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Introducing the Chapters and Focus
Virginia Schmied and Gill Thomson
Globally there is increasing concern about women's health in the perinatal period (from pregnancy through to 12 months after birth). This concern is well-illustrated by the recent (2016) Lancet series on maternal health. Eminent authors argue that the burden of poor maternal health â mortality and severe morbidity â is concentrated among vulnerable populations. Across the globe many women miss out on quality maternity care particularly women who are marginalised including migrant, refugee and internally displaced women, Indigenous women, women living in poverty and women living in fragile states (McDougall, Campbell & Graham, 2016, p. 5). Less is said however, in this landmark series about the psychosocial health and well-being of women, their infants and families.
Psychosocial risk and resilience in the perinatal period is the focus of this edited book. The impetus for this has come from an increasing concern for the social and emotional health of women, their children and families in the perinatal period and how health professionals and maternity and child health services best respond to these needs.
This book aims to:
- Provide in-depth insights into the risk factors, psychosocial concerns and support for women and families who are marginalised and/or experiencing complex life situations and experiences across the perinatal period.
- Highlight individual, family, community and service system resilience (or protective) factors that can help to mitigate against adverse outcomes (for service users, families as well as professionals).
- Identify âpromisingâ, evidence-based interventions to respond to diversity and to address psychosocial issues and complex needs.
- Consider implications for care practices and health service delivery within Western models of maternity care.
In the following sections we discuss why maternal psychosocial health matters. We then provide definitions into the key concepts of this book â âriskâ and âresilienceâ â which have been considered in different population groups in the proceeding chapters. Finally, an outline of what is addressed in each of the chapters is provided.
Why maternal psychosocial health matters
Reports of maternal deaths in the United Kingdom (UK) indicate that suicide is one of the leading causes of mortality in the year after birth (Knight, Tuffnell, Kenyon, Shakespeare, Gray & Kurinczuk, 2015). In the UK, one in eleven women who died during or up to six weeks after pregnancy, died from mental health-related causes. However, almost a quarter of all maternal deaths between six weeks and a year after birth are related to mental health problems, and one in seven of the women who died in this period died by suicide (Knight et al., 2015). The higher prevalence of late maternal deaths (between 43 days and one year after birth) is supported by Australian research where suicide and accidental injury are the two leading causes of death for women within one year of birth (Thornton, Schmied, Dennis, Barnett & Dahlen, 2013), International data suggest that the prevalence of maternal mental health problems have at best remained static over the past 20 years (Schmied et al., 2013; Ibanez, Blondel, Prunet, Kaminski & Saurel-Cubizolles, 2015) or are increasing, particularly women diagnosed with anxiety disorders (Fairbrother, Young, Janssen, Antony & Tucker, 2015).
Recognising and addressing woman's social and emotional needs in the perinatal period is critical. Treatments and service design and delivery have typically been informed by either a biomedical or psychological approach focused on the individual (Davydov, Stewart, Ritchie & Chaudieu, 2010). More recently, models such as Developmental Origins of Behaviour, Health and Disease (Marmot, 2010) and socio-ecological model of development (Bronfenbrenner, 1979) that emphasise the significant and long-term consequences of maternal (and increasingly paternal) psychosocial health for the developing child, are informing interventions and service delivery for women, families and communities.
The Developmental Origins of Behaviour, Health, and Disease concept describes pregnancy and the early postnatal period as periods of opportunity and risk (Marmot, 2010). This is a time of âdevelopmental plasticityâ when a number of physical, social, environmental, behavioural and psychological factors may influence the biology of the developing child (Moore, McDonald & McHugh-Dillon, 2015; Van den Bergh, Mulder, Mennes & Glover, 2005), and as a consequence affect a child's competence across a range of areas, from health and social behaviour to employment and educational attainment (Coles, Cheyne & Daniel, 2015; Tickell, 2011). A child's neurological development across the early stages of their life provides the foundations for future cognitive capacities. For example, the biological effects of birth weight on brain development interact with other social determinants to influence a child's cognitive development (Marmot, 2010).
Evidence has demonstrated that insults during sensitive developmental periods, such as pregnancy or in the early childhood period (up to three years of age), may trigger the reprogramming of genetic tissue which in turn, not only predisposes the individual to behavioural problems, learning difficulties, delayed cognitive development in childhood, but may also lead to early cognitive decline, psychopathology, cancer, cardio-metabolic, neuroendocrine and other diseases in adult life (Murgatroyd & Spengler, 2011). Disease processes such as diabetes, heart disease and cancer, previously thought to develop due to adult lifestyle behaviours, have now been linked to prenatal and early childhood experiences (Fairbrother et al., 2015; Power, Kuh & Morton, 2013). Most recently Dahlen and colleagues (2013) have put forward the Epigenetic Impact of Childbirth (EPIIC) hypothesis. They argue that evidence is emerging that certain intrapartum and early neonatal interventions â specifically the use of synthetic oxytocin, antibiotics and caesarean section â affect the epigenetic remodelling processes and subsequent health of the mother and offspring (Dahlen et al., 2013).
The social ecological model: Bronfenbrenner (1979) proposed an ecological model to explain influences on child development at all levels (see Figure 1.1). He placed the child at the centre and argued that the child's development was influenced not only by the more proximal, and relatively stronger influences, of the parents and family, peers, school and neighbourhood, but also by distal factors of the broader social context such as the media, parents' work arrangements and governmental policies. The social ecological model helps to understand the multifaceted and interactive effects of personal, family and environmental factors that determine behaviours, and for identifying behavioural and organisational touchpoints and mediators for promoting health and well-being. For example, a child whose mother is experiencing depression and has casual, low-paid work, and a father who is unemployed, living in a disadvantaged community is more likely to experience poor developmental outcomes.
