Natalia Pilarska, Nikola Siemińska, Weronika Skonieczna Self-care and risk of postpartum depression

Artykuł jest dostępny na warunkach międzynarodowej licencji 4.0 (CC BY-NC-ND 4.0).

Introduction

Time of crisis – pregnancy in the face of the COVID-19 pandemic and war

According to the data from the report published by the Institute of Psychology of the University of Warsaw (2020), the COVID-19 pandemic has negatively affected the mental health of the majority of respondents aged 18 to 78 (62%). During a pandemic, human social needs are not met, among other things, due to widespread isolation. According to Tomaszewski (1982), this can be defined as a situation of deprivation, which may result in a decrease in both the body’s efficiency and the efficiency of the individual. Data from a report published by the UN (2020) indicate that during the COVID-19 pandemic, there are significantly higher levels of anxiety and depression in various countries. Worldwide, the problem of depression affects as many as 264 million people, and as a result, the number of packages of antidepressants purchased is still significantly increasing. Currently, it is 20.7 million packages a year, which is a millionth increase compared to the previous year (Długosz, 2020). The effects of the pandemic can also be seen in the results of research conducted by Chodkiewicz (2020). They show that alcohol consumption increased during the lockdown: in Poland, as many as 30% of people drank alcohol riskily. Although the diagnosis is not unambiguous, it may be an expression of a reaction to stress (Chodkiewicz, 2020). According to Heitzmann (2020), in the face of a pandemic, people are overly vigilant and their attention is limited only to this problem. In addition, it is a time when the individuals feel a strong fear of them and their family becoming infected, the consequences of which are often exaggerated and even harmful adherence to recommendations regarding disinfection and sterility. With the emergence of the pandemic, the intensification of certain symptoms began to be recorded, i.e. panic attacks, anxiety, as well as certain tendencies to analyze in detail changes in the functioning of one’s body – cough, body temperature or shortness of breath (Heitzmann, 2020). The pandemic is a particularly difficult situation for teenagers and young adults (Pyżalski, 2020; Przybysz, 2021), which is manifested, among others, in the increase in the number of suicide attempts and self-mutilation. In the era of the on-going pandemic, war broke out in Ukraine. Currently, there is a trace number of scientific studies in the field of psychology that would refer to the Russian attack on Ukraine. Current studies suggest that future research should pay special attention to how important life events, including confrontation with war, influence individual beliefs and attitudes (Timmer et al., 2022). The times in which we currently live are important for moral beliefs regarding violence (Timmer et al., 2022), but, as we suspect, also for other aspects of human mental functioning. Appropriate mental health and stress management services are therefore essential to help populations experiencing war and other traumatic events restore homeostasis.

