Psychological distress in mothers of children admitted to a nutritional rehabilitation unit in Malawi – a comparison with other paediatric wards

In a previous study we found a very high prevalence of psychological distress in mothers of children admitted to a nutritional rehabilitation unit (NRU) in Malawi, Africa. The objective of this study was to compare the prevalence and severity of maternal distress within the NRU with that in other paediatric wards. Given the known association between poor maternal psychological well‐being and child undernutrition in low‐ and middle‐income countries, we hypothesised that distress would be higher among NRU mothers. Mothers of consecutive paediatric inpatients in a NRU, a high‐dependency (and research) unit and an oncology ward were assessed for psychological distress using the Self‐Reporting Questionnaire (SRQ). Two hundred sixty‐eight mothers were interviewed (90.3% of eligible). The prevalence of SRQ score ≥8 was 35/150 {23.3% [95% confidence interval (CI) 16.8– 30.9%]} on the NRU, 13/84 [15.5% (95% CI 8.5–25.0%)] on the high‐dependency unit and 7/34 [20.6% (95% CI 8.7–37.9%)] on the oncology ward (χ² = 2.04, P = 0.36). In linear regression analysis, the correlates of higher SRQ score were child diarrhoea on admission, child diagnosed with tuberculosis, and maternal experience of abuse by partner; child height‐for‐age z‐score fell only just outside significance (P = 0.05). In summary, we found no evidence of greater maternal distress among the mothers of severely malnourished children within the NRU compared with mothers of paediatric inpatients with other severe illnesses. However, in support of previous research findings, we found some evidence that poor maternal psychological well‐being is associated with child stunting and diarrhoea.     

Maternal mental health symptoms are positively related to emotional and restrained eating attitudes in a statewide sample of mothers participating in a supplemental nutrition program for women,infants and young children

Postpartum, low‐income mothers are at risk for mental health symptoms and obesity, and disordered eating attitudes may be associated with both mental health and obesity in this vulnerable population. The study objective is to determine whether higher levels of mental health symptoms are associated with increased odds of emotional and restrained eating attitudes in this sample of Special Supplemental Nutrition Program for Women, Infants and Children (WIC) participants. Data on 711 mothers of infants <13 months from a statewide sample of Maryland WIC participants were collected via telephone survey. Maternal mental health symptoms were measured on continuous scales for depression (PRIME‐MD), stress (Perceived Stress Scale) and anxiety (Spielberger State‐Trait Anxiety Inventory). Emotional and restrained eating attitudes were measured with questions adapted from the Dutch Eating Behavior Questionnaire. Multivariate logistic regression analysis was used. Obesity [body mass index (BMI) ≥ 30] was explored as a moderating variable. Mothers reporting higher levels of depression symptoms [odds ratio (OR) = 3.93, 95%CI: 2.71–5.69], anxiety symptoms (OR = 1.96, 95%CI: 1.47–2.65), stress symptoms (OR = 2.09, 95%CI: 1.67–2.61) and high overall mental health symptomatology (OR = 3.51, 95%CI: 2.43–5.3) had increased odds of emotional eating attitudes. There were significant associations between symptoms of depression (OR = 1.59, 95% CI: 1.12–2.25) and increased odds of restrained eating attitudes. Obesity did not moderate the association. Mothers with mental health symptoms are at risk for disordered eating attitudes, which may increase risk of poor diet. These findings underscore the need for greater focus on addressing maternal mental health status and eating attitudes in the postpartum period.     

