Arch Womens Ment Health DOI 10.1007/s00737-015-0511-6
ORIGINAL ARTICLE
Maternal attitudes, depression, and anxiety in pregnant and postpartum multiparous women Laura E. Sockol & Cynthia L. Battle
Received: 26 June 2014 / Accepted: 8 February 2015 # Springer-Verlag Wien 2015
Abstract The Attitudes Toward Motherhood (AToM) Scale was developed to assess women’s beliefs about motherhood, a specific risk factor for emotional distress in perinatal populations. As the measure was initially developed and validated for use among first-time mothers, this study assessed the reliability and validity of the AToM Scale in a sample of multiparous women. Maternal attitudes were significantly associated with symptoms of depression, even after controlling for demographic, cognitive, and interpersonal risk factors. Maternal attitudes were also associated with symptoms of anxiety after controlling for demographic risk factors, but this association was not significant after accounting for cognitive and interpersonal risk factors. Compared to primiparous women from the initial validation study of the AToM Scale, multiparous women reported lower levels of social support and marital satisfaction. The relationships between cognitive and interpersonal risk factors and symptoms of depression and anxiety were comparable between multiparous and primiparous women.
Keywords Depression . Anxiety . Maternal attitudes . Postpartum . Pregnancy . Risk factors
L. E. Sockol Williams College, Williamstown, MA, USA L. E. Sockol (*) : C. L. Battle Alpert Medical School of Brown University, Providence, RI, USA e-mail: [email protected] C. L. Battle Butler Hospital, Providence, RI, USA C. L. Battle Women & Infants Hospital of Rhode Island, Providence, RI, USA
Depression and anxiety are common during pregnancy and the first year postpartum (Bennett et al. 2004; Ross and McLean 2006). Beyond causing distress and impairment among women who experience psychological symptoms, these disorders are associated with a range of negative fetal and child outcomes. Prenatal depression and anxiety are associated with increased risk of adverse birth outcomes (Grote et al. 2010; Kim et al. 2013), and symptoms during the first year postpartum are associated with increased risk for negative behavioral, cognitive, and emotional child outcomes (Goodman et al. 2011; Grace et al. 2003; Littleton et al. 2007; O’Conner et al. 2002). Research has identified a wide range of risk factors for these disorders, including demographic, social, and psychological factors (Beck 2001; O’Hara and Swain 1996; Robertson et al. 2004). Most of these risk factors are not specific to perinatal women and are associated with increased risk for emotional distress in the general population. However, there is a subset of women who appear uniquely vulnerable to depression and anxiety during the transition to parenthood. For example, women whose first depressive episode occurs during the postpartum period are at increased risk for subsequent postpartum depressive episodes, but at no greater risk for future depressive episodes that are unrelated to childbearing (Cooper and Murray 1995). In order to identify these women, a better understanding of risk factors that are specific to perinatal populations is necessary. Women’s beliefs about motherhood are a cognitive risk factor that many be uniquely associated with depression and anxiety during the perinatal period. According to the cognitive model, dysfunctional or maladaptive cognitions confer risk for poor emotional and behavioral outcomes in the context of relevant stressors (Beck and Haigh 2014). While most research on cognitive risk factors for depression and anxiety has focused on general biases in cognition, there is also evidence that content-specific maladaptive beliefs can confer risk
L.E. Sockol, C.L. Battle
in the context of relevant stressors. For example, when students receive lower-than-expected grades, beliefs related to academic competence are more predictive of depressive symptoms than general cognitive biases (Hilsman and Garber 1995). When the nature of a potential future stressor is known, as is true during the transition to parenthood, content-specific risk factors may be more indicative of the risk for distress than more general patterns of cognitive biases. This suggests that dysfunctional or maladaptive beliefs about motherhood may be associated with increased risk for depression and anxiety specifically during the transition to parenthood. The Attitudes Toward Motherhood (AToM) Scale was developed to assess women’s beliefs about motherhood in order to facilitate study of the relationship between this potential risk factor and symptoms of depression and anxiety among perinatal women (Sockol et al. 2014). This measure addressed conceptual and psychometric limitations of previous measures that had been developed to assess maternal attitudes. The initial validation study of the AToM Scale found that maternal attitudes are associated with symptoms of depression and anxiety during pregnancy and the early postpartum period, even after controlling for other demographic, cognitive and interpersonal risk factors (Sockol et al. 2014). A major limitation of the initial validation study of the AToM Scale was that the study only assessed maternal attitudes among primiparous women. While there is a wide range of research characterizing the initial transition to motherhood, relatively less is known about women’s experiences when their families grow (O’Reilly 2004). There is some evidence that rates of postpartum depression may be higher among