Background: Maternal mental health during pregnancy and its effects on offspring outcomes have received increased attention as a public health concern. This thesis aimed to examine and evaluate current research into the long term effects of maternal antenatal anxiety on offspring’s psychological development and markers of developmental psychopathology. This thesis also aimed to identify protective factors to parental distress during pregnancy. Self-compassion and adult attachment security have been found to be protective psychological factors for ameliorating stress in general adult samples. Therefore the empirical paper aimed to investigate the effect of these factors during the antenatal period. Method: A systematic literature review of prospective studies examining the effects of maternal antenatal anxiety on child psychopathology and neurodevelopment literature identified 16 relevant prospective studies. The empirical study recruited a general population sample of women and their partners during their second trimester of pregnancy. They completed self-report assessments of self-compassion, adult attachment security, mood and antenatal attachment. Neonatal birth outcome data was collected as follow-up data. Results: The systematic literature review results indicate that maternal antenatal anxiety can be measured and does have a negative impact on offspring development. The results also identified a broad risk phenotype, suggesting that interventions should not necessarily only be targeted at women reaching clinical caseness. The review highlighted a lack of specificity regarding possible psychological mechanisms of the relationship between maternal antenatal anxiety and offspring outcomes. The results of the empirical paper indicated that higher levels of self-compassion and attachment security were related to fewer self-reported symptoms of distress in mothers and their partners. Self-compassion was found to mediate the relationship between attachment security and distress in mothers. Neither antenatal attachment nor neonatal birth outcomes were significantly related to attachment security, self-compassion or levels of distress. Conclusions: The results of the systematic review should broaden public health concern. A need for future research is identified in terms of understanding the process of maternal-foetal programming, protective mediating factors and effective interventions. The role of self-compassion as a protective mediating factor is discussed in relation to identification and treatment of distress during the antenatal period.

Magister Public Health - MPH / Common perinatal mental disorders (CPMDs) are increasingly being recognised as an important public health issue including depression and anxiety. In low and middle income countries such as Rwanda, CPMDs are prevalent among women in perinatal period. In Africa, the estimated prevalence rates of depression are 11.3% and 18.3% during ante-postnatal respectively, while ante-postnatal anxiety rates are 14.8% and 14% respectively. However, in Rwanda there is limited literature on CPMDs. This study was aimed at determining the occurrence of CPMDs in a selected district hospital of the Eastern Province in Rwanda as well as the factors associated with CPMDs in the selected study area. A descriptive quantitative cross-sectional survey was conducted with a sample of one hundred and sixty five mothers in perinatal period, who were selected systematically. Demographic data and factors associated with CPMDs were determined using structured questionnaire and combined screening tools such as Zungu Self-rating anxiety scale (SAS) and Edinburgh Postnatal Depression Scale (EPDS). The Cronbach alpha values were 0.87 and 0.89 for SAS and EPDS respectively. SPSS Version 21 was utilized to analyse data. Univariate, bivariate correlational and multivariate analyses were performed. Most of the respondents (38.2%) were aged 25-29 years; Protestants (77.6%); married (44.8%); unemployed (77%) and had a primary school level of education (60.6%). With respect to participants in antenatal period (51.5%); 14.5% had a clinical level of anxiety and 19.4% had depression. In terms of participants in postnatal period (46.7%); 22.5% had a clinical level of anxiety and 29.7% had depression. However, participants in both periods (1.8%) all had a normal level of anxiety and 1.2% had depression.

Background: Antenatal Psychosocial Assessment (APA) has recently been introduced into routine antenatal care, but the ways in which maternity service providers assess and respond to maternal stress are subject of debate. There is a lack of consensus on the instrument(s) of choice and lack of evidence regarding appropriate interventions. Further, national guidelines have not kept apace with the conceptual shift from ‘postnatal depression’ to ‘perinatal anxiety and depression’. Adopting the Medical Research Council Complex Interventions Framework, the ARMS research aimed to inform the development of interventions that support women who are experiencing, or at risk of, mild-moderate mental health disorder in pregnancy. Methods: A mixed methods approach was adopted. In the quantitative element (Study Part 1) participants (n=191) completed a questionnaire when attending for their first formal antenatal appointment, using a procedure and materials that had been previously tested in a pilot study. Details including mental health assessment and referrals were obtained from their health records, following delivery. In the qualitative element (Study Part 2) a sub-sample of women (n=22) experiencing high levels of maternal stress took part in up to three serial in-depth interviews during pregnancy and the early postnatal period.Findings: Maternal stress was found to be common. Using the Edinburgh Postnatal Depression Scale (EPDS) threshold of ≥10, approximately 1 in 4 women were classed as high depression (halving to 1 in 8 at the more conservative threshold of ≥13). Almost 1 in 3 women were classed as high anxiety, using the state scale of the State-Trait Anxiety Inventory (STAI-S, threshold ≥41), compared with 1 in 5 using the two-item GAD (threshold ≥3). Fewer than half of the women identified as high anxiety were identified by both measures. Factor analyses of the symptom measures were consistent with wider literature suggesting a three-item anxiety component of the EPDS; however, concurrent validation using regression analyses did not indicate that the EPDS could be used as an anxiety case finding instrument. Women reported that maternal stress had significant impact on their lives that may not be captured with existing clinical approaches. Women commonly found it difficult to self-assess severity of maternal stress and the assessment process could itself act as an intervention. The research provided the first validation of the depression case finding questions in UK clinical practice. The Whooley items completed in clinical practice identified only half of the possible cases identified by the EPDS, at both commonly adopted EPDS thresholds. Inclusion of the Arroll 'help' question as a criterion improved specificity of the assessment completed in clinical practice but substantially compromised sensitivity, missing 9 in 10 possible cases. Women’s mental health history and treatment history were similarly under-reported, particularly concerning anxiety. APA was introduced into routine clinical practice without attention to topics of relevance to women, context of disclosure or to provision of adequate resources for consistently responding to identified need. Women experiencing, or at risk of, mild-moderate disorder were thus usually ineligible for further support. Implications: Care pathways are needed that encompass both assessing and responding to maternal stress, where communication with health professionals, subsequent referral and management are addressed. The development, implementation and evaluation of low-cost resources embedded in such pathways are a priority and the research presented in the thesis offers a foundation on which to build.