Key learning points:
– A significant proportion of pregnant women and new mothers are vulnerable
– Vulnerability in women during this period is strongly associated with compromised long-term outcomes for the child
-Midwives have a key role to play in identifying vulnerable women and ensuring that they receive appropriate support
Parenting begins in pregnancy with a range of health behaviours and psychological changes in the pregnant women and her partner. These changes are designed to protect the fetus and optimise his or her development, and continue into the immediate and later postnatal period (i.e. the first year of the infant’s life).
Vulnerability in the mother-to-be or newly delivered woman can impact on her capacity for such parenting, with long-term consequences for the child. This is due primarily to the fact that pregnancy and the postnatal period are sensitive developmental periods. These are biological time-points during which the impact of experiences on the brain of the fetus and infant are particularly strong, and when certain types of experience need to be present to ensure optimal development. The ‘biological embedding of early social adversity’ refers to the way in which experiences of adversity during the perinatal period. This can affect physiological and cellular pathways, increasing the later likelihood of disease,1 and psychosocial vulnerability in pregnant women or new mothers. It is an important source of such adversity for the unborn or newborn child.
This article summarises some of the recent research in terms of what is meant by ‘psychosocial vulnerability’ during the perinatal period, and what is now known about the impact of such vulnerability on the long-term wellbeing of the fetus, newborn baby and later child. It also describes the role of the midwife in identifying such women and ensuring that they receive appropriate support.
Defining vulnerability during the perinatal period
The phenomenon of fetal programming refers to changes in the environment in utero during specific critical or sensitive periods and the long-term effect on the child. Original interest focused specifically on the consequences of the mother’s physical health (e.g. nutritional state) in terms of the occurrence of later cardiovascular and related diseases in the child and adult. More recent research has highlighted the role of the mother’s psychosocial wellbeing during pregnancy in terms of the physical development of the fetus (e.g. birthweight for gestational age, earlier delivery and pregnancy induced hypertension) and later psychopathology (e.g. stress regulation; emotional and behavioural problems).
As a consequence of fetal programming the fetus is vulnerable to adversity that arises both as a consequence of factors that have a direct impact on the fetus/unborn baby and factors that have an impact via more indirect pathways. In terms of direct pathways, for example, women who are experiencing stress have a high cortisol level, which may then cross the placental barrier and adversely effect the fetal developing central nervous system (CNS) via its impact on neurotransmitters (e.g. norepinephrine, serotonin, dopamine); vasoconstriction and fetal hypoxemia. Alcohol (and other substances) are teratogens that also have a direct impact on the fetal developing CNS. For example, moderate alcohol consumption during pregnancy can cause fetal alcohol spectrum disorder (FASD), which is now recognised to be one of the largest preventable set of birth defects.2
The fetus can also be affected by factors that have an impact through more indirect pathways. For example, stress and the consumption of teratogens are strongly associated with a range of psychiatric problems. These include: post traumatic stress disorder (PTSD) and personality disorder, and with the occurrence of domestic abuse (around one-third of which begins in pregnancy).3 They are also associated with a reduced capacity to think about the developing baby (known as low reflective functioning), and an increased likelihood of having ‘disengaged’ or ‘distorted’ mental images of the baby. Research suggests that these factors (e.g. mental health problems, domestic abuse. substance use e.t.c.) can impact the fetus and newly born baby. This is because they not only result in poorer physical health behaviours in pregnancy, but because they are associated with a poorer level of involvement with the unborn baby and a poorer capacity to care for the baby when he or she is born. Infants under one represent over a tenth (i.e. 11.3%) of children who are the subject of a child protection plan,4 with neglect (49%) and emotional abuse accounting for nearly three-quarters of these.4
Underlying many of these problems are ‘unresolved trauma’ due to the mother’s experience of abuse and neglect in her own childhood. Such unresolved trauma is associated with parent-infant interaction in the postnatal period that has been defined as ‘hostile and helpless’5 and is characterised by behaviours that dysregulate the infant and result in them having a ‘disorganised attachment’.6
The prevalence of vulnerability in the perinatal period
A significant proportion of women experience problems in pregnancy and the immediate postnatal period that makes them vulnerable. For example, between 12% and 20% of women experience anxiety or stress in pregnancy,7 around 4.4% of women use illicit substances in pregnancy,8 and one-in-nine women are affected by domestic abuse during pregnancy or after giving birth.9
However, the majority of vulnerable women will have more than just one of these sources of adversity present, with the most vulnerable group experiencing as many as five or more adverse factors that represent a risk both to their own wellbeing and that of their unborn/newborn baby. Many of these women will be experiencing social adversity (e.g. poverty and/or housing problems e.t.c), in addition to the psychological problems discussed previously.
