MATERNAL ANXI ETY I N THE PRE- AND POSTNATAL PERI OD: A LI TERATURE REVI EW
Luciana Leonet t i Cor r eia1 Mar ia Beat r iz Mar t ins Linhar es2
Cor r eia LL, Linhar es MBM. Mat er nal anxiet y in t he pr e- and post nat al per iod: a lit er at ur e r eview . Rev Lat ino- am
En fer m agem 2 0 0 7 j u lh o- agost o; 1 5 ( 4 ) : 6 7 7 - 8 3
This st udy int ended t o pr esent a syst em at ic r eview t o analyze t he em pir ical st udies published bet w een 1998 and 2003 about m at er nal anx iet y in t he pr enat al and post nat al per iods, focusing on pr e- t er m and t er m bir t hs. Ninet een st udies w er e found; six of w hich evaluat ed m at er nal anxiet y in t he pr enat al per iod, 12 st udies ev aluat ed anx iet y in m ot her s in t he post nat al per iod and only one st udy ev aluat ed m at er nal anx iet y in bot h per iods. The r esult s show ed t hat high lev els of m at er nal anx iet y in t he pr enat al phase w er e associat ed w it h obst et r ic pr oblem s, em ot ional dam ages t o fet al developm ent , behavior al pr oblem s in childhood and adolescence. The m ot her s pr esent ed higher anx iet y lev els w hen com par ed w it h t he fat her s. The co- occur r ence of m at er nal an x iet y an d d ep r ession w as f ou n d . Th e m at er n al an x iet y assessm en t is r elev an t t o id en t if y b ot h m at er n al m ent al healt h and child dev elopm ent at r isk .
DESCRI PTORS: anx iet y ; pr em at ur e bir t h; t er m bir t h
ANSI EDAD MATERNAL EN EL PERÍ ODO PRENATAL Y POSTNATAL: REVI SI ÓN DE LA
LI TERATURA
La finalidad de est a r evisión sist em át ica de la lit er at ur a fue analizar la pr oducción cient ífica ent r e 1998 y 2003 de est udios em pír icos en la t em át ica de ansiedad en las fases pr enat al y post nat al, enfocando nacim ient os del pr e- t er m ino o del t ér m ino. Se obt uvier on 19 ar t ículos, de los cuales 6 evaluar on la ansiedad m at er nal en el per íodo pr enat al, 12 est udios evaluar on la ansiedad en m adr es en el per íodo post nat al y solam ent e un est udio ev alu ó la an siedad m at er n al en am bos per íodos. Los r esu lt ados dem ost r ar on qu e alt os n iv eles de an siedad m at er nal en la fase pr enat al fuer on asociados a com plicaciones obst ét r icas, daños al desar r ollo fet al, pr oblem as em ocion ales y com p or t am en t ales en la in f an cia y la ad olescen cia. Las m ad r es h ab ían p r esen t ar on n iv eles m ay or es de ansiedad en com par ación con los niv eles pr esent ados por los padr es. Se v er ificó la co- ocur r encia ent r e los niveles de ansiedad m at er nal y la depr esión. La evaluación de la ansiedad m at er nal es r elevant e par a ident ificar r iesgos en la salud m ent al m at er nal y en el desar r ollo del niño.
DESCRI PTORES: an siedad; n acim ien t o pr em at u r o; n acim ien t o de t ér m in o
ANSI EDADE MATERNA NOS PERÍ ODOS PRÉ E PÓS- NATAL: REVI SÃO DA LI TERATURA
Rev isão sist em át ica da lit er at u r a qu e t ev e por obj et iv o an alisar a pr odu ção cien t íf ica en t r e 1 9 9 8 e 2003 de est udos em pír icos sobr e a t em át ica ansiedade m at er na, nas fases pr é e pós- nat al, focalizando t ant o n ascim en t os p r é- t er m o q u an t o a t er m o. For am ob t id os 1 9 ar t ig os, d os q u ais seis av aliar am a an sied ad e m at er na no per íodo pr é- nat al, 12 est udos av aliar am a ansiedade em m ães no per íodo pós- nat al e apenas um est u d o av aliou a an sied ad e m at er n a em am b os os p er íod os. Os r esu lt ad os m ost r ar am q u e alt os n ív eis d e ansiedade m at er na na fase pr é- nat al for am associados a com plicações obst ét r icas, pr ej uízos ao desenvolvim ent o fet al, pr oblem as em ocionais e de com por t am ent o na infância e na adolescência. As m ães apr esent ar am m aior es n ív eis de an siedade qu an do com par ados aos n ív eis apr esen t ados pelos pais. Foi v er if icada a co- ocor r ên cia en t r e os n ív eis d e an sied ad e e d ep r essão m at er n a. A av aliação d a an sied ad e m at er n a é r elev an t e p ar a ident ificação de r iscos na saúde m ent al m at er na e no desenv olv im ent o da cr iança.
