International Journal of Technology Assessment in Health Care, 8:Suppl. 1 (1992), 123-128. Copyright © 1992 Cambridge University Press. Printed in the U.S.A.
PREVALENCE AND SIGNIFICANCE OF SOCIAL AND PSYCHOLOGICAL RISK FACTORS DURING PREGNANCY Gunilla Sydsjo University Hospital, Linkoping
Abstract Moderate psychosocial problems identified during early pregnancy in 78 women were found to predispose for various "complications" during gestation, but not for prematurity or obstetrical complications during delivery. However, from a normal postnatal status the children of these mothers demonstrated a significantly unfavorable somatic, as well as psychomotoric development, until the age of 4. Pregnant women with certain psychosocial problems must be early identified and property attended to in order to preclude an adverse child development.
Modern antenatal care has proved itself increasingly efficient at identifying, managing, and sometimes preventing a series of noxious somatic conditions and disorders that may appear in association with pregnancy. As a consequence, the relative proportion of problems during gestation associated with psychological and social predicaments is growing. Such quandaries are sometimes referred to as psychosocial risk factors. They are often characterized by the fact that they tend to be nonspecific for the state of pregnancy. This is contrary to other major complications associated with gestation, such as pregnancy-induced hypertension and intrauterine growth retardation. Nonetheless, according to the literature, psychosocial dilemmas during pregnancy may well have adverse effects on the delivery and on the state of the newborn. There is also evidence to suggest that early child development may be hampered by the presence of various psychosocial predicaments in the family. The definition of so-called psychosocial risk factors carries with it certain problems, especially in an international context, since these factors seem to be closely related to cultural tradition, general socioeconomic conditions prevailing in society, as well as the health and social security systems available. This sometimes makes international studies partly incomparable. Thus, what might be regarded as a significant psychosocial problem in Italy and in the United States may not be so in Sweden and vice versa. This investigation was supported by grants from the Swedish National Delegation for Social Research, the Research Fund of County Council of Ostergotland, and Linkoping University, Medical Faculty.
123
Sydsjo
Hence, psychosocial problems must be clearly defined and studied in the context where they are going to be met and dealt with in practice. The importance of studying psychosocial problems appearing during pregnancy and their possible relations to adverse pregnancy outcomes and impaired child development follows from the clinical need to try to reduce, or even prohibit, some of the pernicious effects that may affect mother and child as a consequence of such problems. There is an inherent vagueness in every attempted definition of a "psychosocial risk factor." For scientific studies of psychosocial risk factors and their possible consequences, we require as strict operational definitions as possible for the symptoms and conditions to be studied. Certainly various conditions and factors do interact; for instance, social predicaments may well induce psychological dilemmas and vice versa. Even with this taken into account, there should be reasonably good options to disclose the prevalence and consequences of some relevant psychosocial "risk factors" in a pregnant population as a whole. The total prevalence of psychosocial risk factors in a pregnant population is, of course, unknown, mainly because it depends on which factors one decides to include. The whole state of pregnancy is in itself so stirring that psychological problems of different grades are likely to be present sometime during any pregnancy. Psychosocial problems of sufficient severity to be thought relevant for pregnancy outcome and child development have recently been retrospectively studied in selected patient samples in Sweden. Thus, amphetamine-addicted mothers and their children were studied by means of information gained from standardized routine obstetrical records without demonstration of any increased amount of obstetrical or delivery complications (4;5). In two studies of children to alcohol-addicted mothers, behavior problems, such as aggressiveness and concentration and perception difficulties, were found to be frequently present. A reduced IQ (down to 70-85) was found among 35% of such children and 50% demonstrated signs of brain damage. At least half of the children had experienced adaptational and psychosocial problems (1;2). In a series of 177 women, who had attended psychiatric services sometime between the 20th week of gestation and 1-year postpartum, it was found that risk factors predisposing for postpartum depression were previous psychiatric illness, feelings of stress and anxiety during pregnancy, and an unstable relationship to the father-to-be (3). One-third of these women were alcoholics or drug abusers. A somewhat increased proportion of obstetrical and delivery complications was noted for these women, though no specific type of complication