multiparous women, especially during the first 6 months postpartum (Mayberry et al. 2007; Righetti-Veltema et al. 2002). There is also evidence that multiparous women have higher levels of overall anxiety compared to primiparous women, although primiparous women report higher levels of fear related to childbirth (Lederman and Weis 2009). The prevalence of risk factors for depression and anxiety may also differ between primiparous and multiparous women. For example, research suggests that marital satisfaction declines after the birth of a couple’s first child (Belsky and Pensky 1988; Cowan and Cowan 1992). As marital dissatisfaction is associated with increased risk for perinatal depression and anxiety (Robertson et al. 2004), this suggests one potential mechanism that might place multiparous women at increased risk for these disorders. Less is known about differences in psychological risk factors, such as maternal attitudes or general cognitive biases, between primiparous and multiparous women. There is evidence that multiparous women have different expectations for pregnancy and early parenthood compared to primiparous women. In a qualitative study of multiparous mothers’ experiences, these women reported that their expectations for parenthood were more realistic
compared to when their first children were born (Lederman and Weis 2009). However, it is important to distinguish between expectations of parenthood and attitudes about parenthood: research suggests that negative expectations of parenthood may actually be protective against depression, while negative attitudes about parenthood are associated with increased risk for depression (Harwood 2004; Sockol et al. 2014; Thomason et al. 2015). Further research is necessary to determine whether or not psychological risk factors, such as general cognitive biases and maternal attitudes, differ between primiparous and multiparous women. In addition to potential differences in the prevalence of risk factors between primiparous and multiparous women, it is also possible that relationships between risk factors and symptoms of emotional distress may be moderated by parity. For example, if experienced mothers have more realistic attitudes about motherhood, these beliefs may be less strongly related to emotional symptoms than other risk factors, such as inadequate social support. Few studies have assessed whether risk factors are differentially associated with symptoms between primiparous and multiparous samples. One study of Korean mothers found that social support, self-esteem, and mode of delivery were most predictive of symptoms of depression among primiparous women, while infant sex, antenatal fetal attachment, and educational status were most predictive of these symptoms among multiparous women (Chung and Joung 2011). This suggests that studies of risk factors for depression and anxiety among perinatal women should assess whether these risk factors differ between primiparous and multiparous women. The primary goal of the current study was to validate the AToM Scale for use in a sample of women with older children who experience subsequent pregnancies (hereafter referred to as multiparous women). We assessed the relationship between maternal attitudes and symptoms of depression and anxiety and compared maternal attitudes to other demographic, cognitive, and interpersonal risk factors for depression and anxiety in this population. We hypothesized that, as for primiparous women, maternal attitudes would have incremental predictive validity for symptoms of depression and anxiety beyond these other risk factors. We also compared results from our sample of multiparous women to results of the initial validation study of the AToM Scale in order to assess whether there are differences in risk factors for depression and anxiety between these groups and whether the relationship between these risk factors and symptoms is moderated by parity.
Method Women were recruited online through general social media sites (e.g., Facebook) and online forums for women who are pregnant or new mothers (e.g., Mothering.com). Recruitment
Maternal attitudes, depression, and anxiety
materials provided information about the study and a link to an online interface through which women could initiate participation. All participants completed the study through this online interface. Women were eligible if they were between the ages of 18 and 45, resided in the USA, were currently pregnant (second or third trimester) or had given birth in the past 6 months, and had at least one older child (biological, adopted, or step-child).1 After providing informed consent and confirming eligibility for the study, women completed a series of self-report measures through the online interface. Participants completed measures of maternal attitudes, general cognitive biases, social support, marital satisfaction, and symptoms of depression and anxiety (described below). Demographic information was collected after all study measures had been completed. Compensation was provided through a raffle for a $100 gift card. We compared findings from the current study with multiparous women to results obtained from the initial validation study of the AToM Scale, which assessed only primiparous women (Sockol et al. 2014). A complete overview of the methods of the initial validation study is described in the original manuscript (Sockol et al. 2014). Women were eligible to participate in the initial validation study if they were pregnant with their first child or had given birth to their first child within the previous 6 month period.
