Journal articles on the topic 'Psychosocial aspects of childbirth and perinatal mental health'

Pregnancy is a transitional period involving the most complex experiences in a woman’s life, during which the woman’s psychological status can be affected by a wide range of psychosocial variables. However, positive interpersonal relationships appear to constitute a supportive network that significantly influences perinatal mental health. Therefore, the presence of a supportive partner works psycho-protectively against the difficulties and pressures created by the transition to maternity. The aim of this study was to review systematically the influence of the partner on the woman’s psychology during the perinatal period. Fourteen research articles from PubMed/Medline, Google Scholar and PsycINFO were included in the review from a total of 1846 articles. Most studies have shown a correlation between the support from the partner and prenatal depression and anxiety. Support from the spouse during childbirth is related to the extent to which women feel safe during labor as well as the stress during childbirth. The role of the partner is very important in the occurrence of perinatal mental disorders in women. Of course, more research needs to be done in the field of perinatal mental health. The risk factors that lead to mental disorders need to be clarified and the role of the partner in the perinatal period requires reinforcement and needs to be given the necessary importance.

Abstract BodyThe risk of mothers to develop a severe mental illness is dramatically increased in the first three months after giving birth. Childbirth has the strongest relationship with postpartum affective psychosis, a condition that is characterized by an acute onset of florid symptoms, usually within 2 weeks of delivery, and atypical features, such as rapidly fluctuating psychotic symptoms, florid motor symptoms, perplexity and high risks to the mother and her baby. Follow up data of women with a first episode suggest that some women only become ill in the context of childbirth whereas in others it is an expression of a lifelong bipolar disorder. Whether this reflects two distinct forms of the disorder or different degrees of vulnerability requires future study. The profound hormonal and metabolic as well as psychosocial changes in the perinatal period give rise to a number of hypotheses that seek to explain the pathogenesis of postpartum psychosis. Current research findings on biological and psychosocial risk factors will be discussed as well as what is currently known about responses to treatment.DisclosureNo significant relationships.

IntroductionDyspareunia is defined as persistent or recurrent genital pain that occurs just before, during or after intercourse. Dyspareunia after childbirth is quite common and have a range of repercussions to women's lives, including their sexual functioning. It could be affected by different risk factors. While role of obstetric factors including mode of delivery has been largely investigated, the influence of psychosocial factors remains unclear.AimsOur purpose was to determine frequency of postpartum dyspareunia and identify related psychosocial factors.MethodsThirty women between 2 and 6 months postpartum were recruited in consultation of maternity and neonatology center of Tunis. Data were taken from medical file and questionnaire designed to record psychosocial data and postpartum sexual function.ResultsThe mean age of women was 28.74 ± 8.4 years. Dyspareunia was reported by 43.33% of women. Dyspareunia was not associated to professional status. On the other hand, dyspareunia was significantly associated to fatigue (P = 0.024), lack of familial support (P = 0.03), conjugal conflicts (P = 0.01).ConclusionWe have found an association between dyspareunia after childbirth and several psychosocial factors, pointing out the influence of social and psychological aspects in the sexual function in women. Thus, management of sexual disorders should take in consideration psychological dimension and involve an appropriate psychological care.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionPsychiatric illness and suicide in particular have been a leading overall cause of maternal mortality in the United Kingdom. Although the most recent Confidential Enquiry into Maternal and Child Health indicated that this is no longer leading causes, mental health problems before and after childbirth have a significant impact on the health of women, family relationships and children's subsequent development.AimsTo identify the current practice for management and prevention of perinatal mental illness within a community mental health setting.To identify the extent to which policy recommendations from NICE “Antenatal and postnatal mental health” been implementedMethodsThe audit included all women who are pregnant, breastfeeding or who are planning to become pregnant and referred to the CMHT between November 2008 to April 201020 Cases identified by asking all team members to recall relevant clients.Results65% of those referred were in the antenatal period and 25% were in the post natal period. 40% of those referred had a pre existing mental illness and 60% were new onset during antenatal & postnatal period.The main diagnosis was depression and anxiety disorders.55% of those referred to the CMHT were on Psychotropic medications. However following the assessment and follow up by CMHT, only 25% of those referred needed to be on the psychotropics.Good compliance was achieved in the documentation of past psychiatric history and family history, provision of appropriate psychosocial interventions and specific considerations for the use of antidepressant medication during pregnancy and the postnatal period.

Perinatal mental health (PMH) has been a growing field of practice for psychiatry in the last decades. It focuses on mental health during pregnancy, childbirth and the postpartum period including the distinctive presentations of mental illness and well‐being challenges associated with parenting experiences. Mental health problems in pregnancy and the postnatal period can have significant differences and challenges to its approach compared to other periods of life. Working in PMH requires specific and updated know­ ‐ledge regarding carers’ experiences and manifestations of mental illness in this particular life stage and psychotropic management during pregnancy and breastfeeding, as well as regarding the mother/parent and baby relationship and bond, and the baby’s safeguarding along several developmental issues. For all this, PMH specialist services and multidisciplinary teams with specific training have been developing to cater to this need in several countries around the world. To provide a broadened overlook on the matter, some key aspects of PMH will be discussed below in this perspective.

Objective: to analyze the psychopathological structure, risk factors and tretment of depressive disorders in women in the postpartum period.Patients and methods. A prospective cohort study included 150 women in the postpartum period (0-3 days after birth), aged 18 to 41 years, with follow-up every two weeks for six months. The evaluation included clinical interviews, Montgomery-Asberg Depression Rating Scale, and the 17-item Hamilton Anxiety Rating Scale.Results and discussion. 11.3% of women developed depression within six weeks after childbirth. Among them, 94.2% presented with mild depression, and 5.8% - moderate. Risk factors associated with postpartum depression included: periods of low mood and anxiety before and during the current pregnancy, traumatic situations during pregnancy, unwanted pregnancy, pathology of pregnancy and childbirth, cesarean section, perinatal status, lack of breastfeeding. All women with postpartum depression were treated with rational-emotive and cognitive-behavioral therapy. A short course of pharmacotherapy was prescribed to 17.6% of them to correct insomnia and anxiety symptoms. Psychotherapy was highly efficient in the treatment of postpartum affective disorders.Conclusion. The postpartum depression prevalence was 11.3%. The severity of postpartum depression was predominantly mild, and the symptoms regressed during treatment within five months in all women.

