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Partner support during the prenatal testing period after assisted conception
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Partner support during the prenatal testing period after assisted conception Joëlle Darwichea,* , Anne Milekb , Jean-Philippe Antoniettia , Yvan Vialc a b c
Family and Development Research Center, Institute of Psychology, University of Lausanne, 1007 Lausanne, Switzerland Department of Psychology, University of Zurich, 8050 Zurich, Switzerland Department of Woman-Mother-Child, University Hospital Lausanne and University of Lausanne, 1007 Lausanne, Switzerland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 November 2017 Received in revised form 4 July 2018 Accepted 10 July 2018 Available online xxx
Background: Pregnancy after infertility is a challenging experience. The first-trimester screening test may add stress. Partner support reduces psychological distress in pregnant women after spontaneous conception. No data are available for women who conceive via assisted reproductive technology. Aim: To assess whether there was a difference between couples who underwent assisted reproductive technology and couples who conceived spontaneously in the support they felt they provided to their partner and whether their perception of support received from their partner reduced their distress. Methods: This longitudinal prospective study included 52 women (spontaneous conception) and 53 women (assisted reproductive technology), as well as their partners. Participants completed the state scale of the State-Trait Anxiety Inventory, the Edinburgh Depression Scale, and two partner-support subscales of the Dyadic Coping Inventory: before prenatal testing (gestational age 12 weeks), immediately after receiving the results (gestational age of approximately 14 weeks), and once all the prenatal screenings had been completed (gestational age 22 weeks). Findings: Women who underwent assisted reproductive technology felt less able to help their partner cope with stress and felt their partner was less able to help them cope with stress than women with spontaneous pregnancy. This difference was not observed in men. Higher perceived partner support lowered the anxiety and depression of couples who conceived spontaneously, but did not benefit couples who followed fertility treatment. Conclusion: These results add to our knowledge of the emotional state of women and their partners during pregnancy after infertility. This knowledge may allow prenatal care providers to offer specialized counselling to women and their partners in the transition from infertility to parenthood. © 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Keywords: Prenatal testing Assisted reproductive technology Partner support Anxiety Depression
Statement of significance
Problem or issue Women undergoing assisted conception and their partners may face psychological distress during pregnancy, particularly at the time of the first-trimester prenatal screening test, due to their history of infertility and medical treatments.
What is already known Partner support is known to minimize the risk of prenatal anxiety and depression in women with spontaneous conception. No data are available for women who underwent assisted conception. What this paper adds Compared with spontaneously conceiving women, women who were pregnant after assisted conception felt that their partner was less able to support them (i.e. there was less perceived received support). In addition, when they felt they received support from their partner, it did not help to reduce their prenatal anxiety and depression.
* Corresponding author at: Institute of Psychology, University of Lausanne, Géopolis, Bureau 4219, 1015 Lausanne, Switzerland. E-mail address: [email protected] (J. Darwiche). https://doi.org/10.1016/j.wombi.2018.07.006 1871-5192/© 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
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1. Introduction Pregnancy after assisted reproductive technology (ART) has been described as a complex emotional experience.1 Women and their partners may experience positive feelings, such as joy and a sense of triumph,2 but may also be more vulnerable to stress due their previous history of infertility and medical treatments. Based on the available data, women and their partners who conceived via ART perceive a greater sense of marital satisfaction, have more positive attitudes toward pregnancy, and show higher levels of attachment to the fetus than couples who conceived spontaneously, while also experiencing more pregnancy-specific anxieties and an increase in anxiety and depression from pregnancy to the post-partum period.3 During pregnancy after ART, prenatal testing may act as an additional stress-inducing event because it addresses sensitive issues related to the viability and health of the fetus.4 This stress may be linked to the procedure itself, the risk of pregnancy loss due to invasive prenatal procedures, or the possibility of an abnormality.4 Based on the limited available data, women who conceive through ART report higher anxiety levels and pregnancy worries before prenatal screening than controls.5 However, the levels of anxiety and depression appear to decrease after the first-trimester prenatal screening in couples who conceived through ART when the result of that test is normal, as shown in a previous study.6 Successful support from each partner in times of stress can buffer the impact on women’s mental and physical health.7 Partner support is described as “all the supportive actions or attitudes that someone exhibits to their partner and perceives to receive from their partner in order to meet their needs”.8 It involves both an active role (providing support) and a passive role (receiving
support).9 Provided support reflects what a partner perceives to invest into the couple relationship to help the other partner cope with stress. Received support pertains to the perception of the support the other partner is willing to provide. Both directions of partner support may be beneficial: providing support may give the partner a sense of meaning or mattering,10 and receiving support may be associated with less vulnerability to stress and better health outcomes.11 To better understand the dynamics of partner support, it is therefore worth distinguishing between perceived support provided and received. A lack of partner support and social support are risk factors for antenatal anxiety and depression.12,13 After spontaneous conception (SC), effective partner support has been shown to predict less anxiety mid-pregnancy, as well as over time until late pregnancy.14 Partner support has also been shown to predict lower maternal and infant postpartum distress12 and is associated with less prenatal depression.13 However, no study has specifically examined partner support in the context of ART. Therefore, this study aimed to compare couples in which the woman had undergone ART with couples in which the woman had conceived spontaneously with respect to the support provided and received during pregnancy. Comparisons were made at three different assessment times during pregnancy: before the first-trimester Down syndrome screening test, which may be considered as a stressor,15 immediately after the receipt of the first-trimester Down syndrome screening result and after the last prenatal test in the fifth month of pregnancy. This study design allowed us to longitudinally examine changes in provided and received partner support over time, as well as the impact of partner support on reducing anxiety and depression.
Table 1 Socio-demographic and medical data for the ART group and the SC group.
Socio-demographic data Women’s age in years (mean SD) Men’s age in years (mean SD) Years of cohabitation (mean SD) % Married (N) Years of desiring a child (mean SD) Couples’ socioeconomic class in % (N)a Upper Upper-middle Middle Lower-middle and lower Medical data Previous pregnancies % (N) No With medical treatment Without medical treatment Weeks of amenorrhea T1 (mean SD) Early pregnancy complications in % (N) Previous prenatal tests % (N) Psychol. sup. during pregnancy % (N) Years of infertility treatment (mean SD) Previous infertility treatment % (N) Source of infertility in % (N) Female origin Male origin Mixed origin Undetermined % FIVb (N) % FIV ICSIc (N)
ART (N = 53)
SC (N = 52)
t-test/χ2 p-values
34.60 3.95 37.30 4.93 6.60 2.80 75.50 (40) 4.30 1.87
30.30 4.35 32.20 5.10 3.40 2.45 44.20 (23) 0.80 0.63
<0.001 <0.001 <0.001 0.002 <0.001
1.90 (1) 28.30 (15) 52.80 (28) 17.00 (9)
1.90 (1) 30.80 (16) 48.10 (25) 19.20 (10)
0.296
69.80 (37) 18.90 (10) 11.30 (6) 11.40 1.28 13.20 (7) 7.50 (4) 43.40 (23) 3.00 2.14 67.90 (36)
80.80 (42) – 19.20 (10) 11.50 1.15 3.80 (2) 0.00 (0) 17.30 (9)
0.016
0.844 0.087 0.043 0.004
28.30 (15) 37.70 (20) 18.90 (10) 15.10 (8) 34.00 (18) 66.00 (35)
a Socioeconomic class determined based on each couple’s highest indicator of socioeconomic position according to Genoud (2011): upper (e.g., university-educated senior managers), upper-middle (e.g., professionals with a university- or secondary-level education), middle (e.g., vocationally trained employees), lower-middle and lower (e.g., apprenticeship-trained skilled tradespeople or unskilled laborers). b Fecondation In Vitro. c Fecondation In Vitro with Intracytoplasmic sperm injection; ART, assisted reproductive technologies; SC, spontaneous conception.
