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Article 48

Partner Support in Pregnancy

Can Prenatal and Postpartum Couples Therapy Reduce Postpartum Pathology and Strengthen Mother-Offspring Attachment?

Cal D. Ledbetter

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Prenatal stress and a negative birth experience can lead to postpartum stress—and in some cases can lead to maternal psychological pathology (Ayers, Eagle, & Waring, 2006; Buitelaar et al., 2003; Czarnocka & Slade, 2000; Dewar, 2008; Held & Rutheford, 2012; Huizink, Mulder, & Buitelaar, 2004; Kofman, 2002; Lemaire, Koehl, Le Moal, & Abrous, 2000; Manly, McMahon, Bradley, & Davidson, 1982; Mulder, Robles de Medina, & Visser, 2003; Righetti-Velterna, Conne-Perreard, Bousquet, & Manzano, 1998; Talge, Neal, & Glover, 2007; Wijma, Soderquist, & Wijma, 1997). Postpartum pathology can cause mothers to feel distant toward their offspring and underestimate their mothering abilities (Davies, Slade, Wright, & Stewart, 2008; Feldman et al., 2009; Murray & Cooper, 1996; Rholes et al., 2011). Studies suggested that support provided by partners to women during pregnancy and during birth can reduce postpartum pathology (Collins, Dunkel-Schetter, Lobel, & Scrimshaw, 1993; Field et al., 1985). “Partner support” is defined as open communication and emotional connection between partners that leads to availability by one to fulfill the other’s needs. In studies of women asked about partner support during pregnancy, many relayed anxiety about the relationship itself (Field et al., 1985; Tanner Stapleton et al., 2012; Whisman, Davila, & Goodman, 2011). Lack of connection within the relationship can lead to a perceived lack of partner support during a mother’s pregnancy and cause stress. It can be a factor in a negative birth experience, which can then lead to postpartum pathology. Postpartum pathology can be a factor in insecure mother-offspring attachment, and can affect the mother-partner relationship. Therefore, can interventions in couples therapy during the early stages of pregnancy lead to healthier mothers, babies, and families?

Prenatal Stress

The mother’s prenatal stress can correlate with stress experienced by the fetus (Buitelaar et al., 2003; Huizink et al., 2004; Kofman, 2002; Lemaire et al., 2000; Talge et al., 2007). Studies have suggested that one possible cause for prenatal stress is issues in the relationship between the mother and partner. A supportive partner during the prenatal stage, however, can reduce the mother’s stress (Tanner Stapleton et al., 2012).

Stress and the Fetus

According to research, a fetus can experience stress prenatally (Lemaire et al., 2000). Studies have suggested that these prenatal stressors can psychologically affect offspring postpartum (Huizink et al., 2004). Cortisol, the hormone that is released in response to stress, correlates in the mother and fetus (Talge et al., 2007). These prenatal releases of cortisol within the fetus can affect the psychological development of offspring postpartum and can lead to psychopathology later in the offspring’s life (Buitelaar, 2003). Some pathologies in offspring that have been theorized to be a result of prenatal stress include: attention deficit and hyperactivity disorder (ADHD), anxiety disorders, delayed language (Kofman, 2002; Talge et al., 2007), depression, and memory issues (Buitelaar et al., 2003).

The Mother-Partner Relationship and Stress

Relationship issues between the pregnant woman and her partner can be the root of prenatal stress. It has been suggested that prenatal stress can be a catalyst that can lead to negative attachment and bonding between the mother and her offspring once the offspring is born (Field et al., 1985; Tanner Stapleton et al., 2012; Whisman et al., 2011). Stress during pregnancy can also lead to poor health decisions including smoking cigarettes, consuming alcohol, and eating unhealthy foods (Lobel et al., 2008). If a pregnant mother perceives she is receiving proper support from her partner, it has been suggested that these stressors can be alleviated (Tanner Stapleton et al., 2012; Whisman et al., 2011). If the fetus’s stress correlates with the mother’s stress, and the mother’s stress can be linked to partner support, would it be possible to reduce stress in both the mother and the fetus and strengthen partner support through interventions with a couples therapist?