was dominating. The neonatal state of the children was, in general, not compromised when compared to a reference group of neonates. Among 69 preschool children with parents who had been admitted to psychiatric departments, the frequency of somatic, as well as emotional symptoms, was significantly increased as compared to a control group of children (6). Although there is evidence in the literature concerning the impact of various psychosocial predicaments on mothers and their offspring in selected groups of women and children, we so far lack information on the frequency of various possibly relevant psychosocial risk factors and social circumstances prevailing in the pregnant population as a whole. We also lack prospective, long-term follow-up studies on the possible relationships between certain, well-defined psychological and social conditions during early pregnancy and the eventual outcome of those pregnancies, as well as the eventual somatic and psychomotoric development of the resulting children. In this respect, Sweden offers a most favorable spot to perform such studies since the existing Health and Social Welfare systems cover the entire population and offer a public antenatal health and social care service accepted and utilized by almost every 124
INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:SUPPL. 1, 1992
Social and psychological risk factors
pregnant woman. We here report in short the main design and major results of such a study, just completed. MATERIALS AND METHODS In 1983, a total of 1,575 pregnant women registered at the public Antenatal Care Clinics (ACC) in Linkoping, the regional capital city in southeast Sweden. These women represented approximately the whole (99%) of the newly pregnant population in that area during that complete year. Usually, pregnant women register at an antenatal care unit (and there are seven in Linkoping) between 10 and 14 weeks after last menstrual period (LMP). A close and continuous personal contact during the whole of pregnancy is generally established between the pregnant woman and her attending midwife. The pregnant woman may well be known by the midwife since an earlier pregnancy. In general, a woman with an uncomplicated pregnancy is expected to see her midwife 12-14 times before delivery and her doctor twice. On a voluntary basis, the gestational length of every pregnancy is estimated by means of ultrasonography between the 12th and 14th week of gestation. For the purpose of this investigation, we decided, with proper permission from the local ethics committee, to try to identify all those pregnant women who were characterized by "drug addiction," "moderate mental insufficiency," or who were associated with "special social circumstances of possible relevance to pregnancy and parenthood." Thus, if the patient herself, her attending midwife, or a social authority recognized that the use of alcohol and/or drugs had adversely affected the social abilities and the health of the patient or her partner, with not only temporary consequences, she was recognized in this study as belonging to the index group of patients. The group of pregnant women with "moderate mental insufficiency" consisted of those who had suffered psychiatric disease cared for by a psychiatrist (e.g., schizophrenia, endogenous depression, and severe neurosis). Furthermore, those with mental disablement or retardation (e.g., those enrolled at "The Board for Provisions and Services to Mentally Retarded") were also included as index patients, as well as those with an unspecific mental insufficiency (e.g., excessive fatigue, general discomfort, irritability, or feelings of personal insufficiency). Pregnant women characterized by "special social circumstances of possible relevance to pregnancy and parenthood" included young women 3 fathers to her children or ^6 children of her own; women holding a permanent sick pension or the family being unemployed for >1 year; and women with earlier children in custody. These were all regarded as index patients. For comparison, a reference group was selected consisting of pregnant women without (to our knowledge) any of the defined characteristics listed above. The reference group consisted of those pregnant women who happened to register at the same ACC immediately after women who were eventually considered to be index patients. Index and reference patients were investigated in the same way by means of repeated semistructured personal interviews combined with analysis of relevant information retrieved from standardized medical and social welfare files. These procedures involved the explicit permission of the women themselves. The following topics were explored: the woman's social background; her previous and current medical status and social situation; her ante- and postnatal consumption of medical care and social welfare; the eventual obstetric outcome of her pregnancy; and finally, the somatic and mental development of her child as repeatedly observed in a standardized fashion at the age INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:SUPPL. 1, 1992
125
Sydsjo