DESCRI TORES: an siedade; n ascim en t o pr em at u r o; n ascim en t o a t er m o
D isponible e n ca st e lla no/ D isponíve l e m língua por t ugue sa SciELO Br a sil w w w .scie lo.br / r la e
1 MSc in Ment al Healt h, Doct or al St udent , Ment al Healt h Pr ogram ; 2 PhD, Pr ofessor, e- m ail: linhar es@fm r p.usp.br. Univer sit y of São Paulo at Ribeir ão Pr et o
A
n x i et y d i so r d er s f i g u r e am o n g t h e m o st fr equ en t psy ch iat r ic disor der s in t h e popu lat ion an da n x i o u s sy m p t o m s a r e a m o n g t h e m o st co m m o n
ones. They can be found in any per son dur ing cer t ain
per iods in his/ her life. How ever, t his anx iet y can be
pat hological w hen it is disproport ional t o t he sit uat ion
t hat unleashes it or w hen t her e is no specific m ot iv e
for it s appearance( 1) or, also, w hen it is an inadequat e
an sw er t o a cer t ain t h r eat , d u e t o it s in t en sit y or
dur at ion( 2).
On t h e on e h an d , p r eg n an cy, d eliv er y an d
t h e p u er p er al st ag e r ep r esen t sen sit iv e p er iod s in
w o m e n ’ s l i f e s p a n . Th e s e p e r i o d s i n v o l v e g r e a t
t r a n s f o r m a t i o n s , n o t o n l y f r o m a p h y s i o l o g i c a l
p e r s p e c t i v e , b u t a l s o f r o m t h e p s y c h o l o g i c a l
p e r sp e ct i v e a n d o f t h e f e m a l e so ci a l - f a m i l y r o l e .
Fu r t h e r m o r e , t h e p h y si ca l ch a n g e s t h a t o ccu r r e d
d u r in g p r eg n an cy can p r ov ok e em ot ion al in st ab ilit y
in w om en( 3).
O n t h e o t h e r h a n d , t h e o c c u r r e n c e o f
m a t e r n a l p sy ch o p a t h o l o g i ca l d i so r d e r s ca n e x e r t
det r im ent al effect s on t he child’s developm ent . Ther e
are t hree possible reasons for t his im pact , w hich are:
t he dir ect effect on t he child, w ho is ex posed t o t he
parent s’ m ent al disorder, t he indirect im pact of parent al
disor der on int er per sonal r elat ions and t he pr esence
of adv er sit ies com m on ly associat ed w it h psy ch iat r ic
disor der s( 4 ).
Due t o t he im pact t hey exer t on t he couple’s
life and t he childr en’s dev elopm ent , am ong m at er nal
psychological sym pt om s, anxiet y and depr ession st and
out , w hich can be m anifest ed in t he pr enat al and in
t he post nat al phase( 5).
Wh en a n or m al an d h ealt h y in f an t is bor n ,
t he m ot her needs t o adapt her idealized im age of t he
baby t o t he r eal baby w ho is act ually t here. How ever,
t his adapt at ion becom es m or e difficult for t he m ot her
of a pr em at ur e baby( 5- 6), as t he im pact of pr em at ur e
birt h t ends t o be an em ot ionally dist ressing exper ience
for m ost m ot her s, w ho can be m or e ex posed t o t he
exper ience of anxious sym pt om s, even w hen t he baby
is clinically st able( 6- 7).
I n or der t o m inim ize t he im pact of im m ediat e
negat ive consequences of t he baby’s pr em at ur e bir t h,
c h a n g e s i n n e o n a t a l c a r e p r a c t i c e s h a v e b e e n
pr oposed, in clu din g st im u lat ion an d en cou r agem en t
of ear ly con t act bet w een m ot h er an d ch ild an d t h e
par ent s’ act ive part icipat ion in car e for t he baby inside
t h e Neo n a t a l I n t en si v e Ca r e Un i t( 4 , 7 - 8 ). Th i s ea r l y
in t er v en t ion m odalit y aim s t o r edu ce h igh m at er n al
an x iet y lev els an d p r om ot e t h e m ot h er s’ ex clu siv e
p sy ch olog ical w ell- b ein g an d r ep r esen t s a m easu r e
t o p r ev en t ad ap t i v e d ev el o p m en t p r o b l em s i n t h e
child( 8).
Th e p u r p o se o f t h i s st u d y w as t o an al y ze
scient ific product ion based on em pirical art icles about
m at er n al an x iet y in t h e pr e- an d post n at al ph ases,
focusing on pre- as w ell as full t erm birt hs.
