Anxiety-depressive symptoms in the context of the type of attitude to pregnancy of women in the postpartum period

Kuzmina Anna Sergeevna PhD in Psychology Associate Professor, Department of Clinical Psychology, Altai State University 656049, Russia, Altai Krai, Barnaul, Lenin str., 61, office 302 annakuz87@yandex.ru Other publications by this author

Praizendorf Ekaterina Sergeevna ORCID: 0000-0002-9014-8927 Senior Lecturer of the Department of Clinical Psychology of Altai State University 656049, Russia, Altaiskii krai, g. Barnaul, ul. Lenina, 61, of. 302 catherinears@list.ru Other publications by this author

The problem of studying anxiety-depressive symptoms in women in the postpartum period and the features of its relationship with the type of attitude to pregnancy is currently becoming increasingly important and is an important area of research located at the intersection of medicine, perinatal and clinical psychology ^{[4, 9, 12]}. The postpartum period is a new stage in a woman's life, the acquisition of a different female identity, a time of emotional and psychological upheaval, and the course of this period is largely related to the specifics of a woman's attitude during pregnancy to herself and her condition ^{[6, 16]}.

In addition, the psychological health of a woman in the postpartum period and the peculiarities of her emotional background determine the health of the child and the peculiarities of its development. Anxiety-depressive symptoms in the postpartum period are also dangerous due to the risk of postpartum depression, suicidal tendencies and self-harm in women ^{[3, 20, 21]}.

Postpartum depression is one of the most socially significant and common problems that significantly affect the health of the mother and many aspects of her life: the family as a whole, relatives and friends, and especially the child. Analysis of scientific sources indicates that a typical depressive episode is experienced by 10-15% of women worldwide after the birth of a child ^{[5, 23, 24]}. Depressive disorder for women can develop into a significant problem, since adequate help may either be late due to late diagnosis, or it may not be at all, since women quite often do not admit and do not talk about their feelings ^{[10, 15, 17]}.

A woman's behavior and her experiences during pregnancy acquire specificity due to the peculiarities of her personality and attitude to pregnancy. The first pregnancy is often designated as a critical moment in the development of female identity, a certain point of no return to the previous relationship with oneself and the world around ^{[1, 8, 22]}.

Modern trends in the development of psychological science lead to an understanding of the pregnancy period as a special period in a woman's life, focusing on transformational processes associated with lifestyle changes: the social situation of personality development is changing, roles are changing, the circle of people involved in interaction is changing, the whole range of solved problems and opportunities, lifestyle in general ^{[11, 18, 19]}.

In general, today a multidirectional approach to the study of the problems of motherhood is being determined, generalizing various scientific directions. Thus, the fundamental aspects of the interaction of mother and child in early ontogenesis are presented in the works of G.G. Filippova, N.N. Avdeeva, G.V. Skoblo, etc.; A.S. Batuev, A.I. Zakharov, etc. studied the features of the emotional state of pregnant women; the issues of maternal deviant behavior are considered in the works of V.I. Brutman, O.V. Bazhenova, A.Ya. Varga and others; individual personal transformations due to the new parental status were studied by O.A. Karabanova, S.Y. Meshcheryakova and others. In most modern scientific works related to the most important aspects of pregnancy, childbirth and motherhood, the authors rely on foreign psychological concepts as a methodological basis. Freud, K. Horney, J. Bowlby, D.V. Winnikota, M. Klein, M. Ainworth.

Research in the field of neurotic reactions during pregnancy and the postpartum period is also presented in science. Thus, some authors point out that the cause that contributes to the occurrence of postpartum depression is the pain experienced and the stress suffered by J.C. Eisenach, J. Kountanis, S.A. Freedman. There is a tendency to divide neurotic disorders in women into three directions: depressive, anxiety-depressive and depressive with obsessive phenomena, presented in the works of I.A. Kolesnikov, P.P. Balashov, A.B. Smulevich and others I.V. Dobryakov indicates the complexity of diagnosing depression due to the fact that some symptoms of this disorder may be inherent in perfectly healthy women.

In perinatal psychology, there are differences in approaches to choosing the basis of the attitude to pregnancy. In general, the selection of typical variants of the attitude to pregnancy is based on the analysis of the characteristics of the mother's personality's response to her own self, to pregnancy, to the surrounding reality and to the circle of subjectively significant persons and situations in this regard.