of 6 and 18 months and 4 years. The details of the design of the study and its results will be published elsewhere. Eventually during 1983, 81 pregnant women were identified as being index patients. All but three agreed to take further part in the investigation, and none of those 78 accepting was lost to follow-up. All women who fulfilled the criteria for being included in the reference group agreed to take part and none was lost to follow-up either. RESULTS
Our primary finding was that the great majority of pregnant women belonging to either of the index subgroups were surprisingly willing to share and discuss their social, as well as psychological problems, with their attending midwife at the ACC. In general, pregnant women in Linkoping register at their ACC at the 9th gestational week past LMP. Our patients belonging to the index group were also found to register fairly early (i.e., on average during the 10th week past LMP). The prevalence of pregnant women in the population studied, characterized by any of several of our arbitrarily selected inclusion criteria, was found to be 5%. Certainly there may be several other criteria that were not included in the present study that rightly could be regarded as potential psychosocial risk factors. Hence, a prevalence figure of 5% is to be regarded as a minimum figure for this type of problem appearing among pregnant women in Sweden. About 70% of all women in the index group spontaneously informed their midwife about existing problems associated with their current social situation. So far as could be checked, no one tried to actively conceal the existence of current psychosocial problems. Instead, women struck by these types of problems appeared to appreciate that someone took their time to care in general for these women and put them into a focus of interest. As a consequence, the staff serving at ACCs should not fear bringing up possible social and/or psychological problems with their patients, since very few indeed seem to dislike or reject such initiatives. On the contrary, they appear to appreciate it. Our two patient groups—the index and the reference patients — were found to be very comparable with respect to age and parity. Index women when compared to reference women were however found to be socially underprivileged from childhood on and they appeared to be significantly more socially alienated at the beginning of pregnancy. Index and reference women paid about the same number of visits to the ACC (i.e., 13 visits on average). However, the attending midwives spent much more time, as measured, on every visit with index women in general. Index women saw the doctor at the ACC more frequently than the reference women, mainly because they applied for sick leave permissions during pregnancy more frequently. Index women also used the Social Welfare Services to a greater extent than the reference women. Hospital admissions were also more frequent within the index group during pregnancy. The most prevalent symptoms presented by the index patients were general fatigue, as well as common symptoms of general discomfort, together with unspecific back pains and abdominal symptoms. The most frequently registered reason for admission into the hospital, which is a free service in Sweden, was suspected preterm uterine contractions. Hence, index women used medical, as well as social welfare services, to a significantly higher extent during pregnancy than did reference women. The index women reported 62% of their pregnancies to be unplanned as compared to 13% in the reference group. When asked about their present attitude to the 126
INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:SUPPL 1, 1992
Social and psychological risk factors
ongoing early pregnancy, index women in general revealed more feelings of rejection and lack of emotional feelings at all with regard to the pregnancy and the forthcoming child. In spite of the apparently more "complicated" pregnancies experienced by the index women in general, the eventual gestation length at childbirth did not differ significantly between the groups. Thus, prematurity and its consequences were not found more frequently among index women. Although index women somewhat more frequently needed epidural anesthesia and paracervical blockade during delivery, the frequency of Caesarian sections did not differ significantly between the groups. Obstetrical delivery complications in general did not differ either. The neonates belonging to the two groups were found to be very comparable with regard to sex, birthweight, and Apgar score at 5' and 10'. There was no difference with regard to congenital anomalies. Swedish mothers and their children traditionally stay for 3-6 days in the hospital after delivery. This enables a close checkup of the somatic, as well as the functional status, of the newborn children and their interactions with their mothers during this period. No differences were observed between the neonates belonging to the two groups with regard to somatic status during the observation period. Still, due to ambiguity expressed by the attending staff at the postnatal ward with regard to the quality of mother-child interaction and the mother's established ability to care for her child, the duration of time spent at the postnatal ward tended to be longer for index mothers in general. One out of five index women stayed more than 10 days, whereas none of the reference women stayed for more than 9 days. Thus, in general, no significant differences could be observed between the groups with regard to maternal and child health during the first days after delivery. After the gestational period, when there was an evident difference with regard to the extent of complications appearing in the two groups, the pregnancy outcomes and the health status of mothers and children seemed to equalize around delivery. Whether this equalization of somatic health status was due to the ACC service or not remains uncertain. Accumulated data from the standardized child health care records, regularly kept until each child had reached 18 months, eventually showed that, whereas 21% of the index children were referred to various types of psychiatric counseling during this period,