The Mother’s Birth Experience

A negative birth experience can possibly lead to issues postpartum (Ayers et al., 2006; Bailham & Joseph, 2003; Czarnocka & Slade, 2000; Held & Rutheford, 2012; Righetti-Velterna et al., 1998; Wijma et al., 1997). As with pregnancy, partner support in the birth experience can help alleviate these issues (Collins et al., 1993; Field et al., 1985).

Negative Birth Experiences and Resulting Issues

The definition of a negative birth experience varies somewhat in professional literature. However, a negative birth experience is generally understood as a birth experience that differs from what the mother had anticipated. There are numerous factors that can contribute to a negative birth experience. Some of these factors include: premature births, medical interventions with instruments by obstetricians, emergency caesarean sections, the mother’s fear for the safety of self and/or offspring, a feeling of helplessness had by the mother, and insufficient support from the hospital staff and the mother’s partner (Czarnocka & Slade, 2000; Dewar, 2008; Wijma et al., 1997).

Two major issues that can arise as a result of a negative birth experience are posttraumatic stress disorder (PTSD; Ayers et al., 2006; Bailham & Joseph, 2003; Czarnocka & Slade, 2000; Wijma et al., 1997) and postpartum depression (Held & Rutheford, 2012; Righetti-Velterna et al., 1998).

It is estimated that 1-2% of women develop PTSD as a result of their birth experience (Ayers et al., 2006; Czarnocka & Slade, 2000; Wijma et al., 1997). PTSD can develop if the mother feels she is not properly supported by her partner and birth staff and if she feels she does not have control over her birth experience (Bailham & Joseph, 2003; Czarnocka & Slade, 2000; Wijma et al., 1997). Factors such as emergency caesarean section, a history of sexual abuse, and a history of anxiety can also contribute to PTSD resulting from the birth experience (Bailham & Joseph, 2003).

It is estimated that anywhere from 10-22% of women experience a form of postpartum depression (Held & Rutheford, 2012; Manly, McMahon, Bradley, & Davidson, 1982; Righetti-Velterna et al., 1998), although general feelings of sadness, or the “baby blues,” may affect up to 75% of women who have just given birth (Held & Rutheford, 2012). Depression may develop following a negative birth experience. Another possible reason for an onset of postpartum depression is early separation of the offspring from the mother (Dewar, 2008).

Once the mother and offspring are home, adjusting to motherhood alone may give rise to negative emotions. Pressure to get back to work and/or having little social support may make a woman feel like she cannot cope with stressful and negative feelings (Held & Rutheford, 2012; Righetti-Velterna et al., 1998). Anxiety about the parenting experience and postpartum stress may also cause problems in the mother-partner relationship (Feldman et al., 2009).

The Mother-Partner Relationship and Postpartum Pathologies

As indicated with prenatal stress, partner support may help to decrease negative experiences during birth by the mother (Collins et al., 1993; Field et al., 1985). If feelings of not being supported can lead to potential pathologies postpartum, can partner support during the birth experience alleviate some of the experiences that lead to postpartum pathologies? Moreover, can couples therapy directly prior to birth help increase partner support of the mother, therefore potentially alleviating some of the problems in the birth experience that may be a factor in the development postpartum pathologies?

Postpartum Stress, Pathology, and Its Effect on Offspring

Stress and pathology in both the mother and the partner can affect offspring (Ayers et al., 2006; Murray & Cooper, 1996; Reynolds, 1997; Rholes et al., 2011; Tanner Stapleton et al., 2012) and the mother-partner relationship (Barnett, Brennan, & Marshall, 1994; Srivastava, McGonigal, Richards, Butler, & Gross, 2006). Support by both the mother and the partner toward each other can help reduce stress and pathology in both the mother and partner (Barnett et al., 1994).

Attachment to the Offspring

Mothers who have experienced PTSD and postpartum depression as a result of their birth experience may have feelings of rejection toward their offspring. This could result in the development of avoidant or anxious attachment to their offspring (also known as “insecure attachment”) (Ayers et al., 2006; Murray & Cooper, 1996; Reynolds, 1997; Rholes et al., 2011; Tanner Stapleton et al., 2012).