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We postulated that1 women who underwent ART and their partners would have more difficulty in providing and receiving support than the women who underwent SC and their partners, as their resources might have been more depleted than those of the SC group due to their history of infertility and medical treatments, and2 the perceived received support would be associated with lower levels of anxiety and depression in both groups, as partner support has been shown to be associated with lower distress in samples of women after SC.12 Anxiety and depression were chosen because these conditions are prevalent during the perinatal period and represent two major risk factors for a series of adverse postnatal outcomes.12 These findings aim to inform prenatal care providers who are on the front lines for interventions to minimize risk of these problems during pregnancy. 2. Methods The measurements were completed on the day before or the day of (but before) the antenatal first-trimester test at approximately 10–12 weeks of gestational age (g.a.) (T1) and upon receiving the test results (the same or next day) at a g.a. of approximately 14 weeks (T2). The same questionnaires were mailed to the couples again before the morphological ultrasound, along with instructions to complete them just after the test at approximately 22 weeks of g.a. (T3). T1 was considered as a stressor and T2 and T3 as times of relief for couples with normal results. 2.1. Study population Data were collected for this longitudinal prospective study between 2012 and 2014. One hundred five couples (N = 210 subjects) were included at T1. Fifty-three, 49, and 44 ART couples were monitored at T1, T2, and T3, respectively, and 52, 48, and 44 SC couples were monitored at T1, T2, and T3, respectively. The power analysis16 indicated a 95% chance of detecting a moderate to large effect size with a sample of 2 50 couples. Seven prenatal test results recorded an unfavorable outcome at T2 — five in the ART group and two in the SC group. The participants’ sociodemographic and medical factors are presented in Table 1. The two groups were similar in terms of their socioeconomic status, but the ART couples were older, had lived together for a longer period, were more often married, and had desired a child for longer than the partners in the SC group. A greater proportion of the ART couples had also experienced a previous pregnancy, undergone prenatal tests, and received psychological support during pregnancy. However, the groups were similar in terms of the number of weeks of amenorrhea at T1 and the rate of early pregnancy complications. 2.2. Measures 2.2.1. Partner support We used two subscales of the Dyadic Coping Inventory (DCI),17 a 37-item questionnaire, to specifically assess perceived provided support and perceived received support (respectively named Supportive Dyadic Coping by oneself and Supportive Dyadic Coping by partner in the original version). These subscales are relevant to assessing partner support when facing stressful events or challenging life transitions. Each subscale has five items rated on a 5-point Likert scale, ranging from 1 (“very rarely”) to 5 (“very often”), and were used to produce an aggregate score. The perceived provided support subscale answers the question “What do I do when my partner is stressed?” The five items are: “I show empathy and understanding”, “I express to my partner that I am on his/her
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side”, “I tell my partner that his/her stress is not bad and help him/ her to see the situation in a different light”, “I listen to my partner and give him/her space and time to communicate what really bothers him/her”, and “I try to analyze the situation together with my partner in an objective manner and help him/her to understand and change the problem”. The perceived received support subscale answers the question “What does my partner do when I am stressed?” The five items are: “My partner shows empathy and understanding to me”, “My partner expresses that he/she is on my side”, “My partner helps me to see stressful situations in a different light”, “My partner listens to me and gives me the opportunity to communicate what really bothers me”, and “My partners helps me analyze the situation so that I can better face the problem”. Higher scores indicate higher levels of perceived emotional support (provided or received). Internal consistency was satisfactory for perceived provided support for both men and women at T1, T2, and T3 (all alphas > 0.77) and for perceived received support for both men and women at T1, T2, and T3 (all alphas > 0.84). 2.2.2. Anxiety Anxiety was assessed with the “state” scale of the State-Trait Anxiety Inventory, Form Y-1 (S-STAI).18 It contains 20 items, each rated on a 4-point Likert scale, ranging from 1 (“not at all”) to 4 (“very much so”). Scores range from 20 to 80, with higher scores indicating greater anxiety. Internal consistency was satisfactory for both men and women at T1, T2, and T3 (all alphas > 0.91). 2.2.3. Prepartum depression We assessed prepartum depression with the Edinburgh Depression Scale, adapted to, and validated for, the antenatal period (EDS).19 This instrument contains 10 items, each rated on a 4-point Likert scale, ranging from 0 (“no, never”) to 3 (“yes, most of the time”). Scores range from 0 to 30, with higher scores indicating the presence of more depressive symptoms. Internal consistency was satisfactory for both women and men at T1, and for women at T2 and T3 (all alphas > 0.85); it was lower for men at T2 and T3 (alphas > 0.67). A score of 15 is considered the clinical cut-off during pregnancy.20 2.3. Procedure Participants were recruited by a registered research psychologist once the pregnancy had been confirmed during a routine doctor’s appointment. The ART couples were recruited from specialized units for assisted reproduction and the SC couples were recruited from the outpatient clinic of a general hospital or from obstetricians in private practice. The women had to be at least 24 years of age and nulliparous (but not primigravida) and be in a romantic relationship to be included in the present study. The couples’ obstetricians or midwives presented the study and provided each couple with an informational letter. The researcher then called the couples who had agreed to be contacted and completely explained the study. The couples initially received an informed consent form, a brief questionnaire about their relationship (e.g., length of the relationship, marital status, and years of desiring a child), and their medical history (e.g., previous pregnancies and early pregnancy complications) to complete and return. They were later mailed the questionnaires used to assess partner support, anxiety, and depression, with instructions to complete them at T1, T2 and T3. The questionnaires completed at T1 and T2 evaluated the effects of the Down syndrome test, and those at T3 evaluated the subjects’ emotional states at the end of the prenatal testing period, once they had been reassured that the pregnancy was progressing well. We instructed the couples to individually complete the questionnaires at home and to date and return each of them by
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mail as soon as they were completed. If a participant had not sent back the questionnaire within 5 days, the researcher contacted the couple by email/phone and reminded them of the importance of returning the questionnaires quickly. If a response was not obtained after 2 weeks and 2 follow-up calls, the subject was recorded as lost to that assessment time. The study protocol was approved by the Ethics Commission of Lausanne University Hospital (Protocol 89/10) before the data were collected. 2.4. Statistical analysis All descriptive analyses and linear mixed models were performed with the R statistical software (lme4 package). The percentage of missing data per questionnaire and per assessment time was less than 1%, suggesting that the participants conscientiously completed the questionnaires. Missing responses to questionnaire items were replaced by the mean score of the subject’s other responses. First, descriptive statistics for the demographic and psychological characteristics were calculated. The independent-sample t test and a χ2 test were used to examine the differences in age, years of cohabitation, marriage, years of desiring a child, socioeconomic status, previous pregnancies, early pregnancy complications, previous prenatal testing, previous psychological support (during pregnancy), and the result of the prenatal test between the ART and SC groups. Second, we described the mean changes in each main variable for all participants and used a one-way ANOVA to examine the differences over time. Correlations of the groups’ characteristics with the dependent variables (anxiety and depression) were calculated. We controlled for the three variables that correlated with our dependent variables (i.e., previous pregnancies, early pregnancy complications, and the result of the prenatal test) in our models. In addition, we conducted confirmatory factor analyses to test whether repeated measures were invariant over time. Strong measurement invariance was established for all our variables of interest.21 Finally, the data were analyzed using linear mixed models.
