This doctoral thesis explores issues related to postnatal mental health from the perspective of professionals, mothers, and significant others. It comprises a literature review, an empirical paper, a critical appraisal of relevant issues, and an ethics section. The literature review reports a meta-ethnographic synthesis of studies exploring the experiences of professionals working with women experiencing postnatal depression (PND). Five themes were identified: (a) conceptualising the label; (b) using ‘my antennae’: recognising PND; (c) ‘permission to speak’: facilitators and fears; (d) whose role is it anyway: professional confidence and expertise; and (e) ‘we’re not user friendly’: navigating the system. Clinical implications were highlighted, including the fostering of liaison between clinical psychologists and perinatal professionals, the importance of mental health training for perinatal professionals, and the development of clear care pathways for all severities of distress. The empirical paper focuses upon mothers who had experienced postnatal psychosis (PP) and their significant others. Seven dyadic interviews were conducted and analysed using interpretative phenomenological analysis. Four themes emerged: (a) ‘she wasn’t herself’: threatened relationships through loss of ‘normal’ self; (b) invalidation and isolation: relational dynamics in seeking, receiving and providing support; (c) ‘the worst life can throw at us’: shared perceptions of trust and respect following PP; (d) a double-edged sword: understanding relationships as negatively and positively influencing PP experience. The paper contributes to the evidence base by highlighting the opportunity for positive transformations in relationships following PP, despite the potential for strain within these relationships. Furthermore, it explores the novel finding that relationships can influence the content of unusual postnatal experiences. Within the critical appraisal, reflections pertinent to the empirical paper are offered. These span the three domains of conceptual, methodological, and ethical issues. The ethics section contains detailed information related to the process of gaining ethical approval for the empirical paper.

Background: Evidence about the effects of perinatal common mental disorders (CMD) on child growth is consistent in South Asian studies but not in Sub Saharan Africa. Aims: To (1) assess the effect of CMD on child growth in Ethiopia using traditional analysis, latent growth modelling (LGM) and multilevel growth modelling (MGM) techniques, and (2) evaluate the effects of other pre-specified risk factors on infant growth using these three modelling techniques Methods: A population based cohort was established between July 2005 and February 2006 in a demographic surveillance site in Butajira, Ethiopia, recruiting 1065 women in pregnancy and followed them with their newly born infants. Main exposure was perinatal CMD measured with locally validated self reporting questionnaire (SRQ-20). The women were interviewed at recruitment, birth, two and 12 months postnatal. In addition to birthweight, infant growth was monitored at two, six, nine, 12 and 18 months of age and standardized using 2006 WHO reference standards. Logistic regression and linear regression were used to model binary and continous infant growth outcomes, respectively, at two, six and twelve months of age. Furthermore, infant growth over the first 18 months of age and predictors of growth patters of these infants were investigated using MGM and LGM. Results: Postnatal and persistent CMD were significant risk factors of compromised initial infant length, and part of the effect on the total length gain was mediated through diarrhoeal episodes. Early infant feeding practices and birthweight did not mediate the effects of CMD on infant growth. Boys perform better in initial weight (in kg) and length (in cm), but worse in initial values of standardized growth measures. Low birthweight and reduced maternal mid upper arm circumference during pregnancy were significant predictors of compromised initial growth.

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Although postpartum psychosis is a devastating and predictable disorder, it has received little attention in biological research. This is the first study assessing cognitive, emotional and neuroimaging correlates of women at risk of postpartum psychosis. We hypothesised that women “at risk” will show decreased brain activation in the dorsolateral prefrontal cortex in a working memory task and increased brain activation in the amygdala in a facial emotion processing task, compared to healthy controls, similar to that observed in bipolar disorder and psychoses unrelated to childbirth. Twenty-five women “at risk” (N=13 due to non-postpartum and N=12 due to postpartum episodes) were compared to 21 healthy women within the first year after delivery. Women took part in two study visits including clinical interviews and a magnetic resonance imaging (MRI) scan. We assessed working memory and emotional face processing using two functional MRI tasks and verbal memory using two behavioural tasks. Groups were matched on sociodemographic background and medical and obstetric history. Women “at risk” showed an activation increase of the midcingulate and temporal cortices compared to healthy controls, which was accompanied by deficits in working and verbal memory performance. Women with postpartum episodes, compared to healthy controls, showed a relative increase in activation to fearful faces in the left inferior frontal gyrus. This study provides preliminary evidence that women “at risk” of postpartum psychosis show cognitive impairments similar to those of patients with bipolar disorder and psychoses unrelated to childbirth. Women with postpartum episodes seem to differ in emotional processing from healthy controls, possibly indicating an increased emotional response to fear. These results represent a first step towards a better understanding of cognitive and emotional processes in postpartum psychosis. When validated in larger and longitudinal studies, they may help clinicians in developing individual management strategies and implementing targeted cognitive trainings or interventions.

