Postpartum depression (PPD) is a common perinatal mental health disorder (CPMD) extensively linked to poor child health outcomes, including increased risk of illness, stunting and underweight. Rates of PPD and child malnutrition are consistently elevated in Sub-Saharan Africa compared to other regions of the world. This includes Northern Uganda, a region devastated by armed conflict and enduring poverty. While the link between PPD and adverse child health outcomes is firmly established, the mechanisms underlying this association remain poorly understood.The current study addresses this gap in the literature through investigating in a sample of Ugandan mothers of children 0 to 23 months how maternal behaviors promoting child health differ in the presence or absence of probable depression. This study also explores how perceived social support and women’s empowerment may moderate the relationship between PPD and mothers’ engagement in these health-promoting behaviors. The study is based on cross-sectional, baseline data collected for a project sponsored by Food for the Hungry Uganda, an international relief and development organization, and in partnership with the Global Mental Health Lab at Teachers College, Columbia University and World Vision International. The study’s sample included 1028 probably depressed and 284 nondepressed Ugandan mothers with at least one child under 24 months of age at the time of interviewing. The study’s findings yielded evidence to support the reliability and validity of the Patient Health Questionnaire-9 and Multidimensional Scale of Perceived Social Support for this sample. While as expected, probable depression was positively associated with child underweight, recent child illness, delayed care seeking for sick children and unsafe disposal of child feces, positive associations were also found between depression and important health-promoting behaviors, for which there is little evidence in the extant literature, including provision of the same amount or more food to a sick child, knowledge of danger signs of childhood illness, and some WASH behaviors. Perceived social support and women’s empowerment indicators were also found to moderate the association between probable depression and some IMCI, IYCF and WASH behaviors. Study limitations, clinical implications and recommendations for further research are discussed.

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Estimates suggest that about eight million American teens and young adults experience clinical symptoms of mental illness. For many, these mental health challenges will develop into a diagnosable and potentially life-long psychiatric disorder. Together they form a large population of adults who enter their prime reproductive age as psychiatric patients. Though individuals with mental illness enjoy the same reproductive rights as those without psychiatric conditions, social and medical discourses often portray their parenthood as risky and undesirable. Women with mental illness are in a particularly difficult position. As women, they are subjected to the gendered expectation that they become mothers. Yet at the same time, their mental illness results in their motherhood being frowned upon. Carrying these contradicting values, this study asks how women with psychiatric disorders make reproductive decisions. Do these women think of their reproductive capacity through the psychiatric framing of risk, or through gendered narratives of desired motherhood? Using open ended interviews with women with a psychiatric diagnosis, this study shows that women with mental illness approach their reproductive decision-making by utilizing narratives of both normal reproduction and disability. Some women portray their mental illness as an obstacle to motherhood while others create a separation between their mental and reproductive health. Still others defy the distinction between psychiatry and normalcy and describe their reproduction as a way to bring the two together. Despite the difference in framing, all the women in this study engage with the discourse of risk(s) that is brought on by their mental illness. To weigh risk and act upon it, they visit their and their peer’s biographical stories of illness, assess their fitness into normative ideas of good motherhood, and evaluate the worth of medical and scientific information. They question the way medical information is created, distributed, and made applicable to the idiosyncrasy of their reproductive life. In doing so, these women draw boundaries around trust as well as redefine medical neutrality. Finally, we show that women with mental illness and their health providers rely on a vaguely defined stepwise plan to approach reproduction. This plan brings normativity – and desirability - to their reproduction at the same time that it threatens to exclude them from motherhood. By bringing these arguments together we arrive at the overall conclusion that women with mental illness do not approach their reproduction as a monolithic group. Nor do they organize along diagnosis lines. This study shows that women across psychiatric diagnoses share similar reproductive desires, some hoping to have children and others wishing to avoid motherhood altogether. The popular idea that certain psychiatric diagnoses render women unsuitable for motherhood is not echoed by the women in this study. Instead, their embodied experience of mental illness allows them to embrace the newfound reproductive choice of psychiatric patients and highlights the stigma that perpetuates fears of motherhood with mental illness.

