This research set out to phenomenologically explore new mothers’ post-natal embodied experiences. The objective of the study was to interview, in a loosely structured way, six first-time mothers, all with babies between the ages of six and twelve months, in order to obtain rich, descriptive material surrounding their experiences of their bodies during pregnancy, childbirth and in the post-natal period. The aim was to provide an interpretive analysis of the data in such a way that would bring new mothers’ embodied experiences to the fore, illuminate the corporeal dimensions of maternity and evoke in the reader a fresh understanding of what it is like to be in a body that has just given birth. Using van Manen’s (1990) hermeneutic approach, the data was rigorously analysed and four main themes came to light: (1) Loss of corporeal autonomy, (2) Becoming an Other, (3) Bodily dis-ease: pain, dissociation and betrayal, and (4) Being-against-time: an unnatural bodily rhythm. What emerged from these findings was the fleshy nature of identity, the interplay between bodies and selves and the capacity for maternity to both make and break (perceived) notions of selfhood. Uncovered were undercurrents of shame and humiliation rooted in maternal experiences of corporeal disintegration, manipulation and violation. Post-natal embodiment emerged as the experience of disruption, displacement and alienation which was not only physical, but emotional and psychological. Inherent in this was a new mother’s sense of ontological security which was threatened by the experience of being (in) a body in flux. The findings therefore highlight the inextricable link between mind and body, thought and emotion, reason and flesh and showcase the importance of incorporating existential understandings of the body into psychotherapeutic practices that aim to support women who have just given birth.

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Perinatal depression is widespread and disabling with a number of negative consequences for the mother, father and child. Prenatal depression, stress and anxiety and a history of depression are significant predictors of perinatal depression suggesting a need for preventative interventions. Helpful psychological interventions for this period are currently scarce and expensive and research examining preventative interventions is lacking. Preliminary evidence suggests that generic and pregnancy-tailored mindfulness courses can reduce stress, anxiety and depression in this population. Because, more broadly, access to mindfulness courses is inequitable, research has begun to focus on the possibility of delivering such courses online, resulting in potentially beneficial courses becoming available with a reduction in cost to the participant and health service. The aim of this doctorate was to conduct a series of sequenced studies culminating in an overall evaluation of mindfulness courses for expectant mothers. In cross-sectional analyses, higher levels of dispositional mindfulness were associated with healthier mood levels suggesting that increasing mindfulness in this population (via a course) may be beneficial. A preliminary evaluation of a face-to-face mindfulness-based course for childbirth and parenting showed promising results for prospective mothers and fathers and further research would be useful. An online mindfulness course delivered to expectant mothers improved prenatal mood compared to a waitlist control group but there was a high level of drop-out for course completers. This high attrition rate, though often noted in internet intervention research, is concerning and warrants further investigation. More generally, mindfulness courses for expectant parents show potential and future work would benefit from larger samples and control group comparisons.

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The birth and hospitalisation of a very low birth weight (VLBW; <1500 grams) infant is often extremely traumatic for parents. Mothers of VLBW infants experience significantly higher rates of posttraumatic stress symptoms (PTSS) than mothers of full-term infants two to three years postpartum (Åhlund, Clarke, Hill, & Thalange, 2009). A pilot study was conducted to examine self-reported PTSS in fathers of VLBW infants two to four years postpartum compared with fathers of term infants. Results were compared with the maternal data from the study by Åhlund et al. (2009). Additional data were collected on self-reported levels of anxiety and depression in fathers. Questionnaire packs containing the Impact of Events Scale-Revised, the Patient Health Questionnaire-9 and the Generalised Anxiety Disorder Seven Item Scale were posted to fathers of infants born two to four years previously. Fathers reported on PTSS relating to the birth and hospitalisation of their infant and current anxiety and depression symptoms. Perceived levels of social support at the time of the birth of their infant were also measured. Responses were received from 26 fathers of VLBW infants and 22 fathers of term infants. PTSS levels were significantly higher in fathers of VLBW infants than those of term infants U = 80.0, z = -4.31, p < .001 and PTSS levels did not significantly differ between fathers and mothers U = 222, z = -1.76, p = .079. There was a significant association between VLBW fathers’ levels of perceived social support and PTSS, but not with anxiety or depression. In conclusion, PTSS are found in fathers of VLBW infants two to four years postpartum and at similar levels to those found in mothers. Implications are discussed with particular reference to increasing psychological support for fathers following the birth of their VLBW infant and areas for further research are considered.