G.G. Filippova introduces the concept of the style of experiencing pregnancy. Highlighting 6 styles of experiencing pregnancy ^[21]:

1. Adequate style:

2. An anxious style of experiencing pregnancy:

3. Euphoric style of experiencing pregnancy:

4. Ignoring style:

5. Ambivalent style:

6. Rejecting style.

The central concept of the work is the definition of the type of attitude to pregnancy, which in the methodology of I.V. Dobryakova is determined through the psychological component of the gestational dominant.

I.V. Dobryakov in his works indicates the occurrence of a gestational dominant during pregnancy, which has psychological and physiological components ^[7]. The gestational dominant ensures that all the body's reactions are directed towards creating optimal conditions for the development of the embryo, and then the fetus, for gestation, and then birth and care of the child ^[13]. I.V. Dobryakov defines the psychological component of the gestational dominant as a set of mechanisms of mental self-regulation aimed at preserving pregnancy and creating conditions for the development of the child, forming a woman's attitude to pregnancy and her behavior during this period ^{[7, 14]}.

In his works, I.V. Dobryakov identifies 5 types of the psychological component of the gestational dominant: optimal, hypogestognosic, euphoric, anxious and depressive, which form a unique profile for each woman of the type of attitude to pregnancy, revealed through a set of scales of I.V. Dobryakov's methodology.

With the optimal type of pregnancy, as a rule, is desirable. A woman has a positive attitude to the fact of her pregnancy, promptly gets registered in a women's consultation and fulfills the doctor's recommendations. Such women are confident in their own parental competence, expect childbirth without unnecessary anxiety and gradually rebuild their lifestyle.

With the hypogestognosic type, a woman tries to ignore the somatic changes associated with pregnancy. Such women try not to change their lifestyle, often infringing on the interests of the child.

With the euphoric type of pregnancy, the background of a woman's mood is elevated throughout pregnancy. Such women are happy to change their lifestyle as soon as they learn about pregnancy, require special care and attention from their loved ones, fulfilling all their whims, but when complications arise, the woman is not ready for constructive actions.

Women with an anxious type from the very beginning of pregnancy experience a high level of anxiety and tension, often have pronounced fears, they are constantly worried about the health of the child, his well-being. After giving birth, such women continue to constantly worry about the well-being of the child, to doubt whether she is doing everything right ^[2].

With a depressive type, a woman remains depressed throughout pregnancy, tearfulness, it may seem to her that pregnancy has greatly spoiled her, violated her relationship with her husband. Such women have no idea about the child, but it may seem to them that it will certainly be inferior. They are sure that they will not cope with the role of a mother ^{[4, 7]}.

So, different types of attitudes to pregnancy determine the direction and severity of the reactions of the pregnant woman's body to create optimal conditions for the intrauterine development of the child.  

Thus, there is a problem that consists in the need to resolve the contradiction between the objective need to provide psychological assistance to women in the postpartum period in terms of eliminating the risk of developing anxiety-depressive symptoms and the lack of scientifically sound ways and means of implementing this process.

In connection with the above, it seems significant to study the anxiety-depressive symptoms of women in the postpartum period in relation to the type of attitude to pregnancy.

The aim of the study was to identify the interrelationships of anxiety-depressive symptoms in women in the postpartum period and the type of attitude to pregnancy.

The subject of the study is the anxiety-depressive symptoms of women in the postpartum period.

Scientific novelty of the research. The existence of interrelations between the appearance of anxiety-depressive symptoms in women in the postpartum period and the type of attitude to pregnancy is theoretically substantiated and empirically proven. Qualitative characteristics of differences in anxiety-depressive symptoms and the type of attitude to pregnancy in women with different types of residence and the presence of maternity care were determined.

Research methodology: typology of the psychological component of the gestational dominant I.V. Dobryakova.

An important concept in the work is the concept of the psychological component of the gestational dominant, which is operationalized through a woman's attitude to her pregnancy.

The hypothesis of the study was the assumption that there are differences in the types of attitudes to pregnancy in women in the postpartum period, depending on the type of residence and use of maternity care and the presence of correlations of anxiety and depression with the type of attitude to pregnancy in women in the postpartum period.

Empirical basis of the study: the study was conducted on the basis of the Altai Regional Clinical Center for Maternal and Child Health with women in the early postpartum period. The respondents were 120 women, average age 22.3 ± 8.2. The postpartum period is from one to seven days from the moment of delivery. The questionnaire data revealed the type of residence of women (city and village), the presence of obstetric care (natural childbirth, planned caesarean section, emergency caesarean section).