METHOD
We ex cl u si v el y sear ch ed em p i r i cal ar t i cl es
in d ex ed in elect r on ic d at ab ases ( Med Lin e, Psy cI n f o
and Lilacs) , t hr ough a sur vey w it h t he follow ing
key-w or ds: m ot her OR m at er n al OR fam ily AND an x iet y
AND pr em at ur it y OR pr et er m OR ver y low bir t h w eight
O R p r e m a t u r e O R n e o n a t e A N D N I CU a n d i t s
c o r r e s p o n d i n g t e r m s i n Po r t u g u e s e ( B r a z i l ) . A l l
r egist er s of ar t icles published bet w een 1998 and 2003,
w hich cont ained any of t he com binat ions of t he k ey
w or ds in t he indexed lit er at ur e, r efer r ing t o em pir ical
r esear ch p u b lish ed in En g lish / Sp an ish / Por t u g u ese,
w ere ident ified, analyzed and classified. To t he result s
obt ained in t his fir st sur v ey ( 62 ar t icles) , w e applied
cr it er ia t o ex clu d e r ev iew ar t icles ( 1 1 ar t icles) an d
ar t icles w hose obj ect iv es w er e incom pat ible w it h t he
t hem e of our r eview ( 26 ar t icles) . Tw ent y- five ar t icles
rem ained, 19 of w hich w ere found in nat ional libraries
an d six w er e ex clu d ed b ecau se t h ey cou ld n ot b e
accessed in Br azil.
RESULTS
I n t h e t o t a l set o f 1 9 st u d i es, si x ( 3 1 % )
assessed m at er nal anxiet y in t he pr enat al phase, one
of w h ich w as a cr oss- sect ion al st u d y ( 9 ), w h ile t h e
ot her s had a pr ospect ive longit udinal design. Only one
st udy inv olv ed m ot her s of low - w eight ( < 2, 500g)( 10)
p r em at u r e b ab ies ( < 3 7 w eek s of g est at ion al ag e)
an d f iv e w er e car r ied ou t w it h m ot h er s of f u ll- t er m
b ab ies.
Tw el v e o f t h e 1 9 st u d i es ( 6 3 % ) a ssessed
m at er nal anxiet y in t he post nat al per iod only, in cr
oss-sect ional st udies. Six of t hese w er e car r ied out w it h
m ot her s of pr em at ur e infant s and six w it h m ot her s of
f u ll- t er m babies.
Only one of t he 19 st udies assessed anx iet y
a co m p a r a t i v e d esi g n b et w een p a i r ed sa m p l es o f
m ot her s of full- t er m babies.
St udies on m at er nal anx iet y in t he pr enat al per iod
As t o t he assessm ent of m at er nal anx iet y in
t he pr enat al phase, only one st udy looked at m ot her s
o f p r e - t e r m a n d l o w b i r t h w e i g h t i n f a n t s. W h e n
ex am in in g t h e r elat ion s b et w een p r en at al m at er n al
p sy ch osocial r isk f act or s an d low b ir t h w eig h t , t h e
a u t h o r s c o n c l u d e d t h a t m a t e r n a l p r e n a t a l r i s k
v ar iables like num ber of cigar et t es sm oked per day,
educat ion level, num ber of daily st r essor s and num ber
of h ou r s w or k ed r epr esen t ed dif f er en t con t r ibu t ion s
for each gr oup of babies as r isk fact or s for low bir t h
w eig h t . Fu r t h er m or e, in n on e of t h e b ab y g r ou p s,
accor d in g t o t h e b ir t h w eig h t p er cen t ile, m at er n al
anxiet y show ed t o be a significant pr edict ive var iable
for low bir t h w eight( 10).
On e st u dy obser v ed t he effect s of m at er nal
a n x i e t y a s a r i sk f a ct o r d u r i n g p r e g n a n cy, w h i ch
e x a m i n e d t h e a s s o c i a t i o n b e t w e e n o b s t e t r i c
c o m p l i c a t i o n s a n d s y m p t o m s o f a n x i e t y a n d
depression in m ot hers of full- t erm infant s. The aut hor s
obser ved t hat w om en diagnosed w it h pr enat al anxiet y
d isor d er h ad a g r eat er p r ob ab ilit y of p r esen t in g a
h ist or y of obst et r ic com plicat ion s du r in g pr egn an cy.
The st udy concluded t hat obst et r ic com plicat ions act ed
as chr onic dist r essor s dur ing pr egnancy( 11).