Research based on the social ecological model demonstrates the impact of the parentâinfant relationship and parenting quality as one of, if not the most important, proximal factor influencing child development. The quality of early parentâinfant interactions directly affects the way the brain develops. Parental sensitivity and the quality of interactions with infants in the first three years of life predict the social and cognitive competence of children extending into adulthood (Raby, Roisman, Fraley & Simpson, 2015). Exposure to harsh and inconsistent discipline and limited cognitive stimulation and or exposure to stressors such as parental mental illness, substance abuse or family violence, poverty, unsafe communities, all interact to determine developmental outcomes for children in the short and long term (Fox, Southwell, Stafford, Goodhue, Jackson & Smith, 2015). Importantly, the presence of risk factors alone does not determine whether or not a child develops his or her potential in life, however the presence of risk factors make it more difficult.
Figure 1.1 The social ecological model
Risk and protective factors and the concept of resilience
A risk factor is defined as a âmeasurable contributor to later negative developmental outcomesâ (Loxley et al., 2004, p. 72). Typically, this applies to risk factors known to impact on child development either in childhood or as an adult.
There are a number of known, identifiable risk factors for poor maternal (and infant) outcomes, including mental health problems (prior and current), domestic and family violence, drug and alcohol misuse, past history of abuse and situational factors such as quality of significant relationships (Schmied et al., 2013), socio-economic circumstances, migrant or refugee status (O'Mahony, Donnelly, Raffin Bouchal & Este, 2013).
Children and adults alike are more vulnerable if exposed to more risk factors and less protective factors â when more protective factors are available this reduces exposure to, or the impact of risk factors.
Protective factors: Less is known about the protective factors for maternal mental health. Loxley et al. (2004, p. 73) conceptualises protective factors as âcharacteristics that buffer, mediate or moderate the influence of risk factors, thereby reducing the likelihood that risk factors will lead to later problem outcomesâ. Protective factors such as self-confidence, good social support, preparedness to utilise services may modify or mediate the relationship between risk factors and maternal and infant outcomes.
Resilience: At its most basic level resilience refers to âpositive adaptation, or the ability to maintain or regain mental health, despite experiencing adversityâ (Herrman, Stewart, Diaz-Granados, Berger, Jackson & Yuen, 2011, p. 259). Resilience was first conceptualised as a personal trait, strengths or assets such as intellectual functioning that helped people survive adversity (Herrman et al., 2011). Later, the concept expanded to include the contribution of systems (families, services, groups, and communities) in assisting people to cope with adversity. Broader definitions were introduced including âthe protective factors and processes or mechanisms that contribute to a good outcome, despite experiences with stressors shown to carry significant risk for developing psychopathologyâ (Herrman et al., 2011, p. 260). The complexity of resilience and its value as a theory or concept in informing interventions is addressed in Chapter 2 in this book. Here Jomeen and colleagues argue as do others, that the theoretical evidence base for this term is limited and contentious.
Overview of the book
In this book we aim to provide insights into the risk factors, psychosocial concerns, resilience and strength based factors and support for women and families who are marginalised and/or experiencing complex life situations and experiences across the perinatal period. Maternal mental health and well-being is central to all chapters in this book and in Chapter 2, Julie Jomeen and colleagues, set the scene by examining the prevalence and risk factors for perinatal mental health problems and discussing the foundations of effective interventions for women.
As illustrated by the social ecological model (Figure 1.1), there are a number of situational factors that may impact on maternal well-being. Many women and families experience marginalisation and stigma, or as Soo Downe describes in the foreword to this book they are âOtheredâ, because of who they are, and isolated as a consequence. In Chapter 3, Marie-Claire Balaam and colleagues examine the experiences of refugee and asylum seeking women. For these women, pre-migration trauma and loss and separation from family contribute to the risk of developing mental health problems. Donna Hartz and Leona McGrath then examine in Chapter 4 the impact that colonisation has had on maternal and infant health amongst Indigenous communities in Australia, New Zealand and Canada. Characteristics of positive policy and service responses and strategies aimed at promoting psychosocial resilience and optimising health outcomes for Indigenous childbearing women, their babies and families in these countries are explored.
In Chapter 5, Brenda Hayman talks about the challenges experienced by lesbian women when seeking maternity care and the limited understanding that maternity care professionals have of their specific needs. Denise Lawler in Chapter 6 offers an important theoretical lens on how mothers with a disability develop their sense of maternal identity and negotiate the stigma and discrimination they experience.
Some women experience significant complexities in their lives and these difficulties can impact on their capacity to parent effectively. Women who experience domestic and family violence (DFV) for example, are also likely to experience antenatal and postnatal anxiety, depression, and post-traumatic stress disorder (PTSD) and some will struggle to parent effectively (Howard, Oram, Galley, Trevillion & Feder, 2013). In Chapter 7, Angela Taft and Lessa Hooker review the prevalence and health impact of DFV in the perinatal period and describe women's experience and stages of women's pathways to safety. This chapter offers important information on how health professionals can respond effectively.
Drug and alcohol use in pregnancy are markers of complex pregnancies and women in this situation often experience multiple comorbidities with adverse fetal and infant outcomes. In Chapter 8, Lucy Burns and colleagues examine the nature, patterns, outcomes and treatments for the most commonly used substances in pregnancy in Australia and the United States. In Chapter 9, Cathrine Fowler and Chris Rossiter focus on the impact of incarceration on mothers and their children â yet this difficult and chaotic situation can be a catalyst for change for women. The authors describe the benefits of delivering relational parenting programmes based on attachment theory in prison with the aim to enhance the mother's knowledge of child development.
Maternal social and emotional health is also associated...