<p><strong>Background:</strong> Perinatal mental health disorders are considered to be a major public health concern. Left untreated, maternal psychopathology can extent to the rest of the family unit, and increase the risk of psychological and psychiatric co-morbidity in the child. Thus, a better understanding of the overall burden of these disorders is fundamental to inform policy makers and produce practice change. Worldwide, perinatal mental health disorders are known to affect approximately 20% of pregnant and postnatal women. However, the prevalence of these disorders in Malta, an island in the center of the Mediterranean Sea with approximately 4,000 births annually, remains unknown. The primary objective of this cross-sectional study will be to address this gap in knowledge and define the local prevalence of perinatal psychopathology.</p><p><strong>Methods:</strong> A representative sample of 300 postnatal women from birth up to one year after childbirth, resident in Malta, will be recruited through a stratified random technique. Participation will involve two phases. In the first stage, selected participants will be asked to self-complete the Edinburgh postnatal depression scale (EPDS), the generalized anxiety disorder-7 item (GAD-7), the Yale Brown obsessive compulsive scale (YBoCS), the Post-Traumatic Stress Disorder Checklist for DSM-V (PCL-5), and the difficulties in emotional regulation scale (DERS) questionnaires. In the second stage, those women who score equal or above the cut-off values in any of these questionnaires, will be assessed using the diagnostic mini-international neuropsychiatric interview (MINI) to confirm or refute a diagnosis of a mental health disorder.</p><p><strong>Conclusions: </strong>In addition to determining the local prevalence, scores from the self-report instruments will be correlated with MINI diagnostic outcomes to determine the best cut-off value for a provisional diagnosis for each of these tools. Basic demographic details and psychosocial characteristics will be recorded.</p>

Background: This study investigates if a non-randomized controlled perinatal health intervention which offers (a) long-term midwife-led breastfeeding support and (b) psychosocial support of women, is associated with the initiation, exclusivity and duration of breastfeeding. Methods: A sample of 1080 women who attended a 12-month intervention before and after childbirth, during a five-year period (January 2014–January 2019) in a primary mental health care setting in Greece, was examined. Multiple analyses of variance and logistic regression analysis were conducted. Results: The vast majority of women (96.3%) initiated either exclusive breastfeeding (only breast milk) (70.7%) or any breastfeeding (with or without formula or other type of food/drink) (25.6%). At the end of the 6th month postpartum, almost half of the women (44.3%) breastfed exclusively. A greater (quantitatively) midwifery-led support to mothers seemed to correlate with increased chance of exclusive breastfeeding at the end of the 6th month postpartum (p = 0.034), and with longer any breastfeeding duration (p = 0.015). The absence of pathological mental health symptoms and of need for receiving long-term psychotherapy were associated with the longer duration of any breastfeeding (p = 0.029 and p = 0.013 respectively). Conclusions: Continuous long-term midwife-led education and support, and maternal mental well-being are associated with increased exclusive and any breastfeeding duration.

IntroductionGestational diabetes mellitus (GDM) carries prenatal and perinatal risk for the mother and her offspring as well as longer-term risks for both the mother (obesity, diabetes, cardiovascular disease) and her child (obesity, type 2 diabetes). Compared with women without GDM, women with GDM are twice as likely to develop perinatal or postpartum depression. Lifestyle interventions for GDM are generally limited to physical activity and/or nutrition, often focus separately on the mother or the child and take place either during or after pregnancy, while their results are inconsistent. To increase efficacy of intervention, the multifactorial origins of GDM and the tight link between mental and metabolic as well as maternal and child health need to be heeded. This calls for an interdisciplinary transgenerational approach starting in, but continuing beyond pregnancy.Methods and analysisThis randomised controlled trial will assess the effect of a multidimensional interdisciplinary lifestyle and psychosocial intervention aimed at improving the metabolic and mental health of 200 women with GDM and their offspring. Women with GDM at 24–32 weeks gestational age who understand French or English, and their offspring and partners can participate. The intervention components will be delivered on top of usual care during pregnancy and the first year postpartum. Metabolic and mental health outcomes will be measured at 24–32 weeks of pregnancy, shortly after birth and at 6–8 weeks and 1 year after childbirth. Data will be analysed using intention-to-treat analyses. TheMySweetHeart Trialis linked to theMySweetHeart Cohort(clinicaltrials.gov/ct2/show/NCT02872974).Ethics and disseminationWe will disseminate the findings through regional, national and international conferences and through peer-reviewed journals.Trial registration numberNCT02890693; Pre-results.

Background: The present study aimed to identify the prevalence of sleep problems among the fathers from the antenatal to postpartum period as well as their risk factors with an aim to develop strategies to assist the fathers during the transition period. Methods: A consecutive sample of 540 Chinese expectant fathers were recruited. Expectant fathers were administered a set of questionnaires at first presentation (12 weeks gestation), 36 weeks pregnancy and 6 weeks after childbirth. Sleep problems was assessed with the Pittsburgh Sleeping Quality Index (PSQI). Demographic and psychosocial risk factors were also assessed. Findings: An alarming 42.2%, 57.5% and 70.3% of the fathers were identified to have sleep problems at early, late pregnancy and six week postpartum respectively. Hierarchical multiple regression analysis showed that poor self-esteem and work family conflict were significant risk factors for sleep problems at early pregnancy and late pregnancy respectively, even after controlling for confounders. Poor social support and work family conflict significantly predicted sleep problems at six week postpartum. Discussions: The prevalence of sleeping problems among the fathers during perinatal period was alarmingly high and warrants serious attention. Given the potential adverse impact of sleep problems on fathers’ mental and physical health as well as caregiving abilities, findings from this study point to the need to equip fathers with psychosocial resources through perinatal psychoeducation, support group and counselling. Caution should be exercised in generalizing the results to fathers of other backgrounds as the sampling of the present study only include a certain area of Hong Kong.

Challenges during the perinatal period can lead to maternal distress, negatively affecting mother-infant interaction. This study aims to retrospectively explore the experiences and needs regarding professional support of mothers with difficulties in mother-infant interaction prior to their admission to an infant mental health day clinic. In-depth semi-structured interviews were conducted with 13 mothers who had accessed an infant mental health day clinic because of persistent severe infant regulatory problems impairing the wellbeing of the infant and the family. Data were transcribed and analyzed using the Qualitative Analysis Guide of Leuven (QUAGOL). Three themes were identified: ‘experience of pregnancy, birth, and parenthood’; ‘difficult care paths’; and ‘needs and their fulfillment’. The first theme consisted of three subthemes: (1) ‘reality does not meet expectations’, (2) ‘resilience under pressure’, and (3) ‘despair’. Mothers experienced negative feelings that were in contradiction to the expected positive emotions associated with childbirth and motherhood. Resilience-related problems affected the mother-child relationship, and infants’ regulatory capacities. Determined to find solutions, different healthcare providers were consulted. Mothers’ search for help was complex and communication between healthcare providers was limited because of a fragmented care provision. This hindered the continuity of care and appropriate referrals. Another pitfall was the lack of a broader approach, with the emphasis on the medical aspects without attention to the mother-child dyad. An integrated care pathway focusing on the early detection of resilience-related problems and sufficient social support can be crucial in the prevention and early detection of perinatal and infant mental health problems.

Introduction Pregnancy and the postpartum are generally characterized by positive feelings and expectations but they may also disguise maternal stress and difficulties. These are typical periods for the onset or relapse of psychiatric symptoms and disorders. Even though suicide during pregnancy and postpartum is rare, it is among the leading causes of maternal perinatal mortality. Objectives To provide an overview on the risk of suicide during pregnancy and postpartum. Methods PubMed database was searched using combinations of the terms “suicide”, combined with “pregnancy” and “depression”. Results The major risk factors for suicidal ideation are previous suicide attempts, self-harm, current or past history of psychiatric disorder, young maternal age, being unmarried, an unplanned pregnancy, substance use disorders, lack effective psychosocial support and discontinuation of psychotropic drugs. Pregnant women with suicidality behavior have also an increased risk for various adverse obstetric outcomes, including miscarriage, preterm delivery, maternal hemorrhage, and stillbirth. Furthermore, the postpartum period is often associated with the onset of mood and psychotic disorders with an increased risk of both suicide and infanticide. Women who have suffered from serious psychiatric conditions either after childbirth or in other phases of life should be informed about the possibility of relapse after subsequent pregnancies, thus presenting a higher risk of suicide. Conclusions During pregnancy and postpartum, it is fundamental to investigate suicide risk, including suicidal ideation, thoughts, and intent, especially (but not only) in women affected by mental pathology. Moreover, maternal suicide behaviour affects the child’s neuropsychological development and can also increase the infant´s suicide risk. Disclosure No significant relationships.