Mat ernal anxiet y was considered a risk fact or
for norm al fet us developm ent in t wo st udies( 9- 12). I n one
of t hese st udies, t he aut hors exam ined t he effect s of
acut e dist ress responses and m at ernal anxiet y on t he
physiological response of fet al heart beat heart rat e. The
w om en w er e subm it t ed t o a dist r ess sit uat ion in t he
t hird sem est er of pregnancy and, t hen, were divided in
t w o g r ou p s accor d in g t o t h e an x iet y lev el. I t w as
co n cl u d ed t h at , al t h o u g h t h er e w as n o si g n i f i can t
difference bet ween t he groups of m ot hers wit h low or
high m at er nal anx iet y lev els, t he fet uses of m ot her s
w i t h h i g h a n x i et y l ev el s r ev ea l ed h i g h h ea r t r a t e
frequencies in com parison wit h t he fet uses of m ot hers
w it h low anx iet y lev els dur ing t he m at er nal dist r ess
sit uat ion. Furt herm ore, t he m ot hers wit h high anxiet y
levels r eact ed t o t he dist r ess sit uat ions w it h differ ent
react ivit y pat t erns t han m ot hers from t he groups wit h
low anxiet y levels( 9). I n t he second st udy( 12) on pregnant
adolescent s, t he relat ion was verified bet ween t he result s
of m at ernal em ot ional ( t rait and em ot ional st at e) and
biological m easures and t he result s of t he react ivit y of
t h e f et u s’ au t on om ou s n er v ou s sy st em , par t icu lar ly
heart t onus. I t was found t hat high scores of negat ive
em ot ions, including m at ernal anxiet y in t he 16t h w eek
of pr egnancy, pr edict ed low hear t t onus in t he fet us
and high Apgar scores 5t h m inut e. These cont radict ory
findings show t he different ial effect of m at ernal em ot ions
during pregnancy and on fet al developm ent . The aut hors
raise t he explanat ory hypot hesis t hat , alt hough anxiet y
is r elat ed w it h t he fet us’ low hear t t onus in t he fir st
sem est er, at t h e sam e t im e, it can in dicat e posit iv e
m at er nal behav ior r elat ed t o concer n w it h pr egnancy
and t he consequent healt h care, which can lead t o bet t er
birt h condit ions for t he baby.
Mat er n al depr ession w as assessed t oget h er
w it h anxiet y in st udies t hat obser ved t hat differ ent ial
effect s of t hese m at er nal indicat or s dur ing childhood
and adolescence( 13- 14). The effect s of pr enat al m at er nal
an x iet y an d pr e- an d post n at al m at er n al depr ession
w er e assessed in t h e p r od u ct ion of b eh av ior al an d
em ot ional pr oblem s in childr en at four y ear s of age.
A significant cor r elat ion w as found bet w een m at er nal
a n x i et y a n d d ep r essi o n m ea su r es i n t h e p r en a t a l
per iod and a m oder at e cor r elat ion bet w een pr enat al
anx iet y and post nat al depr ession. The high lev els of
pr en at al an x iet y an d pr e- an d post n at al depr ession
w er e r esp on sib le f or d ou b lin g or t r ip lin g t h e m ean
rat e of behavioral and em ot ional problem s in children
at four y ear s of age. Pr enat al m at er nal anx iet y and
p o s t n a t a l m a t e r n a l d e p r e s s i o n c o n t r i b u t e d
i n d ep en d en t l y i n t h e p r ed i ct i o n o f b eh av i o r al an d
em ot ion al pr oblem s in ch ildr en assessed at t h e age
of f ou r( 1 4 ). On t h e ot h er h an d, w h en ex am in in g t h e
r elat ions bet w een pr e- and per inat al event s and r isks
f o r t h e d e v e l o p m e n t o f p sy ch o p a t h o l o g i e s d u r i n g
adolescence, it was obser v ed t hat , dur ing pr egnancy,
m ot her s w ho pr esent ed em ot ional pr oblem s, including
anx iet y and depr ession, had childr en w it h a gr eat er
p r o b a b i l i t y o f d e v e l o p i n g m a j o r d e p r e s s i o n a n d
behav ior al disor der s dur ing adolescence. Hence, t he
findings of t his st udy indicat e t hat m at er nal anx iet y
a n d d e p r e s s i o n a p p e a r a s r i s k f a c t o r s f o r t h e
dev elopm ent of psy chopat hologies dur ing t he child’s
ad olescen ce( 1 3 ).
Su m m ar izin g, it w as f ou n d in t h ese st u dies
t hat t he occurrence of high levels of m at ernal anxiet y
in t h e pr en at al ph ase w as associat ed w it h a h igh er
num ber of obst et r ic com plicat ions( 11) and j eopar dized
f e t a l d e v e l o p m e n t , s u c h a s a h i g h e r n u m b e r o f
a b n o r m a l i t i e s( 1 2 ) a n d h i g h f e t a l h e a r t r a t e
of m at ernal anxiet y in t his phase w ere associat ed w it h
em ot ional and behavioral problem s, in children at t he
age of four( 14) as w ell as in adolescent s( 13). How ever,
t he pr esence of m at er nal anx iet y did not ser v e as a
significant pr edict or of low bir t h w eight( 10).
St udies on t he assessm ent of m at ernal anxiet y in t he
post n at al per iod
St udies t hat assessed anx iet y in m ot her s of
full- t er m babies appoint har m ful effect s for t he baby’s
dev elopm en t . Wh en v er if y in g t h e r elat ion s bet w een
m at er nal m ood, including m at er nal anx iet y, and t he
developm ent of full- t er m babies assessed t hr ough t he
Gr if f it h s Scale at t h e ag e of t h r ee m on t h s, it w as
obser v ed t hat t he m ot her s’ scor es on Zung’s Anx iet y
Scale p r ed ict ed t h e b ab ies’ d ev elop m en t scor es on
t h e Gr i f f i t h s Scal e; t h e h i g h er m o t h er s sco r es o n
Zung’s Anx iet y Scale ( gr eat er m at er nal anx iet y ) , t he
low er t he babies’ developm ent scor es on t he Gr iffit hs
Scale, appoint ing gr eat er com m it m ent of t he babies’
dev elopm en t( 1 5 ).
