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Royal Society of Medicine Forum: Caring for the emotions in pregnancy, birth and beyond.
This is a report of a joint meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine with the Royal College of Midwives and the Association of Community Based Maternity Care, held on Thursday 24th April 2003.

This report is to be published in the Midwives Journal of the Royal College of Midwives. It is reproduced here with their consent and our thanks.

First session. Chaired by Dr. Luke Zander, Retired GP and founder of the Forum.

Antenatal anxiety and its effects on the baby.
From Professor Tom O’Connor (TO), Departments of Child and Adolescent Psychiatry and Social, Genetic and Developmental Psychiatry, Institute of Psychiatry, London.

Previous animal investigations link antenatal stress with a range of persistent behavioural abnormalities in the offspring. In non-human primates antenatal stress is linked with neuromotor deficits, hypotonia, inattention, atypical social behaviour and enhanced stress reactivity, persisting into adult life (Schneider et al. 2000). Pregnancies in malnourished Netherlands mothers in World War 2 have been linked to increased major depression in the adult lives of their offspring (Brown et al.2000).
Most physiological explanations tell us that the stress response system resides in the hypothalamic-pituitary-adrenal (HPA) axis, but additional explanations are likely. The maternal stress hormone cortisol is known to correlate with fetal cortisol levels (Gitau et al. 1998); this mediates increased uterine artery tone, impairing blood flow through the placenta, with effects which only occur in the fetus from 22-24 weeks gestation (Teixeira et al. 1999). This timing of stress in pregnancy may be crucial - mixed handedness, believed to be due to impaired neurological development, is apparent at about 3½ yrs in the children of mothers whose anxiety occurred at about 18 weeks gestation. Antenatal stress is also associated with poor obstetric outcomes, e.g. premature birth, low birth weight (Copper et al. 1996).

The purpose of the current study is to examine whether the stress effect is also found in humans through middle childhood and beyond. Evidence will be reviewed, with findings derived from a large UK community sample. The implications of women’s antenatal anxiety effect will be considered.

The current study is based on the Avon Longitudinal Study of Parents and Children (ALSPAC), a prospective, community-based study that has followed a cohort of more than 10,000 women representative of the UK population from early pregnancy. An estimated 85 to 90% of those eligible took part. The average age was 28 years; 45% were primiparae, while 6% already had two children. Self-report measures of maternal anxiety and depression were assessed at 18 and 32 weeks in pregnancy and at 8 weeks and 21, 33, 47, and 81 months postnatally by questionnaire, using Crown-Crisp for anxiety and the Edinburgh Postnatal Depression Scale (EPDS) for depression. This is ongoing.

Children's behavioural and emotional problems have been assessed by parent report using the Strengths and Difficulties Questionnaire (SDQ; Goodman 1997) at ages 47 and 81 months so far; the children are now about 11 years old. The information generated is controlled for obstetric factors (birth weight for gestational age, parity, mode of delivery, smoking and alcohol use, and pregnancy problems) and for postnatal anxiety and depression; measures of socio-economic adversity such as crowded accommodation and education are also taken into account.

Analysis of this research using odds ratios shows that children whose mothers experienced high levels of anxiety in late pregnancy exhibited higher rates of behavioural and emotional problems at 81 months of age, evidence that such anxiety has a programming effect on the fetus which lasts at least until middle childhood (Barker 1995). Furthermore, the effect at 81 months is comparable to that obtained at 47 months, and was roughly equal in boys and girls; this suggests the kind of persistent effect proposed in the animal literature, and it is independent of maternal postnatal anxiety. There is in fact a need for greater synthesis of animal and human investigation of stress and development.

Anxiety in pregnancy strongly predicts postnatal depression. Since postnatal depression is frequently preceded by depression in pregnancy, and antenatal anxiety is now shown to be associated with behavioural and emotional problems in children, then the effects which have been attributed to postnatal depression may be explained by antenatal anxiety. The additive – antenatal and postnatal - effects on children at age 4 years are demonstrated to a degree which is clinically meaningful. The prediction from the antenatal period when postnatal assessments are covaried is inconsistent with simple rater bias and genetic transmission explanations.

The need for further research is apparent, the following questions requiring answers:
         ·        Are the psychological and physiological effects of antenatal anxiety maintained at later assessments?
·        Is the HPA axis a mediating mechanism?
·        What postnatal factors modify the effects of antenatal anxiety?
·        Are interventions to reduce antenatal anxiety effective in preventing adverse outcomes?
·        What is the interplay between the HPA axis-mediated effect of antenatal anxiety and genetic vulnerability?

This information requires us to pay as much attention to anxiety in pregnancy as to depression after it: antenatal stress is a public health concern.

References
Schneider ML, Moore CF. (2000) Effect of antenatal stress on development: A non-human primate model. In: C. Nelson (Ed.) Minnesota Symposium on Child Psychology. New Jersey: Erlbaum pp. 201-243

Gitau R, Cameron A, Fisk NM, Glover V. (1998) Fetal exposure to maternal cortisol. Lancet 352: 707-708.

