The ‘ordinary miracle’ of pregnancy and birth is a time of enormous physiological, social and psychological change for women. How a woman and her significant others adapt to the changes in this period can influence the woman’s adjustment and her chance of developing mental health difficulties. This matters for the woman, but it also matters for her baby and for the beginnings of their relationship.
Factors influencing the transition to motherhood
The transition to motherhood begins antenatally and is influenced by an array of factors, such as the life circumstances of the parents, the social environment, and the circumstances of conception. It is also influenced by the level of support provided by the woman’s partner and family, as well as the physical health of the mother and her unborn baby. The mother’s experiences within her family of origin, her past or current mental health issues and any current or unresolved conflict, loss or trauma can also affect, and sometimes disrupt, this transition (Mares, Newman & Warren, 2011).
The perinatal period is a time of enormous change and opportunity. It is also the period when women are most likely to develop mental health difficulties. Psychologists can have an important role providing mental health treatment in this period, which benefits the mother, her partner and of course her baby. Yet, mental health difficulties are only one end of a continuum of adjustment. While not every pregnant woman develops mental health difficulties, every pregnant woman must accommodate and adjust to the baby growing within her. Psychologists can also have an important role supporting adjustment and the psychological work of pregnancy.
The psychological work of pregnancy
During the nine months of pregnancy, the mother begins to imagine the baby she is carrying. Brazelton and Cramer (1990) described pregnancy as the dawning of attachment, a period of rehearsal and anticipation. The mother must also adjust to the changes to her identity, body, relationships and career, as well as prepare for birth, and begin to reconcile the sacrifices associated with becoming a mother. Her relationship with her partner also undergoes substantial change, and, although this can have considerable bearing on adjustment and on the work psychologists undertake, this will not be the focus of this paper.
The psychological aspects of pregnancy evolve alongside the physiological changes. The physiological aspects of pregnancy tend to be the focus of attention, while the psychological aspects of pregnancy and new parenthood tend to receive less consideration. For psychologists working in this area, normative psychoeducation about anxiety, ambivalence and the evolving nature of psychological states in pregnancy can be relieving for many women. When normative psychoeducation is insufficient, this may be the first indication that the woman requires further assessment and treatment.
Previous pregnancy loss can alter the psychological adjustment to pregnancy. Pregnancy loss can take many forms, such as miscarriage and stillbirth, termination, infants born with a disability, prolonged infertility as well as adoption or the removal of a baby. Women may present with heightened anxiety, anger, guilt or shame. In this situation, the woman and her partner may benefit from the opportunity to work with a psychologist to help them grieve past losses while also preparing for the new baby.
The first trimester – adjusting to the idea of pregnancy
The first trimester of pregnancy is the period between conception up until 12-weeks’ gestation. It is a period of marked hormonal and physiological changes, but in the absence of obvious external signs of pregnancy. In this period, women are most likely to experience fatigue and nausea which can cloud or intensify emotional responses. For a woman with constant nausea and vomiting, it can be difficult to feel excited about the pregnancy, and may even intensify ambivalence and questions about continuing the pregnancy. For another woman with a history of miscarriage, the hormonal changes can intensify anxiety about carrying a baby to term. Fetal screening, which is now available in the first trimester, can be reassuring for parents or it may introduce intense anxiety about the baby’s health and development. Threatened miscarriage or previous pregnancy loss can also interfere with imagining the baby-to-be.
Psychologists can support families coming to terms with these experiences, as well as assist them to understand the baby’s cues and communications, and remain emotionally connected to their baby.
The second trimester – the fetus is experienced as separate to the mother
During this phase, the mother feels the baby move for the first time, and the mother may feel more physically comfortable and continues to imagine her baby. Stern (1995) noted that generally between the fourth and seventh months of gestation, imaginings about the baby intensify, are elaborated, and peak around the seventh month. He noted that between the seventh and ninth month, the specificity of these imaginings reduces, and this slight disorganisation creates room for the mother to connect with the ‘real’ baby, as distinct from the baby of her imagination (Brazelton & Cramer, 1990). For psychologists in clinical practice there are several self-report measures which can be used to assess the maternal-fetal relationship (for a review of measures see Brandon, Pitts, Denton, Stringer & Evans, 2009).