Postpartum depression

Childbirth and motherhood can evoke many emotions of a different nature in women. Mothers have to adapt to their new role, which can be difficult for some of them. One of the mental disorders that may occur after childbirth is postpartum depression (Kossakowska, 2019), one of the predictors of which may be the presence of depression during pregnancy (Ogbo et al., 2018). It affects 10 to 20% of mothers (Kossakowska-Petrycka, Walęcka-Matyja, 2007). During the COVID-19 pandemic, this number increased by 25.7%, although the scale of the problem may be much larger (Davenport et al., 2020). Postpartum depression is a disorder that manifests (within 4 weeks of delivery) with symptoms that meet the criteria for major depression (Diagnostic and Statistical Manual of Mental Disorders. Fifth Edition, 2013). However, it is recognized that the condition may develop within the first year after delivery (Stuart-Parrigo, Stuart, 2014). Its symptoms may include: anxiety, guilt, mood swings, fear of being a bad mother, sleep problems, lack of interest in their environment, difficulty concentrating and making decisions, and thoughts of hurting herself or her child (American Psychological Association, 2008). The ongoing depression of the mother may result in disturbed relations between her and the child, as well as its negative impact on the behavioral, cognitive and emotional development of the child (O’Hara, McCabe, 2013). Mothers in this state have a problem with proper care of their offspring. Activities such as caring for or putting a child to sleep become a challenge for them. Breastfeeding may also be difficult due to avoiding contact with the infant. It is indicated that this way of nutrition is recommended and the healthiest, due to the benefits for the child and mother (Kossakowska, 2018). The inability or unwillingness to breastfeed may have an adverse effect on the parent-child bond and, as a result, on the health and proper development of the infant. Studies have shown functional disorders, such as difficulty eating or sleeping, in infants as young as three months of age whose mothers with postpartum depression struggled to relate to their baby, addressed them and smiled to them less (Righetti-Veltema et al., 2002). Information obtained through various types of interactions between the child and the mother shape its subsequent reaction patterns (Kossakowska, 2019). In a situation where the expectations of the interaction of the child with the mother are disturbed, the child becomes overly vigilant to signals transmitted by other people. As a result, there is also a risk of developing an anxious attachment style (Chrzan-Dętkoś, Kalita, 2019). The consequences of depression apply not only to infancy, but may also extend to childhood or school age. The child may show less creativity in play and lower cognitive performance (Bernard-Bonnin, 2004). Preschool children showed a greater number of internalizing symptoms (hypersensitivity, anxiety) and externalizing symptoms (aggressiveness, oppositional defiant behavior; Essex et al., 2001). At school age, attention deficits and reduced IQ scores are possible (Bernard-Bonnin, 2004). In children in the early school period, lower social competences and lower adaptation to the school environment were also found (Kersten-Alvarez et al., 2012). According to the study, 11-year-olds whose mothers suffered from postpartum depression exhibited more varied and severe aggressive behavior than other children their age. Violence was more common among boys than girls and mainly involved fighting with peers. The association of these behaviors with maternal postpartum depression may be explained by problems in regulating attention and emotions (Hay et al., 2003). Moreover, the children of women with this condition are four times more likely to develop a mental disorder at the age of 11 than children whose mothers did not have postpartum depression (Pawlby et al., 2008). A mother’s postnatal depression can have long-term consequences for her baby’s development, especially when it occurs between the second and eighth month after birth. This causes behavioral problems in children around three and a half years old, increases the risk of math difficulties at 16, and increases the possibility of depression at 18 (Netsi et al., 2018). The cited studies show that postpartum depression is a burdensome phenomenon not only for the ill mother herself, but it can also negatively affect the child’s development in many aspects of functioning. The effects of postpartum depression, manifested not only in infancy, but also in the later stages of a child’s life, illustrate how important this issue is. For this reason, its symptoms should not be underestimated and psychological and psychiatric help should be sought (Chrzan-Dętkoś, Kalita, 2019). Professional aid helps to return to a state of balance, but preventive actions, such as popularizing the phenomenon of self-care, are even more important here, because they can prevent very difficult experiences and the consequences associated with them.

The self-care phenomenon

Initially, the self-care model functioned as a practical-theoretical model of nursing care created by Dorothea Orem (Denyes, Orem, Bekel, 2001), gaining great popularity in nurse education and nursing practice. From the psychoanalytic perspective, the self-protective functions of the ego have been described in the last century (Khantzian, Mack, 1983). In Polish science, self-care was described by Suchańska (2001). The individual’s self-care competence is an expression of the internalization of a mother’s love, where behaviors such as containing emotions, protecting against threats, maintaining the will to live and following the child’s needs play an important role (Krystal, 1977; Khantzian, Mack, 1983). Following the above, the quality of the early relationship of the child with the mother is an important factor in the context of the development of self-care competences. Social psychology does not directly describe the subject of self-care, however, the issue closest to it is the phenomenon of maximizing happiness. Wojciszke (2021) describes four very specific areas where you can “take care of your happiness” and fight for it. The four areas highlighted include: relationships with people, resourcefulness and achieving goals, optimism vs. worrying, body and spirituality. And so, helping others, being kind, strengthening relationships with people, expressing gratitude and forgiveness are behaviors that, as a consequence, result in a higher level of happiness. In addition, practicing resourcefulness (both task-oriented and emotional), doing what really interests the individual, and pursuing goals with commitment are aspects of another area where it is possible to maximize your happiness. In addition, practicing optimism and combating the tendency to worry construct a cognitive level of caring for one’s own happiness. Practicing religion and taking care of the body are also important elements of maximizing happiness (Pilarska, Liberska, 2017). According to Cook-Cottone and Guyker (2018), self-care is defined as the daily process of becoming aware of and attending to basic physiological and emotional needs. It is crucial to shape the daily routine, taking care of relationships and your environment, which will also be an expression of caring for oneself. Thanks to the component of mindful awareness, it is possible to take even more complete and comprehensive care of oneself. Mindful self-care is an essential component of physical and emotional well-being. Self-care is associated with positive physical health, emotional well-being and mental health. Constant and intentional practice of mindful self-care is seen as a protective measure, as it prevents the onset of symptoms of a mental disorder, occupational or school burnout, and improves productivity at work and school (Cook-Cottone, Guyker, 2018). Research in this area is conducted, among others, in occupational groups where exposure to occupational burnout and severe stress are high (Depner, Cook-Cottone, Kim, 2021). The aforementioned studies focused on palliative care workers, but there are definitely many more professional groups that are confronted with severe stress on a daily basis and are at risk of occupational burnout (especially in the era of a pandemic). Childcare is not usually associated with burnout in the professional sphere, however, it can result in another type of burnout, namely parental burnout (Szczygieł et al., 2020), which also poses a threat to children’s development.