Teixeira J, Fisk N, Glover V. (1999) Association between maternal anxiety in pregnancy and increased uterine artery resistance index: cohort based study. BMJ 318: 153-157.

Brown AS, van Os J, Driessens C, Hoek HW, Susser ES. (2000) Further evidence of relation between prenatal famine and major affective disorder. Am J Psychiatry 157: 190-195.

Copper RL, Goldenberg RL, Das A, Elder N, Swain M, Norman G, et al. (1996) The preterm prediction study: Maternal stress is associated with spontaneous preterm birth at less than thirty-five weeks' gestation. Am J Obstet Gynecol 175:1286-1292.

Barker DJ. (1995). The fetal origins of adult disease. Proc R Soc Lond B Biol Sci 262:37-43.

Goodman R. (1997) The strengths and difficulties questionnaire: A research note. J Child Psychol Psychiatry 38:581-586.

Maternal depression and its impact on the child – findings from an 11 year follow up study.
From Susan Pawlby, Department of perinatal psychiatry, Institute of Psychiatry, London, with Professor Deborah Sharp, University of Bristol, and Professor Dale Hay, Cardiff University, and the late Professor Channi Kumar of the Institute of Psychiatry and others.

The affective disturbances following childbirth are of three sorts: 'baby blues', a common disturbance occurring within the first few days following delivery, usually short-lived and characterized primarily by lability of mood; puerperal psychosis, a major disorder which is relatively rare, following one in 500 births, and requiring psychiatric management; and postnatal depression, an affective disorder of moderate severity that occurs after one in ten births. It is this last category with which I shall be concerned. In an 'average' UK health district with a population of 350,000 and an annual rate of live births of 5,000, there will be about 500 cases each year of women with depressive disorders in the first few months after delivery. There is little that is remarkable about the epidemiology, clinical features or course of postnatal depression compared with depressions arising at other times (Cooper and Murray, 1998). Many of these depressions remain undetected and most of the rest are managed by general practitioners and health visitors. By definition postnatal depression impairs the mother in her daily life and often this means that her relationship with her baby will be affected. The importance of detecting and responding to these cases is underlined by the growing knowledge of adverse effects on the psychological development of the children (Murray and Cooper, 1997).

In a prospective, longitudinal community study carried out in south east London (the South London Child Development Study - Sharp, Hay, Pawlby et al., 1995; Hay, Pawlby, Sharp et al., 2001) 149 mothers - 87% of the original randomly selected sample - were interviewed clinically at 3 months postpartum. 89% of the mothers described themselves as working class; 72% are of white British origin. The study followed families when the children were 4 and 11 years old, and now at age 16. The findings at 11 years follow. Almost half of the 11 year-olds were not living with both biological parents; half were boys.

1 in 9 women without previous psychiatric histories developed postnatal depression; the figure was 1 in 4 where there was such a history, 1 in 3 for depression during the pregnancy, and 1 in 2 for both previous and pregnancy histories. Mixed anxiety and depression were common, although depression was the primary diagnosis. 42% reported no episodes of depression during the 11 years; 6% had been depressed only at the time of the 3-month interview; 35% had been depressed subsequently, and 16% were depressed at 3 months and later.

The symptoms of such depression are well known, and the behaviour of these mothers toward their babies is abnormal in one way or another: they may be expressionless, with limited physical contact, minimal coherent speech, not focussed on the baby, and the reactions of babies to these withdrawn mothers include distress, impairment of attentiveness and of sensitivity to maternal cues. Or the mothers may be intrusive, over-stimulating, using exaggerated fake facial expressions and loud non-contingent speech. Their babies become passive, disengaged and less focussed in play. [A video clip demonstrated the inability of a depressed 29 year-old mother to develop a relationship with her baby of 5 weeks. Both mother and baby show flat affect; engagement fails on both sides.]

When mothers had been depressed 3 months postpartum the children’s IQs at age 11 were lower, chiefly in sensorimotor functioning, than those of children whose mothers had not been depressed. The effect was more apparent in the boys, and the observations were controlled for multiple mental health, intelligence, and social factors affecting the family. Examining teachers noted hyperactivity and attention deficit in these children. Difficulties in reading comprehension and mathematical reasoning were found, and the children were much more likely to have been on the educational special needs register; they were more often the subjects of statements of educational need, by a factor of twelve. Peer relationships were unaffected.

These affected children were four times as likely to have a definable psychiatric disorder with impairment of daily life, not necessarily requiring treatment, at age 11. Separation anxiety would, for example, be of a degree preventing a child from going out to play with friends. Boys were five times, girls seventeen times as likely as the unaffected to have more than one psychological diagnosis. The girls were much more likely to have disruptive behaviour disorders. If these children did not have the opportunity in the early months to learn to regulate their attention during rewarding interactions with their mothers (Hay, 1997) they may continue to experience difficulty attending in the classroom. It is well known that academic and behavioural problems in middle childhood predict later psychopathology, conduct problems and delinquency, especially for boys.

