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Antenatal and postnatal depressive symptoms: Association with quality of mother–infant interaction

https://doi.org/10.1016/j.infbeh.2019.101386Get rights and content

Highlights

  • Mothers with postnatal depressive symptoms (PDS) had lower quality of mother–infant interaction.

  • Maternal sensitivity did not differ if they also presented antenatal depressive symptoms (ADS).

  • Presence of PDS with ADS was associated to an intrusive interaction style and more severe symptoms.

  • Presence of only PDS was associated to a nonresponsive interaction style.

Abstract

Antenatal and postnatal depression are independently associated with an increased risk of adverse infant development. A key linking mechanism is the quality of mother–infant interaction.

Objectives

This study assesses the association between postnatal depressive symptoms (PDS) and their severity, with the quality of mother–infant interaction and compare the quality of mother–infant interaction and severity of the symptoms depending on the presence or absence of antenatal depressive symptoms (ADS).

Methods

observational study in 177 psychosocial risk mother–infant dyads from Chile (infant aged 2–12 months).

Results

Mothers with PDS had lower maternal sensitivity and a more intrusive/controlling style than mothers without PDS, although the severity of the symptoms was not associated with lower maternal sensitivity. Maternal sensitivity did not differ in the postnatal depressed mothers depending on the presence of ADS, although the mothers differed in interaction style and the severity of symptoms. Mothers with ADS and PDS presented with a predominant intrusive/controlling interaction style and more severe depressive symptoms, whereas those with only PDS presented with a predominant nonresponsive/passive interaction style and reduced severity of symptoms.

Conclusions

The results corroborate the need to offer treatment and dyadic interventions to antenatal and postnatal depressive mothers and postulate that the presence of antenatal depressive symptoms may influence the subsequent mother–infant interaction style and greater severity of symptoms.

Introduction

Perinatal mental health problems are a significant challenge for world public health, with perinatal depression being the most frequent, defined as a major depressive episode with peri-partum onset, i.e., symptom onset during pregnancy or in the four weeks following delivery (American Psychiatric Association, 2013). Perinatal mental health problems are associated with a significant cost burden on children's health, education, and social services (Bauer et al., 2015). A recent meta-analysis shows a worldwide prevalence of perinatal depression of 11.9% (Woody, Ferrari, Siskind, Whiteford, & Harris, 2017), with an important heterogeneity among different countries, increasing in middle and low-income countries, nations with significantly higher rates of income inequality, and with populations of greater psychosocial risk (Field, 2010; Hahn-Holbrook, Cornwell-Hinrichs, & Anaya, 2018).

Maternal depressive symptoms often begin in the antenatal period (Raskin, Easterbrooks, Lamoreau, Chie Kotake, & Goldberg, 2016; Wisner et al., 2013). The reported prevalence of antenatal and postnatal depression is similar (Woody et al., 2017), and both conditions are independently associated with an increased risk of adverse infant development, affecting the cognitive, emotional, and behavioral development of children (Grace, Evindar, & Stewart, 2003; Pearson et al., 2012). The literature demonstrates that antenatal depression is a strong predictor for postnatal depression (Ko, Rockhill, Tong, Morrow, & Farr, 2017; Toohey, 2012) and for deficits in child development (Figueiredo & Conde, 2011; Munoz, Agruss, Haeger, & Sivertsen, 2006). In addition, some of the effects described in the children of depressed mothers may be explained by the presence of depressive symptoms during pregnancy, independent of the presence of postnatal symptoms (Deave, Heron, Evans, & Emond, 2008; Stein et al., 2014). Furthermore, depression during the peripartum period has been associated with anxiety symptoms and parental stress, which negatively influences the dyadic adjustment (Rollè et al., 2017; Vismara et al., 2016). The onset of depressive symptoms in the mother would be influenced by their own levels of anxiety and parental stress.

Given the high prevalence of perinatal depression and its negative impact on child development and health, it becomes relevant to understand the possible underlying mechanisms to explain its effect on child socioemotional development. Various mechanisms have been described, including genetic factors, epigenetic factors, and quality of mother–infant interaction, the latter being considered the most important mechanism over the long term and the key linking mechanism (Murray, Cooper, & Fearon, 2014; Stein et al., 2014).