BackgroundIn a perinatal cohort of women in urban and rural Turkey, we investigated associations between antenatal depressive symptoms and subsequent changes in perceived quality of key family relationships.MethodOf 730 women recruited in their third trimester (94.6% participation), 578 (79.2%) were reassessed at a mean of 4.1 (s.d. = 3.3) months after childbirth, 488 (66.8%) were reassessed at 13.7 (s.d. = 2.9) months, and 448 (61.4%) at 20.8 (s.d. = 2.7) months. At all four examinations, self-reported quality of relationship with the husband, mother and mother-in-law was ascertained using the Close Persons Questionnaire with respect to emotional support, practical support and negative aspects of the relationship. Antenatal depressive symptoms were defined using the Edinburgh Postnatal Depression Scale. A range of covariates in mixed models was considered including age, education, number of children, family structure, physical health, past emotional problems and stressful life events.ResultsKey findings were as follows: (i) reported emotional and practical support from all three relationships declined over time in the cohort overall; (ii) reported emotional support from the husband, and emotional and practical support from the mother-in-law, declined more strongly in women with antenatal depressive symptoms; (iii) associations between depressive symptoms and worsening spouse relationship were more pronounced in traditional compared with nuclear families.ConclusionsAntenatal depressive symptoms predicted marked decline in the quality of key relationships over the postnatal period. This may account for some of the contemporaneous associations between depression and worse social support, and may compound the risk of perinatal depression in subsequent pregnancies.

ABSTRACTDepression is widely prevalent among women in the child-bearing age, especially during the antenatal and postnatal period. Globally, post-partum depression has been reported in almost 10% to 20% of mothers, and it can start from the moment of birth, or may result from depression evolving continuously since pregnancy. The presence of depression among women has gained a lot of attention not only because of the rising incidence or worldwide distribution, but also because of the serious negative impact on personal, family and child developmental outcomes. Realizing the importance of maternal depression on different aspects-personal, child, and familial life, there is a crucial need to design a comprehensive public health policy (including a mental health strategy), to ensure that universal psychosocial assessment in perinatal women is undertaken within the primary health care system. To conclude, depression during pregnancy and in the postnatal period is a serious public health issue, which essentially requires continuous health sector support to eventually benefit not only the woman, but also the family, the community, and health care professionals.

Objective: High levels of distress have previously been reported among expectant fathers, with the level of distress for new fathers falling after the birth and during the first year of their infants’ lives. The aim of the present study was to report on the associations with the fathers’ initial high levels of distress. Method: The men completed a series of questionnaires on various aspects of their psychological functioning at a baseline assessment when their partners were in the late first trimester of their pregnancy. The General Health Questionnaire-28 (GHQ-28) was the key measure of psychological distress for the present study. Men scoring >5 on the GHQ were considered to be cases of distress. The cases and non-cases were contrasted on the baseline psychosocial measures. Results: A total of 312 men completed the questionnaires, of whom 18.6% were designated as cases. GHQ caseness was associated with high levels of symptoms on other measures of psychological distress, higher levels of alcohol consumption, poorer quality of their current intimate relationship, poorer social support, a lower quality of life, high levels of neuroticism and the use of immature ego defences. Multiple regression analysis identified the key variables associated with psychological distress to be high levels of neuroticism, dissatisfaction with social support and an excess number of additional life events. Conclusions: Psychological distress among expectant fathers is associated with a range of psychological variables, particularly poor marital relationship and poor social networks. This is consistent with a general vulnerability model for psychological distress. Fathers who had insufficient information about pregnancy and childbirth were also at risk of being distressed, suggesting that more attention needs to be paid to providing information to men about their partner's pregnancy, childbirth and issues relating to caring for a newborn infant.

Introduction. Breastfeeding is a natural form of infant nutrition during evolution that determines the optimal formation of baby's health, its physical, mental and intellectual development. The aim of the research. To learn the influence of social, informational and psychological factors on the duration of breastfeeding. Materials and methods. 200 mother-child pairs were examined. Research results. According to the survey, it was found that 86,4 % of children were breastfed in the first month of life. At 6 months, ration contained breast milk approximately 58,5 %, up to 1 year - 29,0 % of the examined children. A children health study, depending on the duration of breastfeeding, showed that healthy children were longer on exceptionally breastfeeding and breastfeeding than those who had any disease during the first year of life. The median duration of exclusive breastfeeding for healthy infants was 3 months and for infants with some disease - 1 month. The breastfeeding support issues in the work of the family doctor, the role of professional advisory help of medical workers for the formation of long and sufficient lactation were discussed. It is established that the use of modern perinatal technologies for pregnancy, childbirth and newborn provides only breastfeeding up to 6 months and optimal breastfeeding. It has found out that the breastfeeding education for mothers, psychological supportive ambience has a positive effect on the duration of breastfeeding and the health of the child. Conclusions. Lactation and breastfeeding is complicated process, but completely controllаble.

British Made Foreign JournalI am writing this just after returning from India and Sri Lanka and, after being exposed to a welter of cultures and religions in the past few days, I have had cause to reflect on the Journal's aspirations to be international. I think I can detect a touch of sophistry here. Professor Navendra Wig, one of the most distinguished of Indian psychiatrists, puts it better. He describes how the government excise records in India refer to locally produced spirits such as brandy and whisky as IMFL – ‘Indian Made Foreign Liquor’1 – and this made him realise that, at heart, he was an IMFD, an ‘Indian Made Foreign Doctor’, as he could never escape his cultural heritage however much he tried. Similarly, I cannot escape the conclusion that we are seen by all non-UK-born readers as a British Made Foreign Journal, with a style and substance that cannot genuinely resonate with all our readers. But we can learn much from each other, as this issue shows. Manoranjitham et al (pp. 26–30) show that even if we were successful in both identifying and treating depressive illness over in the West, it might have little impact on suicide in south India as there overt depression appears to be rare prior to suicide, and what matters much more is simple stress and isolation following loss. Why south India is different from the UK, and even Pakistan2 here, is a puzzle, but such research shows that we cannot export or import evidence derived from only one country if it is at least partly dependent on culture and setting. Fottrell et al (pp. 18–25) similarly demonstrate the tremendous value of one of the most joyous of events, childbirth, in Benin where perinatal mortality is high, so that even the trauma of a baby almost dying can be overcome triumphantly by the exuberance of successful motherhood. But it is equally important to report results that are entirely consistent with those in countries of different cultures, and Chen et al (pp. 31–35) find that recurrence of self-harm in Taiwan follows a pattern that is virtually identical to that in Western countries.3–5 Large international studies can allow for cultural and national variations and Bottomley et al (pp. 13–17) illustrate this in comparing risk factors for both onset of depression and recovery. Bisson et al (pp. 69–74) do likewise and in their guidelines for psychosocial care after disasters involved experts from 25 nations across the world – quite a feat.