1. We used a linear mixed model with two main effects (time and group) and one interaction effect (time group) to test whether the two conception groups differed in provided and received support and whether these differences varied over the three assessment times. 2. We then used the linear mixed models described below. In the first model, we tested the association between perceived received support and women’s anxiety while controlling for men’s anxiety and men’s perceived provided support. In the second model, we tested the association between perceived received support and men’s anxiety while controlling for women’s anxiety and women’s perceived provided support. Equivalent models were conducted using depression as the outcome. The potential confounding variables (previous pregnancies, early pregnancy complications, and the result of the prenatal test) were controlled in the models. The use of linear mixed models has the advantage of allowing a single time point to be eliminated for subjects who are missing a time point.22 Based on the recommendations of Nakagawa and Schielzeth,16 we calculated two types of R2 for each of the four models (marginal (R2[m]) and conditional (R2[c]). Time was treated as a discrete variable in all analyses. The reference levels for coding were Time 1 (for time), “no” for a previous pregnancy, “ART group” for the mode of conception, “no” for early pregnancy complications, and “favorable outcome” for the prenatal test. Probability values of p 0.05 were considered significant in all analyses. 3. Results 3.1. Descriptive results The mean perceived provided support, perceived received support, anxiety, and depression scores are presented in Table 2. Couples’ scores were not statistically significantly different from the DCI manual reference standards (a sample of 1327 women and 1027 men).17 The women were more anxious than their partners at T1 (ART group), T2 (both groups) and T3 (SC group) and showed more depressive symptoms at all three time points (Supplemental Fig. 1a and b). However, their mean anxiety and depression scores
Table 2 Mean and standard deviation of study variables for women and men and differences across time. SC
ART Women
Provided support T1 T2 T3 ANOVA/p-valuesa Received support T1 T2 T3 ANOVA/p-valuesa Anxiety T1 T2 T3 ANOVA/p-valuesa Depression T1 T2 T3 ANOVA/p-values
Men
Women
Men
n
M
SD
n
M
SD
n
M
SD
n
M
SD
53 49 44
18.87 19.30 19.55 0.162
3.01 2.53 2.81
51 47 42
19.80 20.09 20.33 0.718
2.84 2.60 2.67
52 48 44
20.60 21.05 20.70 0.266
3.24 3.09 2.74
51 47 42
20.24 20.19 20.49 0.784
3.04 2.81 2.21
53 49 43
19.09 19.57 19.72 0.512
3.71 3.25 3.40
52 47 42
18.71 19.34 19.90 0.104
3.33 3.42 3.03
52 48 44
20.85 20.92 20.52 0.718
3.51 3.13 3.55
52 47 44
19.56 20.53 20.20 0.098
3.65 3.41 3.22
53 49 45
39.16 35.10 33.21 <0.001
11.09 9.88 9.35
52 48 45
33.35 31.41 31.78 0.261
9.02 7.42 8.24
52 47 45
35.45 34.76 33.94 0.508
9.36 11.12 9.14
52 46 44
32.33 29.77 29.07 0.016
9.04 7.71 7.06
53 49 45
6.46 5.53 5.96 0.351
5.95 4.91 4.94
53 49 44
3.63 3.14 3.45 0.395
2.93 2.81 2.80
52 47 45
5.21 5.18 5.64 0.717
5.13 4.33 4.28
52 47 43
3.44 3.06 2.66 0.175
3.13 2.89 2.55
Note. M, mean; SD, standard deviation; n = number of subjects at each assessment time; ART, assisted reproductive technologies; SC, spontaneous conception.
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remained in the nonclinical ranges. Anxiety decreased over time in ART women and in SC men (see also Ref. 6).
3.3. Perceived support received from the partner and its effects on anxiety and depression
3.2. Perception of provided and received support
A significant interaction was observed between the group and the perceived support received from the partner (see Table 3 for a summary of the results and Supplemental Table 1a-1d for the detailed results). Above and beyond partners’ anxiety (or depression) and partners’ reported provided support, a greater amount of perceived received support was associated with reduced anxiety and depression at all three assessment times in both men and women in the SC group (anxiety: β = 0.07 + [ 1.16] = 1.09 in women and β = 0.14 + [ 0.80] = 0.66 in men; depression: β = 0.01 + [ 0.58] = 0.57 in women and β = 0.05 + [ 0.27] = 0.22 in men). However, the men and women in the ART group did not experience this effect (anxiety: β = 0.07 in women and β = 0.14 in men; depression: β = 0.01 in women and β = 0.05 in men).
The analyses were performed using a mixed model with two main effects (time and group) and one interaction effect (time group). 3.2.1. Support provided by men and support received by women No significant group effect (F[2,174.19] = 0.49, p = 0.617) or interaction effect (F[2,174.19] = 0.10, p = 0.901) was observed for the men’s perception of the support they provided to their partners (see Fig. 1a). However, a group effect (F[1,107.42] = 5.63, p = 0.019) was observed for the women’s perception of the support they received. Women in the ART group felt that they received less support from their partners than women in the SC group (see Fig. 1b). 3.2.2. Support provided by women and support received by men Our results also showed a group effect (F[1,108.34] = 9.95, p = 0.002) for the women’s perception of the support they provided. Women in the ART group felt they provided less support to their partners than women in the SC group (Fig. 1c). No group or interaction effects were observed for the men’s perception of the support they received (Fig. 1d).
4. Discussion This study adds to the literature on the emotional experience of couples during pregnancy after ART. Its novelty is the focus on an unexplored topic: how ART couples, whose resources might be depleted due to the experience of infertility and its treatment, deal with the stress induced by prenatal testing. The ART and SC groups were more similar than different in terms of their levels of prenatal anxiety and depression, and anxiety tended to decrease over time
Fig. 1. (a) Support men provided to their partners. (b) Support women received from their partners. (c) Support women provided to their partners. (d) Support men received from their partners.
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Table 3 Main and interaction effects of perceived received support from partner on anxiety and depression. Predictors Women Main effects Group Perceived received support Interaction Group perceived received Partial regression coefficient Group (0 = ART, 1 = SC) Perceived received support Group perceived received 2 R [m]/R2[c] Men Main effects Group Perceived received support Interaction Group perceived received Partial regression coefficient Group (0 = ART, 1 = SC) Perceived received support Group perceived received R2[m]/R2[c]
support
support
support
support
Anxiety
Depression
F(1,98) = 0.08, p = 0.777 F(1,254) = 0.50, p = 0.480
F(1,96) = 0.02, p = 0.898 F(1,242) = 4.52, p = 0.034
F(1,241) = 9.29, p = 0.003
F(1,239) = 9.47, p = 0.002
β = 1.83 β = 0.07 β = 1.16** 0.14/0.62
SE = 1.99 SE = 0.28 SE = 0.38
β = 0.70 β = 0.01 β = 0.58** 0.13/0.59
F(1,98) = 0.54, p = 0.462 F(1,248) = 0.23, p = 0.630
F(1,100) = 0.04, p = 0.846 F(1,243) = 0.01, p = 0.945
F(1,254) = 5.96, p = 0.015
F(1,258) = 5.81, p = 0.017
β = 0.07 β = 0.14 β = 0.80* 0.10/0.60
SE = 1.69 SE = 0.25 SE = 0.33
β = 0.17 β = 0.05 β = 0.27* 0.08/0.63
SE = 0.98 SE = 0.14 SE = 0.19
SE = 0.59 SE = 0.09 SE = 0.11
Note. SE, standard error. Model controlled for assessment time, partner’s levels of anxiety/depression, partner’s support provided, previous pregnancy, early pregnancy complications, result of the prenatal test (see Table III-supplementary material, for the detailed results). Group: 0 = ART, 1 = SC, [m] = marginal, [c] = conditional. * p < 0.05. ** p < 0.01.
(see also Ref. 6). The women in both groups tended to be more anxious and depressed than the men, confirming previous reports that prenatal anxiety and depression levels are higher in women than in men.23 These results have been partially attributed to the invasive nature of prenatal testing procedures (e.g., amniocenteses), which may particularly increase women’s anxiety as they undergo the procedure. They may also be related to the fact that women are physically involved in the pregnancy and that hormonal changes may affect their emotional well-being.24 Also, they may experience a strong sense of worry due to the responsibility they feel during the transformative event of becoming a mother.25
Our hypothesis that the men in the ART group would report that they provided (and received) less support than men in the SC group was not supported. The process of infertility treatments causes stress in both partners, but the sources of the stress differ because of the gender-specific roles in pregnancy. When stressed, men have been reported to provide lower-quality support than similarly stressed women.30 Therefore, the men may have overestimated the support they actually provided. More research is needed to assess the gender-specific perceptions and expectations related to partner support during pregnancy after ART. For example, observational studies that rate support could refine our understanding of partner-support dynamics.