The phenomenon of self-care and postpartum depression

The conducted review of databases shows that research verifying the relationship between self-care and postpartum depression is not often carried out. In the literature, more attention is paid to self-care in general in the postpartum period, although according to Barkin and Wisner (2013), many popular self-report questionnaires focused on assessing the mother’s well-being do not emphasize the role of self-care. Mothers in the early postnatal period are reported to often neglect their self-care needs (e.g., eating or coping with pain) in favor of caring for their newborn (Lambermon et al., 2020). This disregard for women’s needs does not only last for a few days, but can span weeks or even months. For example, not getting enough sleep, which is one of the pillars of health, can lead to symptoms of postpartum depression (Kurth et al., 2016). Research by Fathi et al. (2017) conducted on a group of Iranian mothers showed that symptoms of postpartum depression were negatively correlated with self-care subscales, as well as with general health, social and environmental activity. In turn, the analysis of self-care of Spanish women at risk of postpartum depression showed significant correlations with social support and spirituality. Religiosity coupled with social support from family and friends was a predictor of low scores for depression (Kim, Dee, 2017), as was high self-esteem (Hobfoll, Leiberman, 1987). It is emphasized that the lack of ability to self-care in mothers with postpartum depression affects both their health and may affect, for example, behavioral disorders of their children (Kim, Dee, 2017). Consistent with the parental effort theory (Trivers, 1972) and the model of resource conservation in the face of stress (Hobfoll, 1989), it has been argued that the ability to care for oneself is an important protective factor for women’s health in the postpartum period. In the Polish literature, studies on self-care competences or attentive self-care are not numerous. So far, an attempt has been made to explore the relationship between attachment styles and the ability to self-care and self-control, as well as self-destructive tendencies in the personality structure. Research results (Suchańska, Pilarska, Brzeg, 2019) indicate that insecure attachment may result in deficits in the area of self-care and self-control. Therefore, in our own research, it was decided to check the importance of self-care for the risk of postpartum depression and hypothesized that a high level of self-care would reduce the risk of postpartum depression in pregnant women. In addition, according to Milgram’s urban overload hypothesis (Aronson, 2004), it was assumed that women in large cities may find it more difficult to receive support, hence the risk of postpartum depression may also be higher in them. We decided to treat the relationships of the remaining variables (age, education, order and week of pregnancy) with the risk of postpartum depression in an exploratory way, especially due to the high heterogeneity of the group and the small number of respondents.

Research procedure

The pilot study was conducted online, using Google Forms, on April 8–13, 2022. The surveys were made available on groups for expectant mothers and social profiles of the authors of the study, and the purpose of the selection of respondents was to reach pregnant women only. This group was selected due to the fact that depression occurring during pregnancy may be one of the determinants of post-partum depression (Pampaka et al., 2019). The research was completely anonymous and involved 55 pregnant women.

Participants voluntarily completed an interview questionnaire (taking into account sociodemographic variables, a sense of support and the impact of the pandemic and war on well-being), the Beck Depression Scale and the Self-Care Questionnaire. The Beck Depression Inventory (Beck, Steer, Brown, 1996) is characterized by satisfactory reliability, the Cronbach’s alpha coefficient for the entire normalization sample was .91, in the pilot study it was slightly lower –.87. The Self-Care Questionnaire (Pilarska, Suchańska, 2021) also has good psychometric properties. The internal consistency of the original, determined on the basis of Cronbach’s alpha, is .92 for the entire questionnaire and ranges from .67 to .86 for individual scales, similar reliability results were achieved in the study (Cronbach’s alphafor the entire questionnaire was also .92). The tool contains 34 items that refer to such manifestations of self-care as: valuing oneself and one’s life, resisting harmful temptations, readiness and initiative to face life’s challenges, assertiveness and defense of one’s rights, belief in the availability and possibility of obtaining social support, interpersonal trust and relational failures, attentive awareness of internal states, self-soothing ability. In both tests, the examined person made a self-description and indicated to what extent he or she identifies with a given term. For the statistical analysis of the obtained results, the non-parametric rho-Spearman correlation test was used, and in order to verify the statistical significance of the built regression model – multiple regression.