BackgroundLow-intensity psychosocial interventions have been effective in targeting perinatal depression, but relevant mechanisms of change remain unknown.AimsTo examine three theoretically informed mediators of the Thinking Healthy Programme Peer-delivered (THPP), an evidence-based psychosocial intervention for perinatal depression, on symptom severity in two parallel, randomised controlled trials in Goa, India and Rawalpindi, Pakistan.MethodParticipants included pregnant women aged ≥18 years with moderate to severe depression, as defined by a Patient Health Questionnaire 9 (PHQ-9) score ≥10, and were randomised to either THPP or enhanced usual care. We examine whether three prespecified variables (patient activation, social support and mother–child attachment) at 3 months post-childbirth mediated the effects of THPP interventions of perinatal depressive symptom severity (PHQ-9) at the primary end-point of 6 months post-childbirth. We first examined individual mediation within each trial (n = 280 in India and n = 570 in Pakistan), followed by a pooled analysis across both trials (N = 850).ResultsIn both site-specific and pooled analyses, patient activation and support at 3 months independently mediated the intervention effects on depressive symptom severity at 6 months, accounting for 23.6 and 18.2% of the total effect of THPP, respectively. The intervention had no effect on mother–child attachment scores, thus there was no evidence that this factor mediated the intervention effect.ConclusionsThe effects of the psychosocial intervention on depression outcomes in mothers were mediated by the same two factors in both contexts, suggesting that such interventions seeking to alleviate perinatal depression should target both social support and patient activation levels.Declaration of interestNone.

Abstract Despite recent applications of a developmental psychopathology perspective to the perinatal period, these conceptualizations have largely ignored the role that childbirth plays in the perinatal transition. Thus, we present a conceptual model of childbirth as a bridge between prenatal and postnatal health. We argue that biopsychosocial factors during pregnancy influence postnatal health trajectories both directly and indirectly through childbirth experiences, and we focus our review on those indirect effects. In order to frame our model within a developmental psychopathology lens, we first describe “typical” biopsychosocial aspects of pregnancy and childbirth. Then, we explore ways in which these processes may deviate from the norm to result in adverse or traumatic childbirth experiences. We briefly describe early postnatal health trajectories that may follow from these birth experiences, including those which are adaptive despite traumatic childbirth, and we conclude with implications for research and clinical practice. We intend for our model to illuminate the importance of including childbirth in multilevel perinatal research. This advancement is critical for reducing perinatal health disparities and promoting health and well-being among birthing parents and their children.

IntroductionOptimal mental health in the pre-conception, pregnancy and postpartum periods is important for both maternal and infant wellbeing. Few studies, however, have focused on Indigenous women and the specific risk and protective factors that may prompt vulnerability to perinatal mental disorders in this culturally diverse population. ObjectivesTo assess mental health contacts in the period before childbirth among Australian Aboriginal and Torres Strait Islander women, the association with socioeconomic factors and whether it differs by geographic remoteness. MethodsThis is a retrospective cohort study of 19,165 Aboriginal mothers and includes all Aboriginal mothers and their children born in Western Australia from January 1990 to March 2015. It draws on population-level, linked administrative data from hospitals and mental health services, with a primary focus on the mental health contacts of Aboriginal women in the 5 years leading up to childbirth. ResultsThe prevalence of maternal mental health contacts in the five years prior to birth was 27.6% (93.6% having a single mental health disorder), with a greater likelihood of contact in metropolitan areas compared with regional and remote settings. There was a positive relationship between socioeconomic advantage and the likelihood of a mental health contact for women in metropolitan (β = 0.044, p=0.003) and inner regional areas (β = 0.033, p=0.018), and a negative association in outer regional (β = -0.038, p=0.022), remote (β = -0.019, p=0.241) and very remote regions (β = -0.053, p<0.001). ConclusionsThe findings from this study provide new insights on the dynamic relationship between SES, geographic location and mental health issues among Aboriginal women in the five years leading up to childbirth. The results underscore the need to apply location-specific approaches to addressing the material and psychosocial pathways that lead to mental health problems and the provision of culturally safe, appropriate and accessible services for Aboriginal women.

A protocol for the screening, detection and treatment of perinatal anxiety and depressive disorders Importance. With a prevalence of 20%, mental health problems are considered as one of the most frequent complications during pregnancy and the postnatal period. Despite their high prevalence, these mental health problems often remain underdiagnosed and undertreated. Objective. The protocol aims to offer perinatal health care workers (health care and mental health care workers) a framework helping them to detect and discuss depressive and anxiety complaints of women during the perinatal period (up to 1 year after childbirth) and to refer them for treatment. Evidence acquisition. The protocol, which was based on international guidelines and recent scientific evidence, was developed by an interdisciplinary task force taking into account concerns about its daily practicability and current perinatal health care. Results. The protocol guides staff through a psychosocial assessment, a stepped screening, a clinical assessment and treatment steps. It is currently being implemented throughout Flanders (Belgium) with support of the Flemish Ministry of Welfare, Public Health and Family. Conclusion. Integrating mental health screening and treatment in standard perinatal care will improve the mental health care for women, their partners and their offspring.

The perinatal period is a time of high risk for women with unipolar and bipolar mood disorders. We discuss treatment considerations for perinatal mood disorders, including unipolar and bipolar depression as well as postpartum psychosis. We further explore the unique issues faced by women and their families across the full trajectory of the perinatal period from preconception planning through pregnancy and following childbirth. Treatment of perinatal mood disorders requires a collaborative care approach between obstetrics practitioners and mental health providers, to ensure that a thoughtful risk : benefit analysis is conducted. It is vital to consider the risks of the underlying illness versus risks of medication exposure during pregnancy or lactation. When considering medication treatment, attention must be paid to prior medication trials that were most efficacious and best tolerated. Lastly, it is important to assess the impact of individual psychosocial stressors and lifestyle factors on treatment response.

AbstractQualitative accounts indicate there are sensory and communication related barriers to adequate childbirth and postnatal healthcare for autistic people. However, little quantitative work has explored the topic. This online survey study explored childbirth and postnatal experiences among 384 autistic and 492 non-autistic people. Compared with non-autistic people, autistic people were more likely to find the sensory aspects of birth overwhelming, and experienced lower satisfaction with birth-related and postnatal healthcare. Autistic people were more likely to experience postnatal depression and anxiety. The findings highlight that sensory and communication adjustments should be made to birth and postnatal healthcare for autistic people. The findings indicate the need for greater autism understanding among professionals and greater postnatal mental health support for autistic people.

SUMMARY In clinical psychiatry, it is common to see pregnant and postpartum patients who express excessive anxiety and concerns about pregnancy or childbearing. This implies the need to distinguish between symptoms that could be considered to be an expected reaction to the situation, the diagnosis of an anxiety disorder or the presence of pregnancy-related (pregnancy-specific) anxiety. The last presents as a specific clinical phenomenon, identified in the literature as concerns exclusively linked to the situation of pregnancy or childbirth. In this article I review key points in the differential diagnosis of perinatal anxiety and its impact on both the pregnancy and the baby, as well as aspects of detection and diagnosis. I also give a brief summary of possible management approaches and treatments.

