression Early regulatory problems Postpartum

Maternal self-confidence has become an essential concept in understanding early disturbances in the mother-child relationship. Recent research suggests that maternal self-confidence may be associated with maternal mental health and infant development. The current study investigated the dynamics of maternal self-confidence during the first four months postpartum and the predictive ability of maternal symptoms of depression, anxiety, and early regulatory problems in infants. Questionnaires assessing symptoms of depression (Edinburgh Postnatal Depression Scale), anxiety (State-Trait Anxiety Inventory), and early regulatory problems (Questionnaire for crying, sleeping and feeding) were completed in a sample of 130 women at three different time points (third trimester (T1), first week postpartum (T2), and 4 months postpartum (T3). Maternal self-confidence increased significantly over time. High maternal trait anxiety and early infant regulatory problems negatively contributed to the prediction of maternal self-confidence, explaining 31.8% of the variance (R = .583, F3,96 = 15.950, p < .001). Our results emphasize the transactional association between maternal self-confidence, regulatory problems in infants, and maternal mental distress. There is an urgent need for appropriate programs to reduce maternal anxiety and to promote maternal self-confidence in order to prevent early regulatory problems in infants.

1. Introduction 1.1. Definition The early mother-infant relationship plays a crucial role in a child’s development (Lomanowska, Boivin, Hertzman, & Fleming, 2015). In order to understand and to identify disturbances in the mother-child relationship, maternal self-confidence has become an important concept. The concept of maternal self-confidence (Teti & Gelfand, 1991) is understood as a special aspect of self-efficacy (Jones & Prinz,

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Corresponding author at: Universitätsfrauenklinik Heidelberg, Im Neuenheimer Feld 440, 69120 Heidelberg, Germany. E-mail address: [email protected] (S. Wallwiener). 1 Equal contributors. http://dx.doi.org/10.1016/j.infbeh.2017.09.011 Received 15 March 2017; Received in revised form 24 August 2017; Accepted 18 September 2017 0163-6383/ © 2017 Elsevier Inc. All rights reserved.

