Treating Postpartum Depression

Over the past decade, the transition to parenthood has been the focus of several studies in social and clinical psychology (Belsky, 1985; Grace, 1993; Mercer, 1981). This transition represents a period of life change and stress for parents (Brown, 1986; Mercer et al., 1988b; Newman & Newman, 1988). The birth of a baby implies a certain disorganization that involves many individual and relationship adjustments. For example, the parents of a newborn are faced with the task of redefining their identities, their relationship with one another, and sometimes their relationship with their other children (Hackel & Ruble, 1992; Kreppner, 1988; Partridge, 1988). Contemporary researchers therefore agree that the outcome of this major transitional period is complex and multi-determined (Brown, 1986; Parke & Beitel, 1988).

The transition may be complicated by problems associated with a high-risk pregnancy. Such a pregnancy is diagnosed when there is a significant possibility of foetal anomaly, foetal death, or a serious health risk for the unborn child or for the expectant mother (Kemp & Hatmaker, 1989; Mercer, 1990; Paquet, 1991). A high-risk pregnancy encompasses a broad spectrum of conditions both for the mother and the foetus, such as diabetes mellitus, hypertension, multiple gestations, risk of premature labour, heightened probabilities of chromosomal aberrations or of congenital malformation, and possible foetal growth retardation (William, 1986; Easterbrooks, 1988). Moreover, high-risk pregnancies have been reported to account for approximately half of all foetal and neonatal deaths (Kopp, 1983; Pernoll et al., 1986). During the past decades, there have been many innovations in prenatal management technologies (Easterbrooks, 1988; Gregg, 1993). These improvements have increased the possibility of giving birth to healthy babies. Nevertheless, research suggests that even when the high-risk pregnancy ends with the birth of a fun-term healthy infant, these prenatal high-risk conditions may interfere with the developmental processes of parenthood (Priel & Kantor, 1988). Few studies have investigated this issue, and the results have been mixed. For instance, some researchers report that high-risk pregnancies do affect the course and the outcome of the adaptation process in parenthood (Mercer & Ferketich, 1990a, b) while others have found no difference in the adaptation process of high- and low-risk parents (Mercer et al., 1988b). Accordingly, further research is needed to provide a clearer picture of the implications for couples living through a high-risk pregnancy.  Since gender differences have often been noted during the parental adaptation process (Belsky et al., 1984; Mercer, 1990), the issue of gender similarities and differences during high-risk pregnancies will also be discussed.

Life changes
High-risk couples (those in which the women experience obstetrical complications) will most likely make important adjustments in their lives much earlier than low-risk couples (those who do not encounter difficulties during pregnancy). High-risk women may have to make such lifestyle alterations as allowing more time for medical checkups, making diet modifications, and restricting physical activity. High-risk men may have to increase their roles in taking care of the other children and doing domestic chores at an earlier stage in the transitional process compared to low-risk men. Accordingly, high- and low-risk parents may have different perceptions regarding the magnitude of life changes engendered by the births of their babies. High-risk parents, who have already made restrictive adjustments in their lives, may perceive less change associated with the birth of their child. Conversely, it is possible that the strain of the high-risk condition renders the couple more sensitive to the additional changes engendered by bearing an infant. As a consequence, they might evaluate the extent of their life changes as more important than low-risk parents would.

Gender may also affect the perception of life changes since parental responsibilities continue to be globally assigned according to gender (Woonett, 1991). For example, most people still consider the mother as the principal caretaker of young children. Therefore, during this transition into parenthood, women may experience more and different life changes than do men.

Parental role attainment process
From a developmental perspective, the high-risk condition may also affect the parental role attainment process (Mercer, 1990; Penticuff, 1982). This process pertains to the development of the parents' self-concept in relation to a particular child and involves a set of tasks to be completed (Mercer, 1990; Rubin, 1984). The parental identity, related to the attachment of the adult to the baby, and the parents' sense of competence will allow the analysis of the parental role attainment process (Walker et al., 1986).

Parental identity and attachment
Some studies have reported that the experience of a high obstetrical risk does not seem to affect the parental attachment process (Kemp & Page, 1987; Mercer et al., 1988b). Others have demonstrated that a high-risk pregnancy woman appears to be more attached to her foetus and subsequently to her infant than is her partner (Mercer & Ferketich, 1990a). Such a difference has not been observed among low-risk condition parents (Condon, 1985; Mercer, 1990). Additionally, research on the impact that risk factors have on the parent-child relationship has detected an interactive effect between the risk status and the sex of the parent (Palm & Palkovitz, 1988; Parke & Beitel, 1988). Women are often more aware of the presence of their unborn children and they will accordingly make changes to their lifestyles to ensure the children's well-being. A parent's desire to protect and ensure the welfare of his or her child has been found to contribute to the development of the parent's attachment to the infant (Condon, 1985). As a consequence, it is presumed that the parental attachment process of women begins earlier regardless of the risk condition. In a high-risk context, however, the gender difference could be accentuated because women may have to make even more adjustments in order to protect their unborn children. Thus, it may be hypothesized that, on the attachment variable, an interaction exists between the risk factor and the gender of the parent. According to the degree of stress associated with the attachment process, men may obtain higher attachment state scores than women during the transition period. Such a difference should be more prominent in the case of high-risk parents.