Background: During the last decades, fathers have increasingly participated in prenatal care, birth preparation classes, and childbirth. However, comparably little is known about the prenatal emotional well-being of fathers, particularly content and extent of broader paternal concerns that may arise during pregnancy beyond those focusing on childbirth. Thus, the aims of this study were to investigate the manifestation of paternal pregnancy-related worries in a population-based sample and to identify relevant associated factors.Materials and Methods: As part of a longitudinal pregnancy cohort at the University Medical Center Hamburg-Eppendorf, Germany, N = 129 expectant fathers were assessed once during pregnancy. Pregnancy-related worries centering around medical procedures, childbirth, health of the baby, as well as socioeconomic aspects were assessed with the Cambridge Worry Scale (CWS). Additionally, paternal socioeconomic background and maternal obstetrical history, symptoms of generalized anxiety and depression, and level of hostility were investigated, as well as perceived social support. The cross-sectional data were analyzed based on multiple regression analyses.Results: The level of reported worries was overall low. Some fathers reported major worries for individual aspects like the health of a significant other (10.9%) and the baby (10.1%), as well as the current financial (6.2%) and employment situation (8.5%). Pregnancy-related worries were negatively associated with household income and positively associated with anxious and depressive symptoms and low perceived social support. Associations varied for specific pregnancy-related worries.Limitations: Due to the cross-sectional data examined in this study, a causal interpretation of the results is not possible. The sample was rather homogeneous regarding its socioeconomic background. More research needs to be done in larger, more heterogeneous samples.Conclusion: Though overall worries were rather low in this sample, specific major worries could be identified. Hence, addressing those fathers reporting major worries regarding specific aspects already in prenatal care might support their psychosocial adjustment. Fathers with little income, those with elevated levels of general anxious and depressive symptoms, and those with less social support reported higher pregnancy-related worries. Our results indicate the relevance of concerns beyond health- and birth-related aspects that could be relevant for fathers. Measurements developed specifically for expectant fathers are needed to properly capture their perspective already during pregnancy.

In developing countries, 15.6% of pregnant women and 19.8% after childbirth experience a mental disorder. In the absence of data on the situation in Cameroon, we carried out a study to determine the prevalence of perinatal mental illness in this hospital and its risk factors among women in perinatal period and the relationship between both at the Yaoundé Gynaeco-Obstetric and Paediatric Hospital, a reference mother and child hospital. We conducted a hospital-based, cross sectional, observational study. Data was collected using structured and semi-structured interviews. There were six sub-themes covered: participants’ socio-demographic profile, clinical profile, perinatal history, psychopathology aspects with the Mini International Psychiatric Interview, the Edinburgh Postnatal Depression Scale, the State Trait Anxiety Inventory and the perinatal mental illness risk factors. Data entry was done using Microsoft Excel 2010 and transferred to Statistical Package for the Social Sciences version 23.0 for analysis. Among 194 women who participated in the study, the general prevalence for perinatal mental disorders was 53.6% (104/194), 25.8% among pregnant women and 27.8% among postnatal women. Comorbidities were present in 17.5% of our study population. We observed that 45.8% suffered from depression, 17% had a risk of suicide, 10.3% suffered from perinatal anxiety, 3.1% presented with post-traumatic stress disorder, 3.6% acute stress disorder, 7.7% had adjustment disorder. Concerning risk factors, we found a significant link between depression and severe anxiety before delivery (p &lt; 0.05) and the absence of social support (p = 0.005). We found that women with at least four risk factors were 1.6 times more likely to present with a perinatal mental disorder. The prevalence of perinatal mental disorders at this Hospital is very high. This highlights the need for institutional screening and management of perinatal mental disorders, which suggests that we explore the situation in others and other health facilities in Cameroon.

Abstract Background Perinatal depression (PND) is a major complication of pregnancy and many risk factors have been associated with its development both during pregnancy and postpartum. The transition to motherhood activates the attachment system. The aim of our study was to investigate the relationship between women’s attachment style (AS) and PND in pregnancy, and 1 month after childbirth, in a large cohort of women. We hypothesized that different patterns of AS were associated with either antenatal or postnatal depression. We, further, explored the role of other possible risk factors such as life-stress events. Methods A final sample of 572 women was enrolled. At the third trimester of pregnancy, clinical data sheet and self-report questionnaires (ASQ, PSS, LTE-Q, and EPDS) were administered. One month after delivery, EPDS was administered by telephone interview. Results We found 10.1% of the women with depression during pregnancy and 11.1% in the postpartum period. The first logistic regression showed that ASQ-CONF subscale (OR = 0.876, p < 0.0001), ASQ-NFA subscale (OR = 1.097, p = 0.002), foreign nationality (OR = 2.29, p = 0.040), low education levels (OR = 0.185, p = 0.012), PSS total score (OR = 1.376, p = 0.010), and recent life adversities (OR = 3.250, p = 0.012) were related to EPDS ≥ 14 during pregnancy. The second logistic regression showed that ASQ-PRE subscale (OR = 1.077, p < 0.001) and foreign nationality (OR = 2.88, p = 0.010) were related to EPDS ≥ 12 in the postpartum period. Conclusions Different dimensions of anxious insecure AS were, respectively, associated with either antenatal or postnatal depression. These findings support the literature investigating subtypes of perinatal depression. The PND may be heterogeneous in nature, and the comprehension of psychopathological trajectories may improve screening, prevention, and treatment of a disorder which has a long-lasting disabling impact on the mental health of mother and child. We provided a rationale for targeting an attachment-based intervention in this group of women.

Abstract Background For most parents, getting pregnant means having a child. Generally, the couple outlines plans and has expectations regarding the baby. When these plans are interrupted because of a perinatal loss, it turns out to be a traumatic experience for the family. Validating the grief of these losses has been a challenge to Brazilian society, which is evident considering the childbirth care offered to bereaved families in maternity wards. Positively assessed care that brings physical and emotional memories about the baby has a positive impact on the bereavement process that family undergoes. Therefore, this study aims to assess the effects supportive guidelines have on mental health. They were designed to assist grieving parents and their families while undergoing perinatal loss in public maternities in Ribeirão Preto, São Paulo state, Brazil. Method A mixed-methods (qualitative/quantitative), quasi-experimental (before/after) study. The intervention is the implementation of bereavement supportive guidelines for women who experienced a stillbirth or a neonatal death. A total of forty women will be included. Twenty participants will be assessed before and twenty will be assessed after the implementation of the guidelines. A semi-structured questionnaire and three scales will be used to assess the effects of the guidelines. Health care professionals and managers of all childbirth facilities will be invited to participate in focus group. Data will be analyzed using statistical tests, as well as thematic analysis approach. Discussion The Perinatal Bereavement guidelines are a local adaptation of the Canadian and British corresponding guidelines. These guidelines have been developed based on the families’ needs of baby memories during the bereavement process and include the following aspects: (1) Organization of care into periods, considering their respective needs along the process; (2) Creation of the Bereavement Professional figure in maternity wards; (3) Adequacy of the institutional environment; (4) Communication of the guidance; (5) Creation of baby memories. We expect that the current project generates additional evidence for improving the mental health of women and families that experience a perinatal loss. Trial registration RBR-3cpthr Plain English summary For many couples, getting pregnant does not only mean carrying a baby, but also having a child. Most of the time, the couple has already made many plans and has expectations towards the child. When these plans are interrupted because of a perinatal loss, it turns out to be a traumatic experience for the family. In Brazilian culture, validating this traumatic grief is very difficult, especially when it happens too soon. The barriers can be noticed not only by the way society deals with the parents’ grief, but also when we see the care the grieving families receive from the health care establishment. Creating physical and emotional memories might bring the parents satisfaction regarding the care they receive when a baby dies. These memories can be built when there is good communication throughout the care received; shared decisions; the chance to see and hold the baby, as well as collect memories; privacy and continuous care during the whole process, including when there is a new pregnancy, childbirth and postnatal period. With this in mind, among the most important factors are the training of health staff and other professionals, the preparation of the maternity ward to support bereaved families and the continuous support to the professionals involved in the bereavement. This article proposes guidelines to support the families who are experiencing stillbirth and neonatal death. It may be followed by childbirth professionals (nurses, midwives, obstetricians and employees of a maternity ward), managers, researchers, policymakers or those interested in developing specific protocols for their maternity wards.

