Our Review of ‘What Are Women Stressed About After Birth?’

This is a really interesting paper that starts with the recognition that pregnancy, birth and becoming a parent require significant adjustment and can be stressful.

Much of the existing research looking at what women are stressed about after birth focuses on specific factors that women might be worried about. It also tends to use quantitative measures of worry. These methods may be subject to social desirability bias if women are worried about social judgement. In ‘What are women stressed about after birth?’, Susan Ayers and colleagues attempt to address this by inviting women to write anonymously about stressors in the perinatal period in an open-ended way.

The data was drawn from a larger randomised control trial (the Health after Birth Trial), which looked at the effectiveness of expressive writing in postnatal health. The trial recruited women from 14 NHS hospitals in England between November 2013 and December 2014. Women were eligible to participate if they were aged over 18 and had had a live baby after 26 weeks’ gestation. All eligible women were invited, 854 agreed to participate and 319 were allocated to the expressive writing condition. 148 completed the expressive writing task. They completed the writing task between 6 and 12 weeks after birth.

Women wrote for 15 minutes a day for three days about ‘an event or difficulty that you have found stressful or upsetting. This might be something about your pregnancy, birth, baby, or might be something else going on in your life’. Women were told that if something was too distressing or overwhelming, they should pick a less stressful event to write about. This was to avoid re-traumatising women who had been through a traumatic event. Women were then asked to rate how upset they were by that difficulty now on a 1 to 10 scale. Demographic measures were recorded at the end of the writing task.

The researchers used content analysis (identifying categories of stressors) and thematic analysis (identifying cross-cutting themes across stressors). Initial coding was conducted by one author, coding schedule developed by two authors and cross-cutting themes identified and agreed by three authors.

Women who took part were aged between 21 and 42. Most were white European (94.3%) and most were married (62.5%) or cohabiting (33.7%). Many were educated to degree level (43.2%). Only two had no educational qualifications. Most were employed (83%) and in professional jobs (53%).

Five categories of stressors were identified. The stress ratings women gave averaged 5.5, suggesting moderate levels of stress. I’ll comment on all categories identified but focus on infant feeding, because that is what we are most interested in at Infant Feeding Alliance:

Category 1: Stressors in pregnancy, birth, or the early postpartum period (reported by 49.3% women). This category included stress about difficult birth experiences, problems after birth (e.g. incontinence) and insensitive care from health professionals.

Category 2: Adjusting to life with a baby (reported by 35.8% women). This included coping with crying, concerns about the impact of a new baby on older children, disagreements with partners, being judged as a single parent, juggling demands, sleep deprivation, exhaustion and loneliness. Of note: loneliness had the highest mean stress rating of any stressor (7.5/10).

Category 3: Problems with the baby’s health (reported by 32.4% women). The most common subcategory here was feeding and digestive problems (12.2%). It also included acute health concerns and fear of the baby becoming ill again if they had had a serious illness.

Women whose babies had been in the NICU reported this as stressful and impacting their feelings about themselves. They reported feeling useless and this experience making it harder to care for and bond with baby (i.e. because of monitors, the baby needing breathing apparatus and not being able to just pick their baby up).

Category 4: Breastfeeding (reported by 23.7% women), including pressure to breastfeed (15.5%). I’ll cover this in more detail than the other categories.

Women wrote of finding breastfeeding to be ‘agony’ and of being in ‘constant pain’. They wrote about feeling anxious, guilty and desperate to give up breastfeeding, but feeling like they had to continue. 5.4% of women wrote about feeling like a bad mum for not breastfeeding, letting their baby down and that other people would think they were a bad mother. 2.7% reported wanting to breastfeed but not being able to, feeling upset that they had ‘failed’ and feeling embarrassed to tell people about it.

Category 5: Changing relationships (reported by 18.2% women). This included not having enough help, physical and emotional distance and sexual difficulties. 2.7% were concerned about not being able to give older children their full attention and about wider family members being uninterested or overbearing.

