Individualni in kontekstualni psihosocialni dejavniki zaščite in ogroženosti duševnega zdravja prvesnic v nosečnosti in po porodu

Rus Prelog, Polona (author), Rus Makovec, Maja (mentor)

Uvod: Depresija, anksioznost in strah pred porodom imajo številne posledice za nosečnice in razvijajoče se otroke. Za mnoge nosečnice je poporodna depresija prva razpoloženjska epizoda v življenju, etiologija poporodne depresije (PPD) in drugih peripartalnih motenj pa še vedno ostaja nejasna. Ne-varne oblike navezanosti v intimnih partnerskih odnosih predstavljajo dejavnik tveganja za simptome depresije. Analize kompleksne povezanosti poglavitnih kazalcev duševnega zdravja prvorodk z njihovimi individualnimi in kontekstualnimi značilnostmi, s poudarkom na intimni navezanosti v tem ključnem časovnem obdobju v slovenskem prostoru nimamo, prav tako ne glede drugih pomembnih medosebnih odnosov. Namen dela: Namen doktorske disertacije je analiza povezanosti določenih individualnih in kontekstualnih dejavnikov (navezovalni odnosi s partnerjem in drugi pomembni medosebni odnosi, doživljanje stresa) s posameznimi kazalci duševnega zdravja (raven depresivnosti, anksioznosti) pri prvorodkah v razponu časa od zadnje tretjine nosečnosti do poporodnega obdobja šestih tednov po porodu. Hipoteza: Osnovna hipoteza je, da so določene napovedne spremenljivke (individualne, s pomembnimi odnosi in s stresom povezane značilnosti prvorodk) povezane s tveganjem za depresivnost in anksioznost pred porodom in tudi s tveganjem za poporodno depresivnost. Zasnova raziskave, opis metod, preiskovancev: Sodelovale so prvorodke v zadnji tretjini nosečnosti, vodene v Porodnišnici Ljubljana UKC LJ (Šola za starše Porodnišnice Ljubljana ter redne ginekološke ambulante Porodnišnice Ljubljana). Vključili smo 325 nosečnic. Retestirane so bile cca 6 tednov po porodu (ko je na vprašalnik odgovorilo 181 nosečnic). Vprašalniki so zajemali osnovne podatke v zvezi z nekaterimi značilnostmi demografskega, socio-ekonomskega in socio-kulturnega statusa, parametre duševnega zdravja pa smo merili s samoocenjevalnimi vprašalniki: vprašalnik o strahu pred porodom, doživljanje navezovalnih odnosov s partnerjem ECR-R (Experience in Close Relationships – Revised) (Fraley, Waller in Brennan, 2000), raven anksioznosti z vprašalnikom Zung (Zung's Self – rating Anxiety Scale) (Zung, 1971) in raven depresije z Edinburško lestvico depresije (Edinburgh Postpartum Depression Scale (EPDS) (Koprivnik in Plemenitaš, 2005). Psihosomatsko stanje smo analizirali z lastnimi konstruiranimi vprašanji glede doživljanja poroda, duševnega doživljanja telesnih težav v nosečnosti ter izpostavljenosti intenziteti stresorjem v zvezi z življenjsko situacijo v zadnjem letu. S tremi modeli linearne regresije smo analizirali povezave med demografskimi, socialnimi in navezovalnimi spremenljivkami in izbranimi kazalci (depresivnostjo, anksioznostjo in strahom pred porodom). Z univariatno logistično regresijo smo testirali povezave med demografskimi, socialnimi in drugimi variablami ter poporodno depresijo prvesnic. Slednjo smo merili z EPDS 10 točk ali več. Rezultati: V tretjem trimesečju smo pri bolj izobraženih prvesnicah in pri tistih z višjo stopnjo čustvene podpore sodelavcev ugotavljali nižjo raven anksioznosti (medtem ko so ostali prediktorji v modelu konstantni). Od vseh prediktorjev v modelu sta bili le navezovalna anksioznost in pa čustvena podpora sodelavcev značilno povezani z nivojem depresije. Navezovalna anksioznost v tretjem trimesečju je bila pomembno povezana z vsemi tremi kazalci duševnega zdravja (nivojem depresije, anksioznosti in strahom pred porodom). Pri 16% (25/156) prvesnic je bilo tveganje za depresijo povišano v zadnjem trimesečju (EPDS  10) in pri 16,2% (27/166) 6 tednov po porodu. Povečano tveganje za poporodno depresijo (PPD) je bilo povezano z nivoji depresivnosti med nosečnostjo, nivoji anksioznosti med nosečnostjo in po porodu, anksioznostjo v partnerskem navezovanju v zadnji tretjini in po porodu in pa povišanim stresom zaradi izgube zaposlitve ali neuspešnim iskanjem zaposlitve v zadnjem letu. Podpora sodelavcev v zadnjem trimesečju je bila zaščitni dejavnik oz. povezana z manjšim tveganjem za PPD. EPDS po porodu pa je bil višji pri bolj izobraženih in bolj anksioznih nosečnicah. Zaključek: Rezultati nakazujejo, da je med obravnavanimi spremenljivkami anksioznost v partnerskem navezovanju lahko ključni kontekstualni dejavnik pri doživljanju anksioznih in depresivnih simptomov v tretjem trimesečju in tudi pomemben dejavnik pri nastanku poporodne depresije. Z usmerjenimi terapevtskimi pristopi je navezovalna anksioznost dostopna modifikaciji. Vključitev oz. upoštevanje stilov navezanosti med partnerjema se lahko izkaže uporabno tudi pri antenatalnem presejanju za poporodne simptome depresije, hkrati pa bi naši rezultati lahko pripomogli k oblikovanju intervenc za zmanjševanje depresivnih simptomov v obporodnem obdobju. Zato je pomembno, da bi PPDS obravnavali v kontekstu individualnih, pomembnih bližnjih in s stresom povezanih dejavnikov. Stres, povezan z zaposlitvijo, pa je pomemben dejavnik, ki bi ga v sodobni obravnavi žensk, ki prvič rojevajo tudi morali upoštevati.

