“I am the worst pregnant woman ever”: A mixed-method study of the nature of psychological distress during pregnancy

Abstract

Pregnancy constitutes a major life event that confronts women with unique physical, social, economic and psychological adjustments. Epidemiological evidence suggests that the prevalence and severity of most common mental health disorders (such as depressive and anxiety disorders) during pregnancy are not different from those in the population of non-pregnant women. However, the mental health state of pregnant women has received considerable clinical and scientific attention because of its suggested influence on the pregnancy outcome, the baby, and the future child. There is emerging evidence that experiencing antenatal distress may lead to suboptimal birth, adverse birth outcome, impaired bonding with the newborn, and postnatal depression. However, little is known about the mechanisms of such relationships, and about the nature of experiencing antenatal distress. This program of work is concerned with investigating the nature of pregnancy distress. The aims of this thesis are two-fold: to explore the experiences of antenatal distress in the Australian and New Zealand context; and to examine the implications of such experiences both for the mother herself and her baby. Using a mixed-method approach within a critical realist framework, this thesis consists of a comprehensive review of the existing literature, a longitudinal psychosocial survey, and in-depth qualitative interviews. This thesis begins with an outline of the research problem and sets the scene by providing the theoretical and methodological assumptions that underlie the design and the conduct of this thesis. In introducing this work, I argue that it is important to draw from a mixed-methodology scholarship grounded in feminism and critical realism to ensure a multi-faceted understanding of such complex phenomena as pregnancy and distress. I then position my research within a background of the existing literature, and pinpoint the gaps which this thesis aims to address. Starting with an epidemiological systematic review, I explore the link between antenatal distress and preterm birth, followed by a meta-synthesis of the qualitative literature that has examined the experience of antenatal distress. First, I suggest that direct causal relationships between antenatal distress and adverse birth outcomes cannot be established in a conclusive way, and secondly I argue that such assumptions can be problematic for women as the experiences of antenatal distress involve a complex journey. I then suggest that pregnancy distress entails a process similar to that of grief and loss as a result of women’s inability to situate their experience within the good and perfect mother discourse. The empirical section of this thesis draws on data I collected both via an online survey and through interviews and is presented in three consecutive studies. The online survey, which was completed by over 290 eligible pregnant women from Australia and New Zealand, consisted of various psychosocial questionnaires administered at three time points (twice during pregnancy and once after birth). This longitudinal data formed the basis for the first empirical study which explored the psychosocial predictors of antenatal distress. In this study I conclude that it is a woman’s overall sense of coherence that predetermines her distress during pregnancy. In order to advance the understanding of the meanings that women ascribed to their experience, and how these affected their ‘at odds’ perceptions of motherhood, I then present the findings from a qualitative study with 18 Australian women who reported pregnancy distress. Together, these studies point to the need to develop a more general framework for understanding antenatal distress allowing for factors such as global sense of fitting into the world, social support and relationships with others, embodied experiences, and cultural meanings around good mothering. The third and final empirical study re-examines the relationship between psychological distress during pregnancy and adverse birth outcomes, suggesting that maternal antenatal distress is not directly linked with adverse birth. This concluding work provides a reassuring message for women who feel emotionally vulnerable during their pregnancy that, despite their distress, they can still achieve an unproblematic birth. The empirical section suggests that there is a broad and contextualized framework within which pregnancy distress needs to be understood, involving both personal characteristics, past experiences, medical predispositions and factors, related to the intersectionality of social, economic and political processes. In closing, I draw together the methodological, theoretical and practical findings of this thesis. I highlight the implications of the way antenatal distress has been understood, theorized and managed in view of medicalization of mental health, pregnancy, stigma, and the cultural imperatives around good mothering. Together the findings of this thesis contribute to deeper understanding of both the multiplicity and the uniqueness of the experience of pregnancy distress; a phenomenon which involves series of individual, biological, psychological, and relational aspects, all occurring in a specific cultural context. This thesis presents important new directions about the ways antenatal distress can be understood, and approaches towards a well-informed and meaningful provision of care.