Results

All the surveyed women were in a romantic relationship, but as many as 1/3 of them declared that they did not feel enough support from their family/friends. Of the study participants, 29% had previously experienced a miscarriage and 9% had experienced postpartum depression (Table 1). The stage of pregnancy at which the pilot study was conducted varied widely, ranging from 8 weeks to 39 weeks of pregnancy (M = 26,49, SD = 8,79, SKE = –,266, K = –,997).

Table 1. Descriptive statistics (age, education, place of residence, experience)

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The respondents were also asked about the extent to which they felt the COVID-19 pandemic and the war in Ukraine had affected their well-being. More than half of the respondents indicated that the pandemic had a very small impact on them, while more than 14% indicated that the impact was significant. However, the responses were the opposite when taking into account the impact of the war in Ukraine. In this question, more than half of the women answered that its impact was significant for their well-being, and 20% that it was small. Analyzing the answers given on the Beck Depression Scale, a disturbing conclusion can be drawn that almost half of women currently have symptoms of moderate depression, which may predispose them to postpartum depression, which is very threatening for the women and also for the child’s development. Unfortunately, 4 of the respondents currently have symptoms of severe depression.

The Table 2 presents descriptive statistics of the intensity of self-care in the group of surveyed women. The coefficient of skewness of the overall result has a negative value (left-skewed distribution), while negative kurtosis indicates the dispersion of the results and their significant differentiation from the average, which may be a consequence of the small group of respondents.

Figure 1.Results obtained on the Beck Depression Scale

Table 2. Descriptive Statistics of Self-Caring Questionnaire scores: Factors and Overall Score (N = 55)

The analysis of the relationship between self-care and the risk of postpartum depression (Table 3) indicates a rather strong and negative significance of the relationship, hence the conclusion that the higher the level of self-care, the lower the risk of postpartum depression.

Table 3. The relationship between the intensity of self-care and the results on the Beck Depression Scale (rho-Spearman Correlation coefficient, N = 55)

The analysis of self-care factors shows that five of them are significantly correlated with the risk of postpartum depression (Table 4). The strongest correlation occurred with the evaluation of oneself and one’s life, quite a strong correlation also occurred with the ability to self-soothe, and the careful awareness of internal states was equally important. A moderate correlation occurred with the belief in the availability and possibility of obtaining social support. The lowest, but still significant correlation was with assertiveness and defending one’s rights. All these correlations were negative.

Table 4.     The relationship between the intensity of self-care factors and the results on the Beck Depression Scale (rho-Spearman Correlation coefficient, N = 55)

Self-care is important for minimizing the risk of postpartum depression to a moderate degree, so an attempt was made to look for other factors relevant to the risk of postpartum depression (Table 5). Thus, the results indicate that the place of residence is significant for the results obtained on the Beck Depression Scale. The correlation between the place of residence and the risk of postpartum depression is positive and moderate, so the larger the place a woman lives the higher the risk of depression. No statistical significance was noted in the other analyses (p > ,05).

Table 5. Relationship of other variables with the results on the Beck Depression Scale (rho-Spearman Correlation coefficient, N = 55)

Taking into account the observed relationships between the variables, it was decided to attempt to build a regression model illustrating the impact of the following variables: the intensity of self-protection and the place of residence for women’s depressiveness. As a result of the regression analysis, a statistically significant model was obtained, including two significant predictors (self-care and place of residence), which explained 33% of the variance of the variable depressiveness of pregnant women (Table 6).

Table 6. Multiple regression analysis for the dependent variable severity of depressiveness in pregnant women (N = 55)