The relative lack of research in mental health in low and middle income countries is symptomatic of the 10/90 gap in general health research where only 10% of the world’s expenditure on health research is dedicated to the poorest 90% of the world’s population. Globally there has been modest declines in both maternal and child deaths but there are still wide disparities between developed and developing countries; as the total number of under 5 deaths has declined, from 11.6 million in 1990 to 7.2 million in 2011, the proportion of deaths occurring in sub-Saharan Africa has increased from 33% in 1990 to 49% in 2011, and the region also bears the biggest burden (>50%) of maternal deaths. Innovations to reducing this burden are urgently needed in parallel with intensified efforts to increase coverage of proven effective maternal and child health interventions. One such innovation might be to include a focus on eliciting contextual determinants, and preventing and/or treating perinatal depression that is depression occurring during pregnancy or after birth, since there is some evidence suggesting that this is associated with adverse effects on infant health and development, and maternal health. This thesis is designed to add to this sparse evidence base by providing data on the burden of antenatal and postnatal depression in rural Ghana, examining determinants of this burden, investigating the links between perinatal depression and maternal and child health outcomes, and evaluating whether a home-visits intervention had reduced this burden. The research was undertaken within seven contiguous districts of the Brong Ahafo region of Ghana between January 2008 and July 2009. All women of reproductive age in these districts were part of a surveillance system supporting two randomised controlled trials that involved 4-weekly visits by resident fieldworkers who collected data on socio-demographics, obstetric histories, pregnancies, births, deaths and infant and maternal health. The research for this PhD involved training the surveillance field workers to also administer the depression module of the Patient Health Questionnaire screening tool (PHQ-9) to pregnant women and recently delivered mothers between 4-12 weeks after birth. 21135 pregnant women and 18356 recently delivered women were screened for depression, 13929 of whom were screened at both time points. The prevalence of postnatal depression (PND) was 3.8% (95% CI 3.5%, 4.1%), comprising 0.1% (95% CI: 0.08%-0.1%) who met criteria for major depression and 3.7% (95% CI: 3.4%-3.9%) for minor depression. The prevalence of antenatal depression (AND) was much higher 9.9% (95% CI: 9.5%-10.3%); 12.5% of these cases persisted into the postnatal period and accounted for 34.4% of postnatal cases. The following determinants were identified for antenatal depression: maternal age 30 years or older, never married, lower wealth status, non-Catholic religion, non-indigenous ethnicity, unplanned pregnancy, and previous pregnancy loss. And the following were identified for postnatal depression: never married, non-indigenous ethnicity, AND, season of delivery, peripartum/postpartum complications, newborn ill-health, still birth or neonatal death. Determinants were similar for ‘new’ cases of postnatal depression and for cases where depression was also detected antenatally. AND was found to be associated with the following consequences: prolonged labour, postpartum complications, peripartum complications, CS/instrumental delivery, severe newborn illness, and bed net non-use during pregnancy. PND was associated with increased risk of infant mortality up to six months (rate ratio [RR], 2·83 (1·56-5·16) and 12 months (RR, 1·79 (1·04-3·09) of age. Postnatal depression was also associated with increased risk of infant morbidity. Home-visits by community volunteers aimed at preventing neonatal deaths had no impact on attenuating prevalence of postnatal depression (relative risk [RR] 0.99 (95% CI 0.65, 1.50; p=0.96). This is the first large cohort study in SSA to provide evidence of determinants and consequences of perinatal depression, rather than studying the more general common mental disorder which include depression. The conclusions reached in this PhD are:1) Most risk factors of postnatal depression relate to adverse birth outcomes of the mother and/or baby, whereas those of antenatal depression are sociodemographic and pregnancy-specific, 2) Both antenatal and postnatal depression may have deleterious effects on the health of the mother and/or on child health and survival, 3) A case for clinical interventions for depression is established both during pregnancy and after birth, 4) Though often self-limiting, tackling antenatal depression could prevent up to a third of the burden of postnatal depression, 5) The timely implementation of such interventions using existing primary care structures may provide an important adjunct to improving maternal health and child health and survival efforts.