Tw o d i f f e r e n t st u d i e s a sse sse d p o st n a t a l
anxiet y in relat ion w it h m ot her- child bonding( 16- 17). The
incidence of m at ernit y blues w as r elat ed w it h bonding
in m ot her s of full- t er m babies in t he post par t um per iod.
I n t his st udy, m at er nal bonding included t w o fact or s:
t he nucleus of m at er nal bonding and m at er nal anxiet y
d i r e ct e d a t t h e ch i l d . Th e a u t h o r s f o u n d st r o n g
cor r elat ion s b et w een m at er n it y b lu es an d m at er n al
anxiet y dir ect ed at t he child and t he m at er nal bonding
nucleus; t he st ronger t he m at er nit y blues, t he higher
t he m at er nal anx iet y lev el dir ect ed at t he child. The
baby’s bir t h or der and m at er nit y blues w ere predict ive
v alu es of m at er n al an x iet y dir ect ed at t h e ch ild( 1 6 ).
An o t h e r st u d y l o o k e d a t m a t e r n a l co n ce r n s a n d
bon din g beh av ior s in t h r ee gr ou ps, dif f er en t iat ed in
t e r m s o f n e o n a t a l r i s k , c o n d i t i o n s o f p r o x i m i t y,
separat ion and pot ent ial loss of t he baby. The findings
show ed t hat high levels of t r ait anxiet y and separ at ion
anx iet y in t he m ot her s, independent ly of t he baby ’s
m edical condit ion and t he separ at ion bet w een m ot her
an d ch ild , ex p lain ed t h e v ar iat ion in t h e cog n it iv e
com pon en t s an d con cer n , st r ess lev el an d m at er n al
st r ess coping in t he post nat al phase( 17).
Th e m at er n al h ist or y of sex u al ab u se w as
co n si d er ed i n t w o st u d i es t h at assessed m at er n al
anx iet y in t he post nat al per iod( 18- 19). The m ot her s of
f u l l - t e r m b a b i e s w e r e d i v i d e d i n t w o g r o u p s ,
differ ent iat ed by t he pr esence of not of sexual abuse
in t h eir ch ildh ood, an d diagn osed w it h at least on e
episode of m aj or depr ession in t he post par t um per iod.
Th e au t h o r s f o u n d t h at m o t h er s w i t h a h i st o r y o f
sex ual abuse pr esent ed higher lev els of anx iet y and
depr ession t han m ot her s in t he cont r ol gr oup( 1 8 ). I n
anot her st udy, t r ait - anx iet y levels w er e com par ed in
t w o gr oups of m ot her, differ ent iat ed accor ding t o t heir
babies’ bir t h condit ion ( pr e- t er m or full- t er m ) and t o
t h e h ist or y of sex u al abu se. Th e gr ou ps of m ot h er s
w er e st r at ified in t er m s of t he pr esence and hist or y
of sexual abuse. I n t he r esult s, consider ing t he baby’s
b ir t h con d it ion an d t h e m ot h er ’s h ist or y of sex u al
abuse, t he gr oups show ed no differ ence in m at er nal
t r ait - anx iet y lev els( 1 9 ).
Tw o st udies assessed m at er nal anx iet y in an
int er vent ion cont ext , com par ing gr oups of m ot her s(
20-21)
. The m at er nal m ood indicat or s ( including anx iet y
and depr ession) , conj ugal sat isfact ion and t he baby ’s
t em peram ent were com pared in t wo groups of m ot hers
of full- t erm babies: one group of m ot hers adm it t ed at
t h e Par ent cr aft Un it of a h ospit al an d a com par ison
group t hat received rout ine follow- up from t he service
unit . The m ean t rait and st at e- anxiet y scores of m ot hers
fr om t he Par ent cr aft Unit w er e higher in com par ison
wit h t he m eans of m ot hers from t he com parison group.
Furt herm ore, t he aut hors found significant correlat ions
bet w een anx iet y and m at er nal depr ession scor es and
t he babies’ difficult t em per am ent , in bot h gr oups of
m o t h e r s ; t h e h i g h e r t h e m a t e r n a l a n x i e t y a n d
depr ession scor es, t h e m or e t h e m ot h er s per ceiv ed
t hat t hese babies had a difficult t em per am ent( 20). I n
anot her st udy, which com pared t wo groups of m ot hers
of babies born wit h very low weight ( < 1,500g) , wit h a
gest at ional age of less t han 30 weeks and adm it t ed in
an NI CU, different iat ed by t heir part icipat ion or not in
t he Buddy Program , t he aut hors assessed t he efficacy
o f t h i s p r o g r a m t o r e l i e v e d i st r e ss, a n x i e t y a n d
depression and prom ot e social support for t he parent s.