Abstract Refugee women are at increased risk to develop perinatal mental health problems, including postpartum depression. The fact that refugee and immigrant women suffering PPD are more likely to be exposed to poverty, lack of social support, or restricted working opportunities suggest that a comprehensive approach that addresses the broader social determinants of health is suited to effectively support their perinatal mental health needs. However, public health programs with such a comprehensive approach are scarce in most European countries. We will present qualitative findings from ‘Health nurses strengthen integration', a universal home visiting program aimed to strengthen the integration of refugee families in Denmark. The program includes a minimum of five 2-h meetings including a mind-mapping of families' psychosocial needs, a focus on parenting in a new culture, and support to connect with social and health services. Nurses are trained in cultural competencies and are provided with interpreters. We conducted 3 focus groups (n = 11) and 2 interviews with health visitors (HV) and 9 interviews with refugee mothers to identify what aspects of a comprehensive approach that foster families' integration can support the mental well-being of refugee mothers after birth. Using thematic network analysis we found how the structure, extra time, and training in cultural competence facilitated HV to use critical self-reflection and cultural sensitivity, use respectful curiosity, create a safe space for sharing, and ‘hand-hold' families in interactions with other services. These practices permitted HV understand the complex needs of families, build trust, and facilitate interactions with others services. Interviews with families illustrated how 1) feeling that someone cared ‘like family', 2) and build-bridging with services (doctor, school, job center) reduced families daily stress. Using the family stress and adaptation theory we will discuss program and policy implications.

Objective: To evaluate the effects of Covid-19 pandemic on mental health of women in the perinatal period, with an accent on the intensity of depressive symptomatology, and explore the relationship between the specific aspects of Covid-19 pandemic and the registered risk factors for perinatal depression in women. Methods: The study sample consisted of 54 patients, with heterogeneous demographic characteristics (age, marital status, educational background, socio[1]economic status and religious affiliation) selected from the Cabinet for women with perinatal mental health issues at the University Clinic for Psychiatry in Skopje, where they were treated in the period from January 2020 until December 2021 The included patients met the criteria for the diagnosis F.32 during pregnancy, or F32.01/F32.02 postpartum depression in compliance to the ICD 10, and were treated accordingly with a combined approach using psychological interventions and psychopharmaceutic treatment encompassing antidepressant, anxiolytic, antipsychotic, mood stabilizing drugs or a combination of the above mentioned. The inclusion criteria mandated that they were pregnant or had a child in the past two years. The participants could have been subjected to inpatient, or outpatient treatment, or a combination of both modalities during this time. In order to minimize the risk of infection during pandemic times, and protect the health of participants and researchers, the interviews were conducted via telephone beginning with obtaining an informed consent for participation in the study from the patients who were primarily informed in detail about the aims of the study, their rights and protection of their data and anonymity. We used the following methodology: - A structured, non-standardized socio-demographic questionnaire including 11 items regarding age, parity, realized pregnancies, course of pregnancy and delivery, type of treatment, pharmacological therapy, marital status, socio-economic status, educational background, religious affiliation and presence of previously established risk factors in the world literature; - A structured, non-standardized questionnaire regarding the effects of Covid-19 pandemic consisting of 11 questions; - Edinburgh Depression Perinatal Scale (EDPS) This is a 10-questions self-reported scale, which proved to be a valuable and efficient tool for screening perinatal depression. Namely, a presence of clinical depression was registered in 17.2% of the included participants using the EDPS, the percentage of perinatal depression before the COVID-19 pandemic ranged between 10-14% and has been presented in the literature. Of these, 37.8% were registered in Spain, and 40.7% in Canada [3]. Results: The statistical analysis of data from the structured non-standardized questionnaire for the effects of Covid-19 pandemic showed no statistical significance in the subjectively reported effects from the pandemic on participants’ mental health based on the question from the structured non-standardized Covid-19 questionnaire “Do you feel that the Covid-19 pandemic had an effect on your mental health prior or after the childbirth?” where 55.6% answered with “Yes” and 44.4% with “No”. In spite of this, we gained a perspective of the prevailing risk factors in this population and the correlational analysis of data from the questionnaires granted us insights into further investigation of the relationship between the co-variables.

