**6. The impact of pregnancy on maternal well-being**

#### **6.1. The physiological effect of pregnancy**

Pregnancy may have an enormous psychological and physiological effect on a woman's body and mind. This is due to suppression of the hypothalamic-pituitary-adrenal axis, which leads to dramatic changes in oestrogen and progesterone levels. Changes in these hormone levels may alter a pregnant woman's coping mechanisms. The physical discomfort of pregnancy, accompanied by anticipation of childbirth and the responsibility of parenthood, often causes anxiety and emotional changes [27].

#### **6.2. Stress alters physiology**

Most of the risk assessment systems in midwifery care focuses on physical characteristics such as age, parity and education; however, these assessment systems are not exclusively suggestive of a risk for maternal morbidity and mortality as they mostly exclude psychosocial factors. A review of several studies by Hamid et al. [25] on the perceptions of antenatal care by women suggests that there are several psychosocial risk factors that need to be taken into consideration in order to ensure a safe pregnancy and delivery. Psychosocial interventions

Furthermore, a systematic review of 16 studies on antenatal screening for postnatal depression by Hamid et al. [25], which involved 23,000 participants, revealed that the proportion of women who are at risk for postnatal depression was between 10 and 67%. The authors further commented that the preliminary evidence suggested that the introduction of screening tools to aid early detection and diagnosis of depression has helped to raise awareness among health

Psychosocial risks are described as the demands or challenges that are psychological or social in origin, having the potential to directly or indirectly alter homeostasis during pregnancy and childbirth [21]. They relate to a combination of the affective states and cognitive factors of anxiety, depression, self-esteem mastery and perceived stress as measured by the scale of Gunn et al. [30]. According to Glazier et al. [28], a psychosocial problem may occur in response to an exposure to a stressful life event, for example, unemployment. The psychosocial response will, however, be determined by the effect it has on an individual, for example, loss of self-esteem and

Fawole et al. [29] have identified the following as some of the psychosocial risk factors that a woman may have experienced or may experience during pregnancy: woman battering; family violence or intimate partner abuse; sexual abuse and harassment; discrimination; gender inequality; past history of depressive disorders; absent/abusive or non-supportive spouse; marital difficulties; pregnancy occurring below 18 years of age, which antedates social development; unintended, unplanned or unwanted pregnancy; maternal or paternal unemployment; adverse life events, for example, loss of spouse; socio-economic factors, for example, poverty; barriers to accessing health care services, for example, distance travelled and transport unavailability; medical disorders, for example, hypertension and HIV/AIDS and poor quality of interaction with health care providers that may lead to non-compliance to planned

Pregnancy may have an enormous psychological and physiological effect on a woman's body and mind. This is due to suppression of the hypothalamic-pituitary-adrenal axis, which leads

have proved to be beneficial in providing comprehensive antenatal care.

care providers regarding social and psychological maternal risk factors.

**5. Possible psychosocial risk factors during pregnancy**

feelings of worthlessness.

20 Selected Topics in Midwifery Care

interventions and defaulting treatment.

**6.1. The physiological effect of pregnancy**

**6. The impact of pregnancy on maternal well-being**

There is a growing body of data suggesting that psychosocial factors such as high stress and low social support negatively affect the success of pregnancy. The findings of a survey by Shamim ul Moula [26] to address relationships between psychosocial variables and serum inflammatory markers during pregnancy support the notion that prenatal stress alters maternal physiology and immune function in a manner that is consistent with an increased risk of pregnancy complications such as preterm delivery and pregnancy-induced hypertension. The conclusion based on the findings of the above survey was a need for the development of strategies for supporting maternal mental health.

### **6.3. The impact of psychosocial stress on maternal and foetal well-being**

It is clear that birth and infant development are affected by prenatal events that could lead to maternal stress. Maternal psychosocial stress has been recently identified as a factor in early foetal development. There is growing evidence that perinatal psychological and environmental stressors are detrimental to pregnancy success and infant outcomes. Stress is often defined as events, situations, emotions and interactions that are perceived as negatively affecting the well-being of an individual or that cause responses that are perceived as harmful [10].

A direct relationship is said to exist between maternal psychological stress and low birth weight, prematurity and intra-uterine growth retention. This is related to the release of catecholamines that results in placental hypo-perfusion and consequent restriction of oxygen and inhibition of nutrients to the foetus, leading to foetal growth impairment [27].