Maternal common mental disorder and infant growth--a cross-sectional study from Malawi

The objective of the study was to investigate the association between maternal common mental disorder (CMD) and infant growth in rural Malawi. A cross-sectional study was conducted at a district hospital child health clinic. Participants were consecutive infants due for measles vaccination, and their mothers.
Mean infant weight-for-age and length-for-age z-scores were compared between infants of mothers with and without CMD as measured using the self-reporting questionnaire (SRQ).
Of 519 eligible infants/mothers, 501 were included in the analysis. Median infant age was 9.9 months. 29.9% of mothers scored 8 or above on the SRQ indicating CMD. Mean length-for-age z-score for infants of mothers with CMD (−1.50 SD 1.24) was significantly lower than for infants of mothers without CMD (−1.11 SD 1.12) Student's t -test: P  = 0.001. This association was confirmed in multivariate analysis. Mean weight-for-age z-score for infants of mothers with CMD (−1.77 SD 1.16) was lower than for infants of mothers without CMD (−1.59 SD 1.09) but this difference was not significant on univariate (Student's t -test: P  = 0.097) or multivariate analysis.
The study demonstrates an association between maternal CMD and infant growth impairment in rural sub-Saharan Africa.     

The relationship between the gendered norm of eating last and mental health of newly married women in Nepal: A longitudinal study

Eating last is a gendered cultural norm in which the youngest daughters-in-law are expected to eat last after serving others in the household, including men and in-laws. Using women's eating last as an indicator of women's status, we studied the association between eating last and women's mental health. Using four rounds of prospective cohort data of 18–25-year-old newly married women (n = 200) cohabiting with mothers-in-law between 2018 and 2020 in the Nawalparasi district of Nepal, we examined the association between women eating last and depressive symptom severity (measured using 15-item Hopkins Symptom Checklist for Depression; HSCL-D). Twenty-five percent of women reported eating last always. The prevalence of probable depression using the established cutoff was 5.5%, consistent with the prevalence of depression in the general population. Using a hierarchical mixed-effects linear regression model, we found that women who always ate last had an expected depressive symptom severity (0–3 on HSCL-D) 0.24 points (95% confidence interval [CI]: 0.13–0.36) greater compared to women who did not eat last when adjusted for demographic variables, household food insecurity, and secular trends. Sensitivity analysis using logistic regression also suggested that women who eat last have greater odds of having probable depression (adjusted odds ratio [AOR] = 4.05; 95% CI: 1.32–12.44). We explored if the association between eating last and depressive symptom severity was moderated by household food insecurity and did not observe evidence of moderation, underscoring the significance of eating last as a woman's status indicator. Our study findings highlight that newly young married women in Nepal are a vulnerable group.     

Guilt,shame, and postpartum infant feeding outcomes: A systematic review

Negative maternal affect (e.g., depression and anxiety) has been associated with shorter breastfeeding duration and poorer breastfeeding intention, initiation, and exclusivity. Other affective states, including guilt and shame, have been linked with formula feeding practice, though existing literature has yet to be synthesised. A narrative synthesis of quantitative data and a framework synthesis of qualitative and quantitative data were conducted to explore guilt and/or shame in relation to infant feeding outcomes. Searches were conducted on the DISCOVER database between December 2017 and March 2018. The search strategy was rerun in February 2020, together yielding 467 studies. The study selection process identified 20 articles, published between 1997 and 2017. Quantitative results demonstrated formula feeders experienced guilt more commonly than breastfeeding mothers. Formula feeders experienced external guilt most commonly associated with healthcare professionals, whereas breastfeeding mothers experienced guilt most commonly associated with peers and family. No quantitative literature examined shame in relation to infant feeding outcomes, warranting future research. The framework synthesis generated four distinct themes which explored guilt and/or shame in relation to infant feeding outcomes: ‘underprepared and ineffectively supported’, ‘morality and perceived judgement’ (breastfeeding), ‘frustration with infant feeding care’ and ‘failures, fears and forbidden practice’ (formula feeding). Both guilt and shame were associated with self‐perception as a bad mother and poorer maternal mental health. Guilt and shame experiences were qualitatively different in terms of sources and outcomes, dependent on infant feeding method. Suggestions for tailored care to minimise guilt and shame, while supporting breastfeeding, are provided.     

