Psychological distress profiles in expectant mothers: What is the association with pregnancy-related and relational variables?

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS: WHAT IS THE ASSOCIATION WITH PREGNANCY-RELATED AND RELATIONAL VARIABLES? Sara Molgora , Valentina Fenaroli , Emanuela Saita PII: DOI: Reference:

S0165-0327(19)31723-9 https://doi.org/10.1016/j.jad.2019.10.045 JAD 11234

To appear in:

Journal of Affective Disorders

Received date: Revised date: Accepted date:

1 July 2019 4 September 2019 28 October 2019

Please cite this article as: Sara Molgora , Valentina Fenaroli , Emanuela Saita , PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS: WHAT IS THE ASSOCIATION WITH PREGNANCY-RELATED AND RELATIONAL VARIABLES?, Journal of Affective Disorders (2019), doi: https://doi.org/10.1016/j.jad.2019.10.045

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS

HIGHLIGHTS 

Although efforts to screen, prevent, and treat maternal distress are growing, perinatal diseases often go undetected and untreated.

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Maternal perinatal disorders might have an impact on subsequent infant development, making women’s mental health during the transition to parenthood a significant public health concern.

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Pregnancy and delivery can be experienced by women as stressful and traumatic not only if there are medical problems and mothers could express their distress in several ways.

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Differentiating different forms of disease by identifying the mother’s psychological profile could help professionals to better understand the experience of these women and to develop targeted and increasingly personalized interventions.

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It is important to take into account not only the intensity of any symptom but also the overall picture of psychological well-being within which each symptomatic form manifests itself.

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS Running head: Psychological Distress Profiles in Expectant Mothers PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS: WHAT IS THE ASSOCIATION WITH PREGNANCY-RELATED AND RELATIONAL VARIABLES? Sara Molgora, Valentina Fenaroli, Emanuela Saita Catholic University of Milan, Italy Corresponding author: Sara Molgora Catholic University of Milan, Largo Gemelli, 1 - 20123 Milan Tel: +390272342347 Fax: +390272345962 E-mail: [email protected] Statement of the individual author’s contributions All authors certify that they have participated in the submitted work. They have contributed in various degree to the final version of the paper. Conflict of interest statement All the authors certify that they have NO affiliations with or involvement in any organization or entity with any financial interest, or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Abstract

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS

Introduction: Research has progressively focused on antenatal psychological disease of expectant mothers, showing that anxiety and depression as well as fear of childbirth occur frequently during pregnancy. Some studies have investigated the connection between anxiety, depression, and fear of childbirth with contrasting results. Several authors have analyzed the association between psychological disease of pregnant women and numerous medical-obstetric and relational variables, still reporting inconclusive findings. The present study had three aims: 1) to investigate the psychological well-being of pregnant women based on their levels of anxiety, depression, and fear of childbirth, by identifying psychological profiles; (2) to analyze the association between the emergent psychological profiles and some medical-obstetric variables related to pregnancy; and (3) to examine the association between these profiles and couple’s adjustment and social support.

Methods: 410 Italian primiparous pregnant women in the 7th-8th month of pregnancy completed a questionnaire packet on site that included the following scales: Wijma Delivery Expectancy Questionnaire, Edinburgh Postnatal Depression Scale, State-Trait Anxiety Inventory, Dyadic Adjustment Scale, Multidimensional Scale of Perceived Social Support.

Results: Findings revealed the presence of three different clusters: “psychologically healthy women” (34.9%), comprised of women characterized by low levels of symptoms on all the scales; “women experiencing pregnancy- and childbirth-related anxiety” (47.3%), which groups

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS women with an average state anxiety over the clinical value; and “psychologically distressed women” (17.8%), comprised of women who reported high levels of symptoms on all the scales, some above the clinical cut-offs. These profiles were not related to the medical-obstetric variables. On the other hand, findings revealed a significant association between marital adjustment as well as social support and cluster membership.

Discussion: These results support the importance of early and multilevel psychological screening in order to understand the experience of pregnant women and to develop targeted and increasingly personalized interventions.