4.1. ART women report that they provide and receive less support
4.2. ART couples: support, anxiety, and depression
Our hypothesis that women in the ART group would report that they provide less support than women in the SC group was supported. Pregnant women may experience significant stress when carrying a child after infertility and its treatment. The cost of effectively supporting a partner might be too high in this setting because the women’s resources are presumably depleted by their struggle to conceive.26 However, the observation that the ART men did not perceive receiving less support than SC men may indicate that they did not necessarily expect more support during the pregnancy period. Prenatal interventions for couples should thus consider that dynamic to reassure the women that their partners may not necessarily expect more support from them. Women in the ART group also felt that they received less support than women in the SC group, although their partners reported that they provided a similar amount of support as the men in the SC group. One potential explanation is that women undergoing ART might have underestimated the support they actually received or expected more or different kinds of support from their spouses. Based on accumulating data, partner support protects pregnant women from depression27 and anxiety28 and reduces cortisol levels in pregnant women.29 Therefore, prenatal interventions for couples should focus on the match between the support provided and support effectively received, as support is known to be most beneficial when it matches the partner’s needs.7
Based on our results, ART women not only felt that they received less support than women in the SC group but also that when they perceived support, it did not reduce their anxiety or depression. This pattern was unexpected but does not necessarily undermine the idea that the partners’ intimate bond is strengthened when they realize they can rely on their partner for support.31 Partner support may be insufficient to reduce anxiety and depression during pregnancy after ART, particularly during the prenatal testing period. ART couples walk on eggshells,32 and factors other than partner support may be more effective in reducing anxiety and depression, such as the healthy progression of the pregnancy or medical reassurance, when ultrasound and prenatal testing results regularly confirm the well-being of the growing fetus. 4.3. Strengths and limitations This study had a repeated-measures design, the assessment times corresponded to the times of prenatal testing, and the two groups compared here had conceived in different ways. The study explored both the received and provided support from a dyadic perspective. The results are interesting, although the methodology and analyses had limitations. First, a larger sample is required to improve the generalizability of the results, although our sample
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shared several characteristics with larger and more representative ART and SC samples. Another limitation was that baseline anxiety or depression scores were not determined before pregnancy, and information concerning a potential history of anxiety or depression was not available. These baseline scores could be compared with the pregnancy and postpartum scores. 4.4. Conclusions and practical implications These results draw attention to the importance of assessing partner support during pregnancy and confirm the need for interventions that improve support. Counseling has proven efficacious during infertility treatment,33 but it needs to continue during pregnancy to improve partners’ mutual support and, therefore, their quality of life. Our results contribute to this literature and suggest that the development of strategies to improve partner support (provided and received) will provide assistance to future parents who need it to become more confident as a couple and in their roles as future parents.34 Other authors also highlight the importance of working on prenatal partner support to improve the future mothers’ well-being and therefore their child’s development.12 Strategies that address partner support during pregnancy appear to be more favorable than strategies that address social support, which have not been shown to be effective.12,35 In particular, an understanding of the reasons for the discrepancies between perceived provided and perceived received support is important to base our interventions on the evidence available regarding ART couples’ emotional needs during pregnancy. These prenatal interventions require a close coordination between the ART and obstetric teams to offer a specific set of services for couples making the transition from infertility to parenthood. The experience of pregnancy and parenthood is one single and continuous story for the couples, whereas the ART and the obstetrics teams are most often located in different places, with different professionals in charge of the couples. Acknowledgments The authors thank Sarah Zimmer for editing the English version of the manuscript. They also thank the recruitment centers (Center for Medically Assisted Procreation; private practitioners Sarah Megalo, MD and Nathalie Rochat Consenti, MD; and Lausanne University Hospital, Lausanne, Switzerland). This research received financial support from the University of Lausanne and the Department of Gynecology-Obstetrics and Genetics of Lausanne University Hospital. The authors have no competing interests to declare. Ethical statement The study protocol was approved by the Ethics Commission of Lausanne University Hospital (Protocol 89/10) before the data were collected (Date of approval: 19 May 2011). Role of the funding The funding source was not involved in the conduct of the research and/or preparation of the article. Conflict of interest None.
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Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.wombi.2018.07.006. References 1. McMahon C.A., Boivin J, Gibson FL, Hammarberg K, Wynter K, Saunders D, et al. Age at first birth, mode of conception and psychological wellbeing in pregnancy: findings from the parental age and transition to parenthood Australia (PATPA) study. Hum Reprod 2011;26:1389–98. 2. Dornelles LM, MacCallum F, Lopes RC, Piccinini CA, Passos EP. The experience of pregnancy resulting from Assisted Reproductive Technology (ART) treatment: a qualitative Brazilian study. Women Birth: J Aust Coll Midwives 2016;29:123–7. 3. Hammarberg K, Fisher JRW, Wynter KH. Psychological and social aspects of pregnancy, childbirth and early parenting after assisted conception: a systematic review. Hum Reprod Update 2008;14:395–414. 4. Kowalcek I. Stress and anxiety associated with prenatal diagnosis. Best Pract Res Clin Obstet Gynaecol 2007;21:221–8. 5. Gourounti K, Anagnostopoulos F, Sandall J. Poor marital support associate with anxiety and worries during pregnancy in Greek pregnant women. Midwifery 2014;30:628–35. 6. Udry-Jørgensen L, Darwiche J, Germond M, Wunder D, Vial Y. Anxiety, depression, and attachment before and after the first-trimester screening for Down syndrome: comparing couples who undergo ART with those who conceive spontaneously. Prenat Diagn 2015;35:1287–93. 7. Cutrona CE, Russell DW. The relationship enhancement model of social support. In: Revenson TA, Kayser KE, Bodenmann GE, editors. Couples Coping with Stress: Emerging Perspectives on Dyadic Coping. Washington DC: American Psychological Association; 2005. p. 73–95. 8. Brassard A, Houde F, Lussier Y. Élaboration et validation du Questionnaire de Soutien Conjugal (QSC). Can J Behav Sci 2011;43:69–77. 9. Bodenmann G, Meuwly N, Kayser K. Two conceptualizations of dyadic coping and their potential for predicting relationship quality and individual wellbeing. Eur Psychol 2011;16:255–66. 10. Taylor J, Turner RJ. A longitudinal study of the role and significance of mattering to others for depressive symptoms. J Health Soc Behav 2001;42: 310–25. 11. Bolger N, Amarel D. Effects of social support visibility on adjustment to stress: experimental evidence. J Personal Soc Psychol 2007;92:458–75. 12. Stapleton LR, Schetter CD, Westling E, Rini C, Glynn LM, Hobel CJ, et al. Perceived partner support in pregnancy predicts lower maternal and infant distress. J Fam Psychol 2012;26:453–63. 13. Pajulo M, Savonlahti E, Sourander A, Helenius H, Piha J. Antenatal depression, substance dependency and social support. J Affect Disord 2001;65:9–17. 14. Rini C, Schetter CD, Hobel CJ, Glynn LM, Sandman CA. Effective social support: antecedents and consequences of partner support during pregnancy. Pers Relatsh 2006;13:207–29. 15. Brisch KH, Munz D, Bemmerer-Mayer K, Kächele H, Terinde R, Kreienberg R. Ultrasound scanning for diagnosis of foetal abnormality and maternal anxieties in a longitudinal perspective. J Reprod Infant Psychol 2002;20: 223–35. 16. Nakagawa S, Schielzeth H. A general and simple method for obtaining R2 from generalized linear mixed-effects models. Methods Ecol Evol 2013;4:133–42. 17. Dyadisches Coping Inventar BG. Test Manual. (Dyadic Coping Inventory [DCI] Manual). Huber & Hogrefe: Bern, Switzerland; 2008. 18. Spielberger CD, Gorsuch RL, Lushene RE, Vagg PR, Jacobs GA. Manual for the State—Trait Anxiety Inventory STAI (Form Y). Palo Alto, CA: Consulting Psychologists Press; 1983. 19. Bergink V, Kooistra L, Lambregtse-van den Berg MP, Wijnen H, Bunevicius R, van Baar A, et al. Validation of the Edinburgh Depression Scale during pregnancy. J Psychosom Res 2011;70:385–9. 20. Matthey S, Henshaw C, Elliott S, Barnett B. Variability in use of cut-off scores and formats on the Edinburgh Postnatal Depression Scale: implications for clinical and research practice. Arch Women’s Ment Health 2006;9:309–15. 21. Cheung GW, Rensvold RB. Evaluating goodness-of-fit indexes for testing measurement invariance. Struct Equ Model 2002;9:233–55. 22. Cnaan A, Laird NM, Slasor P. Using the general linear mixed model to analyse unbalanced repeated measures and longitudinal data. Stat Med 1997;16:2349– 80. 23. Teixeira C, Figueiredo B, Conde A, Pacheco A, Costa R. Anxiety and depression during pregnancy in women and men. J Affect Disord 2009;119:142–8. 24. Kammerer M, Taylor A, Glover V. The HPA axis and perinatal depression: a hypothesis. Arch Women’s Ment Health 2006;9:187–96. 25. Furber C, Garrod D, Maloney E, Lovell K, McGowan L. A qualitative study of mild to moderate psychological distress during pregnancy. Int J Nurs Stud 2009;46:669–77. 26. Dunkel-Schetter C, Skokan LA. Determinants of social support provision in personal relationships. J Soc Pers Relat 1990;7:437–50. 27. Cheng ER, Rifas-Shiman SL, Perkins ME, Rich-Edwards JW, Gillman MW, Wright R, et al. The influence of antenatal partner support on pregnancy outcomes. J Women’s Health 2016;25:672–9.