Considering that the interactions between the primary caregiver and the infant compose the basis of the infant’s psychological development and are modulated by the capacity of the adult to respond to the child's signals (Schore, 2002), the quality of mother–infant interaction could provide a comprehensive framework with which to explain the effects of postnatal depression on child development. Depressive mothers have difficulties reading the emotionally communicative signals of their babies and responding to them adequately. This difficulty translates into frequent, prolonged, and rarely resolved disagreements, which consequently generate chronic experiences of negative affect in the interaction between the mother and the child (Tronick & Reck, 2009), with a subsequent decrease in maternal sensitivity, understood as the mother’s ability to respond to her child’s psychosocial and emotional needs (Crittenden, 2006; Marrone, 2001).

The impact of postnatal depression on infants is at least partly mediated through the effect of depression in reducing maternal sensitivity, decreasing the quality of the concurrent interaction (Klein, Kotov, & Bufferd, 2011; Leerkes et al., 2015; Musser, Ablow, & Measelle, 2012). Some studies report in mothers with postpartum depression less adequate styles of mother-infant emotion regulation, "excessive" or "insufficient" interactive contingency and difficulties in responding to the mental states of their babies (Beebe et al., 2008; Bigelow et al., 2018; Riva Crugnola et al., 2016).However, the mechanisms underlying the effect of antenatal depression in later mother–infant interaction are less clear, and it has been suggested that antenatal depression may disrupt the initial development of maternal sensitivity (Pearson et al., 2012).

In addition to being sensitive, optimal mother–infant interactions are also characterized by non-intrusive maternal behavior. Depressed mothers with equivalent levels of depression have different ways of interacting with their children. Two groups of interaction styles have been described: one intrusive/controlling and the other nonresponsive/passive (Field, 2010; Murray et al., 2014; Riva Crugnola et al., 2016; Tronick & Reck, 2009). Nonresponsive/passive mothers are emotionally disconnected from their children, have a flat affect, and have greater difficulties stimulating their children. Mothers described as intrusive/controlling behave in an extremely active and overstimulating manner and may become hostile, and their predominant affect is irritability. The literature describes different long-term outcomes in children according to the predominant mother- infant interaction style. Infants of nonresponsive/passive mothers present lower Bayley mental development scales scores than infants of intrusive mothers at one year of age (Jones, Field, Davalos, & Pickens, 1997) and more long-term internalizing and cognitive problems (Murray, Hipwell, Hooper, Stein, & Cooper, 1996; Wagner, Propper, Gueron-Sela, & Mills-Koonce, 2016). The children of intrusive mothers, conversely, have greater externalizing symptoms and behavioral problems (Mäntymaa, Puura, Luoma, Salmelin, & Tamminen, 2004; Morrel & Murray, 2003).

Other factors that may interfere with how depressed mothers interact with their children are the severity and chronicity of the symptoms. Mothers with chronic depressive symptoms present fewer positive feeding and face-to-face interactions with their infants (Weinberg et al., 2001), and their children experience greater long-term negative effects (Olhaberry et al., 2014; Stein et al., 2014). Studies have found that more chronic and severe maternal depression is associated with higher levels of externalizing symptoms, internalizing symptoms, and fewer positive maternal-child interactions (O’Connor, Langer, & Tompson, 2017). Even so, some studies show that even subclinical depression may exert effects on mother–infant interaction (Weinberg et al., 2001).

Although the relevance of perinatal depression has been increasingly studied, there is scant literature on the trajectory of maternal perinatal depressive symptoms, and most studies are cross-sectional and evaluate antenatal and postnatal depression separately (Underwood, Waldie, D’Souza, Peterson, & Morton, 2016). For this reason, the contribution of antenatal depressive symptoms to postnatal symptoms is not completely known (Stein et al., 2014). Studies have reported that mothers who are depressed during pregnancy and continue to exhibit postnatal depression present greater severity and chronicity of symptoms and have poorer treatment outcomes than those who do not present depressive symptoms until after the birth (Wisner et al., 2013). What is lacking in the literature is an examination of the differences in the quality of mother–child interaction or interaction styles depending on the time of onset of depressive symptoms. To better understand the mechanism by which antenatal depression affects the quality of mother–infant interaction in the postnatal period, studies are required that follow the trajectory of symptoms from pregnancy.