none of the reference children needed such attention. Index children in general were more frequently hospitalized and spent more days at the children's hospital than reference children, the main reasons for admittance being various infections, mainly gastroenteritis, and upper respiratory tract infections. At the age of 4, every child in Sweden is checked carefully by nurses and pediatricians at the public Child Health Center with respect to his or her somatic health and developmental status. Mental abilities and psychomotor maturity are also assessed. These checkups are standardized and the results recorded in a uniform way. Blind analysis of the results of the tests performed at the age of 4 revealed that 21 out of 51 examined index children were not regarded to have reached the expected level of psychomotor development, whereas this was true for only 1 out of 64 reference children. CONCLUSION
The present investigation seemed to reveal that major psychosocial risk factors were present in at least 5% of the pregnant population in Linkoping, Sweden. Women with "drug abuse," "moderate mental insufficiency," and those characterized by one or several "specific social circumstances of possible relevance to pregnancy and parenthood" during early pregnancy ran an increased risk to experience a more INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:SUPPL. 1, 1992
127
Sydsjo
"complicated" pregnancy than other pregnant women. In spite of the fact that we seem to lack special means for rational treatment for these women's complaints, but are able to devote more time to them for unspecific patient care, there appears to be no increased risk for major pregnancy disturbances or eventual obstetric delivery complications for these women. The somatic and mental health status of mother and child in the early postpartum period seemed to be comparable when index mother-and-child pairs were compared to reference mother-and-child pairs. However, soon after childbirth it became apparent that the lines of child development within the two groups were not parallel, but diverged at the expense of the index children. This tendency became more manifest over time. When the children had reached 4, it was obvious and shocking. Patients and mother-child pairs belonging to all subgroups within the index group of patients (i.e., "drug abusers," women with "moderate mental insufficiency," and those women who were characterized by "special social circumstances of possible relevance to pregnancy and parenthood") all contributed to the inferior results observed for this group of women. There were no specific subgroups observed that carried a specifically serious burden of risk. From the results, it follows that already early in pregnancy we may be able to identify specific fetuses with a bleak prognosis indeed for their somatic development and psychomotoric maturity at the age of 4. This holds true even for a pregnant population not at all struck by severe poverty or misery in general, as is the case in Sweden. All possible attempts should be made to prevent this gloomy and detrimental progression of events. These pregnant women deserve at least as much notice and attention as do pregnant women with somatic risk factors. Of course, not all risk factors may be eliminated or their consequences precluded since the type of risk factors varies. However, some will probably lend themselves to some form of supporting therapy, by means of individual teaching and information. Pregnancy itself may be a very special condition during human life, when significant and positive changes in life-style and behavior may take place if properly induced. However, such changes will have to be initiated during early pregnancy and probably followed up for a considerable time after delivery. REFERENCES
1. Aronsson, M., Carlsson, C, Johansson, P. R., et al. Alkohol och graviditet. Ldkartidningen, 1977, 74, 3074-79. 2. Aronsson, M. Children of alcoholic mothers. Dissertation. Goteborg: University of Goteborg, 1985. 3. Bagendahl-Strindlund, M. Parapartum mentally ill mothers and their children. Dissertation. Stockholm: University of Stockholm, 1987. 4. Ericsson, M., Larsson, G., Winbladh, B., & Zetterstrom, R. The influence of amphetamine addiction on pregnancy and the newborn infant. Acta Psediatrica Scandinavica, 1978, 67, 95-99. 5. Larsson, G. The amphetamine addicted mother and her child. Acta Psediatrica Scandinavica, 1980, 278(suppl.). 6. Larsson, G., & Larsson, A. Health of children whose parents seek psychiatric care. Acta Psychiatrica Scandinavica, 1982, 66, 154-62.