IntroductionLike other forms of embodiment, pregnancy has increasingly become subject to representation and interpretation via digital technologies. Pregnancy and the unborn entity were largely private, and few people beyond the pregnant women herself had access to the foetus growing within her (Duden). Now pregnant and foetal bodies have become open to public portrayal and display (Lupton The Social Worlds of the Unborn). A plethora of online materials – websites depicting the unborn entity from the moment of conception, amateur YouTube videos of births, social media postings of ultrasounds and self-taken photos (‘selfies’) showing changes in pregnant bellies, and so on – now ensure the documentation of pregnant and unborn bodies in extensive detail, rendering them open to other people’s scrutiny. Other recent digital technologies directed at pregnancy include mobile software applications, or ‘apps’. In this article, we draw on our study involving a critical discourse analysis of a corpus of pregnancy-related apps offered in the two major app stores. In so doing, we discuss the ways in which pregnancy-related apps portray pregnant and unborn bodies. We place a particular focus on the ludification and gamification strategies employed to position pregnancy as a playful, creative and fulfilling experience that is frequently focused on consumption. As we will demonstrate, these strategies have wider implications for concepts of pregnant and foetal embodiment and subjectivity.It is important here to make a distinction between ludification and gamification. Ludification is a broader term than gamification. It is used in the academic literature on gaming (sometimes referred to as ‘ludology’) to refer to elements of games reaching into other aspects of life beyond leisure pursuits (Frissen et al. Playful Identities: The Ludification of Digital Media Cultures; Raessens). Frissen et al. (Frissen et al. "Homo Ludens 2.0: Play, Media and Identity") for example, claim that even serious pursuits such as work, politics, education and warfare have been subjected to ludification. They note that digital technologies in general tend to incorporate ludic dimensions. Gamification has been described as ‘the use of game design elements in non-game contexts’ (Deterding et al. 9). The term originated in the digital media industry to describe the incorporation of features into digital technologies that not explicitly designed as games, such as competition, badges, rewards and fun that engaged and motivated users to make them more enjoyable to use. Gamification is now often used in literatures on marketing strategies, persuasive computing or behaviour modification. It is an important element of ‘nudge’, an approach to behaviour change that involves persuasion over coercion (Jones, Pykett and Whitehead). Gamification thus differs from ludification in that the former involves applying ludic principles for reasons other than the pleasures of enjoying the game for their own sake, often to achieve objectives set by actors and agencies other than the gamer. Indeed, this is why gamification software has been described by Bogost (Bogost) as ‘exploitationware’. Analysing Pregnancy AppsMobile apps have become an important medium in contemporary digital technology use. As of May 2015, 1.5 million apps were available to download on Google Play while 1.4 million were available in the Apple App Store (Statista). Apps related to pregnancy are a popular item in app stores, frequently appearing on the Apple App Store’s list of most-downloaded apps. Google Play’s figures show that many apps directed at pregnant women have been downloaded hundreds of thousands, or even millions, of times. For example, ‘Pregnancy +’, ‘I’m Expecting - Pregnancy App’ and ‘What to Expect - Pregnancy Tracker’ have each been downloaded between one and five million times, while ‘My Pregnancy Today’ has received between five and ten million downloads. Pregnancy games for young girls are also popular. Google Play figures show that the ‘Pregnant Emergency Doctor’ game, for example, has received between one and five million downloads. Research has found that pregnant women commonly download pregnancy-related apps and find them useful sources of information and support (Hearn, Miller and Fletcher; Rodger et al.; Kraschnewski et al.; Declercq et al.; Derbyshire and Dancey; O'Higgins et al.). We conducted a comprehensive analysis of all pregnancy-related smartphone apps in the two major app stores, Apple App Store and Google Play, in late June 2015. Android and Apple’s iOS have a combined market share of 91 percent of apps installed on mobile phones (Seneviratne et al.). A search for all pregnancy-related apps offered in these stores used key terms such as pregnancy, childbirth, conception, foetus/fetus and baby. After eliminating apps listed in these searches that were clearly not human pregnancy-related, 665 apps on Google Play and 1,141 on the Apple App Store remained for inclusion in our study. (Many of these apps were shared across the stores.)We carried out a critical discourse analysis of these apps, looking closely at the app descriptions offered in the two stores. We adopted the perspective that sees apps, like any other form of media, as sociocultural artefacts that both draw on and reproduce shared norms, ideals, knowledges and beliefs (Lupton "Quantified Sex: A Critical Analysis of Sexual and Reproductive Self-Tracking Using Apps"; Millington "Smartphone Apps and the Mobile Privatization of Health and Fitness"; Lupton "Apps as Artefacts: Towards a Critical Perspective on Mobile Health and Medical Apps"). In undertaking our analysis of the app descriptions in our corpus, attention was paid to the title of each app, the textual accounts of its content and use and the images that were employed, such as the logo of the app and the screenshots that were used to illustrate its content and style. Our focus in this article is on the apps that we considered as including elements of entertainment. Pregnancy-related game apps were by far the largest category of the apps in our corpus. These included games for young girls and expectant fathers as well as apps for ultrasound manipulation, pregnancy pranks, foetal sex prediction, choosing baby names, and quizzes. Less obviously, many other apps included in our analysis offered some elements of gamification and ludification, and these were considered in our analysis. ‘Pregnant Adventures’: App Games for GirlsOne of the major genres of apps that we identified was games directed at young girls. These apps invited users to shop for clothes, dress up, give a new hair style, ‘make-over’ and otherwise beautify a pregnant woman. These activities were directed at the goal of improving the physical attractiveness and therefore (it was suggested) the confidence of the woman, who was presented as struggling with coming to terms with changes in her body during pregnancy. Other apps for this target group involved the player assuming the role of a doctor in conducting medical treatments for injured pregnant women or assisting the birth of her baby.Many of these games represented the pregnant woman visually as looking like an archetypal Barbie doll, with a wardrobe to match. One app (‘Barbara Pregnancy Shopping’) even uses the name ‘Barbara’ and the screenshots show a woman similar in appearance to the doll. Its description urges players to use the game to ‘cheer up’ an ‘unconfident’ Barbara by taking her on a ‘shopping spree’ for new, glamorous clothes ‘to make Barbara feel beautiful throughout her pregnancy’. Players may find ‘sparkly accessories’ as well for Barbara and help her find a new hairstyle so that she ‘can be her fashionable self again’ and ‘feel prepared to welcome her baby!’. Likewise, the game ‘Pregnant Mommy Makeover Spa’ involves players selecting clothes, applying beauty treatments and makeup and adding accessories to give a makeover to ‘Pregnant Princess’ Leila. The ‘Celebrity Mommy’s Newborn Baby Doctor’ game combines the drawcard of ‘celebrity’ with ‘mommy’. Players are invited to ‘join the celebrities in their pregnancy adventure!’ and ‘take care of Celebrity Mom during her pregnancy!’.An app by the same developer of ‘Barbara Pregnancy Shopping’ also offers ‘Barbara’s Caesarean Birth’. The app description claims that: ‘Of course her poor health doesn’t allow Barbara to give birth to her baby herself.’ It is up to players to ‘make everything perfect’ for Barbara’s caesarean birth. The screenshots show Barbara’s pregnant abdomen being slit open, retracted and a rosy, totally clean infant extracted from the incision, complete with blonde hair. Players then sew up the wound. A final screenshot displays an image of a smiling Barbara standing holding her sleeping, swaddled baby, with the words ‘You win’.Similar games involve princesses, mermaids, fairies and even monster and vampire pregnant women giving birth either vaginally or by caesarean. Despite their preternatural status, the monster and vampire women conform to the same aesthetic as the other pregnant women in these games: usually with long hair and pretty, made-up faces, wearing fashionable clothing even on the operating table. Their newborn infants are similarly uniform in their appearance as they emerge from the uterus. They are white-skinned, clean and cherubic (described in ‘Mommy’s Newborn Baby Princess’ as ‘the cutest baby you probably want’), a far cry from the squalling, squashed-faced infants smeared in birth fluids produced by the real birth process.In these pregnancy games for girls, the pain and intense bodily effort of birthing and the messiness produced by the blood and other body fluids inherent to the process of labour and birth are completely missing. The fact that caesarean birth is a major abdominal surgery requiring weeks of recovery is obviated in these games. Apart from the monsters and vampires, who may have green- or blue-hued skin, nearly all other pregnant women are portrayed as white-skinned, young, wearing makeup and slim, conforming to conventional stereotypical notions of female beauty. In these apps, the labouring women remain glamorous, usually smiling, calm and unsullied by the visceral nature of birth.