Depression Before, During, and After Pregnancy

A mother’s depression during the perinatal period is crucial in determining her offspring’s risk of developing a low level of psychosocial functioning or a high level of emotional or behavioral problems.1 Disruptions in mother-infant interaction are considered to be a primary mechanism for transmitting these outcomes.2

Most research to date has focused on postnatal depression (PND), or postpartum depression, as the cause of poor quality mother-child interactions, meaning that women with PND may be unresponsive to or withdraw from the infant, or they may be intrusive or controlling, showing diminished sensitivity to their infants’ behaviors and needs. Less studied is whether depression occurring during the antenatal, or prenatal, period, which affects as many as 20% of pregnancies, can also interfere with the mother-infant bond.3

Prior research has shown that both PND and antenatal depression are associated with poorer bonding and increased maternal unresponsiveness postnatally, but most of these studies were conducted using self-report measures.

Prior Depression as a Factor in Perinatal Depression

It is known that a history of major depressive disorder (MDD) is one of the largest risk factors for perinatal MDD, and that perinatal MDD is associated with difficulties in the mother-infant interaction. With this in mind, Dr. Rebecca H. Bind of the Institute of Psychiatry, Psychology, and Neuroscience at King’s College in London, and colleagues sought to investigate whether these difficulties would be present even in women with a past history of MDD but who did not meet the criteria for depression during pregnancy. They showed that antenatal depression as well as a lifetime history of depression disrupts mother-infant interactions, regardless of whether the mother has postnatal depression.4

Women in the study were either healthy (n=51), had active MDD during pregnancy (n=52), or had a history of MDD but a healthy pregnancy (n=28). Subjects in both depression groups showed a reduced quality of interaction with their infants postnatally compared with the healthy group. At 8 weeks, 62% of mothers in the depression group and 56% in the history-only group scored in the lowest category of dyadic synchrony – the reciprocal back and forth interactions between mothers and infants – compared with 37% in the healthy group (P=0.041). At 12 months, 48% and 32% of the depression group and history-only group, respectively, scored in the lowest category, compared with 14% in the healthy group (P=0.003).4

One possible neurobiological explanation for the persistent effects of past depression is that women with depression outside the perinatal period have lingering dysregulation of circulating oxytocin levels, which affects the formation of the mother-infant bond.4

Antenatal Depression

Dr. Bind and her team also tested whether women with depression presented with other clinical or sociodemographic risk factors that may have contributed to the association between maternal depression and difficulties in the mother-infant interaction.

Causes of Antenatal Depression

According to a prior literature review and meta-analysis, the most relevant factors contributing to antenatal depression or anxiety are:3

  • a lack of a partner or social support
  • history of abuse or domestic violence
  • personal history of mental illness
  • unplanned or unwanted pregnancy
  • adverse events in life and high perceived stress
  • pregnancy complications
  • pregnancy loss

However, contrary to these previous studies, childhood maltreatment in Dr. Bind’s research did not affect the mother-infant interaction and postnatal depression had only a marginal effect if it occurred in the first 8 weeks following birth.4 Instead, Dr. Bind’s team shares that the most likely contributors to difficulties in the mother-infant interaction are material socioeconomic difficulties and a dysregulation of the infant’s orientation skills, which include the ability to attend to auditory and visual stimuli that indicate readiness for social interaction.

Predictors of Mother-Infant Interaction Quality: Is Genetic Transmission Possible?

In Dr. Bind’s study, neonates were assessed for their ability to engage in auditory and visual stimuli at 6 days using the Neonatal Behavioral Assessment Scale (NBAS).5 Those in the depression and history-only groups exhibited decreased social-interactive behavior. Such decreases, along with findings of lower maternal socioeconomic status (SES), also became important predictors of mother-infant interaction quality.

Hierarchical regression models showed that dyadic synchrony became less a function of depression status, but more the result of SES and NBAS scores at 8 weeks and SES alone at 12 months.4 Similar findings have been reported with regard to socioeconomic factors and NBAS scores, although depression was never included before this study as a variable.

Dr. Bind’s group suggested that genetic transmission of maternal depression may be responsible for the infants’ behavioral alterations, or that because each member of the dyad influences the response in the other, parenting difficulties in mothers and temperament difficulties in the infants may perpetuate each other.

In this study, women with only a history of depression had better SES scores, which represented the presence of protective factors that may have shielded them from becoming depressed during pregnancy but were not enough to preserve the quality of the mother-infant interaction. This finding speaks to the numerous, overlapping factors that influence maternal psychopathology and the maternal-infant bond.

Optimal Mother-Infant Bonding Takes Place Early

Interestingly, while women in both the depression and history-only groups of Dr. Bind’s study were more likely to be postnatally depressed than women in the healthy group, the presence of postnatal depression did not predict dyadic synchrony. The team found that antenatal depression is more predictive than PND in how the dyad will behave, possibly because antenatal depression may lead to disrupted fetal attachment and early postpartum bonding.

Indeed, other research shows that the presence of PND itself does not disrupt the mother-infant relationship if optimal bonding is present early on in the postnatal period.6

Postpartum and Perinatal Care: Clinical Implications

Dr. Bind’s study shows that support for mother-infant dyads at risk for interaction difficulties should begin during pregnancy and should be targeted to women with current MDD as well as to those with a history of clinically significant depression. At 8 weeks, many dyads in the depression and history-only groups are at risk, according to the CARE-Index,7 indicating the need for parental treatment psychotherapy, and a significant proportion of these dyads remain at risk at the 12-month mark. Surprisingly, Dr. Bind’s team also found that even some healthy dyads fall into the inept range of the CARE Index at 8 weeks postnatal, suggesting that all expectant mothers would benefit from support before giving birth.

According to Dr. Bind’s paper, such support could be provided through educational materials that show examples of:

  • sensitive mothering behaviors
  • ways to engage with the fetus and infant
  • behaviors to expect from an infant
  • developmental milestones

Perinatal Education

Perinatal education could be incorporated into birthing classes and health visits.

According to Dr. Bind, her team’s findings highlight the importance of support from perinatal services for women identified to be vulnerable and notes that helpful interventions, such as video feedback and structured mother-baby activities, should be more widely available. “This way,” Dr. Bind concluded in her paper, “we may be able to break the intergenerational transmission of psychopathology that begins with maternal depression (lifetime or in pregnancy) and may lead to increased mental health problems in offspring via, at least in part, a disrupted mother-infant interaction.”

References
Last Updated: Aug 13, 2021