(factor 1; e.g., BIf I make a mistake, people will think I am a bad mother^), beliefs related to maternal responsibility (factor 2; e.g., BI am the only person who can keep my baby safe^), and maternal role idealization (factor 3; e.g., BIt is wrong to have mixed feelings about my baby;^ Sockol et al. 2014). Higher scores on the AToM Scale indicate more maladaptive attitudes toward motherhood. General cognitive biases were assessed using the 17-item version of the Dysfunctional Attitudes Scale (DAS; de Graaf et al. 2009). Higher scores on the DAS indicate more dysfunctional attitudes. Interpersonal risk factors We assessed overall satisfaction with social support using the Multidimensional Scale of Perceived Social Support (MSPSS; Zimet et al. 1988), which assesses satisfaction with support received from partners, family, and friends. Higher scores indicate greater social support. We assessed marital satisfaction using the Dyadic Adjustment Scale (DYAD; Spanier 1976). Higher scores indicate greater levels of marital satisfaction. Psychological symptoms Symptoms of depression were assessed using the Edinburgh Postnatal Depression Scale (EPDS; Cox et al. 1987). Due to concerns regarding an inability to provide follow-up care to study participants, item 10 (assessing suicidality) was not administered. Higher scores indicate greater levels of depressive symptoms. Symptoms of anxiety were assessed using the Beck Anxiety Inventory (BAI; Beck et al. 1988). Higher scores indicate greater levels of symptoms of anxiety.
Measures Cognitive risk factors Maternal attitudes were assessed using the Attitudes Toward Motherhood (AToM) Scale, a 12-item scale that assesses women’s attitudes about motherhood (Sockol et al. 2014). Attitudes are cognitions that are characterized by an evaluative component and differ from other types of cognitions, such as expectations (beliefs that represent predictions about what will occur in the future) or experiences (beliefs that represent past events). For example, while a woman might have an expectation that she will not have trouble adjusting to motherhood, she might have an attitude it would be unacceptable to experience difficulties with this adjustment. The initial validation study of the AToM Scale suggested that the scale measures women’s beliefs in three domains: beliefs related to others’ judgments 1
In this study, we were interested in the experiences of women who already identify as mothers when their families grow. This includes both women who have previously given birth to biological children and women who parent non-biological children (e.g., step-children, adopted children), as these women also identify as mothers. We conducted analyses of the subset of our sample who reported having only biological older children vs. women who were parents of non-biological children and we found no differences; thus, we present findings for the full sample.
Measures in the initial validation study of the AToM Scale The initial validation study used the same measures to assess maternal attitudes, general cognitive biases, social support, marital satisfaction, and depression. In the initial validation study, symptoms of anxiety were assessed using the StateTrait Anxiety Inventory (STAI; Spielberger 1983). As a result, when anxiety was assessed as an outcome in comparisons of primiparous and multiparous women, the BAI and STAI were transformed into Z scores prior to analyses. Internal reliability for all study measures was very good to excellent (see Table 1).