The aim of this thesis is to provide an understanding of motherhood and the mother-infant relationship within the context of postnatal distress. To facilitate this, it is necessary to understand universal experiences of motherhood as well as mental health difficulties following childbirth. Part of this understanding includes mothers’ experiences and management of distressing, repetitive thoughts of infant harm. Therefore, paper one consists of a literature review in which 10 empirical studies regarding thoughts of intentional infant harm (TIIHs) were critically appraised and synthesised. These thoughts were experienced in clinical and non-clinical samples. Common themes were found in terms of cognitive, emotional and behavioural responses to TIIHs and understood within the context of the parenting role. This review differentiated TIIHs between psychotic and non-psychotic difficulties and identified the need to understand such thoughts within mothers’ experiences of postpartum psychosis (PP). Paper two is a qualitative study exploring mothers’ experiences of PP and recovery. Purposive sampling was used to interview eight women across the United Kingdom. Transcripts were analysed using Interpretative Phenomenological Analysis (Smith, Flowers, & Larkin, 2009) and four super-ordinate themes were identified: ‘becoming unrecognisable’, ‘mourning losses’, ‘recovery as an ongoing process’ and ‘post-traumatic growth’. These themes demonstrated the need for physical and psychological space to facilitate recovery following childbirth. Paper three provides a personal reflective account of completing this thesis. The dynamic process of transitioning to a qualified psychologist is likened to the transformative process of motherhood. Ethical issues and the recent surge in perinatal mental health awareness are presented.

The aim of this thesis was to investigate engagement in the antenatal psychosocial intervention 'Preparing for Parenthood' designed to reduce postnatal depression, run within the current maternity system, to identify factors predictive of engagement. The quantitative study investigated three components of health-promotion behaviour: health locus of control, social support and negative life events within an ongoing randomised controlled trial (RCT). Women were identified as at risk of postnatal depression by a screening questionnaire, 'Pregnancy and You', at 15-20 weeks gestation (n=400). A baseline assessment was completed 4 weeks later (n=292). Women who wished to have the opportunity to attend the intervention were randomised to an intervention (n=103) or control condition (n=106). The intervention consisted of six, 2-hour sessions held every week preceded by an initial introductory meeting and followed by a postnatal reunion session at the Leicester General hospital, run by two female course leaders whose backgrounds were in mental health. An outcome assessment of measures of engagement was completed at 3 months postnatally with all willing participants. In a qualitative study (n=82), the procedures used followed that of the quantitative study where appropriate. The same psychosocial intervention (n=15) was implemented. The outcome interview was completed between two and three months postnatally and consisted of 9 questions (n=12). Analysis using the grounded theory technique identified two main categories of themes, clustering at either the screening stage or at the intervention stage itself. Seven themes were identified as influential in initiating engagement with the intervention; and eight themes were identified as being influential in maintaining engagement with the intervention. It was concluded that actual health-promotion behaviour was not predictable using the three hypothesised measures of prediction, in this population, and for this intervention. The findings of the qualitative study enabled potential improvements to the intervention to be identified as possible ways of gaining and maintaining participant interest, and therefore engagement.