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28. Akiki S, Avison WR, Speechley KN, Campbell MK. Determinants of maternal antenatal state-anxiety in mid-pregnancy: role of maternal feelings about the pregnancy. J Affect Disord 2016;196:260–7. 29. Giesbrecht GF, Poole JC, Letourneau N, Campbell T, Kaplan BJ. APrON study. The buffering effect of social support on hypothalamic-pituitary-adrenal axis function during pregnancy. Psychosom Med 2013;75:856–62. 30. Bodenmann G, Meuwly N, Germann J, Nussbeck FW, Heinrichs M, Bradbury TN. Effects of stress on the social support provided by men and women in intimate relationships. Psychol Sci 2015;26:1584–94. 31. Peterson BD, Pirritano M, Block JM, Schmidt L. Marital benefit and coping strategies in men and women undergoing unsuccessful fertility treatments over a 5-year period. Fertil Steril 2011;95:1759–63 e1.
32. Sandelowski M, Harris BG, Black BP. Relinquishing infertility: the work of pregnancy for infertile couples. Qual Health Res 1992;2:282–301. 33. Frederiksen Y, Farver-Vestergaard I, Skovgård NG, Ingerslev HJ, Zachariae R. Efficacy of psychosocial interventions for psychological and pregnancy outcomes in infertile women and men: a systematic review and metaanalysis. BMJ Open 2015;5:e006592. 34. Zemp M, Milek A, Cummings EM, Bodenmann G. Longitudinal interrelations between dyadic coping and coparenting conflict in couples. J Child Fam Stud 2017;26:2276–90. 35. Hodnett ED, Fredericks S. Support during pregnancy for women at increased risk of low birthweight babies. Birth 2003;30:278.
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Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
Partner support during the prenatal testing period after assisted conception Joëlle Darwichea,* , Anne Milekb , Jean-Philippe Antoniettia , Yvan Vialc a b c
Family and Development Research Center, Institute of Psychology, University of Lausanne, 1007 Lausanne, Switzerland Department of Psychology, University of Zurich, 8050 Zurich, Switzerland Department of Woman-Mother-Child, University Hospital Lausanne and University of Lausanne, 1007 Lausanne, Switzerland
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 November 2017 Received in revised form 4 July 2018 Accepted 10 July 2018 Available online xxx
Background: Pregnancy after infertility is a challenging experience. The first-trimester screening test may add stress. Partner support reduces psychological distress in pregnant women after spontaneous conception. No data are available for women who conceive via assisted reproductive technology. Aim: To assess whether there was a difference between couples who underwent assisted reproductive technology and couples who conceived spontaneously in the support they felt they provided to their partner and whether their perception of support received from their partner reduced their distress. Methods: This longitudinal prospective study included 52 women (spontaneous conception) and 53 women (assisted reproductive technology), as well as their partners. Participants completed the state scale of the State-Trait Anxiety Inventory, the Edinburgh Depression Scale, and two partner-support subscales of the Dyadic Coping Inventory: before prenatal testing (gestational age 12 weeks), immediately after receiving the results (gestational age of approximately 14 weeks), and once all the prenatal screenings had been completed (gestational age 22 weeks). Findings: Women who underwent assisted reproductive technology felt less able to help their partner cope with stress and felt their partner was less able to help them cope with stress than women with spontaneous pregnancy. This difference was not observed in men. Higher perceived partner support lowered the anxiety and depression of couples who conceived spontaneously, but did not benefit couples who followed fertility treatment. Conclusion: These results add to our knowledge of the emotional state of women and their partners during pregnancy after infertility. This knowledge may allow prenatal care providers to offer specialized counselling to women and their partners in the transition from infertility to parenthood. © 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
Keywords: Prenatal testing Assisted reproductive technology Partner support Anxiety Depression
Statement of significance
Problem or issue Women undergoing assisted conception and their partners may face psychological distress during pregnancy, particularly at the time of the first-trimester prenatal screening test, due to their history of infertility and medical treatments.
What is already known Partner support is known to minimize the risk of prenatal anxiety and depression in women with spontaneous conception. No data are available for women who underwent assisted conception. What this paper adds Compared with spontaneously conceiving women, women who were pregnant after assisted conception felt that their partner was less able to support them (i.e. there was less perceived received support). In addition, when they felt they received support from their partner, it did not help to reduce their prenatal anxiety and depression.
* Corresponding author at: Institute of Psychology, University of Lausanne, Géopolis, Bureau 4219, 1015 Lausanne, Switzerland. E-mail address: [email protected] (J. Darwiche). https://doi.org/10.1016/j.wombi.2018.07.006 1871-5192/© 2018 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.
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1. Introduction Pregnancy after assisted reproductive technology (ART) has been described as a complex emotional experience.1 Women and their partners may experience positive feelings, such as joy and a sense of triumph,2 but may also be more vulnerable to stress due their previous history of infertility and medical treatments. Based on the available data, women and their partners who conceived via ART perceive a greater sense of marital satisfaction, have more positive attitudes toward pregnancy, and show higher levels of attachment to the fetus than couples who conceived spontaneously, while also experiencing more pregnancy-specific anxieties and an increase in anxiety and depression from pregnancy to the post-partum period.3 During pregnancy after ART, prenatal testing may act as an additional stress-inducing event because it addresses sensitive issues related to the viability and health of the fetus.4 This stress may be linked to the procedure itself, the risk of pregnancy loss due to invasive prenatal procedures, or the possibility of an abnormality.4 Based on the limited available data, women who conceive through ART report higher anxiety levels and pregnancy worries before prenatal screening than controls.5 However, the levels of anxiety and depression appear to decrease after the first-trimester prenatal screening in couples who conceived through ART when the result of that test is normal, as shown in a previous study.6 Successful support from each partner in times of stress can buffer the impact on women’s mental and physical health.7 Partner support is described as “all the supportive actions or attitudes that someone exhibits to their partner and perceives to receive from their partner in order to meet their needs”.8 It involves both an active role (providing support) and a passive role (receiving
support).9 Provided support reflects what a partner perceives to invest into the couple relationship to help the other partner cope with stress. Received support pertains to the perception of the support the other partner is willing to provide. Both directions of partner support may be beneficial: providing support may give the partner a sense of meaning or mattering,10 and receiving support may be associated with less vulnerability to stress and better health outcomes.11 To better understand the dynamics of partner support, it is therefore worth distinguishing between perceived support provided and received. A lack of partner support and social support are risk factors for antenatal anxiety and depression.12,13 After spontaneous conception (SC), effective partner support has been shown to predict less anxiety mid-pregnancy, as well as over time until late pregnancy.14 Partner support has also been shown to predict lower maternal and infant postpartum distress12 and is associated with less prenatal depression.13 However, no study has specifically examined partner support in the context of ART. Therefore, this study aimed to compare couples in which the woman had undergone ART with couples in which the woman had conceived spontaneously with respect to the support provided and received during pregnancy. Comparisons were made at three different assessment times during pregnancy: before the first-trimester Down syndrome screening test, which may be considered as a stressor,15 immediately after the receipt of the first-trimester Down syndrome screening result and after the last prenatal test in the fifth month of pregnancy. This study design allowed us to longitudinally examine changes in provided and received partner support over time, as well as the impact of partner support on reducing anxiety and depression.