Data analysis We first assessed descriptive statistics for the primary study measures and assessed each measure for normality. As participants’ scores on the BAI, DYAD, and MSPSS were not normally distributed, these variables were square root transformed prior to data analysis. Next, we assessed the relationships among the primary study variables using correlations. We also compared the
L.E. Sockol, C.L. Battle Table 1 Demographic characteristics of multiparous women (current study) and primiparous women (initial validation study)
Age, M (SD) Gestational age (weeks), M (SD) Infant age (weeks), M (SD) Number of older children, M (SD) Age of oldest child, M (SD) Sample Pregnant Postpartum Relationship status Married In a relationship, living together In a relationship, not living together Other Race/Ethnicity Asian/Pacific Islander Black/African-American Caucasian Latina Native American/Alaskan Native Annual household income
ORIGINAL ARTICLE
Maternal attitudes, depression, and anxiety in pregnant and postpartum multiparous women Laura E. Sockol & Cynthia L. Battle
Received: 26 June 2014 / Accepted: 8 February 2015 # Springer-Verlag Wien 2015
Abstract The Attitudes Toward Motherhood (AToM) Scale was developed to assess women’s beliefs about motherhood, a specific risk factor for emotional distress in perinatal populations. As the measure was initially developed and validated for use among first-time mothers, this study assessed the reliability and validity of the AToM Scale in a sample of multiparous women. Maternal attitudes were significantly associated with symptoms of depression, even after controlling for demographic, cognitive, and interpersonal risk factors. Maternal attitudes were also associated with symptoms of anxiety after controlling for demographic risk factors, but this association was not significant after accounting for cognitive and interpersonal risk factors. Compared to primiparous women from the initial validation study of the AToM Scale, multiparous women reported lower levels of social support and marital satisfaction. The relationships between cognitive and interpersonal risk factors and symptoms of depression and anxiety were comparable between multiparous and primiparous women.
Keywords Depression . Anxiety . Maternal attitudes . Postpartum . Pregnancy . Risk factors
L. E. Sockol Williams College, Williamstown, MA, USA L. E. Sockol (*) : C. L. Battle Alpert Medical School of Brown University, Providence, RI, USA e-mail: [email protected] C. L. Battle Butler Hospital, Providence, RI, USA C. L. Battle Women & Infants Hospital of Rhode Island, Providence, RI, USA
Depression and anxiety are common during pregnancy and the first year postpartum (Bennett et al. 2004; Ross and McLean 2006). Beyond causing distress and impairment among women who experience psychological symptoms, these disorders are associated with a range of negative fetal and child outcomes. Prenatal depression and anxiety are associated with increased risk of adverse birth outcomes (Grote et al. 2010; Kim et al. 2013), and symptoms during the first year postpartum are associated with increased risk for negative behavioral, cognitive, and emotional child outcomes (Goodman et al. 2011; Grace et al. 2003; Littleton et al. 2007; O’Conner et al. 2002). Research has identified a wide range of risk factors for these disorders, including demographic, social, and psychological factors (Beck 2001; O’Hara and Swain 1996; Robertson et al. 2004). Most of these risk factors are not specific to perinatal women and are associated with increased risk for emotional distress in the general population. However, there is a subset of women who appear uniquely vulnerable to depression and anxiety during the transition to parenthood. For example, women whose first depressive episode occurs during the postpartum period are at increased risk for subsequent postpartum depressive episodes, but at no greater risk for future depressive episodes that are unrelated to childbearing (Cooper and Murray 1995). In order to identify these women, a better understanding of risk factors that are specific to perinatal populations is necessary. Women’s beliefs about motherhood are a cognitive risk factor that many be uniquely associated with depression and anxiety during the perinatal period. According to the cognitive model, dysfunctional or maladaptive cognitions confer risk for poor emotional and behavioral outcomes in the context of relevant stressors (Beck and Haigh 2014). While most research on cognitive risk factors for depression and anxiety has focused on general biases in cognition, there is also evidence that content-specific maladaptive beliefs can confer risk
L.E. Sockol, C.L. Battle
in the context of relevant stressors. For example, when students receive lower-than-expected grades, beliefs related to academic competence are more predictive of depressive symptoms than general cognitive biases (Hilsman and Garber 1995). When the nature of a potential future stressor is known, as is true during the transition to parenthood, content-specific risk factors may be more indicative of the risk for distress than more general patterns of cognitive biases. This suggests that dysfunctional or maladaptive beliefs about motherhood may be associated with increased risk for depression and anxiety specifically during the transition to parenthood. The Attitudes Toward Motherhood (AToM) Scale was developed to assess women’s beliefs about motherhood in order to facilitate study of the relationship between this potential risk factor and symptoms of depression and anxiety among perinatal women (Sockol et al. 2014). This measure addressed conceptual and psychometric limitations of previous measures that had been developed to assess maternal attitudes. The initial validation study of the AToM Scale found that maternal attitudes are associated with symptoms of depression and anxiety during pregnancy and the early postpartum period, even after controlling for other demographic, cognitive and interpersonal risk