Over the last 20 years, adolescent health researchers, practitioners and advocates have zeroed-in on the global problem of ‘child marriage.’ Defined as a formal or informal marital union before 18 years, child marriage affects both boys and girls, but disproportionally affects girls. Globally, child marriage is noticeably prevalent but on a downward trend, with the proportion of 20-24 year old women marrying before 18 years decreasing from 25% to 19%, from 2008 to 2020 (UNICEF, 2018; 2022). Extensive research has shown the adverse consequences of marrying during adolescence, ranging from increased risk of maternal mortality and birth complications, intimate partner violence (IPV), adverse mental health and intergenerational poverty outcomes (Burgess et al., 2022; Clark, 2004; Nour, 2009; Otoo-Oyortey & Pobi, 2003; UNICEF, 2018). From a rights perspective, child marriage is considered a violation of girls’ and boys’ ‘right’ to fully consent into marriage before reaching age of majority, internationally recognized as 18 years of age (Bruce, 2003; Nour, 2009). As such, child marriage is recognized as a human rights violation under several international treaties, including the Convention on the Rights of the Child (CRC). The term ‘child marriage’ is commonly used to convey the human rights violations that early marital practices have for under-age girls and boys. While the term ‘child marriage’ has mobilized consensus and solidarity toward the issue, this terminology also homogenizes the issue of marriage as a problem affecting the ‘girl child’ with little to no agency in the marriage decision-making process. More specific to Uganda, this ‘child marriage’ terminology can be problematic where marriage more commonly occurs during middle to late adolescence (15-19 years) and when adolescents may exert varying degrees of agency and consent in the marital decision-making process. Except for Chapter 1 which explores ‘child marriage’ global and national movements, I intentionally use the terminology ‘adolescent marriage’ (as marriage before age 18), rather than ‘child marriage,’ throughout this dissertation. Despite the global push to ‘end child marriage’ over the last decade, there is limited research about how broader social and structural factors may be driving declines in adolescent marriage (Muthengi et al., 2021; Plesons et al., 2021). In particular, we have a limited understanding about how global efforts, social processes and norms might work together to drive marriage declines among adolescents. Through a mix of policy, quantitative and qualitative methods, this dissertation examines the policy, structural and social mechanisms that have contributed to declining adolescent marriage among adolescent girls in the context of southcentral Uganda. Chapter 1 begins with a broader contextual lens, examining the political evolution of the global ‘child marriage’ movement, and how the ‘problem’ of child marriage was then taken-up by government and civil society actors in Uganda. This chapter is informed by 20 key informant interviews with Ugandan and global stakeholders working on child marriage and a desk review of over 130 documents gathered across four years. This chapter highlights how the global ‘child marriage’ movement marked a political shift in adolescent girl funding, repackaging the issue of early marriage as an issue of ‘child protection.' The focus on child protection, rather than adolescent sexuality, was instrumental in mobilizing attention from liberal and conservative funders in the Global North and policy-makers in the Global South. In the priority country of Uganda, multiple factors influenced the national policy uptake of child marriage, including: 1. Regional campaigns that created consensus among Eastern and Southern African country leadership to address child marriage; 2. The availability of national data that showed the reach and severity of child marriage within Uganda; 3. The cultural and political appeal of child marriage as an issue of ‘child rights’, rather than one of ‘sexuality,’ and; 4. A network of government leaders, academics, international non-governmental organizations (INGOs) and civil society organizations (CSOs) who coalesced behind the issue in Uganda. Chapter 2 focuses-in on the southcentral region of Uganda, leveraging close to 20 years of quantitative data to understand how social and structural factors are affecting adolescent marriage declines in the region. Using data from 13 surveys (1999-2018) of the Rakai Community Cohort Study (RCCS), I couple decomposition and causal inference methods to assess how social determinants and adolescent pregnancies have contributed to adolescent marriage declines among 15 to 17 year old girls. I find that both marriages and pregnancies among adolescent girls substantially declined over the last 20 years, from 24% to 6%, and 28% to 8%, respectively, between 1999 and 2018, as a result