Table 1 Socio-demographic and medical data for the ART group and the SC group.
Socio-demographic data Women’s age in years (mean SD) Men’s age in years (mean SD) Years of cohabitation (mean SD) % Married (N) Years of desiring a child (mean SD) Couples’ socioeconomic class in % (N)a Upper Upper-middle Middle Lower-middle and lower Medical data Previous pregnancies % (N) No With medical treatment Without medical treatment Weeks of amenorrhea T1 (mean SD) Early pregnancy complications in % (N) Previous prenatal tests % (N) Psychol. sup. during pregnancy % (N) Years of infertility treatment (mean SD) Previous infertility treatment % (N) Source of infertility in % (N) Female origin Male origin Mixed origin Undetermined % FIVb (N) % FIV ICSIc (N)
ART (N = 53)
SC (N = 52)
t-test/χ2 p-values
34.60 3.95 37.30 4.93 6.60 2.80 75.50 (40) 4.30 1.87
30.30 4.35 32.20 5.10 3.40 2.45 44.20 (23) 0.80 0.63
<0.001 <0.001 <0.001 0.002 <0.001
1.90 (1) 28.30 (15) 52.80 (28) 17.00 (9)
1.90 (1) 30.80 (16) 48.10 (25) 19.20 (10)
0.296
69.80 (37) 18.90 (10) 11.30 (6) 11.40 1.28 13.20 (7) 7.50 (4) 43.40 (23) 3.00 2.14 67.90 (36)
80.80 (42) – 19.20 (10) 11.50 1.15 3.80 (2) 0.00 (0) 17.30 (9)
0.016
0.844 0.087 0.043 0.004
28.30 (15) 37.70 (20) 18.90 (10) 15.10 (8) 34.00 (18) 66.00 (35)
a Socioeconomic class determined based on each couple’s highest indicator of socioeconomic position according to Genoud (2011): upper (e.g., university-educated senior managers), upper-middle (e.g., professionals with a university- or secondary-level education), middle (e.g., vocationally trained employees), lower-middle and lower (e.g., apprenticeship-trained skilled tradespeople or unskilled laborers). b Fecondation In Vitro. c Fecondation In Vitro with Intracytoplasmic sperm injection; ART, assisted reproductive technologies; SC, spontaneous conception.
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We postulated that1 women who underwent ART and their partners would have more difficulty in providing and receiving support than the women who underwent SC and their partners, as their resources might have been more depleted than those of the SC group due to their history of infertility and medical treatments, and2 the perceived received support would be associated with lower levels of anxiety and depression in both groups, as partner support has been shown to be associated with lower distress in samples of women after SC.12 Anxiety and depression were chosen because these conditions are prevalent during the perinatal period and represent two major risk factors for a series of adverse postnatal outcomes.12 These findings aim to inform prenatal care providers who are on the front lines for interventions to minimize risk of these problems during pregnancy. 2. Methods The measurements were completed on the day before or the day of (but before) the antenatal first-trimester test at approximately 10–12 weeks of gestational age (g.a.) (T1) and upon receiving the test results (the same or next day) at a g.a. of approximately 14 weeks (T2). The same questionnaires were mailed to the couples again before the morphological ultrasound, along with instructions to complete them just after the test at approximately 22 weeks of g.a. (T3). T1 was considered as a stressor and T2 and T3 as times of relief for couples with normal results. 2.1. Study population Data were collected for this longitudinal prospective study between 2012 and 2014. One hundred five couples (N = 210 subjects) were included at T1. Fifty-three, 49, and 44 ART couples were monitored at T1, T2, and T3, respectively, and 52, 48, and 44 SC couples were monitored at T1, T2, and T3, respectively. The power analysis16 indicated a 95% chance of detecting a moderate to large effect size with a sample of 2 50 couples. Seven prenatal test results recorded an unfavorable outcome at T2 — five in the ART group and two in the SC group. The participants’ sociodemographic and medical factors are presented in Table 1. The two groups were similar in terms of their socioeconomic status, but the ART couples were older, had lived together for a longer period, were more often married, and had desired a child for longer than the partners in the SC group. A greater proportion of the ART couples had also experienced a previous pregnancy, undergone prenatal tests, and received psychological support during pregnancy. However, the groups were similar in terms of the number of weeks of amenorrhea at T1 and the rate of early pregnancy complications. 2.2. Measures 2.2.1. Partner support We used two subscales of the Dyadic Coping Inventory (DCI),17 a 37-item questionnaire, to specifically assess perceived provided support and perceived received support (respectively named Supportive Dyadic Coping by oneself and Supportive Dyadic Coping by partner in the original version). These subscales are relevant to assessing partner support when facing stressful events or challenging life transitions. Each subscale has five items rated on a 5-point Likert scale, ranging from 1 (“very rarely”) to 5 (“very often”), and were used to produce an aggregate score. The perceived provided support subscale answers the question “What do I do when my partner is stressed?” The five items are: “I show empathy and understanding”, “I express to my partner that I am on his/her
3
side”, “I tell my partner that his/her stress is not bad and help him/ her to see the situation in a different light”, “I listen to my partner and give him/her space and time to communicate what really bothers him/her”, and “I try to analyze the situation together with my partner in an objective manner and help him/her to understand and change the problem”. The perceived received support subscale answers the question “What does my partner do when I am stressed?” The five items are: “My partner shows empathy and understanding to me”, “My partner expresses that he/she is on my side”, “My partner helps me to see stressful situations in a different light”, “My partner listens to me and gives me the opportunity to communicate what really bothers me”, and “My partners helps me analyze the situation so that I can better face the problem”. Higher scores indicate higher levels of perceived emotional support (provided or received). Internal consistency was satisfactory for perceived provided support for both men and women at T1, T2, and T3 (all alphas > 0.77) and for perceived received support for both men and women at T1, T2, and T3 (all alphas > 0.84). 2.2.2. Anxiety Anxiety was assessed with the “state” scale of the State-Trait Anxiety Inventory, Form Y-1 (S-STAI).18 It contains 20 items, each rated on a 4-point Likert scale, ranging from 1 (“not at all”) to 4 (“very much so”). Scores range from 20 to 80, with higher scores indicating greater anxiety. Internal consistency was satisfactory for both men and women at T1, T2, and T3 (all alphas > 0.91). 2.2.3. Prepartum depression We assessed prepartum depression with the Edinburgh Depression Scale, adapted to, and validated for, the antenatal period (EDS).19 This instrument contains 10 items, each rated on a 4-point Likert scale, ranging from 0 (“no, never”) to 3 (“yes, most of the time”). Scores range from 0 to 30, with higher scores indicating the presence of more depressive symptoms. Internal consistency was satisfactory for both women and men at T1, and for women at T2 and T3 (all alphas > 0.85); it was lower for men at T2 and T3 (alphas > 0.67). A score of 15 is considered the clinical cut-off during pregnancy.20 2.3. Procedure Participants were recruited by a registered research psychologist once the pregnancy had been confirmed during a routine doctor’s appointment. The ART couples were recruited from specialized units for assisted reproduction and the SC couples were recruited from the outpatient clinic of a general hospital or from obstetricians in private practice. The women had to be at least 24 years of age and nulliparous (but not primigravida) and be in a romantic relationship to be included in the present study. The couples’ obstetricians or midwives presented the study and provided each couple with an informational letter. The researcher then called the couples who had agreed to be contacted and completely explained the study. The couples initially received an informed consent form, a brief questionnaire about their relationship (e.g., length of the relationship, marital status, and years of desiring a child), and their medical history (e.g., previous pregnancies and early pregnancy complications) to complete and return. They were later mailed the questionnaires used to assess partner support, anxiety, and depression, with instructions to complete them at T1, T2 and T3. The questionnaires completed at T1 and T2 evaluated the effects of the Down syndrome test, and those at T3 evaluated the subjects’ emotional states at the end of the prenatal testing period, once they had been reassured that the pregnancy was progressing well. We instructed the couples to individually complete the questionnaires at home and to date and return each of them by