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2005). Maternal self-confidence is defined as a mother's confidence in her own abilities to successfully raise her child, to be able to handle aspects of daily parenting, and to correctly interpret her child's signals (Zahr, 1991), representing her ability to create an environment which positively influences the infant's development (Reck, Noe, Gerstenlauer, & Stehle, 2012; Zietlow, Schluter, Nonnenmacher, Muller, & Reck, 2014). In the literature, the terms “maternal self-efficacy” and “maternal self-confidence” are used as synonyms (Teti & Gelfand, 1991). In the sense of a feedback mechanism, high maternal self-confidence supports feelings of success, which in turn perpetuates maternal self-confidence. The downside is that in mothers with low maternal self-confidence, problems in parenting will be expected and interpreted as failure, weakening maternal self-confidence in turn (Sanders & Woolley, 2005; Jones & Prinz, 2005). According to Bandura's theory of self-efficacy, women with high levels of maternal self-efficacy usually enjoy the new challenge of motherhood, while women with low maternal self-confidence tend to be afraid of the adjustments of motherhood and suffer mentally and physically (Bandura, 1977). 1.2. Impact on the child Low maternal self-confidence can also cause long-term behavioral or affective disorders in children as it directly influences the parenting style: While, on the one hand, low maternal self-confidence is more often associated with a coercive parenting style with tough penalties (Bugental & Cortez, 1988), recent studies emphasized that the higher the levels of maternal self-confidence are, the more is warmth, sensitivity, and responsiveness shown towards the child (Stifter & Bono, 1998), (Teti & Gelfand, 1991), preventing the development of anxiety and depressive disorders or behavioral problems in children and adolescents in the long term and promoting social competence, self-confidence, and educational achievement (Sanders & Woolley, 2005; Tucker, Gross, Fogg, Delaney, & Lapporte, 1998; Reck et al., 2012). 1.3. Influencing variables Maternal self-confidence itself is a dynamic, time-dependent process potentially influenced by different variables, including the mother’s mental health. Although maternal self-confidence is known to affect mental and physical health of both mother and child, research concerning influencing variables, especially in the peripartum period, is rare among the current literature. 1.3.1. The influence of time First of all, time itself seems to play an important role. As women established routine in everyday life with their child and got a sense for their specific needs, several authors registered an increase in maternal self- confidence during the first months postpartum (Porter & Hsu, 2003; Zietlow et al., 2014). Interestingly, this development failed to appear in women in whom current or remitted postpartum depression was diagnosed (Howell, Mora, DiBonaventura, & Leventhal, 2009; Logsdon, Wisner, & Hanusa, 2009). 1.3.2. Maternal mental illnesses The perinatal period seems to increase a woman‘s vulnerability to psychiatric disorders due to increased physical and mental stress as well as hormonal changes (Goodman et al., 2014). Among all diseases, anxiety and depression are observed most frequently, with prevalence rates of approximately 18.4% pre- and 19.2% postnatally for depression (Babb, Deligiannidis, Murgatroyd, & Nephew, 2015) and 25% pre- and 11.1% postnatally for anxiety (Dubber, Reck, Muller, & Gawlik, 2015), respectively. Previous studies revealed that maternal anxiety and/or depression may have far- reaching detrimental effects on maternal selfconfidence. To date, only few studies have distinguished between anxiety and depression, which might be due to high comorbidity rates between the two entities that are estimated to be around 50% (Andrews, Sanderson, Slade, & Issakidis, 2000; Hendrick, Altshuler, Strouse, & Grosser, 2000; Masi et al., 2004). Logsdon et al. (2009) demonstrated that maternal self-confidence rose in all mothers during the first weeks postpartum, except for mothers suffering from postpartum depressive disorders (Logsdon et al., 2009). This effect was observed even when depressed mothers were treated successfully, and it continued after remission. As a possible cause, Hopkins et al. discussed a more negative perception of oneself and the interaction with the child compared to nondepressed mothers, leading to the assumption of not being capable of fulfilling the parental role (Hopkins et al., 1987). In contrast, maternal self-confidence appears to be a protective factor for postpartum depressive disorders (Cutrona & Troutman, 1986; Howell et al., 2009; Sevigny & Loutzenhiser, 2010; Porter & Hsu, 2003). In the area of anxiety research, only few studies focused on the effects of anxiety on maternal self-confidence. Hsu and Sung found a correlation between low maternal self-confidence and maternal separation anxiety in a sample of first-time mothers (Hsu & Sung, 2008). Reck et al. demonstrated that a currently existing anxiety or depressive disorder had a significant, negative impact on the development of maternal self-confidence, whereas a „remitted anxiety disorder“ proved to be the strongest predictor of low maternal self- confidence two weeks postpartum (Reck et al., 2012). Zietlow et al. showed in a sample of women with postpartum depressive and/or anxiety disorders according to DSM-IV criteria that affective mental illnesses had a long-term negative impact on maternal self-confidence even up to 3–6 years later (Zietlow et al., 2014). This might be traced back to avoidance behavior, often accompanying anxiety disorders (Otto et al., 2016; Raymond, Steele, & Series, 2017). It is conceivable that anxious mothers tend to avoid anxiety-inducing situations with their child, potentially hindering them from acquiring positive experiences that could strengthen their self- confidence (Jones & Prinz, 2005; Kunseler, Oosterman, de Moor, Verhage, & Schuengel, 2016; Sanders & Woolley, 2005). 229