Fifteen,female and stressed: changing patterns of psychological distress over time

BACKGROUND: Despite a widespread view that the mental health of young people has deteriorated, the evidence base is limited by the lack of comparable datasets over time, and their capacity to test specific hypotheses about the causes of such change, in this case those particularly affecting young females. METHOD: Two cohorts of 15-year-olds in the West of Scotland, surveyed in 1987 and 1999, were compared, using the 12-item version of the General Health Questionnaire to measure psychological distress (GHQ caseness, cut-off 2/3), together with items and indices of personal and performance worries. RESULTS: Between 1987 and 1999, GHQ caseness increased significantly for females (from 19% to 33%), but not males (13% to 15%), a change particularly experienced by females from non-manual and skilled manual backgrounds. With one notable exception (unemployment), most worries also increased for both sexes, a gender gap emerging in respect of worries about school performance, females worrying more. While the effect of personal worries (e.g., looks and weight) on GHQ caseness persisted over time in both sexes, that of performance worries only emerged for females in 1999. Using survey date as an indicator, a relationship between proximity to exams and GHQ caseness was also only found among females in 1999. CONCLUSION: The increase in levels of psychological distress among young females over this period may be explained by an increase in educational expectations, which together with more traditional concerns about personal identity, appear to have elevated levels of stress, with adverse consequences for mental health.     

Comparison of two strategies to improve infant sleep problems, and associated impacts on maternal experience, mood and infant emotional health: a single case replication design study

Background

Infant sleep problems (ISP) are common and have known effects on parental mood. There is debate as to whether treatment strategies may impact on the infant's emotional health.

Aims

To compare the effectiveness of two treatment strategies for ISP on the infant's sleep, maternal mood, and the infant's emotional health. The two strategies are 1) systematic ignoring with minimal check (‘SI-mc’: commonly known as ‘controlled crying’), and 2) a new, but similar, method where parents feign sleep inside the infant's room before intervening (parental presence with minimal check: ‘PP-mc’).

Design

Participants were randomised to one of the two conditions. Measures were taken at baseline, then three weeks and four months post-intervention.

Subjects

Data were collected from 16 families with infants aged 6–18 months who were seeking professional help with their infant's sleep difficulties.

Outcome measures

Measures of infant sleep, maternal experiences and mood, and infant emotional health were collected.

Results

Both treatments were effective, with a third to a half of families reporting decreased ISP by 3 week post intervention, and nearly all reporting decreased ISP by follow-up. Similarly, most mothers in both treatments reported improvements to their experiences or mood, and there was no discernable disruption to infant emotional health.

Conclusions

These findings support previous research into the effectiveness of SI-mc. The study also expands the research into the effectiveness of parental presence by showing that with the inclusion of the minimal check component, which may be preferred by both parents and clinicians over non-responding to the crying infant, the strategy is as effective as SI-mc.     

Breastfeeding duration and postpartum psychological adjustment: role of maternal attachment styles

Aim:   Depressive and anxiety symptoms are common in new mothers. The aim of this study is to explore the link between postpartum psychological adjustment and feeding preferences of the mothers.
Methods:   Sixty mothers and newborns were enrolled in this prospective, longitudinal study. Maternal depressive symptoms were screened by the Edinburgh Postpartum Depression Scale (EPDS), and maternal anxiety level was assessed by the State-Trait Anxiety Inventory at 1 month postpartum. The Multidimensional Scale of Perceived Social Support was used for the assessment of maternal social support. The Adult Attachment Scale was used to determine the attachment style of the mother. Infants were examined and evaluated at 1 and 4 months of life.
Results:   All mothers started breastfeeding their infants postpartum; 91% and 68.1% continued exclusive breastfeeding at 1 and 4 months, respectively. The first-month median EPDS score of mothers who breastfeed at the fourth month was statistically significantly lower than those who were not breastfeeding (6 and 12, respectively) ( P  = 0001). The first-month median EPDS score of mothers with secure attachment was lower than the median score of mothers with insecure attachment (5 and 9, respectively) ( P  < 0001). Exclusive breastfeeding rate was not statistically different among mothers with secure and insecure attachment styles. The median state and trait anxiety scores and social support scores of mothers were not different between groups according to breastfeeding status.
Conclusions:   This study has shown an association between higher EPDS scores and breastfeeding cessation by 4 months after delivery.     