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INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:SUPPL. 1, 1992
PREVALENCE AND SIGNIFICANCE OF SOCIAL AND PSYCHOLOGICAL RISK FACTORS DURING PREGNANCY Gunilla Sydsjo University Hospital, Linkoping
Abstract Moderate psychosocial problems identified during early pregnancy in 78 women were found to predispose for various "complications" during gestation, but not for prematurity or obstetrical complications during delivery. However, from a normal postnatal status the children of these mothers demonstrated a significantly unfavorable somatic, as well as psychomotoric development, until the age of 4. Pregnant women with certain psychosocial problems must be early identified and property attended to in order to preclude an adverse child development.
Modern antenatal care has proved itself increasingly efficient at identifying, managing, and sometimes preventing a series of noxious somatic conditions and disorders that may appear in association with pregnancy. As a consequence, the relative proportion of problems during gestation associated with psychological and social predicaments is growing. Such quandaries are sometimes referred to as psychosocial risk factors. They are often characterized by the fact that they tend to be nonspecific for the state of pregnancy. This is contrary to other major complications associated with gestation, such as pregnancy-induced hypertension and intrauterine growth retardation. Nonetheless, according to the literature, psychosocial dilemmas during pregnancy may well have adverse effects on the delivery and on the state of the newborn. There is also evidence to suggest that early child development may be hampered by the presence of various psychosocial predicaments in the family. The definition of so-called psychosocial risk factors carries with it certain problems, especially in an international context, since these factors seem to be closely related to cultural tradition, general socioeconomic conditions prevailing in society, as well as the health and social security systems available. This sometimes makes international studies partly incomparable. Thus, what might be regarded as a significant psychosocial problem in Italy and in the United States may not be so in Sweden and vice versa. This investigation was supported by grants from the Swedish National Delegation for Social Research, the Research Fund of County Council of Ostergotland, and Linkoping University, Medical Faculty.
123
Sydsjo
Hence, psychosocial problems must be clearly defined and studied in the context where they are going to be met and dealt with in practice. The importance of studying psychosocial problems appearing during pregnancy and their possible relations to adverse pregnancy outcomes and impaired child development follows from the clinical need to try to reduce, or even prohibit, some of the pernicious effects that may affect mother and child as a consequence of such problems. There is an inherent vagueness in every attempted definition of a "psychosocial risk factor." For scientific studies of psychosocial risk factors and their possible consequences, we require as strict operational definitions as possible for the symptoms and conditions to be studied. Certainly various conditions and factors do interact; for instance, social predicaments may well induce psychological dilemmas and vice versa. Even with this taken into account, there should be reasonably good options to disclose the prevalence and consequences of some relevant psychosocial "risk factors" in a pregnant population as a whole. The total prevalence of psychosocial risk factors in a pregnant population is, of course, unknown, mainly because it depends on which factors one decides to include. The whole state of pregnancy is in itself so stirring that psychological problems of different grades are likely to be present sometime during any pregnancy. Psychosocial problems of sufficient severity to be thought relevant for pregnancy outcome and child development have recently been retrospectively studied in selected patient samples in Sweden. Thus, amphetamine-addicted mothers and their children were studied by means of information gained from standardized routine obstetrical records without demonstration of any increased amount of obstetrical or delivery complications (4;5). In two studies of children to alcohol-addicted mothers, behavior problems, such as aggressiveness and concentration and perception difficulties, were found to be frequently present. A reduced IQ (down to 70-85) was found among 35% of such children and 50% demonstrated signs of brain damage. At least half of the children had experienced adaptational and psychosocial problems (1;2). In a series of 177 women, who had attended psychiatric services sometime between the 20th week of gestation and 1-year postpartum, it was found that risk factors predisposing for postpartum depression were previous psychiatric illness, feelings of stress and anxiety during pregnancy, and an unstable relationship to the father-to-be (3). One-third of these women were alcoholics or drug abusers. A somewhat increased proportion of obstetrical and delivery complications was noted for these women, though no specific type of complication was dominating. The neonatal state