The researchers identified three cross-cutting themes: 1) Negative self-appraisals (reports of being a bad mum and a failure, most commonly mentioned in relation to breastfeeding stress and problems with the baby’s health); 2) Feelings of guilt, which were reported across all five categories but most commonly in relation to breastfeeding and adjusting to life with a baby; 3) Lack of support from others, most commonly reported in pregnancy, birth, or the early postpartum period, where women reported insensitive care from health professionals, as well as in relation to a lack of support from fathers and other family members.

So, what do we make of all this?

The authors acknowledge that there is a likely selection bias because the largely white European educated people who took part are not representative of the wider population. The authors rightly emphasise this selection bias and the low percentage of women who elected to take part. However, I would also note that this study recruits from a wide population of people using NHS services. Many studies in infant feeding recruit though social media channels or advertise in special interest groups and parenting forums (e.g. attachment parenting forums and NCT groups), so, personally, I think the broad recruitment strategy is a strength of this study. But I also agree with the authors’ caution and their statement that further research needs to identify the stressors of women in diverse groups and with fewer years of education.

The authors suggest that interventions that target these stressors may reduce stress and facilitate adjustment. They suggest breastfeeding support, peer support or parenting interventions. I don’t disagree but I do have some reservations here. We need to ensure that these interventions are effective, provided with compassion, responsive to women’s needs and concerns (not just to public health agendas) and don’t inadvertently compound distress. Here are some reasons for my concerns:

15.3% of this sample reported pressure to breastfeed and feeling ‘desperate to give up’. Breastfeeding support services are often run by peer supporters who are very passionate about breastfeeding and explicitly set out to validate, affirm, praise and even protect women’s decision to breastfeed. Here’s what one recent review of studies found about how peer supporters respond to women who might want to give up breastfeeding:

‘Peers are motivated when they feel their work is valued and feel demoralised when they feel they are not appreciated. In consequence, peers tend to be more responsive to mothers who actively seek their support and convey their appreciation… and disengage when mothers do not respond to offers of help or decide to formula feed their babies… Over time, there is a tendency for interventions to focus resources towards mothers who are more motivated to breastfeed.’

I suspect that infant feeding services are not meeting the needs of women who decide to stop breastfeeding. We live in a context where ‘idealised images’ of bottle-feeding babies are not permitted to be displayed in public services, while promotional images of breastfeeding are displayed widely in the services new parents use. Even basic information about how to prepare formula and clean equipment are not allowed to be in leaflet racks.

Women in this study described being in ‘agony’ and ‘constant pain’ as a result of breastfeeding. Such experiences are not discussed in antenatal education. On the contrary, guidelines to healthcare professionals are as follows:

‘Whatever the discussion, it is important that health workers give only evidenced-based information and that they are steadfast in their messaging around the superiority of breastfeeding for the health and wellbeing of mother and baby. It is also important that health workers do not undermine breastfeeding by implying that it is inherently hard and success uncertain. Challenges with breastfeeding that are discussed should be in the context of prevention and solutions if things do go wrong. The aim of the discussions should be for mothers to feel empowered to breastfeed their baby.’

It seems to me that the severity of breastfeeding problems needs to be acknowledged in healthcare professional training and antenatal education. We also need to ensure that infant feeding support services are responsive to those women who are ‘desperate to give up’, as well as to those who wish to continue breastfeeding.

The authors also suggest the need for individually tailored support and sensitive, compassionate communication from healthcare professionals. This seems consistent with a recent review of the Baby Friendly Initiative in the UK. This found that women felt their expectations of breastfeeding from antenatal education were a long way from reality and that they wanted less generic and more tailored support.

So, all in all, a fantastic and fascinating paper about women’s experience. I think the authors have avoided some pitfalls of other research by recruiting via NHS services rather than by social media and by giving women the opportunity to express their concerns freely.

I hope this leads on to further research and questioning about how services can better address the concerns of women in the perinatal period and develop safe, effective and compassionate services that provide practical solutions and ameliorate psychological distress.

This is an edited version of a review first published as a thread on Twitter.

Dr Ruth Ann Harpur

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