INTRODUCTION Research on women’s mental health during the transition to parenthood has progressively shifted from the postnatal period only to include the perinatal period. Starting from the evidence that women can already experience psychological distress during pregnancy (Biaggi, Conroy, Pawlby, & Pariante, 2016; Heron et al., 2004), a growing number of studies have focused on antenatal anxiety and, especially, mood (i.e., depression) disorders (van de Loo et al., 2018). Although data on the occurrence rates of anxiety and depression during pregnancy vary widely among the studies ‒ due to some methodological issues (e.g., trimester of assessment, women’s characteristics, screening tools, etc.), the incidence of these symptoms in expectant mothers is found to be considerable across countries (Nasreen et al., 2018). In general, anxiety is more prevalent than depression among mothers during the prenatal period (Bayrampour, Vinturache,

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS Hetherington, Lorenzetti, & Tough, 2018; Nasreen et al., 2018; van de Loo et al., 2018). Specifically, the prevalence of an anxiety disorder is found to affect around 15% to 40% of expectant mothers, based on the presence of anxiety symptoms in at least one antenatal assessment (Dennis, Falah-Hassani, & Shiri, 2017; Grigoriadis et al., 2018; van de Loo et al., 2018), while the estimated prevalence of depression is between 7% and 12%, up to 30%, based on the presence of any depressive symptom in at least one antenatal assessment (Pampaka et al, 2018). Furthermore, anxiety and depressive symptoms in comorbidity are common during pregnancy (Figueiredo & Conde, 2011; Nasreen et al., 2018). For example, the meta-analysis by Falah-Hassani and colleagues (2017) found a percentage between 6.3 and 9.5 of expectant mothers ‒ respectively, depending on whether moderate to severe or mild to severe symptoms of depression were considered ‒ reported both anxiety and depressive symptoms. These rates suggest that anxiety and depression occur quite frequently during pregnancy and, moreover, that they are more prevalent during pregnancy than in the postpartum period (Carter, Bond, Wickham, & Barrera, 2019; Nasreen et al., 2018). Moreover, research has progressively begun to focus more on fear of childbirth (FOC) in pregnant women (Fenwick, Gamble, Nathan, Bayes, & Hauck, 2009; Molgora et al., 2018; Pazzagli et al., 2015; Poggi, Goutaudier, Séjourné, & Chabrol, 2018;

is nen et al., 2014),

showing that about 25-30% experience moderate-high levels of fear during pregnancy, with a prevalence of severe fear – also called tokophobia (Hofberg & Brockington, 2000) – of around 14% (O’Connell et al., 2017). Although we still do not have a clear definition of FOC, a severe (or extreme) fear of childbirth can be conceptualized as a clinical condition that is characterized by several symptoms (sleep disorders, panic attacks, etc.). This condition interferes with a woman’s daily life and with her ability to cope with labor and delivery,

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS worsening how she experiences the birth and increasing her postpartum psychological disease (Laursen, Hedegaard, & Johansen, 2008). Previous research investigated the connection between anxiety, depression, and FOC during pregnancy with contrasting results. Indeed, although some studies found an association (Laursen et al., 2008; Rouhe, Salmela-Aro, Gissler, Halmesmäki, & Saisto, 2011), the study by Storksen and colleagues (2012) reported that the majority of women with fear were neither anxious nor depressed. Furthermore, Huizink and colleagues (2004) defined anxiety during pregnancy as a specific anxiety disorder characterized by intense fear, and, in so doing, removed the distinction between fear and anxiety, while Rondung and colleagues (2016) reported that fear, anxiety, and depression are distinct constructs that cannot be overlapped. And again, some authors (Hall et al., 2009) considered anxiety and depression as risk factors for the development of FOC. These findings suggest the complexity of the relationship between anxiety symptoms, depressive symptoms, and fear of childbirth and the need for further investigation (Molgora et al., 2018). Some studies have investigated the association between the overall psychological wellbeing of expectant mothers and a variety of medical-obstetric variables as well as relational variables prior to and during pregnancy that could have an impact on the woman’s mental health (Furtado, Chow, Owais, Frey, & Van Lieshout, 2018). For example, considering medicalobstetric variables, a previous miscarriage was found to be a significant predictor of poorer mental health during pregnancy (Costa et al., 2017; Togher, Treacy, O’Keeffe, & Kenny, 2017). Furthermore, high risk pregnancies are associated with higher levels of fear of childbirth and nearly doubled the odds of experiencing depression compared with low-risk pregnancies (Kozhimannil, Pereira, & Harlow, 2009; Yali & Lobel, 1999). As to relational variables, several