For a visual representation of the empirical research base, we present a table.

Table 1.

Description of the sample population

Research methods and techniques:

A questionnaire identifying age, marital status, availability of maternity care, type of residence.

Hospital Anxiety and Depression Scale (HADS). The Hospital Anxiety and Depression Scale HADS (The Hospital Anxiety and Depression Scale Zigmond A.S., Snaith R.P.) is designed for the primary detection of depression and anxiety in general medical practice.

The test of a pregnant woman's relationship is TOB(b) (Eidemiller E. G., Dobryakov I. V., Nikolskaya I. M.), which contains three blocks of statements reflecting the following three aspects:

A. The attitude of a woman to herself pregnant.

B. Women's relations in the emerging mother-child system.

B. The relationship of a pregnant woman to the relationship of others to her.

In each block there are three sections in which various concepts are scaled. Each of them is represented by five statements reflecting five different types of the psychological component of the gestational dominant (PCGD). The subject is asked to choose one of them that best suits her condition.

Block A (a woman's attitude towards herself as a pregnant woman) is represented by the following sections:

I. Attitude to pregnancy.

II. Attitude to lifestyle during pregnancy.

III. The attitude during pregnancy to the upcoming birth.

Block B (the relationship of a woman in the mother-child system formed during the nine months of pregnancy) contains sections:

I.                  Treating yourself as a mother.

II. Attitude to your child.

II.               Attitude to breastfeeding.

Block B (the relationship of a pregnant woman to the relationships of others to her) is represented by the following sections:

I.                  Attitude towards me, pregnant, husband.

II.               Attitude towards me, pregnant, relatives and loved ones.

III.            The attitude of strangers towards me, pregnant, strangers. The test is given in full.

As a result of processing the test, an individual profile of the attitude to pregnancy is obtained, which contains five scales that determine the severity of the types of psychological component of the gestational dominant: optimal, hypogestognosic, euphoric. Thus, the test results for each woman include an individual profile reflecting the severity of 5 types of attitudes to pregnancy.

Methods of mathematical and statistical data processing: one-factor analysis of variance ANOVA, Student's T-test, Spearman correlation analysis.

The Student's t-test revealed differences in anxiety-depressive symptoms and types of attitude to pregnancy in women with different types of residence (see Table 2, Fig. 1, 2).

Table 2.

The results of the Student's t-test in women in the postpartum period, depending on the type of residence

Symbols:N is the sample size, M is the arithmetic mean, SD is the standard deviation, p is the significance level, * is the significance level p=0.05.

Figure 1. Comparative analysis of the average values for anxiety symptoms in women in the postpartum period, depending on the type of residence, p= 0.05.

The analysis of Figure 1 showed that rural women are significantly more likely to experience increased anxiety in the early postpartum period. They are experiencing tension, restless thoughts are spinning in their head, they are experiencing excitement and fear, they are extremely concerned about the organization of household life and economy in their absence, they worry and think that something terrible may happen. They are also concerned about the issues of providing medical care to them and the child. Perhaps this may be due to the difficulties of obtaining medical services in rural areas.

Figure 2 shows significant differences in the types of attitudes towards pregnancy in women during the postpartum period, depending on the type of residence.

Figure 2. Comparative analysis of the average values of indicators of the types of attitude to pregnancy in women in the postpartum period, depending on the type of residence, p= 0.05.

The analysis of Figure 2 showed that rural women are significantly more characterized by a hypogestognosic type of attitude to pregnancy, in which women tend to underestimate the importance and seriousness of what is happening to them. After giving birth, they are not inclined to change their lifestyle. Child care, as a rule, is entrusted to other persons (grandmothers, older children). For urban women, the depressive type of attitude to pregnancy is significantly more characteristic, depressive experiences manifest themselves, first of all, in a sharply reduced background of the mood of pregnant women. So, a woman who dreamed of having a child may begin to claim that now she does not want him, does not believe in her ability to raise a healthy child. Women believe that pregnancy has "disfigured them", they are afraid of being abandoned by their husband, they often cry. In severe cases, super-valuable, and sometimes delusional hypochondriac ideas, ideas of self-abasement appear, suicidal tendencies are found in women with high values on the depressive type of attitude to pregnancy scale.