of educational and economic improvements. Among all social determinants, girls’ secondary schooling was more closely associated with lower risk of marriage and pregnancy (aOR marriage = 0.09; 95%CI=0.07, 0.12; aOR pregnancy = 0.14; 95% CI=0.11; 0.19). In the causal mediation analyses, lower pregnancy rates partially explained the positive effect of higher secondary schooling on lower risk of adolescent marriage. Decomposition analyses showed that the declines in adolescent marriage between 1999 to 2018 were primarily attributed to pregnancy declines, and to a lesser extent, improvements in education and SES. These findings reemphasize the sizeable role of education in preventing adolescent marriages, in line with Uganda’s national educational investments such as universal primary education (UPE). Yet, these findings also underline the importance of adolescent pregnancy prevention to delay age at marriage. In the same region of southcentral Uganda, Chapter 3 uses secondary ethnographic data to more deeply explore the social mechanisms and norms that have contributed to changes in adolescent marriages. I qualitatively explore how the region’s social and economic changes have affected social norms about adolescent sex, courtship, and marriage in Rakai, Uganda. This analysis is informed by 16 focus group discussions and 15 key informant interviews conducted in 2018 with younger and older women and men, ranging from 16 to 77 years old. In comparing generational perspectives, I identify a ‘normative transition’, in which new structures are transforming courtship and marriage processes for young people. First, the HIV epidemic significantly weakened family structures, and in the process, courtship and marriage guidance previously provided by families and elders; second, the loss of land ownership in between generations has made marriage preparations more difficult for young people; and third, new social spaces outside the family home – including discos, mobile phones and schools - have expanded young people’s romantic geographies prior to marriage. These changes have reduced the importance of the family institution in the marital decision-making process, while increasing young women’s and men’s autonomy in engaging in premarital sex, choosing their partners, and delaying marriage. Although these changes have delayed age at marriage beyond adolescence, this transition has introduced unanticipated challenges for young people as they enter adulthood, including lack of overall parental, familial and elder guidance in their relationship and marriage formation processes. Taken together, these findings highlight the complexity of adolescent marriage changes and prevention efforts at the global, Ugandan, and southcentral region of Uganda. First, global and national ‘child marriage’ movements played a significant role in the uptake of child marriage as an issue of ‘child protection’, rather than one about ‘sexuality’ in Uganda. Yet looking at the context of southcentral Uganda, adolescent pregnancies and adolescent marriages declines appear to be closely linked, highlighting the importance of conceptualizing adolescent marriage as not just a child protection issue, but one of adolescent sex and sexuality. Lastly, I find that broader structural and social changes in Rakai have substantially changed adolescent norms around sex, courtship, and marriage, delaying age at marriage in between generations. However, young people are encountering new challenges as they enter adulthood and romantic relationships in the absence of pre-existing elder and familial systems and networks. Additional research should focus on understanding the unintended consequences of catalyzing norm change and delaying age at marriage, including how these changes might affect familial and community relationships and kinships. Twenty years into the global push to end ‘child marriage’, this dissertation research provides new insights into the complex structural, social and sexuality drivers of adolescent marriage changes in Uganda. Despite the substantial progress in adolescent marriage declines, this research points to key gaps that will need to be addressed to improve adolescent SRH rights and needs in Uganda, the East African region, and beyond. Of particular importance is the need to center adolescent sexuality within current child marriage efforts, as well as focusing on the broader social changes affecting adolescent relationship formation, rather than exclusively focusing on age at marriage as a marker of social change.

Studies have found that the type of parenting a child receives affects his or her subsequent development. This study investigates the relative influence of maternal parenting behavior and the impact of multiple variables influencing the quality of mothers' parenting behaviors. This knowledge will help to understand how early attachment experiences impact future parenting behavior.