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1.3.3. Infant‘s temperament Several authors have demonstrated the influence of an infant's temperament on maternal self-confidence (Cutrona & Troutman, 1986; Teti & Gelfand, 1991). Several authors could show that children who require a high degree of attention and who do not respond to their mother‘s attention in a consistent way may weaken a mother‘s self-efficacy beliefs (Cutrona & Troutman, 1986; Porter & Hsu, 2003). Core symptoms reveal themselves in symptoms characteristic of age and developmental stage, including excessive crying, sleeping problems, and feeding difficulties, which can occur separately or in combination (German Society of Child and Adolescent Psychiatry, 2007) (Sidor, Fischer, Eickhorst, & Cierpka, 2013). Crying in the first three months is regarded as an expression of normal adjustment; however, excessive crying or whining beyond the first 3–4 months of life is seen as a regulatory problem in early infancy (Barr, 1990; Papousek & von Hofacker, 1998). As a meaningful risk factor, early parent-infant interactions have been studied with dysfunctional patterns potentially leading to aggregation or maintenance of early regulatory problems (von Hofacker & Papousek, 2008). 1.4. Aim of the study Taken together, these data suggest that an association between maternal self-confidence, mental health, and early regulatory problems can be hypothesized. Therefore, the present study aimed to examine the course of maternal self-confidence in the first four months postpartum and to gather data showing the link to symptoms of depression and anxiety. We also specifically analyzed the link between maternal self-confidence and early infant regulatory problems. hypothesizing that low maternal self-confidence fosters regulatory problems. To the knowledge of the authors, this is the first study to examine the effects of maternal self-confidence on early infant regulatory problems in the postpartum period. 2. Methods 2.1. Participants and study design This longitudinal, prospective study was conducted in Southern Germany at a perinatal center of maximum care between January and August 2014. The study was designed to gather comprehensive data in a diverse sample of women in Germany during pregnancy and up to four months postpartum on medical, sociodemographic, and psychological factors. Participants were recruited while waiting for their routine medical check-ups. The eligibility criteria included being 18 years and older and having a sufficient knowledge of the German language. The questionnaires were developed to include a range of psychometrically validated tools as wells as scales covering sociodemographic and medical data and were completed at three different time points: third trimester (T1, N = 330), first week postpartum (T2, N = 247), and 4 months postpartum (T3, N = 154). The first questionnaire was filled out on-site while the other questionnaires were mailed to the participants at a nominated address and returned in envelopes provided. All medical details were double checked for accuracy with the hospital's medical and delivery record. In this part of the study, we focus on maternal self-confidence and its link to maternal psychological symptoms and early infant regulatory problems. Only women with complete data at T3 and who delivered at term were included in the analyses (N = 130). Women with preterm births were excluded (n = 18), as preterm birth is assumed to affect the early mother-child-interaction and to interact with feeding, sleeping, and crying behavior in infants. The return rate at TIII was 46.7%, which is comparable to similar studies (Gawlik, Muller, Hoffmann, Dienes, & Reck, 2015). Ethics approval was granted by the Ethical Committee of the University of Heidelberg. 2.2. Measurements 2.2.1. Lips maternal self-Confidence scale (LMSCS) In the first week and after four months postpartum, maternal self-confidence was assessed with the German version of the LMSCS. The LMSCS was developed by Lips and Bloom in 1993 and translated into German by Reck & Stehle (Reck et al., 2012). The questionnaire consists of 24 items that can be answered by a six-point Likert-scale, e.g., “I feel nervous and unsure of myself when dealing with my child(ren): I strongly agree (1) − I strongly disagree (6)”. Answers are coded with points, some items are reversed, and the responses are summed up to a total sum score. Higher scores indicate higher maternal self-confidence. In our sample, the LMSCS showed an excellent internal consistency at T2 with Cronbach‘s α = 0.96 and a good internal consistency at T3 with Cronbach‘s α = 0.885. 2.2.2. Edinburgh postnatal depression scale (EPDS) The Edinburgh Postnatal Depressive Scale (EPDS) was used to detect symptoms of perinatal depression. It was originally developed by Cox et al. (Cox, Holden, & Sagovsky, 1987) and translated into German by Bergant et al. (Bergant, Nguyen, Heim, Ulmer, & Dapunt, 1998). The EPDS consists of 10 items scored from 0 to 3 (normal response 0 and severe response 3) assessing depressive symptoms during the past seven days. The scale is sensitive to changes in severity of depression and has been shown to have a sensitivity and specificity of 91% and 95%, respectively, in predicting depressive disorders (Matthey, Barnett, Kavanagh, & Howie, 2001). Internal consistency proved to be good for our sample (T1: α = .87, T2: α = .86). 230

