The bloom is (slightly) off the rose: the motherhood effect on psychological functioning in successive pregnancies

Abstract

Objective:

To examine the maternal psychological state during the course of two successive pregnancies.

Methods:

The sample consisted of 73 women drawn from a larger maternal-fetal cohort that participated during two pregnancies. Women completed self-report psychological questionnaires at 24, 30, and 36 weeks gestation to index maternal depressive symptoms, trait anxiety, and pregnancy hassles and uplifts. Analyses examined stability of maternal symptoms across successive pregnancies in the same women. .

Results:

Antenatal symptoms of depression and anxiety exhibited strong intra-individual stability between successive pregnancies. Mean differences in maternal symptoms were not detected for either at 24, 30 or 36 weeks gestation, excepting elevated anxiety symptoms at the mid-point due to greater fluctuation in maternal anxiety during the prior pregnancy. Subsequent pregnancies were associated with less intense uplifting feelings about the pregnancy on each measurement occasion.

Conclusions:

Findings suggest marked consistency in maternal psychological orientation across subsequent pregnancies, though parity also plays a role in the maternal experience.

Introduction

Pregnancy and the postpartum period are accompanied by changes in emotional state, both positive and negative [1]. Although much of the research literature has focused on psychological hazards of pregnancy, recent national estimates suggest lower rates of severe psychological distress among pregnant (4.8%) and postpartum women (5.4%) relative to nonpregnant/non-postpartum women ages 18 to 44 (7.4%) [2]. Nonetheless, pregnancy is often a key event in women’s lives and characterizing the natural history of maternal prenatal and postnatal psychological functioning contributes to fuller understanding of women’s lives. Prior research to date has largely focused on measuring psychological functioning in a single pregnancy. One exception to this is a single study documenting stability in postpartum depressive symptoms following two pregnancies [3]. Little is known about the association of maternal psychological state in the antenatal period across successive pregnancies.

Among studies that have examined psychological state in one pregnancy, most [3], but not all [4] existing prospective studies have found that depressive symptoms are generally stable (i.e., consistent in rank-ordering among individuals) when assessed more than once. Anxiety symptoms have been shown to be stable as well [4, 5], as have pregnancy-specific hassles [1]. A handful of studies have shown stability persists to the postnatal period; one study revealing stability in maternal symptoms of depression and anxiety from the prenatal period through eight months postpartum [6], and in a second, independent sample that stability of maternal symptoms and depression and anxiety continues through two years postpartum [7]. In contrast to measures of psychological distress, even fewer studies have examined stability of maternal well-being in pregnancy. One report suggests pregnancy-specific uplifts are also stable [1].

However, maternal psychological state during the course of pregnancy may depend on childbearing experience. A single longitudinal study evaluated changes in psychological functioning over time between nulliparous and multiparous women [7]. Results revealed a “motherhood effect”. That is, when accounting for parity, psychological distress during pregnancy was elevated in women with other children, yet over time it decreased such that by two years postpartum it met the rising levels of distress expressed by first time mothers. Although these findings suggest that women with and without children respond affectively to pregnancy differently, it remains unclear whether these between group results translate to successive pregnancies of the same woman. Here we leverage prospective multi-cohort data with a subset of repeat participants to examine stability of maternal psychological orientation during the course of two successive pregnancies.

Methods

Participants

A sub-sample of 73 women who participated in a research program focused on maternal-fetal functioning and development during two pregnancies was drawn from a larger cohort. At the initial pregnancy, women were relatively mature (M = 30.7 years, SD = 3.5), educated (M = 17.4 years, SD = 1.6) and married (n = 73, 100%). In each instance of participation, women carried low-risk singleton pregnancies resulting in normal birth outcomes (n=146 infants; GA: M = 39.3 weeks, SD = 1.1; 5-min Apgar: M = 8.9, SD = 0.7). Sample characteristics of this sub-sample are comparable to the larger cohort [8]. Pregnancies were separated by approximately 3 years (subsequent pregnancy M maternal age = 33.5 years, SD = 3.7). For the majority of women (n= 56, 77%) the first study participation was their first pregnancy; the subsequent pregnancy was the next pregnancy almost exclusively (n = 71, 97%).