The Buddy Pr ogr am inv olv ed t he offer ing of suppor t
t o t he m ot her s by ot her v olunt ar y par ent s w ho had
been t h r ou gh t h e ex per ien ce of h av in g t h eir babies
hospit alized at an NI CU. The aut hors observed t hat , at
baseline, t he m ot hers from bot h groups present ed high
l e v e l s o f d i st r e ss, a n x i e t y, d e p r e ssi o n a n d so ci a l
suppor t . The m ot her s w ho par t icipat ed in t he Buddy
Program displayed lower st at e- anxiet y and depression
scores and a great er percept ion of social support t han
m o t h e r s f r o m t h e c o n t r o l g r o u p . N o s i g n i f i c a n t
differ ences w er e found bet w een t he gr oups for t r ait
Mat er n al an x iet y w as also assessed on t h e
basis of r epor t s on m ot h er s’ ex per ien ces r elat ed t o
t he separat ion from t heir full- t erm babies, hospit alized
at an NI CU. Wit h r espect t o t he r esult s of t he r epor t s
ob t ain ed f r om t h e m ot h er s’ ex p er ien ces d u r in g t h e
b ab ies’ h osp it alizat ion , t h e m ot h er s ex p r essed t h at
t h ey f el t an x i et y d u e t o t h e p ossi b i l i t y of cau si n g
pr ej u dice t o t h e baby t h r ou gh t h e ear ly separ at ion ,
due t o t he baby’s hospit alizat ion at t he NI CU( 22).
When assessing t he st at e- anx iet y of fat her s
and m ot her s of full- t er m babies in t he post nat al per iod,
using t he STAI , t he aut hor s em phasized t he m ot her s’
v u l n er a b i l i t y i n v i ew o f t h e b a b y ’ s b i r t h , a s t h ey
pr esen t ed h igh er lev els of an x iet y t h an t h e f at h er s
d u r in g all post n at al assessm en t s( 2 3 ). Th ese f in d in g s
cor r obor at e t he r esult s found in anot her st udy car r ied
out w it h m ot her s and fat her s of pr em at ur e and low
bir t h w eight babies hospit alized at an NI CU( 24).
Th e st u dies t h at assessed m at er n al an x iet y
and depr ession levels in t he post nat al per iod appoint ed
t h a t , i n d e p e n d e n t l y o f t h e b a b y ’ s b i r t h co n d i t i o n
( p r em at u r e or f u ll- t er m ) an d h osp it alizat ion at an
NI CU, t hese sy m pt om s co- occur( 15- 17,20,25- 26), r at ify ing
t he r esult s of st udies t hat assessed m at er nal anx iet y
in t he prenat al period( 13- 14).
Be s i d e s b e i n g a n i m p o r t a n t p r e d i c t o r o f
d ev elop m en t p r ob lem s in b ab ies( 1 5 ), h ig h lev els of
m at er nal anxiet y have been associat ed w it h a hist or y
of m at ernal sexual abuse( 18). Furt herm ore, high levels
of t r ait - anx iet y hav e been associat ed w it h v ar iat ions
in cognit ive com ponent s and concerns, dist ress levels
and coping( 17). I n an int er vent ion cont ext , t he m ot her s’
st at e- an x iet y lev els w er e sign if ican t ly r edu ced af t er
t heir part icipat ion in int ervent ion program s( 21) and t he
p r e se n ce o f h i g h l e v e l s o f m a t e r n a l a n x i e t y w a s
associat ed w it h t he babies’ difficult t em per am ent( 20).
Finally, independent ly of t he baby’s birt h condit ion and
h o sp i t a l i za t i o n a t a n NI CU, st u d i es t h a t a ssessed
m ot her s’ and fat her s’ anx iet y unanim ously appoint ed
t h at t h e m ot h er s pr esen t ed h igh er lev els of an x iet y
in com par ison w it h t he fat her s( 2 3 - 2 4 , 2 6 ), w hile st udies
t h a t a s s e s s e d m a t e r n a l a n x i e t y a n d d e p r e s s i o n
a p p o i n t e d t o w a r d s t h e c o - o c c u r r e n c e o f t h e s e
sym pt om s( 15- 17,20,25- 26).
St udies on t he assessm ent of m at ernal anxiet y in t he
pr e- and post nat al per iod
On e sin g le st u d y w as car r ied ou t in v olv in g
m o t h e r s o f f u l l - t e r m b a b i e s a n d a w i t h i n g r o u p
co m p a r i so n d esi g n , co m p a r i n g t h e a ssessm en t o f
m at er nal anxiet y in t he pr e- and post nat al phase. The
au t h or s ch eck ed f or associat ion s b et w een an x iet y,
depr ession and t he qualit y of t he m ar it al r elat ion and
m at er nal per cept ions of t he baby ’s t em per am ent and
of changes in t he sense of m at er nal self- efficacy. I t
w as found t hat m at er nal st at e- anxiet y w as negat ively
cor r elat ed w it h m at er n al ef f icacy in t h e f ir st m on t h
aft er bir t h. When com par ing t he pr enat al per iod w it h
t w o m om ent s in t he post nat al per iod ( at one and t hr ee
m ont hs) , t hey found a significant increase in t he sense
of m at er nal self- efficacy over t im e. Fur t her m or e, t hey
o b s e r v e d a s i g n i f i c a n t d e c r e a s e i n a n x i e t y a n d
depr ession scor es, in t he m ot her s’ posit ive percept ions
of t h eir m ar r iag e an d n eg at iv e p er cep t ion s of t h e
baby’s t em per am ent , w hen com par ing t he assessm ent
m om ent s in t he pr e- and post nat al per iod( 27).