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2.2.3. State-Trait anxiety inventory (STAI) The STAI was developed in 1970 by Spielberger et al. and is based on Cattell‘s theory of anxiety (Julian, 2011). We used the German version that was translated by Laux et al. (Reck et al., 2013). The STAI consists of two scales (STAI-S and STAI-T) with 20 items each, to separately assess anxiety as a general characteristic (=trait) or as a temporary condition (=state). Items are coded with points (1–4), that are added to a total value. A total value of 20 means absolute absence of anxiety whereas 80 points means highest level of anxiety. The STAI was validated for pregnancy by Grant, McMahon, and Austin (2008). Internal consistency proved to be excellent for our sample (STAI-S T1: α = .93, T2: α = .91; STAI-T T1: α = .92, T2: α = .91). 2.2.4. Questionnaire for crying, sleeping, and feeding (SFS) The SFS was used after 4 months postpartum to identify symptoms of early infant regulatory problems by means of parental selfreport. The questionnaire refers to a “typical week” in everyday family life and can be applied within the first year. The assessment criteria were tested by Groß et al. in a sample of 642 infants (both clinical and nonclinical subsamples) and matched with a behavior diary conducted by the parents as well as clinical diagnosis in the clinical subsample (Groß and Bonney, 2013). The questionnaire contains 52 items assessing the frequency and intensity of crying (according to the criteria of Wessel), feeding, and sleeping (Barr, 1990; Gross, Reck, Thiel-Bonney, & Cierpka, 2013; Papousek & von Hofacker, 1998). Questions are answered according to a 4-point Likert-scale in the response mode “1 = never/seldom” to “4 = always”. The SFS consists of 3 subscales which all showed good to acceptable internal consistencies in our sample: 1) 24 items for crying, whining, and sleeping (α = .84); 2) 13 for feeding (α = .75); and 3) 12 items for “coregulation” (α = .79) The answers are coded with points and added to a total sum score. The more difficulties children show in terms of crying, feeding, and sleeping, the higher the scores are in the SFS. The SFS is used as an element in diagnosing early regulatory problems and in research (Sidor et al., 2013). 2.3. Statistical analyses We used the Statistical Package for Social Sciences (IBM® SPSS® v. 23.0.0.0) for all analyses conducted. Power estimates were computed using G-Power v. 3.1.9.2 (Faul, Erdfelder, Buchner, & Lang, 2009; Faul, Erdfelder, Lang, & Buchner, 2007). Prior to all analyses, Little’s Missing Completely at Random (MCAR-) test was carried out to evaluate differences between excluded cases and the remaining sample (Little, Roderick J. A. 1988). For the MCAR test, the following variables were considered: sociodemographic variables (e.g., age, graduation), pregnancy- and birth-related variables (e.g., gestation age and APGAR values) as well as questionnaire data (e.g., STAI and LMSCS scores). The results of the MCAR test were not significant (χ2 = 8,092.11, df = 7,949, p = .13); the case-exclusions were valid for our sample and the subpopulation representative for the larger sample. In addition, missing values are unlikely to depend on third variables. Due to scale-specific amounts of missing values, the valid number of cases n varied depending on the data subsets statistic. Linear regression models were chosen to evaluate the independent contribution of the study variables for maternal self-confidence at T3. Using stepwise forward regression analysis, variable selection ends if R2 does not significantly change by selection of further variables. Since a forward regression analysis bears the risk of not selecting independent variables with small, but meaningful effects, a backward procedure was also applied. Secondly, an analysis of covariance (ANCOVA) for repeated measures was conducted to evaluate the change of maternal selfconfidence between T2 and T3, adjusted for the significant regression predictors of the first step as covariates. Effect sizes are reported as partial η2, which is a sample-based estimator of explained variance. According to Cohen (Cohen 1977), η2 = .01 or r = .1 are small, η2 = .06 or r = .3 are medium-sized, and η2 = .14 or r = .5 are large effects. Two-sided statistical significance was evaluated at the 5% level. 3. Results 3.1. Sample characteristics The average age at study inclusion was 33.66 years (SD = 4.06 years). The majority of women in the sample were married and living together with their husband (80%). Just under half of the women were primiparous (40%). More than half of the women (53.8%) had a university degree. Approximately two thirds of the women (67.5%) had an income level of more than 2000 € per month. Half of the women (47.2%) had a vaginal delivery. Approximately one third of the women (33.1%) had a planned and one fifth of the women (19.7%) a secondary cesarean section. Questionnaire data are presented in Table 1. We considered scores one SD above the mean (one SD below the mean for the LMSCS) as indicative of considerable impairment (see XX for similar procedures). 3.2. Confounder analyses Sociodemographic factors (age, marital status, educational level, and parity) and birth-related variables (delivery mode) were included as covariates in the analysis. There was no association between maternal self-confidence at T2 and maternal age (r = .00, p = .99), education (r = −.01, p = .93), family income (r = .02, p = .72), and parity (r = .09, p = .30). At T3, maternal self-confidence was not associated with maternal age (r = −.11, p = .18) or with education (r = −.06, p = .44), family income (r = −.06, p = .49), or birth mode (r = .06, p = .47). However, one week after delivery (T2), there was a significant correlation between LMSCS scores and a delivery by cesarean 231

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Table 1 Descriptive statistics of questionnaire data.