Scharff and Scharff (1998) defined anxious attachment as a parent-offspring attachment style that is marked by fear and clinginess by the offspring. Anxious attachment many times happens when a parent develops an overt need to depend on the offspring to help alleviate the parent’s own negative feelings. As a result, offspring have trouble regulating their own emotions and may cling to the parent to avoid having to experience negative feelings. Avoidant attachment is marked by tendencies to ignore. Parents may not develop close feelings with their offspring and ignore them or have little to do with them. As a result, offspring will learn to not be able to rely on the parents and will then also ignore the parents (Scharff & Scharff, 1998).

Field et al. (1985) suggested that mothers who experienced postpartum depression had lower levels of mother-offspring interaction than mothers who did not show signs of postpartum depression. In addition to PTSD and postpartum depression, postpartum anxiety can also affect mother-offspring attachment (Davies et al., 2008; Feldman et al., 2009; Murray & Cooper, 1996; Rholes et al., 2011). In a 2009 study by Feldman et al., it was suggested that mothers dealing with their own anxiety had less sensitivity toward their offspring and less social engagement with their offspring. In this study mothers with major depressive disorders and anxiety disorders were evaluated in the first postpartum year. Mother-offspring interaction was evaluated as well as emotional regulation and fear. Cortisol levels were monitored at baseline and reactivity. It was suggested in this study that offspring of mothers with anxiety disorders had similar stress reactivity to the offspring of mothers with depressive disorders.

These problems with the parent-offspring attachment can affect behavior in the offspring (Davies et al., 2008; Feldman et al., 2009; Murray & Cooper, 1996; Rholes et al., 2011). These insecure attachments can result in low social engagement, less mature behavior regulation, more negative emotionality (Feldman et al., 2009) and deficits in cognitive functioning by the offspring (Murray & Cooper, 1996).

Postpartum Issues and the Mother-Partner Relationship

Issues within the mother-partner relationship can be exacerbated by the introduction of offspring into the home (Frosch, Mangelsdorf, & McHale, 1998). Postpartum issues not only affect the mother of the offspring but can also affect the partner (Don & Mickelson, 2012). It has been suggested that partners of new mothers report martial dissatisfaction and less intimacy when mothers show symptoms of postpartum depression (Zelkowitz & Milet, 1996). Iles, Slade, and Spiby (2011) suggested that both partners’ stress-levels correlate postpartum. In this study, when couples were observed 3 months postpartum, the researchers suggested that the partner’s acute trauma response predicted mother’s posttraumatic stress. Rholes et al. (2011) suggested that insecure attachment between the mother and offspring, and depressive symptoms in the mother, correlated with the satisfaction in the relationship between mother and partner. It has also been suggested that reported dissatisfaction in partner support and the relationship can be a factor in postpartum depression experienced by the partner (Don & Mickelson, 2012). The partner’s perception of the relationship and support can determine the status of the relationship one year following the birth of offspring (Srivastava et al., 2006). It has been suggested that a good partnership following the birth of an offspring will determine the mental health of both the mother and the partner (Barnett et al., 1994).

Conclusion: A Case for Advocating Better Partner Support

Individual studies, pulled together to support each other, may give a broader perspective of the outcomes of prenatal and postpartum stress on mothers, partners, and offspring. Many studies cited in this paper have a common thread—partner support. The purpose of this paper was to outline the relationship between stress in pregnancy and the development of pathology among offspring. Another purpose was to suggest that stress can affect the mental health of the offspring, mother, and the mother’s partner. Additionally, stress during pregnancy, a negative birth experience, and postpartum pathology can be mitigated by perceived partner support. The logical goal, then, would be to reduce stress during pregnancy by strengthening the perceived support given by the partner.

Studies cited in this paper suggested that partner support prenatally and postpartum can reduce stress experienced by the mother (Collins et al., 1993; Field et al., 1985; Tietjen & Bradley, 1986; Whisman et al., 2011). Studies also suggested that partner support during the birth experience resulted in better postpartum experiences, less anxiety, lower rates of depression, higher self-esteem, and more time spent with offspring (Kennell, Klaus, McGrath, Robertson, & Hinkley, 1991; Scott, Berkowitz, & Klaus, 1999; Talge et al., 2007). Studies suggested that distress in both the mother and the offspring can be reduced by supportive partners (Field et al., 1985; Tanner Stapleton et al., 2012; Whisman et al., 2011). A study cited in this paper also suggested that support from the mother postpartum can help reduce negative feelings had by the partner (Don & Mickelson, 2012).