Third trimester – preparing for the arrival
In the final months of pregnancy, women typically begin to prepare for the arrival of the baby and shift their attention to the birth, which can evoke intense anxiety. Women are encouraged to consider the practical aspects of delivery and pain-relief options. During this stage, anxieties about something going wrong with the birth and/or their baby may re-emerge.
Labour and birth
It is impossible to capture the range of experiences and reactions that women and their partners can have to the birth of their baby. Parental attributions and experiences during labour and birth contribute to the relationship with the baby, and can shape the meaning of what the baby represents for its particular family.
A difficult or traumatic birth can leave a mother emotionally and physically exhausted. This can sometimes result in a cascade of difficulties with feeding, settling and other mother-infant relationship difficulties. Research suggests that approximately two to nine per cent of women meet criteria for post-traumatic stress disorder (PTSD) following childbirth (Grekin & O’Hara, 2014), and these estimates increase to between 24 and 44 per cent amongst mothers of high-risk infants who require admission to the neonatal intensive care unit (Kim, et al., 2015). (Also, see article on depression in pregnancy and the postpartum period p. 20.)
When the nine months of pregnancy are truncated by premature birth, parents may be left feeling incomplete, unprepared and awash with a variety of anxieties about the health of their baby. Feelings of anxiety about the baby’s health or feelings of guilt for not having carried the baby to term can be carried over into early parent-infant relationships. Other times a birth may be regarded by the medical staff as being routine and successful, but the woman feels it failed to meet her expectations and she felt afraid and out of control. This mother may later present to a psychologist because she is not enjoying motherhood and believes she is failing to meet (her) standards of a good mother. Psychologists can support families coming to terms with these experiences, as well as assist them to understand the baby’s cues and communications, and remain emotionally connected to their baby.
Attachment issues in the transition to motherhood
Attachment issues are woven into the transition to motherhood. As parents begin to contemplate their relationship with the baby, both during pregnancy and later with their newborn, their own attachment (or relationship) history, usually within their family of origin, comes to the fore. During this period, relationship issues can be powerfully reactivated, potentially reworked and transmitted intergenerationally from the mother to her infant. The capacity of the mother to respond sensitively to her baby is at the heart of secure infant attachment. It is well understood that maternal mental health issues can compromise the mother-infant relationship.
Reactivation and reworking of attachment
The mother’s attachment status shapes the way she organises her thoughts, feelings and memories of herself and others in relationship with her. These are Bowlby’s internal working models. Pregnancy and birth can be a period of intense reorganisation of identity, leading to reflections on the way the woman herself was parented. Old attachments can be reactivated as parents consider the relationships they wish to repeat or transform (Stern, 1991).
Intergenerational transmission of attachment
In the transition to motherhood, a woman’s identity shifts from that of a child (dependent upon her parent) to that of a parent (responsible for her own child) (Stern, 1991). In this shift, the woman draws upon her history of identifications with her own mother (or other maternal/parental figures) (Fraiberg, Adelson & Shapiro, 1975). These early memories of being cared for are stored in procedural memory and are often not accessible via narrative. However, they have a marked effect upon development and our capacity to form relationships, and are the relational mechanism underlying the intergenerational transmission of attachment. In an important study, Fonagy, Steele and Steele (1991) found that maternal representations of attachment amongst pregnant women predicted the security of their infant’s attachment at 12 months in 75 per cent of cases. Unresolved loss or trauma can transmit to infants via these specific interactional patterns (Newman, Sivaratnam & Komiti, 2015). Attachment representations can be modified with sufficient alternative relationship experiences, and pregnancy and parenthood often provide an important opportunity for integration of new information and change in internal working models. Thus, psychologists working in the perinatal period can assist women with this transition to ultimately enhance mother-infant relationships, as well as identify early those at risk of relationship difficulties and begin the work of true early intervention.