Maternal self-confidence (LMSCS) at T2 Maternal self-confidence (LMSCS) at T3 Maternal depressive symptoms (EPDS) at T1 Maternal depressive symptoms (EPDS) at T2 Maternal state anxiety (STAI-S) at T1 Maternal state anxiety (STAI-S) at T2 Maternal trait anxiety (STAI-T) at T1 Maternal trait anxiety (STAI-T) at T2 Infant crying/sleeping (SFS-CS) at T3 Co-regulation (SFS-CR) at T3 Infant feeding (SFS-F) at T3

N

Min

Max

M

S.E.

SD

n (%) 1SD below/abovea M

130 130 130 128 126 128 127 130 104 122 124

31.00 43.00 0.00 0.00 23.00 21.00 21.00 20.00 1.00 1.17 1.00

142.00 144.00 22.00 21.00 73.00 65.26 60.00 56.00 3.14 3.55 1.85

111.38 124.72 6.45 6.61 38.35 33.10 34.72 33.07 1.63 2.39 1.17

2.46 1.17 0.44 0.46 0.92 0.80 0.75 0.77 0.04 0.05 0.02

28.03 13.32 5.00 5.16 10.28 9.08 8.42 8.77 0.38 0.60 0.23

18 17 25 25 20 18 22 22 16 26 19

(13.8) (13.1) (19.2) (19.5) (15.9) (14.1) (17.3) (16.9) (15.4) (21.3) (15.3)

Notes. a. 1 SD above the mean for all measures but LMSCS; 1 SD below the mean for LMSCS.

section (r = .13, p < .05) as well as parity (r = .22, p = .04). As only parity was associated with specific study variables (state anxiety at T1: r = .29, p = .01; crying/sleeping at T3: r = −.30, p = .02), we adjusted our regression model for parity. 3.3. Prediction of maternal self-confidence (LMSCS) at T3 Bivariate Pearson correlations between study variables and maternal self-confidence (LMSCS) at T3 are shown in Table 2. All significantly correlated variables including maternal depressiveness (EPDS), trait and state anxiety (STAI) at T1 and T2, regulatory problems (SFS subscales) at T3, as well as parity were included in the stepwise regression algorithm. The final model was significant (R = .583, F3,96 = 15.950, p < .001) and included infant crying and sleeping problems at T3 (SFS: β = −.493, p < .001) as well as trait anxiety at T1 (STAI: β = −.274, p = .01) as significant, negative predictors, explaining 31.8% (adjusted) of the variance in maternal self-confidence. The forward regression steps are reported in Table 3. Multicollinearity can be excluded as the variance inflation factor (VIF) is almost equal to one for every variable in every step. Infant crying and sleeping already explained 25.3% of adjusted variance in step 1. Step 2 (trait anxiety) contributed a further 6.5% (adjusted). The backward procedure led to exactly the same result after 7 steps of variable exclusions (not reported). The power to detect small effects (f2 = .02) for regression coefficients in this analysis was 1-β = .36, for medium-sized effects (f2 = .15), and for large effects (f2 = .35) 1-β > .99. The linear relationships between these three variables and maternal self-confidence are shown in Fig. 1 (values were z-standardized). 3.4. ANCOVA for repeated measures of maternal self-confidence (LMSCS at T2 and T3) This model was performed to investigate the influence of time (T2 and T3), trait anxiety (STAI-T at T1), infant crying and sleeping problems (SFS at T3), as well as the interaction effects between these variables with time (Table 4). The ANCOVA showed significant main effects of trait anxiety (STAI-T at T1: F1,98 = 9.714, p = .002, η2 = .090), but no main effect of infant crying and sleeping problems (SFS-CS at T3: F1,98 = 2.014, p = .159, η2 = .020). However, an interaction effect between time of measurement and infant crying and sleeping problems was significant (F1,98 = 6.401, p = .013, η2 = .061), which results from the fact that infant crying and sleeping problems were correlated to maternal self-confidence at T3 (r = −.515, p < .001) but not at T2 (r = .038, p = .703). Additionally, there was a significant main effect of time (F1,98 = 7.929, p = .006, η2 = .075). In general, maternal self-confidence increased from T2 (M = 111.03, S.E. = 2.79) to T3 (M = 125.02, S.E. = 0.84). The power to detect small effects (f = .10) in this Table 2 Pearson correlations between study variables and maternal self-confidence (LMSCS) at T3. Maternal depressive symptoms (EPDS) at T1