factors (Sockol et al. 2014). A major limitation of the initial validation study of the AToM Scale was that the study only assessed maternal attitudes among primiparous women. While there is a wide range of research characterizing the initial transition to motherhood, relatively less is known about women’s experiences when their families grow (O’Reilly 2004). There is some evidence that rates of postpartum depression may be higher among multiparous women, especially during the first 6 months postpartum (Mayberry et al. 2007; Righetti-Veltema et al. 2002). There is also evidence that multiparous women have higher levels of overall anxiety compared to primiparous women, although primiparous women report higher levels of fear related to childbirth (Lederman and Weis 2009). The prevalence of risk factors for depression and anxiety may also differ between primiparous and multiparous women. For example, research suggests that marital satisfaction declines after the birth of a couple’s first child (Belsky and Pensky 1988; Cowan and Cowan 1992). As marital dissatisfaction is associated with increased risk for perinatal depression and anxiety (Robertson et al. 2004), this suggests one potential mechanism that might place multiparous women at increased risk for these disorders. Less is known about differences in psychological risk factors, such as maternal attitudes or general cognitive biases, between primiparous and multiparous women. There is evidence that multiparous women have different expectations for pregnancy and early parenthood compared to primiparous women. In a qualitative study of multiparous mothers’ experiences, these women reported that their expectations for parenthood were more realistic
compared to when their first children were born (Lederman and Weis 2009). However, it is important to distinguish between expectations of parenthood and attitudes about parenthood: research suggests that negative expectations of parenthood may actually be protective against depression, while negative attitudes about parenthood are associated with increased risk for depression (Harwood 2004; Sockol et al. 2014; Thomason et al. 2015). Further research is necessary to determine whether or not psychological risk factors, such as general cognitive biases and maternal attitudes, differ between primiparous and multiparous women. In addition to potential differences in the prevalence of risk factors between primiparous and multiparous women, it is also possible that relationships between risk factors and symptoms of emotional distress may be moderated by parity. For example, if experienced mothers have more realistic attitudes about motherhood, these beliefs may be less strongly related to emotional symptoms than other risk factors, such as inadequate social support. Few studies have assessed whether risk factors are differentially associated with symptoms between primiparous and multiparous samples. One study of Korean mothers found that social support, self-esteem, and mode of delivery were most predictive of symptoms of depression among primiparous women, while infant sex, antenatal fetal attachment, and educational status were most predictive of these symptoms among multiparous women (Chung and Joung 2011). This suggests that studies of risk factors for depression and anxiety among perinatal women should assess whether these risk factors differ between primiparous and multiparous women. The primary goal of the current study was to validate the AToM Scale for use in a sample of women with older children who experience subsequent pregnancies (hereafter referred to as multiparous women). We assessed the relationship between maternal attitudes and symptoms of depression and anxiety and compared maternal attitudes to other demographic, cognitive, and interpersonal risk factors for depression and anxiety in this population. We hypothesized that, as for primiparous women, maternal attitudes would have incremental predictive validity for symptoms of depression and anxiety beyond these other risk factors. We also compared results from our sample of multiparous women to results of the initial validation study of the AToM Scale in order to assess whether there are differences in risk factors for depression and anxiety between these groups and whether the relationship between these risk factors and symptoms is moderated by parity.
Method Women were recruited online through general social media sites (e.g., Facebook) and online forums for women who are pregnant or new mothers (e.g., Mothering.com). Recruitment
Maternal attitudes, depression, and anxiety
materials provided information about the study and a link to an online interface through which women could initiate participation. All participants completed the study through this online interface. Women were eligible if they were between the ages of 18 and 45, resided in the USA, were currently pregnant (second or third trimester) or had given birth in the past 6 months, and had at least one older child (biological, adopted, or step-child).1 After providing informed consent and confirming eligibility for the study, women completed a series of self-report measures through the online interface. Participants completed measures of maternal attitudes, general cognitive biases, social support, marital satisfaction, and symptoms of depression and anxiety (described below). Demographic information was collected after all study measures had been completed. Compensation was provided through a raffle for a $100 gift card. We compared findings from the current study with multiparous women to results obtained from the initial validation study of the AToM Scale, which assessed only primiparous women (Sockol et al. 2014). A complete overview of the methods of the initial validation study is described in the original manuscript (Sockol et al. 2014). Women were eligible to participate in the initial validation study if they were pregnant with their first child or had given birth to their first child within the previous 6 month period.