Infants admitted to a neonatal intensive care unit: parental psychological status at 9 months

AIM: This paper reports on the 9-month follow-up of parents who had an infant admitted to neonatal intensive care unit (NICU) compared to parents of full-term health infants. The psychological status of the parent groups is compared and factors associated with status change are examined. METHODS: Prospective longitudinal study of random sample of 447 parents (mother and father with an infant admitted to the NICU and 189 parents (mother and father) with term infant not requiring NICU admission. Parents' depression and anxiety symptoms were assessed at infant birth and 9 months later. RESULTS: The increased levels of depression and anxiety symptoms evident in NICU parents after their infant's birth were no longer apparent by 9 months. Higher initial symptom severity and perceived quality of the couple relationship were most commonly associated with improvement. Other factors related to symptoms change were number of baby hospitalizations for fathers and being in the NICU, age and living with the infant's father or mother. CONCLUSION: For the majority of parents having an infant admitted to the NICU does not result in ongoing psychological distress.     

Birthweight and psychological distress in adult twins: a longitudinal study

AIM: To assess the relation between birthweight and psychological distress as measured by the Malaise Inventory in adult twins. METHODS: Data were drawn from the 1958 British birth cohort study, which included twins followed from birth to age 42 y. We examined the relation between birthweight and psychological distress at ages 23, 33 and 42 y measured by the psychological scale of the Malaise Inventory. Analyses were performed both between subjects (n = 282) and within twin pairs (n = 112). The generalized estimating equations approach was used to handle the repeated measurements. RESULTS: Between the 282 twins, the difference in psychological distress score was -0.45 (95% confidence interval -0.74 to -0.15) per Z-score increase in birthweight-for-gestational age. Within twin pairs, the heavier co-twins tended to have a psychological distress score lower than that of their lighter co-twins, the mean difference being -0.35 (-0.78 to 0.09). CONCLUSION: Results from the between-subject analysis agreed with previous findings from adult singletons that psychological health is related to birthweight. The within-pair analysis suggested a similar relation but did not attain statistical significance.     

Regional variations in prevalence of postpartum depressive symptoms: Population‐based survey

The purpose of the present study was to verify that there are regional variations in the detection rate of postpartum depressive symptoms in mothers. A population‐based survey of all women who gave birth in Fushimi Ward, Kyoto City during the period 1 December 2008–31 October 2010 was carried out. The Edinburgh Postnatal Depression Scale (EPDS) was completed by 2567 mothers of infants to measure postpartum depressive symptoms. The detection rate of postpartum depressive symptoms was compared between five localities. A significant difference was found between the lowest detection rate of postpartum depressive symptoms (8.4%) and the highest (18.1%; P < 0.001). A significant positive correlation was found between the proportion of houses in the locality receiving public assistance and the detection rate of postpartum depressive symptoms. The detection rate of postpartum depressive symptoms shows regional variations, suggesting a relationship with the poverty rate.     

The Nature of the Mother's Tie to Her Infant: Maternal Bonding under Conditions of Proximity, Separation, and Potential Loss

Attachment has generally been examined from the infant's perspective. We focused on mothers' post-partum thoughts and behaviors. Guided by an ethological approach, maternal bonding was examined under conditions of proximity, separation, and potential loss. Ninety-one mothers were interviewed: mothers of full-term infants who maintained continuous proximity to the infant, mothers of healthy premature infants who were separated from the infant, and mothers of very low birthweight infants who experienced potential loss and prolonged separation. Mothers of term infants reported medium-to-high levels of preoccupations with thoughts of infant safety and well-being. Preoccupations increased with separation (Group 2) and significantly decreased with impending loss (Group 3). Attachment behaviors and representations were the highest among mothers of term infants and declined linearly with the duration of mother-infant separation. Maternal trait anxiety and depression were related respectively to higher levels of preoccupations and reduced attachment behaviors and representations, independent of the infant medical condition and mother-child separation. Discussion focused on the comparability of maternal and infant attachment in relation to the neurobiological system underlying bond formation.     