This study used a multi-method approach to explore factors associated with high and low depression in a sample of rural mothers living in poverty. From a sample of 117 women with very high or very low CES-D depression scores, 40 cases were randomly selected for in-depth qualitative analysis. Qualitative comments about a variety of issues were explored including health, mental health, childcare, transportation, community, social support, and family of origin experiences. Quantitative data were then used in response to themes that emerged from the literature and the qualitative findings. All 117 eligible participants were used for quantitative analysis to increase power. Analysis of the qualitative data revealed several critical differences between the two groups. Low risk participants mentioned fewer health issues and less severe health problems as compared to their high risk counterparts. Mental health issues were reported more in the high risk group, with this group being more likely to have multiple family members experiencing symptoms. All participants reported receiving social support, however, the low risk group reported positive social support experiences, while the high risk group reported ambivalent relationships with the people who provided them with social support. Reported family of origin experiences were quite different between the two groups, with the low risk group reporting more positive past and current relationships. Quantitatively, several interesting results were revealed, many confirming the qualitative findings. Mothers showing higher levels of depression reported significantly more health problems for themselves, their partners, and their children. Additionally, participant's work status, income, perceived adequacy of income, childhood welfare use, and presence of partner were significantly related to depression. Low risk respondents were more likely to be working, perceive their income as adequate, and have a partner. They were also less likely to have received welfare as a child and had higher incomes. The findings offer important implications for future research and policy. Risk for depression seems to be related to a variety of factors, indicating that something should be done to minimize an individual's likelihood toward experiencing depression. This study ultimately provided a clearer picture of the existence of depressive symptoms among women with children living in rural poverty. / Graduation date: 2003

Adolescent mothers are a vulnerable population for a multitude of reasons. For one, adolescent mothers concurrently undergo two significant developmental phases and transitions: adolescence and parenting. Adolescence is the psychosocial period of adjustment marked by dramatic neural, hormonal, cognitive, psychological, physical, and biological changes. While adolescence is a time of cognitive advancement, it is also a time of stress, identity development, peer pressure, mood disruptions, and emotion regulation difficulties. While parenthood presents with positive changes, it simultaneously introduces challenges, such as increases in caretaking responsibilities, time commitment, and distress. Additionally, as statistics have shown, many adolescent mothers face a host of risk factors (e.g., poverty, low socioeconomic status (SES), and low educational attainment), making these “adolescent mothers at risk (AMARs)” a highly vulnerable population. Adolescence is also a time when substance use initiation and experimentation occur. While some level of substance use is normative among adolescents, substance use is especially detrimental for adolescent mothers and their children. According to the literature, substance-using mothers differ from their non-substance-using counterparts in terms of how the former parent their children. For example, substance-using mothers tend to display decreased levels of warmth (Barnow, Schuckit, Lucht, John, & Freyberger, 2002; Gruber and Taylor, 2006; Mayes & Truman, 2002; Suchman et al., 2007) as well as extreme styles of parenting (e.g., minimal supervision and intolerant attitudes) (Suchman & Luthar, 2000). This dissertation used archived data to examine AMARs and explore their levels of distress tolerance, substance use, and parenting attitudes and beliefs. Specifically, this dissertation sought to address the following questions: Is there an association between distress tolerance, substance use, and parenting attitudes and beliefs? Does substance use mediate the association between distress tolerance and parenting attitudes and beliefs? Seventy-two mothers living in nine Transitional Living Programs (TLPs) across a Northeast state were interviewed. Participants were aged 16-22 years with a mean age of 19. Participants were predominantly Latino and African American, and nearly half of the participants reported having a history of living in foster care or group home with an average of five years spent in these institutions. Data were collected from the baseline interview of a pilot randomized control trial examining an intervention for increasing positive parenting among homeless AMARs. Distress tolerance was operationalized via the Distress Tolerance Scale (Simons & Gaher, 2005), and parenting attitudes and beliefs were operationalized through the Adult Adolescent Parenting Inventory-2 (Bavolek & Keene, 2010). Lifetime and recent frequency of substance use was also examined. Race/ethnicity was controlled for in all analyses because the past literature has documented racial/ethnic minority adolescent mothers experiencing more adversities and vulnerabilities compared to their White counterparts (Huang et al., 2014, 2019). Consistent with the literature, we found an association between distress tolerance and substance use, substance use and parenting attitudes and beliefs, as well as distress tolerance and parenting attitudes and beliefs. Specifically, there was an association between low distress tolerance and high levels of substance use; high levels of substance use and poor parenting attitudes and beliefs; and low distress tolerance and poor parenting attitudes and beliefs. In terms of the mediation analysis, only substance use within the past six months mediated the relationship between distress tolerance and parenting attitudes and beliefs. In other words, low distress tolerance led to higher levels of substance use within the past six months, which in turn led to poorer parenting attitudes and beliefs. One implication of the results is that recent substance use, rather than lifetime history, has a more salient effect on parenting attitudes and beliefs. Overall, the majority of the AMARs in the current study’s sample demonstrated resilience and had scores reflective of positive parenting attitudes and beliefs despite their notably low levels of distress tolerance. While the results of the study are promising, they should be interpreted with caution considering several limitations, including a small effect size from the mediation analysis and potential underreporting among AMARs. Future research should continue to explore various iterations of the research question (e.g., different combinations of distress tolerance, substance use, and parenting attitudes and beliefs as the independent, mediating, and outcome variables) and psychometric properties of the measures utilized.