(factor 1; e.g., BIf I make a mistake, people will think I am a bad mother^), beliefs related to maternal responsibility (factor 2; e.g., BI am the only person who can keep my baby safe^), and maternal role idealization (factor 3; e.g., BIt is wrong to have mixed feelings about my baby;^ Sockol et al. 2014). Higher scores on the AToM Scale indicate more maladaptive attitudes toward motherhood. General cognitive biases were assessed using the 17-item version of the Dysfunctional Attitudes Scale (DAS; de Graaf et al. 2009). Higher scores on the DAS indicate more dysfunctional attitudes. Interpersonal risk factors We assessed overall satisfaction with social support using the Multidimensional Scale of Perceived Social Support (MSPSS; Zimet et al. 1988), which assesses satisfaction with support received from partners, family, and friends. Higher scores indicate greater social support. We assessed marital satisfaction using the Dyadic Adjustment Scale (DYAD; Spanier 1976). Higher scores indicate greater levels of marital satisfaction. Psychological symptoms Symptoms of depression were assessed using the Edinburgh Postnatal Depression Scale (EPDS; Cox et al. 1987). Due to concerns regarding an inability to provide follow-up care to study participants, item 10 (assessing suicidality) was not administered. Higher scores indicate greater levels of depressive symptoms. Symptoms of anxiety were assessed using the Beck Anxiety Inventory (BAI; Beck et al. 1988). Higher scores indicate greater levels of symptoms of anxiety.
Measures Cognitive risk factors Maternal attitudes were assessed using the Attitudes Toward Motherhood (AToM) Scale, a 12-item scale that assesses women’s attitudes about motherhood (Sockol et al. 2014). Attitudes are cognitions that are characterized by an evaluative component and differ from other types of cognitions, such as expectations (beliefs that represent predictions about what will occur in the future) or experiences (beliefs that represent past events). For example, while a woman might have an expectation that she will not have trouble adjusting to motherhood, she might have an attitude it would be unacceptable to experience difficulties with this adjustment. The initial validation study of the AToM Scale suggested that the scale measures women’s beliefs in three domains: beliefs related to others’ judgments 1
In this study, we were interested in the experiences of women who already identify as mothers when their families grow. This includes both women who have previously given birth to biological children and women who parent non-biological children (e.g., step-children, adopted children), as these women also identify as mothers. We conducted analyses of the subset of our sample who reported having only biological older children vs. women who were parents of non-biological children and we found no differences; thus, we present findings for the full sample.
Measures in the initial validation study of the AToM Scale The initial validation study used the same measures to assess maternal attitudes, general cognitive biases, social support, marital satisfaction, and depression. In the initial validation study, symptoms of anxiety were assessed using the StateTrait Anxiety Inventory (STAI; Spielberger 1983). As a result, when anxiety was assessed as an outcome in comparisons of primiparous and multiparous women, the BAI and STAI were transformed into Z scores prior to analyses. Internal reliability for all study measures was very good to excellent (see Table 1).
Data analysis We first assessed descriptive statistics for the primary study measures and assessed each measure for normality. As participants’ scores on the BAI, DYAD, and MSPSS were not normally distributed, these variables were square root transformed prior to data analysis. Next, we assessed the relationships among the primary study variables using correlations. We also compared the
L.E. Sockol, C.L. Battle Table 1 Demographic characteristics of multiparous women (current study) and primiparous women (initial validation study)
Age, M (SD) Gestational age (weeks), M (SD) Infant age (weeks), M (SD) Number of older children, M (SD) Age of oldest child, M (SD) Sample Pregnant Postpartum Relationship status Married In a relationship, living together In a relationship, not living together Other Race/Ethnicity Asian/Pacific Islander Black/African-American Caucasian Latina Native American/Alaskan Native Annual household income