This study uses Interpretative Phenomenology Analysis to explore the lived experience of postnatal depression. The four participants, all aged 30 years or above at the birth of their first child, had never suffered from depression prior to the birth. Each was interviewed on two separate occasions, with a period of 4 to 6 months between interviews. The inductive approach of IPA sought to capture the richness and complexity of participants’ lived emotional world. Six superordinate themes emerged from the interviews: striving to be a perfect mother; feeling a failure; being sucked dry; shame of the others gaze; feeling stuck and overwhelmed and becoming lost. Participants sacrificed themselves in the hopeless pursuit of their own expectations of being the perfect mother and fulfilling all their child’s needs. Not wanting to appear inadequate to others, and desperate to make sense of what was happening to them, they continued to suffer in silence in a context of depleting resources and the loss of their former life, wellbeing and sense of self. The findings suggest that particular themes of postnatal depression exist within older mothers’ experiences. While such themes may be less relevant to younger mothers, their presence suggests a tailored treatment approach for older first-time mothers with PND. Aspects of these findings can be found in previous postnatal depression research with primigravida and multigravida women of varying ages. In a situation where postnatal depression is the most common complication of childbearing in the UK, affecting between ten and fifteen percent of new mothers (Royal College of Psychiatrists, 2014) and where the birth rate for women aged 30+ is growing faster than for any other age group in the UK, research that furthers understanding of the experience of postnatal depression for mothers in this age group can help guide interventions and support. (The words ‘postnatal depression’ and ‘postpartum depression’ are used interchangeably in this text).

The presented thesis was completed by Sarah Rees for the Doctorate degree of Clinical Psychology (DClinPsy) at Cardiff University. The thesis title is ‘A systematic review and empirical study investigating the impact of perinatal anxiety on mother-infant interaction at six-months postpartum and children’s emotional problems at age three years’. This thesis was submitted on the 30th May 2017 and comprises three papers. Papers 1 and 2 have been prepared for submission to European Child and Adolescent Psychiatry. Paper 1 presents a systematic review on the evidence for the impact of perinatal anxiety on children’s emotional problems. A literature search was conducted and 14 studies were identified that satisfied inclusion criteria for the review. Whilst the findings of this review indicate that there is evidence for both maternal antenatal and postnatal anxiety having an adverse impact on child emotional outcomes, the evidence appears stronger for the negative impact of antenatal anxiety. Several methodological weaknesses make conclusions problematic and replication of findings is required to improve identification of at-risk parents and children with appropriate opportunities for intervention and prevention. Paper 2 presents an experimental study, which explores the role of antenatal and postnatal anxiety on children’s emotional problems at age three years. A sample of 186 women and their first-born children were followed from pregnancy to age three years postpartum. Mothers completed antenatal and postnatal anxiety measures. Maternal care-giving behaviour was assessed using observations of a mother-infant interaction task. At three years, the Child Behaviour Check List (CBCL) was administered to assess for children’s emotional problems. Results indicated that maternal antenatal anxiety and postnatal depression independently predicted higher reported emotional problems in children at age 3 years after controlling for postnatal anxiety and antenatal depression symptoms. Postnatal depression was found to partially mediate the association between antenatal anxiety and children’s emotional problems. Antenatal anxiety was associated with elevated maternal negative affect at 6 months postpartum. However, the association between antenatal anxiety and children’s elevated emotional problems at age 3 was not explained by maternal negative affect at 6 months postpartum. These data suggest that children’s emotional problems are adversely affected by maternal antenatal anxiety and postnatal depression. This has implications for targeting intervention or prevention in the antenatal period to prevent adverse emotional outcomes in children. Paper 3 is a critical reflection of the systematic review, the empirical paper and the research process as a whole. Strengths and limitations are discussed as well as clinical and research implications.