Associations between antenatal depression and neonatal outcomes in Malawi

Studies from several low‐ and middle‐income countries have shown that antenatal depression may be a risk factor for poor neonatal outcomes. However, those studies conducted in sub‐Saharan Africa have not consistently demonstrated this association. We set out to investigate whether antenatal depression is associated with shorter duration of pregnancy and reduced newborn size in rural Malawi. Pregnant women recruited from four antenatal clinics to the International Lipid‐Based Nutrient Supplements Project‐DYAD‐Malawi (iLiNS‐DYAD‐M) randomised controlled trial of nutrient supplementation were screened for antenatal depression in the second or third trimester using a locally validated version of the Self Reporting Questionnaire (SRQ). Outcomes were duration of pregnancy, birthweight, newborn length for age z‐score (LAZ), head circumference z‐score, and mid‐upper arm circumference (MUAC). Other potential confounding factors and predictors of birth outcome were measured and adjusted for in the analysis. 1,391 women were enrolled to the trial. 1,006/1,391 (72.3%) of these women completed an SRQ and gave birth to a singleton infant whose weight was measured within 2 weeks of birth. 143/1,006 (14.2%) scored SRQ ≥ 8, indicating likely depression. Antenatal depression was not associated with birth weight, duration of pregnancy, newborn LAZ, or head‐circumference Z‐score. There was an inverse association with newborn MUAC (adjusted mean difference ? 0.2 cm (95% CI ?0.4 to 0, p = 0.021) the significance of which is unclear. The study was conducted within a randomised controlled trial of nutritional supplementation and there was a high proportion of missing data in some enrolment sites; this may have affected the validity of our findings.     

Sleep problems in young infants and maternal mental and physical health

AIM: Sleep problems in the second 6 months of life are common and associated with maternal depression. This paper extends previous research to (i) establish the prevalence of sleep problems in younger infants from a broader socio-economic spectrum, (ii) examine the relationship between infant sleep problems and maternal physical, as well as mental, health, and (iii) explore mothers' sleep quality as a potential mediator of this relationship. METHODS: Design: Cross-sectional, community survey in Melbourne, Australia. Sample: Mothers of 3- to 6-month-old infants (mean 4.6 months) recruited from well-child clinics in six sociodemographically diverse metropolitan local government areas. Outcome measures: Maternal mental and physical health; standardised questionnaire on infant sleep patterns; maternal report of an infant sleep problem (yes/no). RESULTS: The survey was completed by 692 mothers; 237 (34%) reported an infant sleep problem, of whom 73 (31%) rated the problem as severe. Sleep patterns characterising a problem included the infant waking seven nights per week, nursing the infant to sleep at the beginning of the night, the infant sleeping in the parent's room, and parental disagreement regarding managing infant sleep. There was no relationship between sleep problems and socio-economic levels. Mothers reporting infant sleep problems had poorer mental and physical health compared with those not reporting sleep problems. CONCLUSION: Sleep problems are common in early infancy across metropolitan socio-economic levels and are associated with poorer maternal health and well-being. Preventive strategies for infant sleep problems need to begin early in primary care to improve mothers' health.     

Differences Between Children of Depressed and Non-depressed Mothers: Locus of Control, Anxiety and Self-esteem: a Research Note

Fifty-six mothers (26 depressed and 30 non-depressed) and their children were assessed on three measures: locus of control, anxiety and self-esteem. T-tests of results indicated significant differences between the groups of mothers across all three measures. There were significant differences between the two groups of children on state anxiety, total score on the self-esteem measure and social self-esteem, with the children of non-depressed mothers being lower on state anxiety and showing higher levels of self-esteem. Other aspects of self-esteem and locus of control did not show significant differences between the groups. A correlation matrix revealed that trait anxiety in the children of depressed mothers was significantly correlated with the mothers' depression, but not the mothers' anxiety. An analysis of discriminant functions found that a more anxious mood state and feelings of fear and worry were associated with the children of the depressed mothers.