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS studies have highlighted the association between couple’s relationship quality and mother’s psychological well-being, considering both possible directions of the effects (Figueiredo et al., 2018). Thus, some authors found that couple relationship is an important factor in determining women’s psychological health (Costa et al., 2017), with a good couple relationship moderating negative effects of emotional strain, while others reported that higher anxiety and/or depression were predictive of decreased relationship quality over the transition to parenthood (Parfitt & Ayers, 2009). Furthermore, social support has also been reported to be associated with mother’s mental health: a lack of or poorly perceived social support represents an important risk factor for the development of FOC and depressive symptoms during pregnancy (Lukasse, Schei, Ryding, & Bidens Study Group, 2014; Poggi et al., 2018). Since a number of studies have reported an association between anxiety, depression, and FOC during pregnancy and several adverse pregnancy and delivery (e.g., fetal distress, preterm birth, operative or emergency delivery, etc.), and postpartum (e.g., impaired mother-infant relationship, women’s postpartum well-being, child’s cognitive and behavioral problems, etc.) outcomes (e.g., Alipour et al., 2012; Bayrampour et al., 2018; Glynn et al., 2018; Jespersen, Hegaard, Schroll, Rosthøj, & Kjærgaard, 2014; Madigan et al., 2018; Staneva, Bogossian, Pritchard, & Wittkowski, 2015), the investigation of mother’s psychological distress during pregnancy is not only a research topic, but also a clinical concern for public health and health care. Indeed, there is increasing evidence that maternal mental illness needs to be screened early in order to promote prevention programs and early interventions, thus reducing the risk of negative physical and psychological health outcomes both for the mother herself and for the baby (Dunkel Schetter & Tanner, 2012; van de Loo et al., 2018).

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS The present study had three aims: (1) to investigate the psychological well-being of pregnant women in Italy based on their levels of anxiety, depression, and fear of childbirth, by identifying psychological profiles; (2) to analyze the association between the emergent psychological profiles and some medical-obstetric variables related to pregnancy (previous miscarriage, threat of miscarriage in the current pregnancy, and presence of any other complications); and (3) to examine the association between these profiles and two relational dimensions (couple’s adjustment and social support). METHOD Procedure and participants This cross-sectional study involved Italian pregnant women in the 7th-8th month of pregnancy recruited from hospitals or family consultation units where they attended antenatal classes, between September, 2015 and December, 2016. Participants were informed about the research aims and methodology and were asked to sign the written consent form. Informed consent forms and all study materials were approved by the authors’ institution’s ethics review board. Women who agreed to participate completed a questionnaire packet on site. Women in the sample met the following inclusion criteria: 1) they were primiparous; 2) they had a single pregnancy; 3) they were fluent in Italian. Of the 650 women eligible for the study, 513 agreed to participate and were recruited after they signed the consent form. Of these, 103 women returned partially incomplete questionnaires and were excluded from the data analysis. Thus, the final sample consisted of 410 women. Measures Women completed a questionnaire packet that included:

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS - Wijma Delivery Expectancy Questionnaire-WDEQ(A) (Wijma, Wijma, & Zar, 1998). The WDEQ(A) is the most frequently used self-report scale to measure childbirth expectations and, specifically, fear of childbirth, calculated on a six-point Likert scale. In this study, the Italian validated version of 14 items (Fenaroli & Saita, 2013)  with a total score that ranges between 0 and 70  was used (Molgora et al., 2018), showing a good internal consistency (Cronbach’s alpha =.79). To date, previous research has not achieved a consistent WDEQ(A) cut-off to identify clinical fear of childbirth; based on some studies that reported severe fear as the top quartile of the continuous measure (Fenwick et al., 2009), we considered the value of 35 as the cut-off to distinguish severe fear. - Edinburgh Postnatal Depression Scale-EPDS (Cox, Holden, & Sagovsky, 1987). This 10-item instrument, with a total score ranging from 0 to 30, was originally developed as a screening tool for postnatal depression and it was subsequently validated with pregnant women, showing good sensitivity and predictive values (Kozinszky & Dudas, 2015). In the current study, the Italian validated version (Benvenuti, Ferrara, Niccolai, Valoriali, & Cox, 1999) was used, with a good reliability (Cronbach’s alpha=.80). According to Gibson and colleagues (2009), the cut-off value of 13 was used to distinguish clinical depression. - State-Trait Anxiety Inventory-STAI (Form Y) (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). This 40-item instrument is a frequently used measure of trait (20 items) and state (20 items) anxiety, with a total score ranging from 20 to 80. In this study, the internal consistency coefficient of the Italian validated version (Pedrabissi & Santinello, 1989) was good (Cronbach’s alpha=.88 for state anxiety and .87 for trait anxiety). Based on previous studies on the Italian pregnant population (Giardinelli et al., 2012; Vismara et al., 2016), the cut-off score of 40 was used to identify both state and trait clinical anxiety.

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS - Dyadic Adjustment Scale-DAS (Spainer, 1976). One of the most widely used instruments to assess couple’s adjustment, it is composed by 32 items, 31 of which are related to the specific dimension of couple adjustment while one item refers to the overall perceived happiness with the relationship. In this study, the Italian validated version (Gentili, Contreras, Cassaniti, & D’Arista, 2002) showed a very good reliability (Cronbach’s alpha=.98). - Multidimensional Scale of Perceived Social Support-MSPSS (Zimet, Dahlem, Zimet, & Farley, 1988). This 12-item instrument, with a 12-80 total score range, measures the perception of social support from three different sources: partner, family, and significant others (e.g., friends). In this study, the Italian validated version was used (Prezza & Principato, 2002) with a very good reliability (Cronbach’s alpha=.98). - Finally, Socio-demographic information (age, education, occupation) and medical-obstetric information about the past (previous miscarriage) and about the course of the current pregnancy (threat of miscarriage, presence of any other complication for the mother and/or the fetus) were investigated. Data analysis The distributions of WDEQ(A), EPDS, STAI, DAS, and MSPSS scores were assessed to verify the normality for asymmetry and kurtosis. The correlation index between the psychological variables (WDEQ(A), EPDS, STAI) was calculated. As suggested by Henry, Tolan, and Gorman-Smith (2005), in order to identify different sub-groups of women characterized by high within-cluster homogeneity and high betweencluster heterogeneity (Hair & Black, 2000), a hierarchical cluster analysis was performed (Ward’s method, Euclidian distance), followed by a K-means cluster analysis on WDEQ(A), EPDS, STAI (both state and trait). In the K-mean cluster analysis we forced the three cluster

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS solution according to findings emerged with the previous cluster analysis. However, according with the exploratory nature of our analysis, we explored other different possible solutions: the three cluster solution emerged as the best one, i.e., the solution reporting the most easily interpretable and clinically meaningful result (Haines et al., 2012). The association between psychological profiles and medical-obstetric variables (previous miscarriage, threat of miscarriage in the current pregnancy, and presence of any other complications) was investigated through chi square statistics. The association between psychological profiles and relational variables (DAS and MSPSS) was tested through two univariate ANOVAs with the Bonferroni correction in the posthoc tests. Statistical analyses were performed using SPSS software, version 25. RESULTS Participants’ mean age was 33.29 years (SD= 5.53; range 18-49). Other descriptive variables of the sample (socio-demographic characteristics and medical-obstetric variables) are presented in Table 1. [INSERT TABLE 1] Descriptive statistics of the psychological variables (WDEQ(A), EPDS, STAI, DAS, and MSPSS) are presented in Table 2. All the variables were normally distributed. Correlation index between these variables is reported in Table 3. [INSERT TABLE 2] [INSERT TABLE 3] Considering the first research aim, a three-cluster solution was found to offer the most interpretable and clinically meaningful solution (Figure 1). All three variables are significant for each cluster (Table 4).