Pearson r p(2-tailed) n

−.169 .055 130

Maternal state anxiety (STAI-S) at T1

−.165 .065 126

Maternal trait anxiety (STAI-T) at T1

−.314 .000** 127

Maternal depressive symptoms (EPDS) at T2

Pearson r p(2-tailed) n

−.180 .043* 128

Maternal state anxiety (STAI-S) at T2

−.334 .000** 128

Maternal trait anxiety (STAI-T) at T2

−.284 .001** 130

Infant crying/sleeping (SFS-CS) at T3

Pearson r p(2-tailed) n

−.515 .000** 104

Coregulation (SFS-CR) at T3

−.225 .013* 122

Infant feeding (SFS-F) at T3

−.281 .002** 124

**Significant at .001 level (2-tailed). *Significant at .05 level (2-tailed).

232

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Table 3 Forward regression analysis on maternal self-confidence (LMSCS) at T3. B

S.E

β

T

p

95% CI lower bound

95% CI upper bound

VIF

Step 1

Constant Infant crying/sleeping (SFS-CS) at T3

154.046 −18.005

6.315 3.777

/ −0.515

24.394 −4.767

0.000 0.000

141.426 −25.552

166.666 −10.457

/ 1.000

Step 2

Constant Infant crying/sleeping (SFS-CS) at T3 Maternal trait anxiety (STAI-T) at T1

167.838 −17.229 −0.434

7.972 3.621 0.164

/ −0.493 −0.274

21.053 −4.759 −2.647

0.000 0.000 0.010

151.902 −24.467 −0.761

183.773 −9.992 −0.106

/ 1.007 1.007

Fig. 1. Linear relationships between trait anxiety (STAI) at T1, infant crying and sleeping problems (SFS) at T3, and maternal self-confidence (LMSCS) at T3. Values were z-standardized.

analysis was 1-β = .51, for medium-sized (f = .25) and large effects (f = .40) 1-β > .99.

4. Discussion The aim of the present study was to investigate maternal self-confidence and its association with maternal mental health and early infant regulatory problems in 130 women. We were able to describe the course of maternal self-confidence over the first four months postpartum and to identify significant predictors. Although maternal self-confidence increased significantly by itself over the first four months postpartum, maternal trait anxiety as well as early infant regulatory problems significantly contributed to the prediction of maternal self-confidence, explaining 31.8% of the variance. 233

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Table 4 Repeated-measures ANCOVA on maternal self-confidence (LMSCS) at T2 and T3 Factor

Type III sum of squares

df

Variance

F

p

Partial η2

Tests of within-subjects effects

Time Time x trait anxiety (STAI-T) at T1 Time x infant crying/sleeping (SFS-CS) at T3 Error

2818.827 2.577 2275.649 34838.356

1 1 1 98

2818.827 2.577 2275.649 355.493

7.929 .007 6.401 /

.006 .932 .013 /

.075 .000 .061 /

Tests of between-subjects effects

Intercept Trait-anxiety (STAI-T) at T1 Infant crying/sleeping (SFS-CS) at T3 Error