• Language: Slovenian
• Keywords: poporodna depresija, anksioznost, strah pred porodom, partnerska navezanost, prvesnice
• Work type: Doctoral dissertation
• Organization: MF - Faculty of Medicine
• Year: 2019
• PID: 20.500.12556/RUL-111846
• COBISS.SI-ID: 302916864
• Publication date in RUL: 16.10.2019

Secondary language

• Language: English
• Title: Individual and contextual protective and risk factors of primiparas' mental health in pregnancy and postpartum

Abstract

Background: Depression, anxiety and fear of childbirth during pregnancy have numerous consequences for women and their developing offspring. For a significant proportion of women, postpartum depression (PPD) is the first mood episode in their lives, yet its aetiology still remains unclear. Insecure attachment in close adult relationships is considered to be a risk factor for depressive symptoms. In Slovenia we lack an analysis of the complex connection of primiparas’ main mental health risk factors to the individual and contextual factors, with an emphasis on intimate attachment or regarding other important interpersonal relations in the crucial time period of peripartum. Study aim: This study aimed to gain further insight into the risk factors for postpartum depression symptoms (PPDS) of nulliparas during the third trimester of pregnancy until 6 weeks postpartum regarding the main demographic and important contextual–relational factors, with an emphasis on partner attachment. Hypothesis: We hypothesized that for nulliparous women there would be a significant prediction of levels of anxiety, depression and fear of childbirth scores in the third trimester of pregnancy and prediction levels of depression postpartum by prediction variables (nulliparas’ chosen individual and contextual factors). Methods: A group of 325 nulliparas in the third trimester of pregnancy was enrolled in a childbirth preparation program. The following instruments were applied: Experiences in Close Relationships-Revised, the Edinburgh Postpatum Depression Scale, the Zung Anxiety Scale, and a questionnaire regarding fear of childbirth. Three separate multiple linear regression models were built to explore the associations between demographic, social and attachment variables and mental health functioning. In the second analysis, 181 nulliparas in the third trimester of pregnancy were included. Univariate logistic regression was used to test the association between demographic, social, environmental, personality and attachment variables and PPD of nulliparas (EPDS  10). A multiple linear regression model was built with the postpartum EPDS as a dependent variable. Results: 16% (25/156) nulliparas were evaluated as being at risk for depression (EPDS  10) in the last trimester and 16.2% (27/166) at six weeks postpartum. During the third trimester, highly educated nulliparas and those with a higher level of co-workers’ emotional support experienced a lower level of anxiety when other predictors in the model were held constant. Of all the predictors in the model, only attachment anxiety and co-workers’ support were statistically significantly associated with the level of depression during the third trimester of pregnancy. Attachment anxiety during pregnancy was significantly associated with all three mental health indicators (level of depression, anxiety and fear of childbirth). In the postpartum period, increased risk for developing PPDS was associated with depression level during pregnancy, anxiety levels during pregnancy and postpartum, intimate-partner-attachment anxiety during pregnancy and postpartum, and elevated stress due to loss of employment or an unsuccessful search for employment in the previous year. Support from co-workers in the last trimester of pregnancy was a beneficial factor for PPD. The EPDS after giving birth was higher for more educated and more anxious primiparas. Conclusions: The results of our study suggest that intimate attachment anxiety could be a key contextual factor for mood and anxiety mental health functioning during the third trimester of pregnancy and an important factor for PPDS development. With appropriate interventions, anxious attachment style is accessible to change. The results suggest that PPDS should be evaluated in the context of individual, important relational and stress-connected factors. The inclusion of attachment styles in assessments of perinatal depressive disorders might prove useful in antenatal screening for high risk of PPDS. Our results could facilitate the formulation of interventions for reducing antenatal depressive symptoms. Work- and career-related stress is an important factor that should be taken into account by experts who deal with nulliparas’ mental health.

• Keywords: postpartum depression, anxiety, fear of childbirth, partner attachment, nulliparas