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS [INSERT FIGURE 1] [INSERT TABLE 4] Cluster 1 (N= 143; 34.9%) is characterized by women with a low level of fear of birth, anxiety (both state and trait), and depression; the average score for each scale is clearly below the clinical cut-off values. We labeled this cluster “psychologically healthy women”. Cluster 2 (N = 194; 47.3%) groups women with an average state anxiety over the clinical value; the other values are below the cut-off, although all (especially fear of childbirth) are higher than those in Cluster 1. We named this cluster “currently anxious women”. Finally, Cluster 3 (N = 73; 17.8%) is comprised of women who reported the highest scores for all the variables. In particular, both fear of childbirth and anxiety (state and trait) exceed clinical cut-offs, whereas the average depression score is just below the threshold. We defined this cluster as “psychologically distressed women”. As regards the second research aim, chi square statistic investigating the association between the three emergent psychological profiles and gynecological and pregnancy-related variables (previous miscarriage, threat of miscarriage in the current pregnancy, and presence of any other complications) was not significant. No medical variables showed differences in the three clusters. Finally, as regards the third research aim, findings revealed a significant association between marital adjustment and cluster membership (F (2, 408) = 18.69, p < .001). Specifically, psychologically healthy women reported an average DAS score that is significantly higher than currently anxious women (mean difference = 8.20; std error = 1.83; p <.001) and psychologically distressed women (m.d. = 13.58; s.e. = 2.34; p <.001); currently anxious women have a DAS score that is significantly higher than psychologically distressed women (m.d. = 5.37; s.e. = 2.20;

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS p <.001). Furthermore, findings revealed a significant association between cluster membership and social support (F (2, 408) = 4.78, p < .01). In particular, social support was significantly different between psychologically healthy women and psychologically distressed women, with woman in the first cluster reporting an average score on MSPSS that is significantly higher than psychologically distressed women (m.d. = 7.15; s.e. = 2.50; p <.05), whereas no differences emerged between psychologically healthy women and currently anxious women, and between currently anxious women and psychologically distressed women. DISCUSSION The present study aimed to investigate the psychological characteristics of Italian primiparous pregnant women based on their levels of anxiety, depression, and fear of childbirth. Results revealed the presence of three different psychological profiles, confirming the findings of our previous exploratory study with a smaller sample (MASKED FOR REVIEW). In particular, the highest percentage of women belong to the “currently anxious women” profile, which is characterized by an average state anxiety score over the clinical cut-off and an average fear of childbirth score below the threshold but higher than the “psychologically healthy women” profile. Thus, about half of the sample seems to experience strong anxiety that seems to be primarily focused on pregnancy and the birth experience. This finding confirms previous studies that highlighted that in the months preceding delivery, expectant mother quite frequently manifest an anxious symptomatology and a feeling of fear connected to an event so laden with uncertainty, whose outcome cannot be predicted. This feeling of uncertainty seems to be particularly present and incisive in women experiencing their first pregnancy, such as those in our sample (Fenwick et al., 2009). Furthermore, the result proves that anxiety is more prevalent than depression among mothers during the prenatal period (Bayrampour et al., 2018; Nasreen et

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS al., 2018; van de Loo et al., 2018). Indeed, psychologically distressed women, who showed high values on all scales – including some above the clinical cut-off – are about a third of currently anxious women. These women are characterized by a general psychological vulnerability that can be presumed to interfere with daily life during pregnancy, as well as the labor and childbirth experience and outcome (Fenwick et al., 2009; Laursen et al., 2008; Staneva et al., 2015). Finally, the first profile, which includes about one third of the sample, is comprised of women who are characterized by general well-being. Although these women represent the most physiological condition, it might be surprising that only one woman in three approaches childbirth without any significant psychological symptoms of distress. Since the relationship between these psychological profiles and the medical-obstetric variables was not significant, we can affirm that a woman’s psychological health does not depend on the progress of pregnancy, that is, the presence of some symptoms of a psychological disease is not affected by the level of obstetric complications for the mother and baby. This finding disconfirms previous studies that found an association between previous miscarriage and serious pregnancy-related complications, and a woman’s poorer mental health (Costa et al., 2017; Kozhimannil et al., 2009). However, we could argue that the presence of only primiparous women in our sample might explain their state of pronounced worry for a completely unknown event, true for half of the sample, beyond any specific problems from the medical standpoint (which were, in any case, present in a low percentage) (Zar et al., 2001). Furthermore, it should be pointed out that the definition of complications varies across studies, making a comparison quite difficult. Finally, considering the association between the psychological profiles and relational well-being, our findings revealed a significant relationship, with psychologically healthy women