Adolescence is a period of rapid development marked by significant neurological and behavioral change. Normative neurological shifts that take place during this stage of life occur in the areas of the brain most associated with response inhibition and emotion regulation which is understood in the context of the observed increases in impulsivity and emotional lability among many adolescents. These facets of development may present unique challenges for those adolescents who enter parenthood ruing this period of life as increasing evidence suggests that emotional and cognitive control are highly related to parenting behavior. Those parents who are better able to modulate their emotional responses are best able to cultivate sensitive and nurturing home environments for their children. Compounding the risk for themselves and their children, adolescent mothers also face a constellation of risk factors including poverty, low educational attainment, elevated levels of stress and high rates of early life trauma exposures. Those adolescent mothers who experience homelessness face additional risk, in part because social support and family involvement have been shown to benefit young parents and their children. A substantive body of literature suggests that these interrelated risk factors may stress the capacity to effectively parent, leading adolescent mothers to be less affectionate, less positive, more hostile and intrusive and less emotionally available when interacting with their children. Consequently, supporting adolescent mothers is of great public health concern as they, and their children, are at risk for a range of non-optimal outcomes. The aim of this dissertation was to contribute to the current body of literature linking maternal emotion regulation with positive parenting practices among a highly vulnerable sample of homeless adolescent mothers and their children. Specifically, this dissertation used archival data to extend the current understanding of these associations by exploring the ways in which early life exposure to psychological aggression influenced the regulatory capacities and parenting behaviors of a sample of homeless adolescent mothers. To date, few studies have utilized a computerized measure of response control and behavioral inhibition under emotionally salient conditions in conjunction with ecologically valid multiple observer coded video observations of parent-child interactions within this high-risk population. Participants (N=72) were adolescent mothers and their children living in nine Transitional Living Programs (TLPs) across a Northeastern state, aged 16-22 years old and predominantly Latinx and Black American. On average, participants had one child (M=1.3 years-old). Nearly half of the participants reported a history of foster care or group home involvement. Thirty-two percent of the sample self-reported clinically significant levels of depression and, on average, participants reported slightly elevated levels of anxiety. Consistent with the literature, the sample evidenced significant trauma exposures with participants reporting having experienced an average of three discrete traumatic events. For example, 37.3% reported having experienced physical violence in their home, 72% reported having experienced violence in their community, 45.3% reported having witnessed violence in their community, and 36.3% reported having experienced some form of sexual abuse. Data were collected from the baseline interview of a randomized control trial examining the effectiveness of an intervention designed to increase positive parenting among a sample of adolescent mothers living in TLPs. For this study, interpersonal trauma exposure was operationalized via the Psychological Aggression Scale of the Parent Child Conflict Tactics Scale (Straus, 1999). Maternal sensitivity and hostility were operationalized using the Sensitivity and Non-Hostility scales of the Emotional Availability Scales, 4th edition (EA Scales; Biringen, 2008). Maternal emotion recognition and regulation were operationalized via the Emotion Go/NoGo (EGNG) paradigm. Maternal depression and anxiety were also examined. Consistent with the literature, this study found evidence for the complex associations between maternal exposure to psychological aggression, maternal emotion regulation and parenting behaviors. Specifically, there was a significant positive association between the accurate discrimination of sad from neutral facial expressions and maternal sensitivity. The accurate discrimination of fearful from neutral facial expressions, however, was associated with less sensitive parenting. Additionally, those mothers who were more impulsive when confronted with sad facial expressions during the EGNG sad emotion “go” task were less sensitive when interacting with their children. This study also found