Parenting role attainment: developing a sense of competence
Several studies have suggested that the physical experience of an obstetrical risk may affect a woman's feeling of personal control (Mercer, 1990, Parke & Beitel, 1988). For example, the increased medical interventions may contribute to a sense of loss of autonomy as well as a diminished sense of parental competence (DeVries, 1988). In this situation, the woman may question her competence in her role of protecting her foetus and doubt her capability as a mother (Kemp & Page, 1987; Mercer, 1990). In general, high-risk women also perceive their children as being more difficult than do low-risk women (Priel & Kantor, 1988). Since there is an inverse relationship between the perception of difficulty in the child's temperament and the parenting sense of competence (Mash & Johnston, 1983), it seems likely that high-risk women would demonstrate a lower sense of competence than low-risk mothers. However, the few investigators who have examined this relationship have obtained mixed results. Some studies have found that risk condition has no impact on the mothers' sense of competence (Mercer & Ferketich, 1990b). Others have reported that high-risk women effectively have a lower sense of self-value (Kemp & Page, 1987). It appears therefore relevant to verify whether high-risk mothers do indeed demonstrate an inferior parenting sense of competence than low-risk mothers.

Predicting how a high-risk pregnancy may influence the development of a man's sense of competence as a parent is more difficult. Men's principal source of support during this period appears to be their spouses (Brown, 1986). Men also tend to rely on their partners to develop their parental competence (Gage & Christensen, 1991; Palm & Palkovitz, 1988). Under high-risk circumstances, however, women are less likely to be available since they are preoccupied with the health risks for themselves and their unborn children (Mercer et al., 1988a). It has been suggested that women may remain in this state of preoccupation for a brief period after their infants are born (Mercer, 1990). As a consequence, it is possible that fathers in the high-risk condition develop a lower sense of parental competence. Nevertheless, it is possible that high-risk fathers feel more competent than their low-risk counterparts because the former had to be more self-reliant during the development of their parenting skills.

Differences may also exist between genders regarding parental sense of competence. Johnston and Mash (1989) have reported that women often demonstrate more confidence in their parenting abilities than do men. For most women, being a parent remains a very important goal in life. A woman's biological role in the care of her unborn infant, coupled with the social perception of mothers being the principal caretakers of young children (Jordan, 1990; Woollett, 1991), makes it likely that a woman will experience a greater sense of competence and more satisfaction in her role as a parent than will a man.
- Dulude, D., Wright, J., Belanger, C.; The effects of pregnancy complications on the parental adaptation process.; Journal of Reproductive & Infant Psychology; Feb 2000; Vol. 18, Issue 1

Personal Reflection Exercise #11
The preceding section contained information regarding the effects of high-risk births on the parents’ emotions.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Study protocol: peer delivered early intervention (Learning through Everyday Activities with Parents for Infants at risk of Cerebral Palsy: LEAP-CP) for First Nation Australian infants at high risk of cerebral palsy - an RCT study

Benfer, K., Boyd, R. N., Roe, Y., Fagan, R., Luke, C., Mick-Ramsamy, L., Whittingham, K., Novak, I., Bosanquet, M., McNamara, L., Khandaker, G., Fogarty, L., Cadet-James, Y., Ruben, A., Comans, T., Smith, A., & Ware, R. S. (2023). Study protocol: peer delivered early intervention (Learning through Everyday Activities with Parents for Infants at risk of Cerebral Palsy: LEAP-CP) for First Nation Australian infants at high risk of cerebral palsy - an RCT study. BMJ open, 13(3), e059531. https://doi.org/10.1136/bmjopen-2021-059531

Peer-Reviewed Journal Article References:
Mitchell, A. M., Porter, K., & Christian, L. M. (2018). Examination of the role of obesity in the association between childhood trauma and inflammation during pregnancy. Health Psychology, 37(2), 114–124. 

Nakić Radoš, S., Matijaš, M., Kuhar, L., Anđelinović, M., & Ayers, S. (2020). Measuring and conceptualizing PTSD following childbirth: Validation of the City Birth Trauma Scale. Psychological Trauma: Theory, Research, Practice, and Policy, 12(2), 147–155.

Psouni, E., & Eichbichler, A. (2020). Feelings of restriction and incompetence in parenting mediate the link between attachment anxiety and paternal postnatal depression. Psychology of Men & Masculinities, 21(3), 416–429.

Online Continuing Education QUESTION 25
What factor does Dulude suggest that  affects a woman's feeling of personal control? Record the letter of the correct answer the CEU Test.