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS reporting the highest levels of marital adjustment and psychologically distressed women reporting the lowest levels. This result highlights the connection between individual and relational well-being during pregnancy (Figueiredo et al., 2018; Lukasse et al., 2014; Poggi et al., 2018), and suggests the specificity of each cluster both at an individual level (i.e., psychological well-being) as well as a relational one. At the same time, social support discriminates psychologically healthy and psychological distressed women: a low level of social support (from one’s partner, family, friends, etc.) is associated with a more or less far-reaching compromise of the woman’s psychological well-being, which can translate into both the manifestation of anxious symptoms connected to the birth event as well as the expression of a more generalized picture of distress. If, therefore, the women who are doing well seem to have a good relational base, whether within the couple or on a social level, the distressed women who are doing less well are characterized by poor relationships on the couple and social levels; the latter finding seems to also act to discriminate between a more generalized and stable compromise of the woman’s psychological well-being and a more circumscribed and contingent one. This finding could lead us to suppose that it is above all the couple relationship that determines the development of symptoms that are contingent on the birth event (less structural). This finding supports the need for the study of the couple relationship during pregnancy, which has been poorly examined to date (Molgora et al., 2018). This study has several limitations. First, it is a cross-sectional study that focused only on pregnancy. It may be important for future research to use a longitudinal design that makes it possible to expand the study to the postpartum period, analyzing the association between (the predictive role of) the psychological profiles and the experience of childbirth and post-partum well-being. Furthermore, it could be interesting to bring forward the assessment during

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS pregnancy to the first trimester. Indeed, almost all studies focus on the final weeks of pregnancy, while data about prevalence rates of depression and anxiety and changes over time during pregnancy vary widely (van de Loo et al., 2018); thus, an early assessment (as early as during the first weeks of pregnancy) could make it possible to identify in a more precise way not just the presence of a symptomatology, but also its evolution (i.e., the trajectories of change) over time (Mughal et al., 2018). Furthermore, this is an observational study that analyzed the association between variables; it would be useful to better understand the direction of the relationship between psychological dimensions and relational variables. Finally, we used a self-report instrument that presents several advantages; however, future studies could include other kinds of instruments (i.e., a clinical interview) that can better capture the complexity of the experience and the different nuances of meaning. IMPLICATIONS FOR PRACTICE Despite the above-mentioned limitations, the findings of this study support the importance of psychological screening of pregnant women in order to identity the specific profile of symptoms that could require different intervention focuses, taking into account not only the intensity of any symptom but also the overall picture of psychological well-being within which each symptomatic form manifests itself. In particular, these results suggest the implementation of multilevel screening that does not focus solely on a few specific dimensions: it emerges from our study, in fact, that significant situations of distress exist even in the absence of a high score (above the cut-off) on the screening scale for depression, perhaps the most classically investigated form of illness. Current health care policies in several countries, which only screen for prenatal depression, should also take into account the multiple forms by which the future mother’s distress can express itself and take form. This is to say that if health care practitioners