We present the results of a comparative analysis of the presence of anxiety-depressive symptoms and attitudes to pregnancy in women in the postpartum period, depending on the use of obstetric care (natural childbirth, planned cesarean section, emergency caesarean section).

The results of the ANOVA one-factor analysis of variance are presented in Table 4 in Figures 4, 5.

Table 4

Results of single-factor ANOVA in women with different types of use of obstetric care in the early postpartum period

Symbols: F – the strength of differences, p – the level of significance * - the level of significance p= 0.05, ** - the level of significance p= 0.01,

As can be seen from Figure 4, the highest values on the depression scale were obtained in women who gave birth to a child without the use of obstetrics.

Symbols: e – natural childbirth, pks – planned caesarean section, ex – emergency caesarean section

Figure 4. Comparative analysis of the average values of depressive symptoms in women in the postpartum period, depending on the use of obstetric aids, p=0.05

Figure 5 shows higher values on the anxiety scale in women who gave birth to a child without the use of maternity care.

Symbols: e – natural childbirth, pks – planned caesarean section, ex – emergency caesarean section

Figure 5. Comparative analysis of the average values for the indicator of anxiety symptoms in women in the postpartum period, depending on the use of obstetrics, p= 0.05

Women who have undergone natural childbirth are more likely to experience depression and anxiety in the postpartum period, which is due to their high personal responsibility and active participation in childbirth, as well as insufficient psychological preparation for childbirth.

An analysis of the questionnaire data showed that only 16% of women attended prenatal training courses, and most often these are women with planned cesarean section who prepare for childbirth and motherhood more carefully.

Spearman's correlation analysis showed a positive relationship between the anxiety scale and the indicator on the anxiety type of attitude to pregnancy scale (r=0.421; p=0.01) and a negative relationship with the indicator on the optimal type of attitude to pregnancy scale (r=-0.348; p=0.01).

Positive correlations of the depression scale with such scales of types of attitude to pregnancy as anxious (r=0.564; p=0.01), depressive (r=0.462; p=0.01), and a negative relationship with the euphoric type of attitude to pregnancy (r=-0.521; p=0.05) were obtained.

The appearance of anxiety-depressive symptoms in women in the postpartum period is interrelated with the type of psychological component of the gestational dominant. A woman's acceptance of pregnancy, physiological changes associated with pregnancy, a positive emotional background, confidence in her own parental competence contribute to resistance to the development of anxiety-depressive symptoms in women in the postpartum period. Anxious and depressive types of attitude to pregnancy associated with fears, expressed fears, tearfulness contribute to the development of anxiety-depressive symptoms in the postpartum period.

Thus, the following conclusions are made in the work:

1. Anxiety symptoms in the postpartum period are more characteristic of women from rural areas, which may be associated with difficulties in obtaining medical services in rural areas, which increases anxiety about their health and the health of the child. Women who have undergone natural childbirth are more likely to experience depression and anxiety in the postpartum period, which is due to their high personal responsibility and active participation in childbirth, as well as insufficient psychological preparation for childbirth. Women with planned cesarean section are characterized by the lowest level of anxiety-depressive symptoms.

2. Rural women have higher rates of hypogestognosic type of attitude to pregnancy, urban women have higher rates of depressive type of attitude to pregnancy.

3. Anxious and depressive type of attitude to pregnancy, associated with fears, expressed fears, tearfulness are risk factors for the development of anxiety-depressive symptoms in women in the postpartum period. The optimal type of attitude to pregnancy is most favorable for the emotional well-being of women in the postpartum period

The study shows qualitative differences in anxiety-depressive symptoms in women due to the presence of the use of maternity care and the type of residence. Differences in the types of attitudes to pregnancy in women with different types of residence were revealed. The interrelationships of anxiety and depression with the type of attitude to pregnancy in women in the postpartum period are analyzed.

The results of the study demonstrate that the type of attitude to pregnancy is a risk factor for the development of anxiety-depressive symptoms in the postpartum period.

Prospects for further research may be related to the study of differences in anxiety-depressive symptoms in women due to the presence of chronic diseases, complications in childbirth, the presence of children, characteristics of marital relations.

The results of this study may be useful for medical psychologists to organize a program of psychological support for pregnant women in terms of psychological education of women at the stage of pregnancy planning and preparation for childbirth. The results may also be interesting for obstetricians and gynecologists in choosing the optimal ways of interaction in the formation of perinatal compliance in childbirth.