#### **6.4. The relationship between antenatal depression and postnatal depression**

There is considerable evidence that postnatal depression is a public health care challenge as it can become chronic, can damage the relationship between the woman and her partner and might have adverse consequences for the emotional and cognitive development of the newborn. Regular assessment of mood during pregnancy should be routine for all women to establish the risk for depression, as postnatal depression can recur. Antenatal mood assessment is one of the most robust predictors of postnatal depression, as 50% of postnatal depression is reported to have begun during pregnancy [27].

There is evidence from research that women with antenatal psychosocial risk factors are more likely to have a postnatal mood disorder, and as such, antenatal assessment can be beneficial for these women. The early identification and management of psychosocial risk factors have been shown to be beneficial in various studies. For example, in the study by Ref. [29], regarding the review of existing tools that are used to assess psychosocial morbidity in pregnant women, and a study by Gunn et al. [30] on anxiety and depression during pregnancy, outcomes were improved by minimising the occurrence of postpartum depression.

Recommendations from a survey by Namagembe [20] were that a search for battering and abuse should be carried out during the antenatal assessment of pregnant women and midwives should have knowledge of the appropriate interventions and be familiar with the resources for referral. The increased cost and complications that may arise as a result of any delays should be a concern for maternal-child health professionals. Routine antenatal and postnatal screening for psychosocial distress has been supported by investigators as a preventive measure for postnatal depression [28].

trials carried out in the United Kingdom and Zimbabwe and of the World Health Organisation

Psychosocial Antenatal Care: A Midwifery Context http://dx.doi.org/10.5772/intechopen.80394 23

The new schedule, as recommended by WHO [30], consists of four visits during pregnancy, the first one being early in pregnancy, with subsequent visits at 26, 32 and 36 weeks. This schedule is designed for the pregnant woman at low risk. These fewer antenatal visits led to poorer psychosocial outcomes and drew attention to greater maternal satisfaction with the routine care that was previously provided. The question is whether there would be an opportunity for

Baldo [7] in a review of the antenatal care debate quoted Mcllwaine (1980) highlighting that he was amazed that pregnant women came for antenatal care and waited in the clinic for 2 hours, only to be seen for 2 minutes by someone laying his or her hands on them, and then leave. The reason for this is the traditional focus on the biophysiology of pregnancy. The author recommended that antenatal care appointments should be structured, focused and advocated for longer first appointments to allow comprehensive assessment in order to

The Changing Childbirth report explicitly confirmed that women should be the focus of antenatal care to enable a woman to make informed decisions based on her needs, having discussed her matters with the midwife involved. Key aspects of care valued by women are

The above are supported by the researcher's findings from a phenomenological study on the expectations of antenatal care by pregnant women. Most women were happy with the physical health care but were dissatisfied with interpersonal aspects, for example, involvement,

As a midwifery lecturer, the researcher often accompanied students for clinical facilitation. On guiding students on psychosocial care of women in the antenatal care clinic, women frequently verbalised social and emotional concerns. The researcher's further experience is that if psychosocial assessment is indeed conducted on a pregnant woman, it usually elicits the

The following are common remarks that were expressed by women during their antenatal

A woman carrying her first pregnancy at age 25, gravida 1 para 0, from one of Gauteng's

*"No one ever asked me this. Why don't everyone do like this? I think I am lucky today, I had so much to ask or discuss previously but there was just no one to listen to me. I moved from a black hospital to a one for whites thinking things will be better but it's the same. We come here, they quickly check the baby, and within 30 minutes you are gone with so much to share, as if the baby is the only one important".* 

A pregnant woman, 42 years old, was asked if the pregnancy was planned at this vulnerable age as her first child was 20 years old. Her response was that she had lost a husband 5 years ago and had recently remarried. She was coping but her challenge was that the first child was

*She then asked for the lecturer's and the student's contact numbers for further consultation.*

reported to be respect, competence, communication, support and convenience [32].

trials in Thailand, Argentina, Cuba and Saudi Arabia during 1996 [31].

the midwives to address psychosocial care within this regime.

address both physiological and psychosocial risk factors.

guidance and communication from the health care providers [33].

woman's current active and significant psychosocial challenges.

provincial hospital's antenatal clinic remarked:

visits while the researcher was engaged in student accompaniment.