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mail as soon as they were completed. If a participant had not sent back the questionnaire within 5 days, the researcher contacted the couple by email/phone and reminded them of the importance of returning the questionnaires quickly. If a response was not obtained after 2 weeks and 2 follow-up calls, the subject was recorded as lost to that assessment time. The study protocol was approved by the Ethics Commission of Lausanne University Hospital (Protocol 89/10) before the data were collected. 2.4. Statistical analysis All descriptive analyses and linear mixed models were performed with the R statistical software (lme4 package). The percentage of missing data per questionnaire and per assessment time was less than 1%, suggesting that the participants conscientiously completed the questionnaires. Missing responses to questionnaire items were replaced by the mean score of the subject’s other responses. First, descriptive statistics for the demographic and psychological characteristics were calculated. The independent-sample t test and a χ2 test were used to examine the differences in age, years of cohabitation, marriage, years of desiring a child, socioeconomic status, previous pregnancies, early pregnancy complications, previous prenatal testing, previous psychological support (during pregnancy), and the result of the prenatal test between the ART and SC groups. Second, we described the mean changes in each main variable for all participants and used a one-way ANOVA to examine the differences over time. Correlations of the groups’ characteristics with the dependent variables (anxiety and depression) were calculated. We controlled for the three variables that correlated with our dependent variables (i.e., previous pregnancies, early pregnancy complications, and the result of the prenatal test) in our models. In addition, we conducted confirmatory factor analyses to test whether repeated measures were invariant over time. Strong measurement invariance was established for all our variables of interest.21 Finally, the data were analyzed using linear mixed models.
1. We used a linear mixed model with two main effects (time and group) and one interaction effect (time group) to test whether the two conception groups differed in provided and received support and whether these differences varied over the three assessment times. 2. We then used the linear mixed models described below. In the first model, we tested the association between perceived received support and women’s anxiety while controlling for men’s anxiety and men’s perceived provided support. In the second model, we tested the association between perceived received support and men’s anxiety while controlling for women’s anxiety and women’s perceived provided support. Equivalent models were conducted using depression as the outcome. The potential confounding variables (previous pregnancies, early pregnancy complications, and the result of the prenatal test) were controlled in the models. The use of linear mixed models has the advantage of allowing a single time point to be eliminated for subjects who are missing a time point.22 Based on the recommendations of Nakagawa and Schielzeth,16 we calculated two types of R2 for each of the four models (marginal (R2[m]) and conditional (R2[c]). Time was treated as a discrete variable in all analyses. The reference levels for coding were Time 1 (for time), “no” for a previous pregnancy, “ART group” for the mode of conception, “no” for early pregnancy complications, and “favorable outcome” for the prenatal test. Probability values of p 0.05 were considered significant in all analyses. 3. Results 3.1. Descriptive results The mean perceived provided support, perceived received support, anxiety, and depression scores are presented in Table 2. Couples’ scores were not statistically significantly different from the DCI manual reference standards (a sample of 1327 women and 1027 men).17 The women were more anxious than their partners at T1 (ART group), T2 (both groups) and T3 (SC group) and showed more depressive symptoms at all three time points (Supplemental Fig. 1a and b). However, their mean anxiety and depression scores
Table 2 Mean and standard deviation of study variables for women and men and differences across time. SC
ART Women
Provided support T1 T2 T3 ANOVA/p-valuesa Received support T1 T2 T3 ANOVA/p-valuesa Anxiety T1 T2 T3 ANOVA/p-valuesa Depression T1 T2 T3 ANOVA/p-values
Men
Women
Men
n
M
SD
n
M
SD
n
M
SD
n
M
SD
53 49 44
18.87 19.30 19.55 0.162
3.01 2.53 2.81
51 47 42
19.80 20.09 20.33 0.718
2.84 2.60 2.67
52 48 44
20.60 21.05 20.70 0.266
3.24 3.09 2.74
51 47 42
20.24 20.19 20.49 0.784
3.04 2.81 2.21
53 49 43
19.09 19.57 19.72 0.512
3.71 3.25 3.40
52 47 42
18.71 19.34 19.90 0.104
3.33 3.42 3.03
52 48 44
20.85 20.92 20.52 0.718
3.51 3.13 3.55
52 47 44
19.56 20.53 20.20 0.098
3.65 3.41 3.22
53 49 45
39.16 35.10 33.21 <0.001
11.09 9.88 9.35
52 48 45
33.35 31.41 31.78 0.261
9.02 7.42 8.24
52 47 45
35.45 34.76 33.94 0.508
9.36 11.12 9.14
52 46 44
32.33 29.77 29.07 0.016
9.04 7.71 7.06
53 49 45
6.46 5.53 5.96 0.351
5.95 4.91 4.94
53 49 44
3.63 3.14 3.45 0.395
2.93 2.81 2.80
52 47 45
5.21 5.18 5.64 0.717
5.13 4.33 4.28
52 47 43
3.44 3.06 2.66 0.175
3.13 2.89 2.55
Note. M, mean; SD, standard deviation; n = number of subjects at each assessment time; ART, assisted reproductive technologies; SC, spontaneous conception.
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remained in the nonclinical ranges. Anxiety decreased over time in ART women and in SC men (see also Ref. 6).
3.3. Perceived support received from the partner and its effects on anxiety and depression
3.2. Perception of provided and received support
A significant interaction was observed between the group and the perceived support received from the partner (see Table 3 for a summary of the results and Supplemental Table 1a-1d for the detailed results). Above and beyond partners’ anxiety (or depression) and partners’ reported provided support, a greater amount of perceived received support was associated with reduced anxiety and depression at all three assessment times in both men and women in the SC group (anxiety: β = 0.07 + [ 1.16] = 1.09 in women and β = 0.14 + [ 0.80] = 0.66 in men; depression: β = 0.01 + [ 0.58] = 0.57 in women and β = 0.05 + [ 0.27] = 0.22 in men). However, the men and women in the ART group did not experience this effect (anxiety: β = 0.07 in women and β = 0.14 in men; depression: β = 0.01 in women and β = 0.05 in men).
The analyses were performed using a mixed model with two main effects (time and group) and one interaction effect (time group). 3.2.1. Support provided by men and support received by women No significant group effect (F[2,174.19] = 0.49, p = 0.617) or interaction effect (F[2,174.19] = 0.10, p = 0.901) was observed for the men’s perception of the support they provided to their partners (see Fig. 1a). However, a group effect (F[1,107.42] = 5.63, p = 0.019) was observed for the women’s perception of the support they received. Women in the ART group felt that they received less support from their partners than women in the SC group (see Fig. 1b). 3.2.2. Support provided by women and support received by men Our results also showed a group effect (F[1,108.34] = 9.95, p = 0.002) for the women’s perception of the support they provided. Women in the ART group felt they provided less support to their partners than women in the SC group (Fig. 1c). No group or interaction effects were observed for the men’s perception of the support they received (Fig. 1d).