DI SCUSSI ON
Focusing on m at er nal anx iet y, m ost of t hese
st u d i e s f o cu se d o n a sse ssm e n t s i n t h e p o st n a t a l
per iod, at t em pt ing t o assess t he effect of t he baby ’s
b i r t h , w h et h er p r em at u r e or n ot , on t h e m ot h er s’
e m o t i o n a l s t a t e . Th u s , i t i s o b s e r v e d t h a t t h e
assessm ent of m at er nal anxiet y in t he post nat al phase
o n l y, w i t h o u t k n o w i n g a b o u t t h e b a se l i n e i n t h e
pr en at al ph ase, can affect t h e u n der st an din g of t h e
r esult s. Fr om a m et hodological view point , w it hin gr oup
c o m p a r a t i v e c o m p a r i s o n r e s e a r c h d e s i g n s a r e
r e co m m e n d e d , w h i ch p e r m i t s t h e a sse ssm e n t o f
an x iet y lev els in t h e pr e- an d post n at al ph ase. Th e
on ly st u dy t h at u sed t h is design obser v ed t h at t h e
n at u r al p assag e of t im e w as an im p or t an t v ar iab le
for t he significant reduct ion of m at ernal anxiet y levels
as w ell as for t he significant increase in t he m ot hers’
sense of self- efficacy( 2 7 ).
Alt hough it has not been dir ect ly associat ed
w it h t he low birt h w eight condit ion( 10), t he pr esence of
h i g h l e v e l s o f m a t e r n a l a n x i e t y i n t h e p r e - a n d
p o st n a t a l p h a se h a s b e e n r e l a t e d w i t h o b st e t r i c
com plicat ions( 11), such as vaginal bleeding and t hr eat s
of abor t ion for ex am ple, and w it h fet al dev elopm ent ,
su ch as d if f er en ces in r eact iv it y p at t er n s an d h ig h
hear t r at e( 9- 12) and also w it h em ot ional and behavior al
p r ob lem s d u r in g ch ild h ood an d ad olescen ce( 1 5 , 1 7 , 2 0 ).
Th is r eaf f ir m s t h e n eg at iv e im p act of t h e m ot h er s’
a n x i e t y o n t h e d e v e l o p m e n t o f t h e i r ch i l d r e n , a s
High lev els of m at er nal anx iet y w er e neit her
r elat ed w it h p r em at u r e b ir t h n or w it h a h ist or y of
m at ernal sexual abuse( 19). How ever, an opposit e r esult
w as found in t he st udy in w hich m ot hers w it h a hist or y
of sexual abuse in childhood pr esent ed high levels of
m at er nal anx iet y( 1 8 ).
As t o t he assessm ent of m ot her s’ and fat her s’
anx iet y, independent ly of t he baby ’s bir t h condit ion,
a l l st u d i e s p o i n t e d t o w a r d s t h e m o t h e r s’ g r e a t e r
em o t i o n a l v u l n er a b i l i t y, a s t h ey p r esen t ed h i g h er
lev els of an x iet y in com p ar ison w it h t h e f at h er s( 2 3
-24,26)
. This finding r eaffir m s t hat , due t o t he phy sical
changes occur r ed dur ing pr egnancy, w om en can have
gr eat er pr opensit y t o em ot ional inst abilit y, as opposed
t o m en( 3).
Fu r t h e r m o r e , t h e r e d u ct i o n i n t h e st a t e
-an x iet y lev els of m ot h er s of pr em at u r e babies w it h
ver y low bir t h w eight , obser ved aft er t heir par t icipat ion
i n i n t e r v e n t i o n p r o g r a m s( 2 1 ), s h o w e d t h a t e a r l y
i n t er v en t i o n a l so co n t r i b u t ed t o t h e p r o m o t i o n o f
m ot h er s’ psy ch ological w ell- bein g( 7 - 8 ). St u dies abou t
t he assessm ent of int er v ent ion and par ent al suppor t
pr ogr am s’ ef f icacy t o r edu ce h igh m at er n al an x iet y
l e v e l s s h o u l d i n c l u d e t h e a n a l y s i s o f i m p o r t a n t
variables for t he est ablishm ent of a cont r ol gr oup, so
as t o al l o w f o r p o ssi b l e co m p ar i so n s b et w een t h e
result s of m at ernal anxiet y assessm ent s. I nt ervent ion
pr ogr am s t o r eliev e anx iet y in par ent s of pr em at ur e
babies hospit alized at NI CU’s should consider t he t ype
of social su p p or t g r an t ed t o p ar en t s of p r em at u r e
b ab ies.