Results discussion

The results which significantly and negatively correlated with the risk of post-partum depression concerned: evaluating oneself and one’s life, self-soothing skills, careful awareness of internal states, belief in the availability and possibility of obtaining social support, as well as assertiveness and defending one’s own rights. In addition, the place of residence turned out to be an important variable. The obtained results of the pilot studies correspond with the studies of Fathi et al. (2017), which indicates that both Iranian and Polish mothers with insufficient self-care are at risk of postpartum depression. Further discussion of the results will be conducted in a way that takes into account the specific factors of self-care. Valuing oneself and one ’s  l i fe is associated with seeing a higher purpose and meaning in one’s existence and living according to relatively precise values. In some aspects, such thinking is fostered by the development of spirituality and religiosity. Spanish research (Kim, Dee, 2017) indicates the important role of religiosity in minimizing the risk of postpartum depression. In addition, participation in organized religious activities (at least several times a month) may contribute to a lower likelihood of postpartum depressive symptoms in women (Mann et al., 2008). The area of religiosity has not been explicitly included in the conducted research, and according to reports, it is an important protective element for mental health (Pilarska, Liberska, 2017). Neglect of basic self-needs by mothers, which fall within the self-soothing skill, in the post-partum period (Lambermon et al., 2020), due to the prioritization of the child’s needs over their own, can have dangerous consequences, such as postpartum depression (Kurth et al., 2016). Suchańska and colleagues (2019) pointed to the importance of attachment for the development of self-care. According to the results of their research, the prevention of postpartum depression should start in the childhood of mothers, because the way in which their attachment develops is important for their self-care and the risk of postpartum depression, and as a consequence, it can protect their children from numerous limitations in development. Otherwise, there is a risk of a vicious circle in which mothers with insecure attachment will not take sufficient care of themselves, and thus experience postpartum depression, which is an unfavorable circumstance for the formation of secure attachment of their own children (cf. Chrzan-Dętkoś, Kalita, 2019). The self-care construct also includes an aspect of mindfulness, which falls within the factor of mindful awareness of internal states. In a study by Felder et al. (2018) women with moderate severity of depression who underwent mindfulness training during pregnancy had a lower risk of depressive symptoms worsening up to 18 months after delivery and were more likely to ask for help in case of depressive symptoms. Considering that mindfulness training can have such positive effects in women suffering from depression during pregnancy, it is possible that it may also be an important factor preventing the occurrence of this mental disorder in the postpartum period. Fortunately, mindfulness is an aspect of functioning that is increasingly recognized and promoted among psychologists and educators. In addition, it is worth looking at the belief in the availability and possibility of obtaining social support. Research results indicate that women living in large cities have a higher risk of postpartum depression (Chaaya et al., 2002; Vigod et al., 2013), which may be associated with greater loosening of interpersonal bonds, reduced social support and greater loneliness (Wojciszke, 2021). It is indicated that a higher risk of postpartum depression, especially within three months after delivery, is associated with lower social support (Taylor et al., 2022). Stein (2021) emphasizes the importance of social support for functioning as a parent. On the one hand, it is necessary to be convinced of the availability of such support, on the other hand, it is even more important to be able to use it and feel that there is enough of it to meet the needs of the family. This social aspect of mothers’ functioning also falls within the scope of self-care. In addition, it is worth considering the ability of women in general to defend their rights and assertive behavior. When explaining gender differences from different research perspectives, a higher level of assertiveness on the part of men than women is clearly visible, which is also related to the areas of values they prefer (Pilarska, 2022). This shows that taking care of yourself in a group of women can be more difficult than in a group of the opposite sex. The above discussion indicates important areas that are worth considering in the prevention and psychotherapy of postpartum depression.

Summary

The topic of self-care in the perinatal period is not sufficiently explored in Poland, although it is an important protective factor during pregnancy, which suggests the need for further, more extensive research. The relationship between self-care and postpartum depression is also not often discussed in the international literature, and the results indicate that it is a strong protective predictor. Developing the topic of self-care is particularly important, because postpartum depression results in negative consequences not only for the woman, but also for her baby. The COVID-19 pandemic and the war undoubtedly affected the mental functioning of society, including the mental health of young mothers. This context may intensify fears and depressive symptoms in the face of starting motherhood. The described consequences of postpartum depression are very burdensome for women, but also for the development of their children. An attempt to avoid incurring such great costs by developing self-care in a group of women, especially those expecting children and living in large cities, can be of great importance for the protection of mental health of a really large social group.

Limitation of own research

In the planned proper research, it will be necessary to reach groups of single mothers with primary or vocational education and minor women, as these people were missing in the pilot study. Some limitation may also be the short period of recruitment of women for the study, the small group of respondents and the significant heterogeneity of the sample. Recruiting a larger group would enable the implementation of more advanced statistical methods (e.g. cluster analysis), and thus it would be possible to capture differences between subgroups of mothers.

It is also worth noting that the survey was made available in groups for expectant mothers, i.e. among women who are interested in the period of pregnancy and childbirth. Conducting research in Medical Centers where women are obliged to carry out pregnancy would make it possible to reach those people who are not active on the Internet. In addition, changing research tools (e.g. to the MSCS and the Edinburgh Postnatal Depression Scale) are also being considered. This will help refine the pilot study.

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