Procedure

Longitudinal designs were implemented for all cohorts; a full description of the antenatal protocol is provided elsewhere [8]. For most cohorts, data were collected three times, corresponding to 24, 30, and 36 weeks gestation. On each occasion, women completed a series of self-report psychological questionnaires.

Measures

Depressive symptoms:

Depressive symptoms were assessed with the 10-item Edinburgh Postnatal Distress Scale (EPDS) [9] or the 20-item Center for Epidemiologic Studies Depression Scale² (CESD) [10]. Higher scores indicate more depressive symptoms. To facilitate comparability, each measure was Z-scored and pooled for use in the analyses.

Trait anxiety:

Trait anxiety (i.e., persistent or enduring aspects of worry) was assessed with the 20-item Spielberger State-Trait Anxiety Inventory, Form Y2 (STAI Y-2) [11]. Higher scores indicate more symptoms of anxiety.

Pregnancy hassles & uplifts:

The Pregnancy Experiences Scale (PES) measures maternal exposures to daily, ongoing uplifts and hassles specific to pregnancy on a 4-point Likert scale; either the 41-item original PES [1] or the 10-item brief PES [12] was administered depending on cohort. Item responses were averaged to derive perceived intensity of hassles and uplifts, with higher values reflecting greater intensity. Intensity (rather than frequency) of hassles and uplifts was selected because it was comparable between the brief and full version of the PES.

Statistical Analyses

Pearson correlations were used to examine stability across repeated measures of psychological functioning. Due to planned differences in study design by cohort, there was variation in available paired psychological data between initial and subsequent pregnancies at the three gestational ages (ns range = 19 to 69). Hierarchical linear modeling (HLM) via the Mixed procedure in SAS (Version 9.4) was used to characterize differences in the change in maternal psychological symptoms over the course of pregnancy and mean level of symptoms. This analytic approach accounts for dependency (i.e., expected correlation) in repeated measures data that exists since the same group of women completed maternal report of depressive and anxiety symptoms and pregnancy specific hassles and uplifts on three occasions in two successive pregnancies. In addition, HLM utilizes restricted maximum likelihood (REML) to account for missing data thereby maximizing statistical power by including all cases. Model contrasts tested differences in maternal psychological distress and well-being measures between pregnancies, both at select cross-sections of gestational ages (24, 30, 36 weeks) and over time.

A sensitivity analysis was conducted constraining the first instance of participation to women who were nulliparous (77%). The findings were unchanged; therefore, to retain the entire subset of women with successive pregnancies we report results using the full sample.

Results

Cross sectional stability in maternal psychosocial functioning between successive pregnancies

Correlations conducted between the initial and subsequent pregnancy revealed high stability in mean levels of depressive symptoms, rs (dfs range 34 to 48) = .52 to .66, ps < .01, trait anxiety, rs (17 to 20) = .67 to .84, ps < .01, and intensity of pregnancy hassles, rs (35 to 65) = .44 to .66, ps < .01, at each of the three gestational age periods. In contrast, stability for more positive impressions of pregnancy, as assessed by the intensity of pregnancy uplifts, was significantly associated between initial and subsequent pregnancies only at 36 weeks gestation, r (37) = .39, p <.05. Correspondence in pregnancy uplifts across pregnancies did not attain significance earlier in gestation, ps = .35 and .13, at 24 and 30 weeks respectively.

Gestational trajectories of maternal psychosocial functioning between successive pregnancies

Table 1 presents modeled means and standard errors for each psychosocial measure over time and by pregnancy. Overall, depressive symptoms significantly increased within pregnancy, β = 0.14, SE = 0.05, t = 3.32, p < .01. However, there was no difference in this pattern of change between successive pregnancies, ps = .23 to .82; depressive symptoms increased similarly near term in both the initial and subsequent pregnancy.

Table 1.