of the children was, in general, not compromised when compared to a reference group of neonates. Among 69 preschool children with parents who had been admitted to psychiatric departments, the frequency of somatic, as well as emotional symptoms, was significantly increased as compared to a control group of children (6). Although there is evidence in the literature concerning the impact of various psychosocial predicaments on mothers and their offspring in selected groups of women and children, we so far lack information on the frequency of various possibly relevant psychosocial risk factors and social circumstances prevailing in the pregnant population as a whole. We also lack prospective, long-term follow-up studies on the possible relationships between certain, well-defined psychological and social conditions during early pregnancy and the eventual outcome of those pregnancies, as well as the eventual somatic and psychomotoric development of the resulting children. In this respect, Sweden offers a most favorable spot to perform such studies since the existing Health and Social Welfare systems cover the entire population and offer a public antenatal health and social care service accepted and utilized by almost every 124
INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:SUPPL. 1, 1992
Social and psychological risk factors
pregnant woman. We here report in short the main design and major results of such a study, just completed. MATERIALS AND METHODS In 1983, a total of 1,575 pregnant women registered at the public Antenatal Care Clinics (ACC) in Linkoping, the regional capital city in southeast Sweden. These women represented approximately the whole (99%) of the newly pregnant population in that area during that complete year. Usually, pregnant women register at an antenatal care unit (and there are seven in Linkoping) between 10 and 14 weeks after last menstrual period (LMP). A close and continuous personal contact during the whole of pregnancy is generally established between the pregnant woman and her attending midwife. The pregnant woman may well be known by the midwife since an earlier pregnancy. In general, a woman with an uncomplicated pregnancy is expected to see her midwife 12-14 times before delivery and her doctor twice. On a voluntary basis, the gestational length of every pregnancy is estimated by means of ultrasonography between the 12th and 14th week of gestation. For the purpose of this investigation, we decided, with proper permission from the local ethics committee, to try to identify all those pregnant women who were characterized by "drug addiction," "moderate mental insufficiency," or who were associated with "special social circumstances of possible relevance to pregnancy and parenthood." Thus, if the patient herself, her attending midwife, or a social authority recognized that the use of alcohol and/or drugs had adversely affected the social abilities and the health of the patient or her partner, with not only temporary consequences, she was recognized in this study as belonging to the index group of patients. The group of pregnant women with "moderate mental insufficiency" consisted of those who had suffered psychiatric disease cared for by a psychiatrist (e.g., schizophrenia, endogenous depression, and severe neurosis). Furthermore, those with mental disablement or retardation (e.g., those enrolled at "The Board for Provisions and Services to Mentally Retarded") were also included as index patients, as well as those with an unspecific mental insufficiency (e.g., excessive fatigue, general discomfort, irritability, or feelings of personal insufficiency). Pregnant women characterized by "special social circumstances of possible relevance to pregnancy and parenthood" included young women 3 fathers to her children or ^6 children of her own; women holding a permanent sick pension or the family being unemployed for >1 year; and women with earlier children in custody. These were all regarded as index patients. For comparison, a reference group was selected consisting of pregnant women without (to our knowledge) any of the defined characteristics listed above. The reference group consisted of those pregnant women who happened to register at the same ACC immediately after women who were eventually considered to be index patients. Index and reference patients were investigated in the same way by means of repeated semistructured personal interviews combined with analysis of relevant information retrieved from standardized medical and social welfare files. These procedures involved the explicit permission of the women themselves. The following topics were explored: the woman's social background; her previous and current medical status and social situation; her ante- and postnatal consumption of medical care and social welfare; the eventual obstetric outcome of her pregnancy; and finally, the somatic and mental development of her child as repeatedly observed in a standardized fashion at the age INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:SUPPL. 1, 1992
125
Sydsjo
of 6 and 18 months and 4 years. The details of the design of the study and its results will be published elsewhere. Eventually during 1983, 81 pregnant women were identified as being index patients. All but three agreed to take further part in the investigation, and none of those 78 accepting was lost to follow-up. All women who fulfilled the criteria for being included in the reference group agreed to take part and none was lost to follow-up either. RESULTS