130141.812 4884.345 1012.875 49275.973

1 1 1 98

130141.812 4884.345 1012.875 502.816

258.826 9.714 2.014 /

.000 .002 .159 /

.725 .090 .020 /

These results provide new insights into the association between maternal self-confidence and the predictive value of increased maternal anxiety as well the transactional association between regulatory problems in infants and maternal self-confidence. So far, no comparable study exists in the literature. 4.1. Development of maternal self-confidence We found the LMSCS to be a reliable questionnaire for assessing maternal self-confidence, with an excellent internal consistency of α = 0.96 at T2 and a good internal consistency of α = 0.885 at T3. Four months postpartum (TIII), mean LMSCS scores for our study population were M = 124.72: 17% of participants scored below and 13% above one standard deviation. Our results are comparable to other studies conducted at similar time points (Reck et al., 2012; Zietlow et al., 2014). Concerning the course of maternal self-confidence itself, we could show that maternal self-confidence rose from an average sumscore of 111 to 125 points (adjusted means) within the first four months postpartum, with time explaining 5.2% of the variance. These results are comparable to other studies conducted shortly after birth (Reck et al., 2012; Zietlow et al., 2014) and are in line with previous findings indicating a significant rise in maternal self-confidence within the first few weeks postpartum (Logsdon et al., 2009; Hsu & Sung, 2008). This dynamic process could be explained by a positive feedback mechanism as hypothesized by Sanders et al.: establishing routine in daily life with the baby leads to feelings of success, which in turn strengthen maternal self- confidence (Jones & Prinz, 2005; Sanders & Woolley, 2005). It would be reasonable to assume that this trend continues as the child becomes older. The child’s needs change according to age and mothers may need to expand and adjust their formerly developed parenting skills. Interestingly, in a study by Zietlow et al. investigating maternal self-confidence up to preschool age, the authors could not show any further significant increase in maternal self-confidence after the average age of 60 days (Zietlow et al., 2014). 4.2. Predictors of maternal self-confidence 4.2.1. Anxiety and depression In our study population, the prevalence for peripartum depression was similar to the findings reported in previous studies. Prenatally (TI), 25% of the study participants achieved EPDS scores above the cut-off value for a minor depression and 7.6% above the cut-off for a major depression (Bergant et al., 1998; Boyce, Stubbs, & Todd, 1993). Postnatally (TIII), 14.6% of the participants achieved EPDS scores above the cut-off value for a minor and 11.3% above the cut-off value for a major depression. Negative correlations between maternal self-confidence and symptoms of anxiety and depression were found at T1 and T2. This is in line with previous findings demonstrating a detrimental effect of maternal psychiatric disorders on maternal self-confidence (Howell et al., 2009; O'Neil, Wilson, Shaw, & Dishion, 2009; Porter & Hsu, 2003; Reck et al., 2012; Sevigny & Loutzenhiser, 2010; Zietlow et al., 2014). As the STAI distinguishes between state and trait anxiety, both types of anxiety independently affected maternal self-confidence negatively. Further regression analyses as well as the analysis of covariance also confirmed maternal anxiety to be a powerful predictor of maternal self-confidence: High levels of trait anxiety during pregnancy (T1) were followed by low maternal self-confidence four months postpartum. These findings are supported by a previous study by Logsdon et al., (2009). Here, the authors found that maternal mental illnesses interfered with the development of maternal self-confidence as described above: maternal self-confidence rose in all mothers during the first weeks postpartum except for mothers suffering from postpartum depressive disorders (Logsdon et al., 2009). Additionally, the EPDS was included in the analysis as a means of distinguishing between anxiety and symptoms of depression. In the final model, elevated depressive symptoms failed to keep their predictive value for maternal self-confidence, despite being significantly correlated to maternal self-confidence initially. Compared to peripartum depression, anxiety seems to have a greater influence on maternal self-confidence. This link could be mediated by avoidance behavior: mothers with symptoms of anxiety might tend to avoid anxiety-related situations, impeding positive experiences that in turn would strengthen their self-confidence. Additionally, this result is in line with a study by Reck et al., investigating the influence of maternal anxiety and depression on maternal self-confidence; they found previous maternal anxiety to have the most significant impact (Reck et al., 2012). 234