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS limit themselves to considering situations that explicitly raise the alarm (that is, full-blown distress), there is the risk that many situations of women who are struggling, but who cannot be pigeonholed within specific parameters, elude observation and the possibility of intervention. Moreover, carrying out screening on several occasions (and not just close to the birth) would help us understand not only the configuration of the woman’s distress, but also its evolution over time (Mughal et al., 2018). CONCLUSIONS Although efforts to screen, prevent, and treat maternal distress are growing, perinatal (i.e., pregnancy and postpartum) psychological diseases often go undetected and untreated (Bales et al., 2005). This may be due, in part, to the limited attention that has been paid to antenatal problems (compared to postpartum disorders), a relative lack of validated screening measures, and a lack of awareness of the risk factors for these disorders (Furtado et al., 2018). Furthermore, individual, organizational, sociocultural, and structural barriers can be responsible for the lack of access to mental health services during the perinatal period, making it a significant public health concern (Sambrook Smith, Lawrence, Sadler, & Easter, 2019). Since several psychological symptoms, and in particular anxiety and depressive symptoms, during pregnancy have been reported to be associated with postpartum disorders that might have an impact not only on mothers themselves but also on mother-child interaction and on subsequent infant development (Riva Crugnola et al., 2016; Rollè et al., 2017), focusing on the prepartum period is of prime importance (Salehi-Pourmehr, Niroomand, Shakouri, Asgarlou, & Farshbaf-Khalili, 2018). In particular, differentiating different forms of psychological disease by identifying the mother’s psychological profile could help us to better understand the experience of these women and to develop targeted and increasingly personalized interventions,

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS not taking for granted that pregnancy and delivery can be experienced as stressful and traumatic only if there are medical problems and that mothers express their distress in a uniform way. Author Statement The manuscript titled “Psychological Distress Profiles in Expectant Mothers: What Is the Association with Obstetric and Relational Variables?” has been seen and reviewed by all authors and all authors have contributed to it in a meaningful way. It has not been published and it is not under consideration for publication elsewhere. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. No acknowledgement mention needs to be reported. No founding source. REFERENCES Alipour, Z., Lamyian, M., & Hajizadeh, E. (2012). Anxiety and fear of childbirth as predictors of postnatal depression in nulliparous women. Women and Birth, 25, 37‐ 43. doi: 10.1016/j.wombi.2011.09.002. Bales, M., Pambrun, E., Melchior, M., Glangeaud-Freudenthal, N. M., Charles, M. A., Verdoux, H. et al. (2005). Prenatal psychological distress and access to mental health care in the ELFE cohort. European Psychiatry, 30, 322-328. doi: 10.1016/j.eurpsy.2014.11.004. Bayrampour, H., Vinturache, A., Hetherington, E., Lorenzetti, D. L., & Tough, S. (2018). Risk factors for antenatal anxiety: A systematic review of the literature. Journal of Reproductive and Infant Psychology, 36, 476-503. doi: 10.1080/02646838.2018.1492097. Benvenuti, P., Ferrara, M., Niccolai, C., Valoriali, V., & Cox, J. L. (1999). The Edinburgh Postnatal Depression Scale: Validation for an Italian sample. Journal of Affective Disorders, 53, 137-141. doi: 10.1016/S0165-0327(98)00102-5.

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS Biaggi, A., Conroy, S., Pawlby, S, & Pariante, C. M. (2016). Identifying the women at risk of antenatal anxiety and depression: A systematic review. Journal of Affective Disorders, 191, 62-77. doi: 10.1016/j.jad.2015.11.014. Carter, E. A., Bond, M. J., Wickham, R. E., & Barrera A. Z. (2019). Perinatal depression among a global sample of Spanish-speaking women: A sequential-process latent growth-curve analysis. Journal of Affective Disorders, 243, 145-152. doi: 10.1016/j.jad.2018.09.006. Costa, E. C. V., Castanheira, E., Moreira, L., Correia, P., Ribeiro, D., & Graça Pereira, M. (2017). Predictors of emotional distress in pregnant women: the mediating role of relationship intimacy. Journal of Mental Health, 1-9. doi: 10.1080/09638237.2017.1417545. Cox, G. L., Holden, G. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of 10-items Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786. doi: 10.1016/0165-0327(96)00008-0. Dennis, C. L., Falah-Hassani, K., & Shiri, R. (2017). Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. British Journal of Psychiatry, 210, 315323. doi: 10.1192/bjp.bp.116.187179. Dunkel Schetter, C., & Tanner, L. (2012). Anxiety, depression and stress in pregnancy: implications for mothers, children, research, and practice. Current Opinion in Psychiatry, 25, 141-148. doi: 10.1097/YCO.0b013e3283503680. Falah-Hassani, K., Shiri, R., & Dennis, C.-L. (2017). The prevalence of antenatal and postnatal co-morbid anxiety and depression: A meta-analysis. Psychological Medicine, 47, 20412053. doi: 10.1017/S0033291717000617.

