Women Wellness: A Mental Health Perspective on Pregnancy

Pregnancy

Biological and Hormonal Changes Changes pregnant women go through can affect their mental wellbeing and overall life. Quality of life in pregnant women has shown to be affected by several aspects, such as physical and psychological health (level of independence, social relationships, environment, and spirituality [9]. Physical complications that are often not talked about enough include preeclampsia. Gestational hypertension, placenta abruption, preterm birth, gestational diabetes, low birth weight, stillbirth, and recurrent miscarriages. Evidence suggests that many of these health issues can continue to be health issues for women in the future. Follow up care after pregnancy is recommended by the National Institute of Health and Care Excellence to be provided with screenings, and guidance on long term risks and ways to maintain a healthy lifestyle post-partum [12]. In the past years technology has provided us with new information to understand the brain during pregnancy.

Magnetic Resonance Imaging (MRI’s) has shown substantial neuroanatomical changes during and after pregnancy. The extreme fluctuation, changes, and interactions between hormones, seems to make structural changes to the brain. These biological changes can lead to changes in maternal behavior such as interactions with infant, how competent they feel taking care of baby, and how mothers’ transitions into the demands if motherhood [13]. More specifically, brain changes during pregnancy and in postpartum period include both reducing and increasing gray matter in the medial prefrontal cortex, lateral prefrontal cortex, cingulate cortex and middle temporal cortex. Research suggests, these areas reduce gray matter during pregnancy but increase during post-partum period. Findings suggest that gray matter changes may influence maternal behavior such as mother infant relationships, attachment styles, higher quality of attachment and social support interactions. Drastic hormonal changes happen in oxytocin, prolactin, estradiol, progesterone, and corticosterone, which in turn create “hormonal-mediated neural plasticity” [13]. These hormones increase during the pregnancy period, reach its peak at birth, and decreases post-partum. Research suggests women reach their base hormonal level around one year mark after post-partum [13].

Mental Health Complications During Pregnancy

Mental health disorders such as post-partum depression (PPD), generalized anxiety disorder and post-traumatic stress disorder (PTSD) are the most common during post- partum period. Current research has found these disorders to often be active simultaneously. Eighty-three percent of women who have perinatal depression will have an anxiety disorder [14]. Post-partum depression is considered a major depression episode happening in the first 12 months postpartum. Being able to identify high risk factors related to sociodemographic factors, obstetrical factors, psychological factors, interpersonal factors, and significant life events during screening processes is crucial to be able to prevent mental health disorders during and after pregnancy. Postpartum depression symptoms appear up with greater prevalence during the first three months of post-partum and seem to decrease overtime [15]. Additionally, experiencing a traumatic childbirth can lead to persistent and long-term mental health complication. Because childbirth is considered a “culturally positive” event, rarely is the term “traumatic” used for a negative childbirth experience. Unpredictable births and pain are often seen as part of the childbirth experience. However, risk factors that can lead to childbirth- related PTSD, include risk factors before, during and after pregnancy such as complications during pregnancy, complication during delivery such as emergency C-section, post-partum hemorrhages and complication after delivery such as resuscitation of baby, and NICU admission [4]. Since, childbirth is also something the whole family experiences, perspective on the women childbirth experience can be unconsciously missed by close relatives. Which in turn leads to a lack of validation to the emotional consequences it can have on mothers. During birthing, women are also exposed to many sensory inputs that can later become triggers and lead to emotional effects if having a traumatic, unexpected, or emergency delivery [4].

Vulnerable Populations

High Risk Pregnancies and NICU According to Stanford Children’s Hospital, there are about half a million babies cared for in a neonatal intensive care unit each year in the U.S. Maternal factors such as being younger than 16 or older than 40 years of age, substance use, diabetes, high blood pressure, multiple pregnancy and sexual transmitted diseases can be reasons to receive neonatal care. However, delivery and baby complications can also lead to Neonatal Intensive Care Unit (NICU) stay [16]. In recent years, an immense number of medical advances have been made in neonatal field, reducing the mortality rate among infants in the NICU. Although many premature babies will survive and have a healthy life, a low percentage of babies who required NICU care often have high risk of mortality, long-term neurological and cognitive impairment, and major disabilities [17]. Mother and baby’s physical health play an important role on the mother’s overall wellness but mental health support and the ability to cope with the NICU stressors are crucial to the mother’s recovery process [18]. According to Vizcarrondo-Oppenheimer, et al. [19] and Hynan, et al. [10]. Mothers of premature infants report twenty to thirty percent higher rates of developing anxiety or depression than those who have a full-term baby. Shepley and Sachs [20]. Advise how a combination of parent’s psychological resources, support, stress levels, and infant’s health will determine parents’ ability to cope with stress while in the NICU. Findings have found that when given proper emotional support, services and information, external stressors such as the labor and delivery experience, type of NICU interventions, communication with NICU staff, breastfeeding experience, financial support, transportation, and home responsibilities can be managed in a healthy manner [18].

Future Recommendations and Preventive Care Screenings and Prevention

Psychological screening and psych education have been found to be one of the most effective strategies in preventing mental health complications [2, 4]. Because symptoms can appear days or weeks after childbirth it is important for healthcare professionals such as obstetricians, general practitioners, nurses, and pediatricians to properly assess women’s mental health. The American College of Obstetricians and Gynecologist recommend screenings to depression should be done at least twice during pregnancy and consistently during post-partum [4]. Although there are some mental health assessments that are reliable such as the Patient Health Questionnaire-9 and Edinburg Postnatal Depression Screen (EPDS-10) [14]. Proper evidenced based screening tools for this population have not yet been clearly recognized [2, 4].

Mental Health Services and Treatment

Depression or Post-partum depression (PPD) have been found to be the most common mental health disorder during pregnancy affecting 1 in every 7 women [14]. Disorders such as anxiety disorder, post-traumatic stress disorder during pregnancy that often get overlooked by health care professionals. Providing on-site psychological treatment and mental health care for these women should be easily accessible during this stage.

Cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR) [4]. mindfulness- based interventions (MBI’s) and acceptance and commitment therapy (ACT) are the most common of psychological therapies being used to address postpartum mental health issues [21, 15]. Using these psychological interventions early in pregnancy has been found to be more effective for maternal mental health than applying them during them post-partum. Findings suggest that infants whose mothers practice mindfulness techniques had better behavioral and emotional regulation skills [20, 22]. Research related to psychological trauma suggests trauma focused psychological treatments are more effective than medications. However, in postpartum depression a combination of medication and psychological services have been found to be the most effective. Especially when symptoms are moderate to severe or have a history of taking medication for depression [14]. Patients and healthcare professionals are sometimes cautious in initiating medication during or after pregnancy. However, it is recommended that the risk and benefits of medication treatment be considered as a team when the risks of no treatment outweigh the risks of no medication [14]. For a long time, trauma therapy during pregnancy was avoided because of the “vulnerability” of this population. However, current research in trauma during pregnancy demonstrated that women can process and eliminate emotional load. This is also an opportunity for women to find different meaning to life experiences during and after pregnancy [4].