A research study conducted by Schulz, Cowan, and Cowan (2006) suggested that couples therapy in pregnancy can significantly help with decline in relationship satisfaction. Other studies have suggested taking the partner into consideration when conducting mental-health interventions with a pregnant woman (Iles et al., 2011; Tanner Stapleton et al., 2012). Understanding the links between partner support and the well- being of mothers, partners, offspring and the mother-partner relationship is a relatively new development in the field of mental-health therapy. Huizink et al. (2004) suggested more studies need to be conducted that look at prenatal care and stress reduction.

While there is much research that can be conducted on this topic, what can be concluded from this paper is that action can be taken prior to the published results of this research. Couples therapy in the meantime can be beneficial for partners embarking on a new stage in their lives. Although there is not yet strong evidence for the results of couples therapy on the stress that exists prenatally and postpartum, therapy can be beneficial for partners in general (Schulz et al., 2006). In the final section of this paper, interventions for therapy with pregnant couples is discussed.

Discussion: Interventions in Prenatal and Postpartum Couples Therapy

Schulz et al. (2006) found that although there is ample research suggesting that couples therapy can help partners transition into parenthood, interventions to help couples transition into parenthood do not exist to the extent they should. Righetti-Velterna et al. (1998) found that new mothers with postpartum depression typically do not seek out, and therefore do not receive, therapy. Heneghan, Mercer, and DeLeone (2004) suggested that mothers with postpartum issues are aware of problems with their mental health and its affect on their offspring, but rarely discuss it with the medical professional they have the most access to—their offspring’s pediatrician—because of a fear of judgment. The researchers suggested that mothers are open to the idea of communicating with pediatricians about mental health if it is brought up to them. They also suggested that mothers are interested in receiving services and are also willing to receive written communication from their pediatrician about postpartum mental health issues.

Therapeutic Interventions

Although research including therapeutic interventions revolving around the mother-partner relationship as it pertains to partner support does not exist to the extent it should, some research exists for interventions when working with specific prenatal and postpartum issues. These interventions may be applied to couples therapy to strengthen the mother-partner relationship and strengthen partner support.

Cognitive Behavioral Therapy can be helpful with mothers suffering from postpartum depression (Tandon, Perry, Mendelson, Kemp, & Leis, 2011). Doherty, Farrell Erickson, and LaRossa (2006) suggested that psychoeducational group classes for parents improved father-child interaction. Group classes consisted of lectures, discussions, videos and role-plays. The goal of the classes was to help partners develop parenting skills, but also to increase support by the mother toward the partner’s interactions with the children. Petch, Halford, Creedy, and Gamble (2012) also suggested couple-relationship education to help increase relationship satisfaction for couples transitioning into parenthood. They suggested that women who received phychoeducation had less negative communication with their partners and less stress surrounding motherhood. The researchers stated, though, that the best results were with high-risk parents. Non-high-risk parents showed very little change.

Schulz, Cowan, and Cowen (2006) suggested that group therapy can help reduce deterioration of couples’ relationships following the birth of a child. Group therapies in this study consisted of couples exploring how they view themselves and their relationship, the split between household duties, communication and problem-solving styles, and values about parenting. Group sessions also focused on the couples’ own childhoods and how their experiences shaped their ideas about their own parenthood. Specific interventions included exploring couples’ attachment styles in their relationships, accepting differences between each other, and learning how to deescalate arguments. The relationships of the couples in these studies did not decline at the same rate as couples who did not receive group interventions.

Goudreau & Duhamel (2003) hypothesized using interventions in five categories: father participation, couple’s adjustment, education, support, and agenda setting. They suggested that of these categories, father participation in the pregnancy was the only category where they saw change. In this study, though, these interventions were being put forth by medical professionals—doctors and nurses—during medical consultations. The limitations they found in lack of movement in the other four categories was tied to time constraints in medical visits.

As evidenced by the contents of this paper, there is a need for research to be done on the efficacy of prenatal and postpartum couples therapy and how it relates to stress, support, relationship satisfaction, postpartum pathology, and attachment to the offspring.