Women's accounts of 'puerperal psychosis' (PP) and 'postnatal depression' (PND) were analysed using a qualitative approach (Interpretive Phenomenological Analysis). The study aimed to explore experiences of PP and PND from women's own perspectives; to see whether accounts of PP and PND can be differentiated from each other; and to see whether taking a gendered perspective and drawing on psychological theories of psychosis can offer ways of understanding the experience of PP. Although only women with a diagnosis of PP reported unusual beliefs or hearing voices (as would be expected since it was these reports that resulted in the diagnosis), there were no differences between groups on other forms of distress such as low mood, anxiety and fear of harm to the baby. There were also no differences in the social and material contexts of women's lives (e. g. financial difficulties, lack of support). The importance of exploring the social and relational context of unusual experiences is emphasised and the content of 'delusions' 'hallucinations' 'paranoia' and 'rumination' (traditionally viewed as incomprehensible), as well as feelings of depression, were found to be related to the difficult transition to motherhood and ambivalence about pregnancy, childbirth and the baby within the context of overwhelmingly positive sociocultural discourses of motherhood. The impact of this context on self-identity (as a woman and a mother) and on having to take control and responsibility whilst remaining powerless in their wider context, were themes common to all six women. The clinical and theoretical implications are discussed, and areas identified for further research.

Background: There is a need to improve identification of mothers at risk of postnatal depression. This study aimed to assess if postnatal ward midwives could identify vulnerable mothers on wards; also to determine if midwives' estimates of risk could add to the predictive value of the Edinburgh Postnatal Depression scale (EPDS; Cox, Holden & Sagovsky, 1987). Method: Using a prospective longitudinal survey design, 121 mothers on postnatal wards in a maternity hospital were recruited within 72 hours of delivery when they completed self-report measures of depressive symptoms (EPDS), infant temperament (lCQ) and parenting confidence (PSOC). Midwives completed a Likert-style questionnaire giving their concurrent views on these variables and estimating mothers' risk ofdepressive symptoms at 10-12 weeks. At follow up by post at 10-12 postnatal weeks, 92 women completed repeat measures. Results: There was a significant relationship between midwives' estimates of risk and mothers' EPDS Time 2 scores. Midwives correctly identified 36.4% of vulnerable women and 97.1% of those who did not develop symptoms of depression. Midwives' estimates of risk added significantly to the variance explained by EPDS Time 1 scores on EPDS Time 2 scores. Conclusion: While midwives' ability to recognise women who are vulnerable to symptoms of postnatal depression is limited, they are rarely mistaken, suggesting they could usefully alert primary care services to give priority to these women.

In study of Puerperal Sepsis has already been made by various observers and from different standpoints. There is however as much information yet to be obtained or confirmed on account of the available statistics being comparatively small. Thus having the control of a large number of patients, I have felt it a duty to endeavour to increase the list of cases of this most important subject. In private practice the opportunity for a systematic research is not great, and the total number of cases seen is relatively small in comparison with those of a large Maternity Hospital with, in addition, an External Department, in which nearly 2500 patients are treated in their own homes annually. Here numbers are obtained and it is possible to collect the cases throughout every month of the year, so that a consecutive list results. In addition to this, I have been unable to find any records of the Bacteriology of fevers of the Puerperium from the Maternity Hospitals of the Three Kingdoms. In reports obtained elsewhere, the investigation has been either a purely Bacteriological one or a Clinical, in which while following the course of each case in reference to treatment, no attempt has been made to ascertain the specific cause. In this study an endeavour has been made to combine these two aspects, the germ being demonstrated at the commencement of the pyrexia, and the case being followed to its termination with a record of the events as they occurred. Although in 1850 Sir J.Y.Simpson published a paper on the "Analogy, between Puerperal and Surgical Fever" and investigations have since proved the analogy, there are still many practitioners who fail to appreciate and even deny their identity, and who will attend a woman in her confinement without any, or but scanty attempts at aseptic precaution, while they will take considerable care before performing any surgical operation. Thus any additional information on the subject seems of some value. A number of inquiries have been made into the Bacteriology of the Vagina, both of non-pregnant and pregnant women, and various results obtained, but a fairly definite conclusion has resulted. Therefore I have not attempted to carry any investigations into this region, but have waited until~the condition of pyrexia manifested itself, and have then endeavoured to ascertain its cause in the simplest manner possible and directly from the uterus.

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