Chile is a Latin American country with 17.5 million inhabitants, a gross domestic product of 22,761 dollars per capita, with a high index of income inequality, reflected in a Gini coefficient of 0.45 (OECD, 2019a, 2019b, 2019c). The public health system in Chile serves 70% of the Chilean population, which is accessed through Primary Health Care (PHC). An eight percent of the gross domestic product goes to the health sector (OECD, 2019a, 2019b, 2019c), and within this expenditure, only 2.6% is directed specifically to mental health (MINSAL, Ministerio de Salud de Chile, 2014). Chile leads the world with the highest rates of postpartum depression, with a prevalence of 38% (35–41%), which has been associated with the country’s high-income inequality (Fisher et al., 2012; Hahn-Holbrook et al., 2018,); indeed, the prevalence increases in cases of lower socioeconomic level and greater psychosocial risk, reaching 50% (Jadresic & Araya, 1995). In addition, one study places Chile as one of the countries with higher figures of preschoolers’ behavioral and emotional problems across many societies (Rescorla et al., 2011).

PHC in Chile assesses the presence of psychosocial risk factors during pregnancy to concentrate interventions with this most vulnerable group (MINSAL, Ministerio de Salud de Chile, 2010). These factors include: admission to prenatal care after 20 weeks, less than 6 years of schooling, under 18 years of age, substance use during pregnancy (tobacco, alcohol or drugs), victim of gender violence, conflicts with motherhood, insufficient social or family support, presence of depressive symptoms, and/or other relevant factors detected.

The main aim of this study is to evaluate the association between postnatal depressive symptoms and their severity, with the quality of mother–infant interaction in Chilean psychosocial risk dyads. The secondary aim is to compare the quality of mother–infant interaction and the severity of the symptoms depending on the presence or absence of antenatal depressive symptoms, this aim is of an exploratory type, as there are no research studies on the subject.

It is hypothesized that postnatal depressive symptoms would be associated with a lower maternal sensitivity, with sensitivity decreasing as the severity of symptoms increases. It is also expected that mothers with postnatal depressive symptoms who also had antenatal depressive symptoms would have lower maternal sensitivity, greater severity of depressive symptoms, and different styles of interaction, than mothers with postnatal depressive symptoms without antenatal depressive symptoms.

Section snippets

Participants

A total of 177 mother–infant dyads participated in this study. These women and their babies had attended two PHC centers located in La Pintana County, a peripheral low-income district in Santiago, Chile, between 2013 and 2015. This county has a young population that is heterogeneous in terms of beliefs and ethnicity. Poverty, drug addiction, alcoholism, and teenage pregnancy are perceived by the population as the biggest health problems.

The inclusion criteria were mother–infant dyads with

General characteristics

The mean score on the EPDS was 9.66 (N  = 177, SD = 6.23, range 0–25). Nearly half of the mothers (46.9%, N = 83) presented with PDS (EPDS score ≥ 10), and one-third of these (N = 33) presented with severe postpartum depressive symptoms (EPDS score ≥ 16).

At their first prenatal check-up, half of the mothers had ADS (49.2%, N = 87); of those, nearly two-thirds presented with later PDS (63.2%, N = 55).

Of the total sample, one-third of the mothers (35%, N = 62) did not have ADS or PDS, 18% (N

Discussion

The current study shows a lower quality of mother–infant interaction in mothers with postnatal depression symptoms as demonstrated by a lower maternal sensitivity and higher maternal controlling scores. No association was observed between the severity of depressive symptoms and a decrease in the quality of the mother–infant interaction. Mothers with postnatal depressive symptoms who also had early antenatal depressive symptoms presented with similar maternal sensitivity but with a different

Funding

This study was funded by a Grant: National Health Research Found FONIS Chile, Grant N° FONIS SA12|2089. This study was supported by the Fund for Innovation and Competitiveness (FIC) of the Chilean Ministry of Economy, Development and Tourism, through the Millennium Scientific Initiative, Grant N° IS130005.

Data availability statement

All data are available atthe Open Science Framework (https://osf.io/auqjp/files/).

Compliance with ethical standards

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed Consent was obtained from all individual participants in the study.

Conflict of Interest: The authors declare that they have no conflict of interest.

Hayes et al. (2013).

Declaration of Competing Interest

The authors declare that they have no conflict of interest.

Acknowledgments

We thank to the mothers and infants who participated in this study. We also acknowledge Patricia Lopez, Paula Ramirez and Maria Isabel Moya, who collaborated with the field research.

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