Modeled means and standard error of maternal psychosocial functioning by pregnancy^a

	First followed pregnancy			Second followed pregnancy
	G1 M (SE)	G2 M (SE)	G3 M (SE)	G1 M (SE)	G2 M (SE)	G3 M (SE)
Depressive symptomsb	0.01 (0.14)	0.01 (0.12)	0.42 (0.15)	−0.08 (0.14)	−0.04 (0.13)	0.15 (0.14)
STAI – Trait	32.46 (1.20)	30.74 (1.20)	33.02 (1.23)	32.83 (0.99)	33.47 (0.99)	33.13 (0.96)
PESIH	1.34 (0.04)	1.32 (0.04)	1.37 (0.04)	1.29 (0.04)	1.34 (0.04)	1.32 (0.04)
PESIU	2.18 (0.06)	2.17 (0.06)	2.22 (0.06)	1.94 (0.06)	1.95 (0.06)	1.90 (0.06)

^aMeans reported in the table are derived from HLM models and are not raw.

^bDepressive symptoms were assessed either by the EPDS or CES-D. To facilitate comparability, each measure was Z-scored and pooled for analysis. Modeled z-scores are reported here; higher scores indicate more depressive symptoms.

Figure 1 depicts a significant difference in maternal trait anxiety symptoms over time by pregnancy. Women reported more variable anxiety in the initial pregnancy, such that anxiety symptoms declined from 24 to 30 weeks (β = 2.36, SE = 1.23, t = 1.92, p = .06) and rose from 30 to 36 weeks (β = −2.62, SE = 1.32, t = −1.99, p < .05) in comparison to the subsequent pregnancy where trait anxiety symptoms exhibited stability. This difference in the trajectory of trait anxiety between pregnancies resulted in significantly lower mean trait anxiety in initial pregnancies at 30 weeks gestation, (β = −2.73, SE = 1.14, t = −2.40, p < .05).

Figure 1:

STAI trait anxiety measured at 24, 30, and 36 weeks gestation fluctuates in the initial pregnancy but remains stable in the subsequent pregnancy.

Women consistently reported a similar intensity of uplifting feelings over the course of gestation, β = 0.01, SE = 0.02, t = 0.07, p = .94 in both pregnancies. However, data depicted in Figure 2 indicate a significant difference in the level of uplifting feelings; women reported a greater intensity of uplifting feelings during the initial pregnancy, β = 0.24, SE = 0.08, t = 3.02, p < .01, compared to the subsequent pregnancy at each gestational age. This finding was limited to pregnancy uplifts; the intensity of pregnancy hassles was not different between pregnancies over time, ps = .11 to .13 or at any gestational age, ps = .33 to .54.

Figure 2:

The intensity of pregnancy uplifts does not change from 24 weeks through term gestation, but is higher for the same women during the initial pregnancy relative to the subsequent pregnancy on all measurement occasions.

Discussion

Maternal report of feelings of psychological distress, including depressive symptoms, anxiety and pregnancy-specific hassles, showed strong correspondence between successive pregnancies, suggesting that the maternal response to pregnancy is primarily driven by more general features of maternal psychological orientation. In contrast, attribution of the uplifting aspects of pregnancy did not show significant stability until near the end of pregnancy (i.e., 36 weeks) and the magnitude of the correlation was much lower than for indicators of distress. Comparisons between initial and subsequent pregnancies confirm prior between-subjects studies documenting a motherhood effect in maternal psychological functioning in pregnancy for some measures but not for others.

The earlier report found that nulliparous women reported greater intensity of pregnancy uplifts [7]; here we also report that women reported greater intensity of pregnancy uplifts with the initial pregnancy, which was the first pregnancy for the majority of participants. Experiences mothers perceive as uplifting, including feeling fetal movement, thinking about the baby’s appearance, and planning a nursery, may yield more intense positive feelings in first and/or earlier pregnancies due to novelty and anticipation of motherhood. A prior report showed that first-time expectant mothers experience greater antenatal attachment [13]. First time mothers may find developing new feelings of parental love and protection particularly uplifting [14]. In contrast to the earlier report [7], and perhaps surprisingly, multiparous women do not report a greater intensity of hassles with a subsequent pregnancy, suggesting that the increased demands of caring for existing children may not be the primary source of reported hassles.