Girls of mothers who suffered postnatal depression do not show the same cognitive deficits as the boys, but they are more likely than the daughters of mothers who had not suffered postnatal depression to have behavioural or emotional symptoms meeting diagnostic criteria for a childhood psychiatric disorder. Difficulties for the girls are becoming more evident in middle childhood, and a further aim of the study is to determine whether there are late appearing effects in girls, who may show elevated rates of anxiety and depressive symptoms and low self-esteem.

Which are the vulnerable mothers and how can we support them in their pregnancies and at the time when they need to develop relationships with their babies? They may have had a past psychiatric history, poor parenting, an unplanned pregnancy or one which they considered terminating, or a deteriorating marital relationship. They may have had the baby blues or been physically unwell since the birth; they may have missed holding their babies early, and they may have had insufficient help since the birth.

Breast feeding of any duration is associated with better outcomes for the children. The support of the fathers plays a significant part: the children who did worst had fathers who themselves had mental health problems, mainly alcoholism. We need to involve the fathers in the care of their partners.

There is widespread public concern about low academic performance and conduct and social problems in school children. Postnatal depression may be an important contributing factor and if adverse effects in children persist through school age, then not only is there a need for special remedial measures, but early secondary prevention through Government initiatives such as Sure Start is a practical possibility.

[A final video clip showed the same mother as in the first clip, happily recovered and relating normally to her cheerful baby.]

References
Cooper PJ. & Murray L. (1998) Postnatal depression. BMJ 316: 1884-6

 
Hay, D.F., Pawlby, S., Sharp, D., Asten, P., Mills, A. & Kumar, R. (2001)
Intellectual problems shown by 11-year-old children whose mothers had
postnatal depression. Journal of Child Psychology and Psychiatry 42: 871-890
 
Murray, L., & Cooper, PJ. (Eds.) (1997) Postpartum depression and child development. Guilford: New York
 
Sharp, D., Hay, D. F., Pawlby, S., Schmücker, G., Allen, H., & Kumar,
R. (1995). The impact of postnatal depression on boys' intellectual
development. Journal of Child Psychology and Psychiatry 3: 1315-1336


Discussion.

A clinical psychologist speculated whether, in the first of SP’s video clips, the baby’s flat affect was less one of a lack of contingency than mood contagion, the baby being dependent on the mother’s signals. The same phenomenon was beautifully apparent in the second clip, where the baby takes on the mother’s mood state of contentment. Dyadic effects, to which TO referred, seem to be playing here. SP could report that such depressed babies can respond positively to non-depressed caregivers, though there is also a lack of contingency. Obstetrician Keith Greene wondered whether a depressed or otherwise unwell (e.g. premature) baby can influence its mother’s mood as the primary effect. SP agreed that there is to some extent a two-way interaction.

Mary Newburn of the NCT asked whether episodes of anxiety prior to a first pregnancy may lead to anxiety during pregnancy. TO: It remains unknown why antenatal anxiety has a stronger long term effect than depression, but it is true that anxiety and depression are frequently present together, that the physiological stress response to both is similar, and that antidepressant medication is quite effective for anxiety also. Many studies have confirmed that both may lead to impaired parenting. It is unclear why anxiety is more rarely the subject of screening; it is perfectly possible.

The problems surrounding significant prematurity are multiple; these babies are vulnerable in numerous ways and accordingly more liable to induce stress in their mothers.

Beverley Beech of AIMS referred to the professionally induced anxiety caused by interventions in pregnancy such as ultrasound screening, the misleading early diagnosis of placenta praevia, and the discouragement of mothers planning home birth by midwives predicting shortage of staff to attend them. Christine Gowdridge of the Maternity Alliance added to these the anxieties caused by the various books on their condition targeted at the pregnant. TO: These reality-based stresses exist against the background of the universal anxiety that all mothers experience about the outcomes of their pregnancies, and may be managed by instruction in coping strategies. (The chair pointed out the need for carers to avoid the errors in communication unfortunately but correctly implied by the question).

Are their policies which could be applied antenatally which involve the often stressful world of work and fathers-to-be? The lack of support in the immediate postnatal period also needs to be addressed; particularly first-time mothers find themselves imprisoned in strange and difficult circumstances.

TO: Any screening for anxiety needs to be targeted; accurate identification of the vulnerable could lead to effective support. But a delegate threw doubt on the validity of the findings presented, and predicted both anxiety caused by the prescription of anxiolytic medication in pregnancy and side effects from it. You will harm your baby if you are under stress is hardly a recipe for its relief.

SP: The sensitive period around three months postpartum implies an urgency in helping parents to develop healthy relationships with their babies, relationships which should if possible be observed in progress. TO: 12 sessions of cognitive-behavioural therapy are much to be recommended; this is a problem with solutions, if the resources can be made available and if causes of anxiety such as those described can be minimized.

These pages last updated 8th December 2006.

Site maintained by Basil Lee, Forum Member.

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