4. Discussion This study adds to the literature on the emotional experience of couples during pregnancy after ART. Its novelty is the focus on an unexplored topic: how ART couples, whose resources might be depleted due to the experience of infertility and its treatment, deal with the stress induced by prenatal testing. The ART and SC groups were more similar than different in terms of their levels of prenatal anxiety and depression, and anxiety tended to decrease over time
Fig. 1. (a) Support men provided to their partners. (b) Support women received from their partners. (c) Support women provided to their partners. (d) Support men received from their partners.
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Table 3 Main and interaction effects of perceived received support from partner on anxiety and depression. Predictors Women Main effects Group Perceived received support Interaction Group perceived received Partial regression coefficient Group (0 = ART, 1 = SC) Perceived received support Group perceived received 2 R [m]/R2[c] Men Main effects Group Perceived received support Interaction Group perceived received Partial regression coefficient Group (0 = ART, 1 = SC) Perceived received support Group perceived received R2[m]/R2[c]
support
support
support
support
Anxiety
Depression
F(1,98) = 0.08, p = 0.777 F(1,254) = 0.50, p = 0.480
F(1,96) = 0.02, p = 0.898 F(1,242) = 4.52, p = 0.034
F(1,241) = 9.29, p = 0.003
F(1,239) = 9.47, p = 0.002
β = 1.83 β = 0.07 β = 1.16** 0.14/0.62
SE = 1.99 SE = 0.28 SE = 0.38
β = 0.70 β = 0.01 β = 0.58** 0.13/0.59
F(1,98) = 0.54, p = 0.462 F(1,248) = 0.23, p = 0.630
F(1,100) = 0.04, p = 0.846 F(1,243) = 0.01, p = 0.945
F(1,254) = 5.96, p = 0.015
F(1,258) = 5.81, p = 0.017
β = 0.07 β = 0.14 β = 0.80* 0.10/0.60
SE = 1.69 SE = 0.25 SE = 0.33
β = 0.17 β = 0.05 β = 0.27* 0.08/0.63
SE = 0.98 SE = 0.14 SE = 0.19
SE = 0.59 SE = 0.09 SE = 0.11
Note. SE, standard error. Model controlled for assessment time, partner’s levels of anxiety/depression, partner’s support provided, previous pregnancy, early pregnancy complications, result of the prenatal test (see Table III-supplementary material, for the detailed results). Group: 0 = ART, 1 = SC, [m] = marginal, [c] = conditional. * p < 0.05. ** p < 0.01.
(see also Ref. 6). The women in both groups tended to be more anxious and depressed than the men, confirming previous reports that prenatal anxiety and depression levels are higher in women than in men.23 These results have been partially attributed to the invasive nature of prenatal testing procedures (e.g., amniocenteses), which may particularly increase women’s anxiety as they undergo the procedure. They may also be related to the fact that women are physically involved in the pregnancy and that hormonal changes may affect their emotional well-being.24 Also, they may experience a strong sense of worry due to the responsibility they feel during the transformative event of becoming a mother.25
Our hypothesis that the men in the ART group would report that they provided (and received) less support than men in the SC group was not supported. The process of infertility treatments causes stress in both partners, but the sources of the stress differ because of the gender-specific roles in pregnancy. When stressed, men have been reported to provide lower-quality support than similarly stressed women.30 Therefore, the men may have overestimated the support they actually provided. More research is needed to assess the gender-specific perceptions and expectations related to partner support during pregnancy after ART. For example, observational studies that rate support could refine our understanding of partner-support dynamics.
4.1. ART women report that they provide and receive less support
4.2. ART couples: support, anxiety, and depression
Our hypothesis that women in the ART group would report that they provide less support than women in the SC group was supported. Pregnant women may experience significant stress when carrying a child after infertility and its treatment. The cost of effectively supporting a partner might be too high in this setting because the women’s resources are presumably depleted by their struggle to conceive.26 However, the observation that the ART men did not perceive receiving less support than SC men may indicate that they did not necessarily expect more support during the pregnancy period. Prenatal interventions for couples should thus consider that dynamic to reassure the women that their partners may not necessarily expect more support from them. Women in the ART group also felt that they received less support than women in the SC group, although their partners reported that they provided a similar amount of support as the men in the SC group. One potential explanation is that women undergoing ART might have underestimated the support they actually received or expected more or different kinds of support from their spouses. Based on accumulating data, partner support protects pregnant women from depression27 and anxiety28 and reduces cortisol levels in pregnant women.29 Therefore, prenatal interventions for couples should focus on the match between the support provided and support effectively received, as support is known to be most beneficial when it matches the partner’s needs.7
Based on our results, ART women not only felt that they received less support than women in the SC group but also that when they perceived support, it did not reduce their anxiety or depression. This pattern was unexpected but does not necessarily undermine the idea that the partners’ intimate bond is strengthened when they realize they can rely on their partner for support.31 Partner support may be insufficient to reduce anxiety and depression during pregnancy after ART, particularly during the prenatal testing period. ART couples walk on eggshells,32 and factors other than partner support may be more effective in reducing anxiety and depression, such as the healthy progression of the pregnancy or medical reassurance, when ultrasound and prenatal testing results regularly confirm the well-being of the growing fetus. 4.3. Strengths and limitations This study had a repeated-measures design, the assessment times corresponded to the times of prenatal testing, and the two groups compared here had conceived in different ways. The study explored both the received and provided support from a dyadic perspective. The results are interesting, although the methodology and analyses had limitations. First, a larger sample is required to improve the generalizability of the results, although our sample
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shared several characteristics with larger and more representative ART and SC samples. Another limitation was that baseline anxiety or depression scores were not determined before pregnancy, and information concerning a potential history of anxiety or depression was not available. These baseline scores could be compared with the pregnancy and postpartum scores. 4.4. Conclusions and practical implications These results draw attention to the importance of assessing partner support during pregnancy and confirm the need for interventions that improve support. Counseling has proven efficacious during infertility treatment,33 but it needs to continue during pregnancy to improve partners’ mutual support and, therefore, their quality of life. Our results contribute to this literature and suggest that the development of strategies to improve partner support (provided and received) will provide assistance to future parents who need it to become more confident as a couple and in their roles as future parents.34 Other authors also highlight the importance of working on prenatal partner support to improve the future mothers’ well-being and therefore their child’s development.12 Strategies that address partner support during pregnancy appear to be more favorable than strategies that address social support, which have not been shown to be effective.12,35 In particular, an understanding of the reasons for the discrepancies between perceived provided and perceived received support is important to base our interventions on the evidence available regarding ART couples’ emotional needs during pregnancy. These prenatal interventions require a close coordination between the ART and obstetric teams to offer a specific set of services for couples making the transition from infertility to parenthood. The experience of pregnancy and parenthood is one single and continuous story for the couples, whereas the ART and the obstetrics teams are most often located in different places, with different professionals in charge of the couples. Acknowledgments The authors thank Sarah Zimmer for editing the English version of the manuscript. They also thank the recruitment centers (Center for Medically Assisted Procreation; private practitioners Sarah Megalo, MD and Nathalie Rochat Consenti, MD; and Lausanne University Hospital, Lausanne, Switzerland). This research received financial support from the University of Lausanne and the Department of Gynecology-Obstetrics and Genetics of Lausanne University Hospital. The authors have no competing interests to declare. Ethical statement The study protocol was approved by the Ethics Commission of Lausanne University Hospital (Protocol 89/10) before the data were collected (Date of approval: 19 May 2011). Role of the funding The funding source was not involved in the conduct of the research and/or preparation of the article. Conflict of interest None.
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