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS A 3- to 6-Months Postpartum Follow-Up Study. Frontiers in Psychology, 7, 938. doi: 10.3389/fpsyg.2016.00938. Wijma, K., Wijma, B., & Zar, M. (1998). Psychometric aspects of the W-DEQ; a new questionnaire for the measurement of fear of childbirth. Journal of Psychosomatic Obstetrics & Gynecology, 19, 84-97. doi: 10.3109/01674829809048501. Yali, A. M., & Lobel, M. (1999). Coping and distress in pregnancy: An investigation of medically high risk women. Journal of Psychosomatic Obstetrics & Gynecology, 20, 3952. doi: 10.3109/01674829909075575. Zar, M., Wijma, K., & Wijma, B. (2001). Pre- and postpartum fear of childbirth in nulliparous and parous women. Scandinavian Journal of Behaviour Therapy, 30, 75-84. doi: 10.1080/02845710121310 Zimet, G. D., Dahlem, N. W., Zimet, S. G., & Farley, G. K. (1988). The Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment, 52, 30-41. doi: 10.1207/s15327752jpa5201_2

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS Table 1. Sample’s descriptive characteristics

(n=410) Education Middle school diploma

2.8%

High school diploma

45.3%

Undergraduate/graduate degree

48.0%

PhD/post-graduate specialization

3.9%

Occupation White collar job/teacher

58.9%

Self-employed

15.1%

(professional/business owner) Unemployed

8.2%

Blue collar

8.1% 5.5%

Executive/manager

3.4%

Homemaker

0.8%

Other

Marital status Married

60.6%

Cohabitant

39.4%

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS Pregnancy Spontaneous fertilization

91.4%

Previous miscarriage

24.3%

Spontaneous

17.0%

Voluntary interruption

5.5%

Therapeutic interruption

1.8%

Complications

29.3%

Placenta previa

2.5%

Detached placenta

2.7%

Hypertension

2.5%

Gestational diabetes

4.5%

Preeclampsia

5.4%

Gestosis

1.8%

Other

9.9%

Threatened miscarriage

10.5%

Clinical cut-off WDEQ(A)>35

26.8%

EPDS > 13

10.0%

STAI_STATE >40

50.0%

STAI_TRAIT >40

30.8%

29

PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS Table 2. Descriptive statistics of individual and relational variables Mean

SD

WDEQ(A)

28.72

9.47

STAI_State

40.02

9.67

STAI_Trait

36.69

8.62

EPDS

6.86

4.30

DAS

97.39

52.11

MSPSS

45.20

25.83

30

31

PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS Table 3. Bivariate correlations among the variables WDEQ(A)

STAI_State

STAI_Trait

EPDS

DAS

MSPSS

.366***

.423***

.305***

-.229***

-.004

.450***

.390***

-.136*

-.205***

.636***

-.340***

-.171**

-.332***

-.151**

WDEQ(A) STAI_State STAI_Trait EPDS DAS MSPSS *p<.05; ** p<.01; ***p<.001

.185**

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PSYCHOLOGICAL DISTRESS PROFILES IN EXPECTANT MOTHERS Table 4. Cluster analysis: ANOVA

Cluster Mean

Error df

Square

Mean

F

Sig.

df

Square

WDEQ(A)

8810.91

2

47.87

407

184.07

.00

STAI_State

9504.20

2

47.71

407

199.21

.00

STAI_Trait

8608.57

2

33.30

407

258.53

.00

EPDS

1345.83

2

12.46

407

108.05

.00

Figure 1. Cluster of pregnant women 60.00 50.00

40.00 30.00 20.00 10.00 0.00 Psychologically healthy women WDEQ(A) STAI_State STAI_Trait EPDS

20.20 31.77 30.58 4.14

Women experiencing pregnancy- and childbirth-related anxiety 31.17 41.63 36.05 6.67

Psychologically distressed women 37.86 50.99 49.41 11.60