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Our results are especially meaningful regarding the fact that both clinical and subclinical symptoms of anxiety and depression were assessed as we did not diagnose anxiety or depressive disorders according to DSM-IV or ICD-10 criteria. In accordance with Weinberg et al., our results support the theory that even subclinical symptoms can decrease maternal self-confidence (Weinberg et al., 2001). As a screening for psychological distress during pregnancy is still not established in standard antenatal care, our results strongly emphasize the need to do so in order to pay special regard to women at risk and to provide psychological support where needed. This seems even more urgent in light of a study by Zietlow et al., who demonstrated a lasting effect on maternal selfconfidence up to preschool age (Zietlow et al., 2014). At this point it is worth highlighting a study conducted by Matthey et al. (2013), who suggested the anxiety subscale of the EPDS might be suitable for detecting peripartum anxiety (Matthey, Fisher, & Rowe, 2013). Indeed, future research should focus on this interesting approach in order to contribute to a holistic peripartum care. 4.2.2. Early infant regulatory problems Early infant regulatory problems were negatively associated with maternal self-confidence at the age of 4 months. Furthermore, regression analysis revealed symptoms of early infant regulatory problems as the strongest predictor of maternal self-confidence, explaining 25.3% of the variance. This is in line with previous research showing an association between a child‘s temperament and maternal self-confidence (Cutrona & Troutman, 1986; Hsu & Sung, 2008; Teti & Gelfand, 1991; Zietlow et al., 2014). Zietlow et al. identified secure attachment behavior, which is closely linked to children‘s regulatory problems, to be the most important predictor for maternal self-confidence at preschool age. It is likely that the variables affect each other: previous research indicated that maternal self-confidence and children‘s regulatory problems have a reverse effect on each other. Low maternal self-confidence influences the way a children‘s behavior is interpreted: women with low maternal self-confidence tend to interpret children‘s behavior as complicated and challenging, which then weakens maternal self-confidence (Teti & Gelfand, 1991). Regarding the analysis of covariance, there was no main effect of infant crying and sleeping problems on maternal self-confidence. Only the interaction term with time reached significance. However, this is not surprising given the fact that regulatory problems were only associated with maternal self-confidence at T3. Our data fail to infer causality, as the SFS was assessed at T3 cross-sectionally to maternal self-confidence since crying in the first three months is regarded as an expression of normal adjustment. Thus, our results either indicate a unidirectional trend towards maternal self-confidence being affected by early regulatory problems or a negative feedback process in which infant regulatory problems and maternal self-confidence mutually worsen. However, the fact that there was no significant association between maternal self-confidence at T2 and infant regulatory problems at T3 speaks more for a unidirectional trend. Nevertheless, alternative approaches to examine the causal direction should be the subject of further research. In summary, mother-child interaction offers a promising approach to prevention and intervention measures to improve maternal self-confidence and reduce anxiety, as both have a negative effect on early infant regulatory problems. These prevention and intervention measures should be offered to women in order to prevent infant regulatory disorders. In this context, it is worth mentioning a study conducted by Gross et al., who could show that a 10-week intervention promoting mother-child interaction was followed by an increase in maternal self-confidence. 4.3. Limitations To our knowledge, the present study is the first to examine the association between maternal mental health and early infant regulatory problems and maternal self-confidence in the postpartum period. However, this study has several limitations. First, data were collected from a highly educated sample of pregnant women rather than from population-based subjects. Furthermore, at about 52,3%, the cesarean section rate of our study population is higher than average in Germany at 31.1% (Bundesamt, 2015). Nationwide the cesarean section rate is between 17 and 51%, with a large variation depending on the patient risk profile of the hospital as well as the region of the country (“Faktencheck Kaiserschnitt. Kaiserschnittgeburten-Entwicklung und regionale Verteilung.,” 2012). Therefore, results especially in relation to the birth mode cannot readily be generalized to broader populations. Second, all variables of interest except medical data were assessed using self-report measurements, potentially bearing a risk for cognitive biases, as especially patients with depressive symptoms tend to direct selective attention to negative information (Gotlib & Joormann, 2010). Additionally, anxiety disorders and children & lsquo;s regulatory problems alike were assessed by self-report measures and not diagnosed according to DSM- IV or ICD-10 criteria. However, as already mentioned, this supports the theory that even subclinical symptoms can decrease maternal self-confidence, emphasizing the relevance of our findings. Finally, we were not able to detect small effects due to the limited sample size or to draw causal conclusions between early infant regulatory problems and maternal self-confidence due to the partly cross-sectional data assessment. After 4 months postpartum, 53.3% of women were lost to follow-up. Although this seems to be a common problem in studies with a comparable study design (Gawlik et al., 2015), one should be cautious in making generalizations from our findings. 4.4. Conclusions The present findings suggest that high trait anxiety during pregnancy and the postpartum period anticipates lower maternal selfconfidence, fostering early regulatory problems in infants, especially regarding crying and feeding. As anticipated, maternal self-confidence rose during the first four months postpartum, with time explaining 5.2% of the LMSCS variance. However, early infant regulatory problems and anxiety provide a remarkable explanation for variance in maternal self235

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confidence four months postpartum (T3) (31.8%), irrespective of time. Considering the mutual influence between maternal selfconfidence and early regulatory problems, our results reinforce existing knowledge pertaining to the transactional relationship between regulatory problems in infants and maternal distress, but also add new aspects to the recent literature by revealing the importance of the concept of maternal self-confidence. Regarding maternal mental health, our findings emphasize the tremendous effect of anxiety, as previous studies mostly did not distinguish anxiety from depression. There is an urgent need for appropriate programs focusing on maternal anxiety to promote maternal self-confidence in order to prevent early regulatory problems in infants. Conflict of interest All authors declare that they have no conflict of interest. References Andrews, G., Sanderson, K., Slade, T., & Issakidis, C. (2000). Why does the burden of disease persist? 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