Outcomes for the infant and child
Research shows that exposure of women in pregnancy to anxiety, depression and stress from a range of sources (e.g. bereavement, relationship problems, external disasters and war), is associated not only with physical problems (e.g. congenital malformations, reduced birthweight and gestational age), but also with a range of neurodevelopmental, cognitive, and emotional and behavioural (e.g. ADHD, conduct disorder) problems. The magnitude is significant with the attributable risk of childhood behaviour problems due to prenatal stress being between 10% and 15%, and the variance in cognitive development due to prenatal stress being around 17%.10
The consumption in pregnancy of teratogens such as alcohol and other substances are also associated with low and very low birthweight, neonatal abstinence syndrome (NAS) (e.g. irritability, severe tremors, hyperacusis, excessive crying, vasomotor instability, diarrhea, restlessness, increased tone, hyperphagia, vomiting, and disturbed sleep), neurobehavioural problems (e.g. poorer state regulation, difficulty being calmed, increased physiological arousal etc, socioemotional problems – attachment and behavioural problems, and cognitive problems (e.g. reduced functioning on a range of measures of development and learning including IQ).
Alcohol and substance dependency and many of the psychiatric problems that are associated with vulnerability during the perinatal period, such as PTSD and personality disorder have also been shown to result in compromised parent-infant interaction. For example, studies that compared parent-infant interaction in babies who were exposed in-utero to substances with normal samples found significantly less sensitive parenting,11 and an increased likelihood of an insecure or disorganised attachment.12 Disorganised attachment has been shown to be associated with significant later psychopathology including externalising disorders,13 and personality disorders.14
Identification of vulnerable women in pregnancy and post delivery
Midwives are one of the key primary care practitioners with both the skills and opportunity to identify women who are ‘vulnerable’ in pregnancy and the immediate postnatal period. Booked-in visits are the first opportunity to do this, but subsequent midwife appointments should also be used to identify sources of vulnerability or risk factors that do not emerge during the early visits.
There is increasing recognition that one of the key factors facilitating the disclosure of sensitive issues that make the woman vulnerable is the level of trust that is established with the midwife. Vulnerable women require continuity in terms of ensuring they receive care from the same midwife, and skillful questioning and conversations on the part of the midwife to provide the opportunities for the disclosure of vulnerabilities.
Effective identification also requires the midwife to work closely with colleagues in health (health visitors, GPs, mental health, substance abuse and domestic violence workers) and in children’s social care (e.g. social workers), to enable effective sharing of information. Such sharing of information may involve informal discussion that alerts colleagues who also have statutory involvement with the family to be aware of potential risk factors, or more formal referral onto health or social care practitioners to ensure the safety of the woman and her baby.
Health visitors also now have a role to support midwives in the identification of problems in the perinatal period using the antenatal promotional interview at 28 weeks and a postnatal promotional interview at eight weeks postnatal.15 Health visitors in many areas across the UK are now trained to conduct these interviews, and they need early information from the midwife about the pregnant women in their caseload to enable them to do this.
Working effectively with vulnerable pregnant women and new mothers
The high prevalence of psychosocial vulnerability in pregnancy and the potential impact on the fetus and infant point to the importance of working effectively in pregnancy with this group of women. Indeed, pregnancy and the postnatal period have been defined as being key periods in terms of the opportunity that they provide to equalise the life-chances of all children.16
The Healthy Child Programme – Pregnancy and the First Five Years of Life15provides an evidence-based programme of interventions aimed at optimising fetal and infant wellbeing by supporting the parents-to-be using universal (aimed at everyone); universal plus (for targeted groups); and partnership plus (aimed at high risk groups) levels of interventions.
Universal methods of working in pregnancy include the antenatal promotional interview (as mentioned previously), consists of an hour long semi-structured interview that explores with the woman issues related to her pregnancy and wider life that are going well, or that are causing her problems. It can be used to support all women in addition to identifying those in need of additional support in terms of universal plus or partnership level intervention.
Universal plus methods should ensure that vulnerable women have access to a targeted preparation for parenthood programme. For example, the NSPCC programme Baby Steps is provided by two practitioners (e.g. health visitor/midwife and children’s centre worker) to groups of vulnerable couples beginning in pregnancy and continuing four weeks into the postnatal period. The programme covers a range of issues including preparation for new roles and responsibilities; emotional changes in pregnancy and following the birth; problem-solving and relationship skills and the importance of the relationship with the baby. Other evidence-based methods of working including home visiting programmes for teenage parents (e.g. FNP), and the delivery of guided self help; computerised cognitive behavioral therapy (CBT) or exercise non-directive counselling (listening visits), brief CBT or IPT for women experiencing chronic stress or anxiety.
Partnership plus involves the development of care pathways that enable women with complex needs to receive appropriate support. In addition to referral to specialist support teams such as adult mental health, substance misuse and domestic abuse workers. It may be necessary to refer the woman to children’s social care for an assessment concerning the future safety of the baby.
Psychosocial vulnerability in pregnant and newly delivered women has been shown to be associated with a range of long-term problems for the unborn and newborn infant. This is a result of the fact that these are sensitive periods in terms of the impact of the environment on the infant’s rapidly developing CNS.
Midwives have a key role to play in identifying women who may be vulnerable and in ensuring that they receive support that is appropriate to their needs, and those of their unborn/newborn baby.
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