Our primary finding was that the great majority of pregnant women belonging to either of the index subgroups were surprisingly willing to share and discuss their social, as well as psychological problems, with their attending midwife at the ACC. In general, pregnant women in Linkoping register at their ACC at the 9th gestational week past LMP. Our patients belonging to the index group were also found to register fairly early (i.e., on average during the 10th week past LMP). The prevalence of pregnant women in the population studied, characterized by any of several of our arbitrarily selected inclusion criteria, was found to be 5%. Certainly there may be several other criteria that were not included in the present study that rightly could be regarded as potential psychosocial risk factors. Hence, a prevalence figure of 5% is to be regarded as a minimum figure for this type of problem appearing among pregnant women in Sweden. About 70% of all women in the index group spontaneously informed their midwife about existing problems associated with their current social situation. So far as could be checked, no one tried to actively conceal the existence of current psychosocial problems. Instead, women struck by these types of problems appeared to appreciate that someone took their time to care in general for these women and put them into a focus of interest. As a consequence, the staff serving at ACCs should not fear bringing up possible social and/or psychological problems with their patients, since very few indeed seem to dislike or reject such initiatives. On the contrary, they appear to appreciate it. Our two patient groups—the index and the reference patients — were found to be very comparable with respect to age and parity. Index women when compared to reference women were however found to be socially underprivileged from childhood on and they appeared to be significantly more socially alienated at the beginning of pregnancy. Index and reference women paid about the same number of visits to the ACC (i.e., 13 visits on average). However, the attending midwives spent much more time, as measured, on every visit with index women in general. Index women saw the doctor at the ACC more frequently than the reference women, mainly because they applied for sick leave permissions during pregnancy more frequently. Index women also used the Social Welfare Services to a greater extent than the reference women. Hospital admissions were also more frequent within the index group during pregnancy. The most prevalent symptoms presented by the index patients were general fatigue, as well as common symptoms of general discomfort, together with unspecific back pains and abdominal symptoms. The most frequently registered reason for admission into the hospital, which is a free service in Sweden, was suspected preterm uterine contractions. Hence, index women used medical, as well as social welfare services, to a significantly higher extent during pregnancy than did reference women. The index women reported 62% of their pregnancies to be unplanned as compared to 13% in the reference group. When asked about their present attitude to the 126
INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:SUPPL 1, 1992
Social and psychological risk factors
ongoing early pregnancy, index women in general revealed more feelings of rejection and lack of emotional feelings at all with regard to the pregnancy and the forthcoming child. In spite of the apparently more "complicated" pregnancies experienced by the index women in general, the eventual gestation length at childbirth did not differ significantly between the groups. Thus, prematurity and its consequences were not found more frequently among index women. Although index women somewhat more frequently needed epidural anesthesia and paracervical blockade during delivery, the frequency of Caesarian sections did not differ significantly between the groups. Obstetrical delivery complications in general did not differ either. The neonates belonging to the two groups were found to be very comparable with regard to sex, birthweight, and Apgar score at 5' and 10'. There was no difference with regard to congenital anomalies. Swedish mothers and their children traditionally stay for 3-6 days in the hospital after delivery. This enables a close checkup of the somatic, as well as the functional status, of the newborn children and their interactions with their mothers during this period. No differences were observed between the neonates belonging to the two groups with regard to somatic status during the observation period. Still, due to ambiguity expressed by the attending staff at the postnatal ward with regard to the quality of mother-child interaction and the mother's established ability to care for her child, the duration of time spent at the postnatal ward tended to be longer for index mothers in general. One out of five index women stayed more than 10 days, whereas none of the reference women stayed for more than 9 days. Thus, in general, no significant differences could be observed between the groups with regard to maternal and child health during the first days after delivery. After the gestational period, when there was an evident difference with regard to the extent of complications appearing in the two groups, the pregnancy outcomes and the health status of mothers and children seemed to equalize around delivery. Whether this equalization of somatic health status was due to the ACC service or not remains uncertain. Accumulated data from the standardized child health care records, regularly kept until each child had reached 18 months, eventually showed that, whereas 21% of the index children were referred to various types of psychiatric counseling during this period,