W h e n a s s e s s i n g m a t e r n a l a n x i e t y,
in depen den t ly of t h e baby ’s bir t h con dit ion an d t h e
m om ent of t his assessm ent , befor e or aft er bir t h, 63%
of t he st udies found a r elat ion bet w een anx iet y and
depression( 15- 17,20,25- 26). High levels of anxiet y seem t o
i n t e r a c t w i t h h i g h l e v e l s o f d e p r e s s i o n , t h u s
st r e n g t h e n i n g t h e f o r m e r ’ s e f f e ct s o n t h e ch i l d ’ s
d ev elop m en t an d on t h e m ot h er ’s em ot ion al w
ell-b ein g .
Th e ef f ect s o f t h e an x i et y an d d ep r essi o n
v a r i a b l e s i n t h e p r e n a t a l p h a se , r e l a t e d w i t h t h e
p r ed ict ion of b eh av ior al an d em ot ion al p r ob lem s in
full- t er m childr en, assessed at t he age of four, w er e
f o u n d i n d e p e n d e n t l y i n o n l y o n e s t u d y( 1 4 ).
Clar ificat ions about t he differ ent ial effect of m at er nal
an x iet y an d depr ession m u st be gu ar an t eed in t h is
k in d of st u dy as, f r om a m et h odological v iew poin t ,
t h er e is a cer t ain d if f icu lt y t o assess an x iou s an d
d ep r essiv e sy m p t om s, d u e t o t h e su p er p osit ion of
t hese t w o set s of sy m pt om s( 1).
I n t he st udies t hat w er e analy zed, m at er nal
an x iet y w as m ain ly assessed t h r ou g h p sy ch om et r ic
sca l e s. W i t h r e sp e ct t o t h e i n st r u m e n t s u se d t o
a s s e s s m a t e r n a l a n x i e t y l e v e l s , t h e S t a t e - Tr a i t
An x iet y I nv en t or y ( STAI ) w as u sed in abou t h alf of
t h e st u d ies ( 5 2 % ) . Tw o ot h er st u d ies ( 1 0 % ) u sed
t h e Cr ow n - Cr isp an d t h e st at e- an x iet y su b scale of
t h e Tr a i t - S t a t e Pe r s o n a l i t y i n v e n t o r y t o a s s e s s
a n x i e t y i n m o t h e r s o f f u l l - t e r m b a b i e s . T h e s e
inst r um ent s pr esent st r ong cor r elat ions w it h t he STAI
an d , t h u s, t h e assessm en t of an x iet y t h r ou g h t h e
sam e v alidat ed inst r um ent or cor r elat ed inst r um ent s
t u r n s t h e r e s u l t s o f b o t h s t u d i e s c o m p a r a b l e .
How ev er, t he st udies t r eat ed t he dat a about anx iet y
m easu r es as scor es, w it h ou t a sp ecif ic an aly sis of
t he value t hey w er e at t r ibut ed. The use of t he STAI
in t he analy zed st udies illust r at es t he im por t ance of
t h e i n s t r u m e n t t o a s s e s s a n x i e t y, w h i c h s h o u l d
en cou r ag e p sy ch om et r ic st u d ies in Br azil.
Var iab les lik e t h e n at u r al p assag e of t im e,
t he baby’s dischar ge fr om t he NI CU and t he pr ovision
of par ent al suppor t , pr esent ed in st udies w it h m ot her s
of pr em at ur e and full- t er m babies, seem t o act in t he
r educt ion of m at er nal anx iet y lev els, as t he m ot her s
h av e t h e oppor t u n it y t o get em ot ion ally r ebalan ced
w hen assum ing t heir r ole as t heir baby’s pr im ar y and
m ain car eg iv er.
CONCLUSI ON
Ret urning t o t he obj ect ive of t his st udy, it w as
f o u n d t h at t h e p r esen ce o f h i g h an x i et y l ev el s i n
m ot her s, independent ly of t he baby ’s bir t h condit ion
and t he m om ent of assessm ent , const it ut es a pot ent ial
r isk fact or for m at er nal em ot ional balance as w ell as
for t he child’s dev elopm ent , ev en in t he fet al per iod.
The ident ificat ion of m at er nal anx iet y lev els
a l l o w s f o r t h e a d e q u a t e i m p l e m e n t a t i o n o f e a r l y
in t er v en t ion m easu r es an d t h e pr ev en t ion or, w h en
inevit able, neut ralizat ion of possible effect s of m at ernal
a n x i e t y r e l a t e d t o d e t r i m e n t a l e f f e c t s o n t h e
dev elopm en t of pr em at u r e in f an t s. Fin ally, r esear ch
on m at er n al an x iet y is f u n d am en t al t o id en t if y t h e
fact or s r elat ed w it h t h e pot en t ial n egat iv e effect on
t h e ch ild dev elopm en t of pr em at u r e as w ell as fu
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