evidence for a significant interaction between maternal exposure to psychological aggression and impulsivity in the EGNG fearful emotion “go” task in the explanation of maternal sensitivity. Specifically, for those adolescent mothers who had experienced psychological aggression, impulsivity when confronted with fearful facial cues on a computerized task was associated with increased maternal sensitivity during dyadic interactions. For those mothers who had not experienced psychological aggression, however, increased impulsivity when confronted with fearful faces on the computerized task was associated with reduced maternal sensitivity. Maternal exposure to psychological aggression was consistently associated with increased hostility with those mothers who had been exposed to psychological aggression evidencing more hostility when interacting with their children. Finally, in optimal conditions on a computerized task (i.e., when confronted with happy faces during the EGNG paradigm) those mothers who were rated as more sensitive during dyadic interactions all responded within approximately the same amount of time to the computerized stimuli. No relationship between maternal sensitivity and mean response time was found in the negatively valenced EGNG conditions. There was not sufficient evidence to suggest that emotion regulation and behavioral impulsivity mediated the relationship between exposure to psychological aggression and parenting behavior. Consistent with the literature, these findings suggest a role for both maternal trauma exposure and regulatory capacities in the explanation of parenting behavior. These findings highlight the need for greater research on these complex and multidetermined relationships, particularly within the highly vulnerable adolescent parent population. Additionally, this study’s findings suggest possible avenues for interventions within this population, highlighting the need to consider the ways in which adolescent mothers’ regulatory capacities may influence their ability to intuit and respond to their children. Directions for future research and clinical implications are discussed.

The present study aimed to explore the objective and subjective experiences of “mistreatment” in maternity care in a diverse cohort of women who gave birth in New York City hospitals to identify the prevalence and risk factors of mistreatment and measure the relationship between mistreatment and mental health (Bohren et al., 2015). The study utilized a mixed-methods cross-sectional approach. To collect the quantitative data, 109 participants <1 year postpartum completed an anonymous online survey comprising a self-report measure of demographic, health and mental health information, several mental health questionnaires and two measures of mistreatment in maternity care. 8 of these participants were interviewed about their childbirth experience. The quantitative data was analyzed utilizing linear regression, moderation analysis and path analysis, and the qualitative data was thematically coded then analyzed using Reflexive Thematic (RT) analysis. These data were then triangulated using a mixed-methods model of mistreatment. In total, 10-15% of the sample experienced mistreatment in the form of Low to Very Low respect and/or autonomy in decision making in their maternity care. Forms of mistreatment included unwanted procedures, provider pressure to undergo procedures, dismissal of women’s concerns, racial discrimination, abandonment, and medical neglect. Approximately 25% of respondents received an unwanted intervention; this was the most significant predictor of mistreatment. This relationship was moderated by race, parity and birth plan. Black, Latinx and Hispanic women experienced the lowest levels of respect in maternity care. Mistreatment in maternity care was correlated with increased risk for postpartum mental illness: decreased respect and autonomy in childbirth was associated with increased postpartum depression and PTSD symptoms. Eight themes were identified in the qualitative analysis: Discrimination and Unfair Treatment, Confusion and Abandonment, Disregard for Patient Autonomy, Hospital-Level Drivers of Mistreatment, Women Treated as Passive, Normalization of Mistreatment, Self-Advocacy and Vulnerability and, Reclaiming Power through Knowledge. Together, the triangulated mixed- methods data were fit to render a comprehensive “model of mistreatment” to illustrate direct and indirect relationships between mistreatment, mental health, race, trauma history, and childbirth preparation. These findings demonstrate that mistreatment is a multi-determined phenomenon that is interdependent with mental health and requires systematic measurement in healthcare treatment, the integration of anti-racist and patient-centered care and improved childbirth education for patients.