There were modest differences in the trajectory of maternal trait anxiety which took a small but significant dip at the beginning of the third trimester during the initial pregnancy. This may coincide with the reassurance of fetal well-being and maternal feelings of physical robustness, followed by an increase in anxious feelings with impending labor and delivery [15]. Although the difference at 30 weeks was significant, maternal anxiety levels were more similar than different in successive pregnancies based on the earlier and later values. Nonetheless, this result supports an earlier between subjects finding of a trend towards lower trait anxiety in nulliparous women detected at 28 weeks gestation [7]. In contrast, we found similar depressive symptoms across pregnancies in the same woman whereas between-subject results have shown having more children was associated with more depressive symptoms [7].

Generalizability of these findings is limited by the nature of this low-risk sample, which represents healthy women with uncomplicated pregnancies. Thus, the current analysis may describe lower levels of psychological distress than what is normative in a high-risk clinical sample. Further, in utilizing a subset of women who participated with two successive pregnancies and reliance on self-report measures of symptoms we are mindful that as volunteers women who opt for repeat study participation may presumably be unique. Although, to this end, we did not detect sociodemographic differences in maternal age or education level between the subset and larger cohort. Finally, the initial pregnancy was the first pregnancy for the majority of the sample. Following a sensitivity analysis we included a number (n=17) of women for whom the initial pregnancy was not their first pregnancy. Given that the current findings showed measures of psychological distress were highly consistent across pregnancies interpretation of the results is likely unaffected. However, in the context of the finding that uplifting feelings were lower in subsequent compared to initial pregnancies, it is important for future work to further disentangle how increasing parity specifically impacts positive emotions in the antenatal period.

Prospectively reported antenatal psychological data across pregnancies in the same woman are rare. This sample offers preliminary support that antenatal psychological distress exhibits marked stability, perhaps across the span of childbearing years. Prior depressive and anxiety symptoms and pregnancy-specific hassles may be a valuable indicator of risk for antenatal maternal mental health in subsequent pregnancies; even, as evidenced in the current sample, in uncomplicated pregnancies. Given that greater intensity of uplifting feelings in first-time mothers may be normative, the lack of these feelings may serve as a risk marker for suboptimal maternal mental health in the postpartum period in addition to traditional measures of psychological distress.

Biography

Kristin Voegtline, Ph.D. is an Assistant Professor of Pediatrics at the Johns Hopkins School of Medicine. She holds a joint appointment in the Department of Population, Family, and Reproductive Health of the Johns Hopkins Bloomberg School of Public Health. Her research is focused on the organizational effects of the prenatal environment on fetal and infant development. She is particularly interested in sex differences in vulnerability to early exposures.

Sara Johnson, Ph.D. is an Associate Professor of Pediatrics at the Johns Hopkins School of Medicine. She also holds joint appointments in the Department of Population, Family of Reproductive Health and the Department of Mental Health in the Johns Hopkins Bloomberg School of Public Health. Her research is focused in two related areas: first, understanding and disrupting intergenerational mechanisms in the transmission of health inequalities, and second, elucidating the biological pathways by which chronic stress and adversity shape brain and behavioral development from the fetal period through adolescence.

Ruthe Huang, B.A. is a graduate student in the Department of Biostatistics at Johns Hopkins School of Public Health. Her research interests lie in the application of longitudinal methods to evaluate trajectories of fetal and child health. She is especially interested in survival analysis, Bayesian methods, and data science applications.

Janet DiPietro, Ph.D. is the Vice Dean for Research and Faculty at the Johns Hopkins Bloomberg School of Public Health and a Professor in the Department of Population, Family, and Reproductive Health. As a developmental psychologist, her research centers on understanding the origins of human development, the interface between individual differences in development and physiology, and the implications of the prenatal period for postnatal life. Her research program, which has been ongoing for over 20 years, extends this interest to the human fetus.