none of the reference children needed such attention. Index children in general were more frequently hospitalized and spent more days at the children's hospital than reference children, the main reasons for admittance being various infections, mainly gastroenteritis, and upper respiratory tract infections. At the age of 4, every child in Sweden is checked carefully by nurses and pediatricians at the public Child Health Center with respect to his or her somatic health and developmental status. Mental abilities and psychomotor maturity are also assessed. These checkups are standardized and the results recorded in a uniform way. Blind analysis of the results of the tests performed at the age of 4 revealed that 21 out of 51 examined index children were not regarded to have reached the expected level of psychomotor development, whereas this was true for only 1 out of 64 reference children. CONCLUSION
The present investigation seemed to reveal that major psychosocial risk factors were present in at least 5% of the pregnant population in Linkoping, Sweden. Women with "drug abuse," "moderate mental insufficiency," and those characterized by one or several "specific social circumstances of possible relevance to pregnancy and parenthood" during early pregnancy ran an increased risk to experience a more INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 8:SUPPL. 1, 1992
127
Sydsjo
"complicated" pregnancy than other pregnant women. In spite of the fact that we seem to lack special means for rational treatment for these women's complaints, but are able to devote more time to them for unspecific patient care, there appears to be no increased risk for major pregnancy disturbances or eventual obstetric delivery complications for these women. The somatic and mental health status of mother and child in the early postpartum period seemed to be comparable when index mother-and-child pairs were compared to reference mother-and-child pairs. However, soon after childbirth it became apparent that the lines of child development within the two groups were not parallel, but diverged at the expense of the index children. This tendency became more manifest over time. When the children had reached 4, it was obvious and shocking. Patients and mother-child pairs belonging to all subgroups within the index group of patients (i.e., "drug abusers," women with "moderate mental insufficiency," and those women who were characterized by "special social circumstances of possible relevance to pregnancy and parenthood") all contributed to the inferior results observed for this group of women. There were no specific subgroups observed that carried a specifically serious burden of risk. From the results, it follows that already early in pregnancy we may be able to identify specific fetuses with a bleak prognosis indeed for their somatic development and psychomotoric maturity at the age of 4. This holds true even for a pregnant population not at all struck by severe poverty or misery in general, as is the case in Sweden. All possible attempts should be made to prevent this gloomy and detrimental progression of events. These pregnant women deserve at least as much notice and attention as do pregnant women with somatic risk factors. Of course, not all risk factors may be eliminated or their consequences precluded since the type of risk factors varies. However, some will probably lend themselves to some form of supporting therapy, by means of individual teaching and information. Pregnancy itself may be a very special condition during human life, when significant and positive changes in life-style and behavior may take place if properly induced. However, such changes will have to be initiated during early pregnancy and probably followed up for a considerable time after delivery. REFERENCES
1. Aronsson, M., Carlsson, C, Johansson, P. R., et al. Alkohol och graviditet. Ldkartidningen, 1977, 74, 3074-79. 2. Aronsson, M. Children of alcoholic mothers. Dissertation. Goteborg: University of Goteborg, 1985. 3. Bagendahl-Strindlund, M. Parapartum mentally ill mothers and their children. Dissertation. Stockholm: University of Stockholm, 1987. 4. Ericsson, M., Larsson, G., Winbladh, B., & Zetterstrom, R. The influence of amphetamine addiction on pregnancy and the newborn infant. Acta Psediatrica Scandinavica, 1978, 67, 95-99. 5. Larsson, G. The amphetamine addicted mother and her child. Acta Psediatrica Scandinavica, 1980, 278(suppl.). 6. Larsson, G., & Larsson, A. Health of children whose parents seek psychiatric care. Acta Psychiatrica Scandinavica, 1982, 66, 154-62.
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