‘Track Your Pregnancy Day by Day’: Self-Monitoring and Gamified PregnancyElements of gamification were evident in a large number of the apps in our corpus, including many apps that invite pregnant users to engage in self-tracking of their bodies and that of their foetuses. Users are asked to customise the apps to document their changing bodies and track their foetus’ development as part of reproducing the discourse of the miraculous nature of pregnancy and promoting the pleasures of self-tracking and self-transformation from pregnant woman to mother. When using the ‘Pregnancy+’ app, for example, users can choose to construct a ‘Personal Dashboard’ that includes details of their pregnancy. They can input their photograph, first name and their expected date of delivery so that that each daily update begins with ‘Hello [name of user], you are [ ] weeks and [ ] days pregnant’ with the users’ photograph attached to the message. The woman’s weight gain over time and a foetal kick counter are also included in this app. It provides various ways for users to mark the passage of time, observe the ways in which their foetuses change and move week by week and monitor changes in their bodies. According to the app description for ‘My Pregnancy Today’, using such features allows a pregnant woman to: ‘Track your pregnancy day by day.’ Other apps encourage women to track such aspects of physical activity, vitamin and fluid intake, diet, mood and symptoms. The capacity to visually document the pregnant user’s body is also a feature of several apps. The ‘Baby Bump Pregnancy’, ‘WebMD Pregnancy’, ‘I’m Expecting’,’iPregnant’ and ‘My Pregnancy Today’ apps, for example, all offer an album feature for pregnant bump photos taken by the user of herself (described as a ‘bumpie’ in the blurb for ‘My Pregnancy Today’). ‘Baby Buddy’ encourages women to create a pregnant avatar of themselves (looking glamorous, well-dressed and happy). Some apps even advise users on how they should feel. As a screenshot from ‘Pregnancy Tracker Week by Week’ claims: ‘Victoria, your baby is growing in your body. You should be the happiest woman in the world.’Just as pregnancy games for little girls portrayal pregnancy as a commodified and asetheticised experience, the apps directed at pregnant women themselves tend to shy away from discomforting fleshly realities of pregnant and birthing embodiment. Pregnancy is represented as an enjoyable and fashionable state of embodiment: albeit one that requires constant self-surveillance and vigilance.‘Hello Mommy!’: The Personalisation and Aestheticisation of the FoetusA dominant feature of pregnancy-related apps is the representation of the foetus as already a communicative person in its own right. For example, the ‘Pregnancy Tickers – Widget’ app features the image of a foetus (looking far more like an infant, with a full head of wavy hair and open eyes) holding a pencil and marking a tally on the walls of the uterus. The app is designed to provide various icons showing the progress of the user’s pregnancy each day on her mobile device. The ‘Hi Mommy’ app features a cartoon-like pink and cuddly foetus looking very baby-like addressing its mother from the womb, as in the following message that appears on the user’s smartphone: ‘Hi Mommy! When will I see you for the first time?’ Several pregnancy-tracking apps also allow women to input the name that they have chosen for their expected baby, to receive customised notifications of its progress (‘Justin is nine weeks and two days old today’).Many apps also incorporate images of foetuses that represent them as wondrous entities, adopting the visual style of 1960s foetal photography pioneer Lennart Nilsson, or what Stormer (Stormer) has referred to as ‘prenatal sublimity’. The ‘Pregnancy+’ app features such images. Users can choose to view foetal development week-by-week as a colourful computerised animation or 2D and 3D ultrasound scans that have been digitally manipulated to render them aesthetically appealing. These images replicate the softly pink, glowing portrayals of miraculous unborn life typical of Nilsson’s style.Other apps adopt a more contemporary aesthetic and allow parents to store and manipulate images of their foetal ultrasounds and then share them via social media. The ‘Pimp My Ultrasound’ app, for example, invites prospective parents to manipulate images of their foetal ultrasounds by adding in novelty features to the foetal image such as baseball caps, jewellery, credit cards and musical instruments. The ‘Hello Mom’ app creates a ‘fetal album’ of ultrasounds taken of the user’s foetus, while the ‘Ultrasound Viewer’ app lets users manipulate their 3/4 D foetal ultrasound images: ‘Have fun viewing it from every angle, rotating, panning and zooming to see your babies [sic] features and share with your family and friends via Facebook and Twitter! … Once uploaded, you can customise your scan with a background colour and skin colour of your choice’.DiscussionPregnancy, like any other form of embodiment, is performative. Pregnant women are expected to conform to norms and assumptions about their physical appearance and deportment of their bodies that expect them to remain well-groomed, fit and physically attractive without appearing overly sexual (Longhurst "(Ad)Dressing Pregnant Bodies in New Zealand: Clothing, Fashion, Subjectivities and Spatialities"; Longhurst "'Corporeographies’ of Pregnancy: ‘Bikini Babes'"; Nash; Littler). Simultaneously they must negotiate the burden of bodily management in the interests of risk regulation. They are expected to protect their vulnerable unborn from potential dangers by stringently disciplining their bodies and policing to what substances they allow entry (Lupton The Social Worlds of the Unborn; Lupton "'Precious Cargo': Risk and Reproductive Citizenship"). Pregnancy self-tracking apps enact the soft politics of algorithmic authority, encouraging people to conform to expectations of self-responsibility and self-management by devoting attention to monitoring their bodies and acting on the data that they generate (Whitson; Millington "Amusing Ourselves to Life: Fitness Consumerism and the Birth of Bio-Games"; Lupton The Quantified Self: A Sociology of Self-Tracking).Many commentators have remarked on the sexism inherent in digital games (e.g. Dickerman, Christensen and Kerl-McClain; Thornham). Very little research has been conducted specifically on the gendered nature of app games. However our analysis suggests that, at least in relation to the pregnant woman, reductionist heteronormative, cisgendered, patronising and paternalistic stereotypes abound. In the games for girls, pregnant women are ideally young, heterosexual, partnered, attractive, slim and well-groomed, before, during and after birth. In self-tracking apps, pregnant women are portrayed as ideally self-responsible, enthused about their pregnancy and foetus to the point that they are counting the days until the birth and enthusiastic about collecting and sharing details about themselves and their unborn (often via social media).Ambivalence about pregnancy, the foetus or impending motherhood, and lack of interest in monitoring the pregnancy or sharing details of it with others are not accommodated, acknowledged or expected by these apps. Acknowledgement of the possibility of pregnant women who are not overtly positive about their pregnancy or lack interest in it or who identify as transgender or lesbian or who are sole mothers is distinctly absent.Common practices we noted in apps – such as giving foetuses names before birth and representing them as verbally communicating with their mothers from inside the womb – underpin a growing intensification around the notion of the unborn entity as already an infant and social actor in its own right. These practices have significant implications for political agendas around the treatment of pregnant women in terms of their protection or otherwise of their unborn, and for debates about women’s reproductive rights and access to abortion (Lupton The Social Worlds of the Unborn; Taylor The Public Life of the Fetal Sonogram: Technology, Consumption and the Politics of Reproduction). Further, the gamification and ludification of pregnancy serve to further commodify the experience of pregnancy and childbirth, contributing to an already highly commercialised environment in which expectant parents, and particularly mothers, are invited to purchase many goods and services related to pregnancy and early parenthood (Taylor "Of Sonograms and Baby Prams: Prenatal Diagnosis, Pregnancy, and Consumption"; Kroløkke; Thomson et al.; Taylor The Public Life of the Fetal Sonogram: Technology, Consumption and the Politics of Reproduction; Thomas).In the games for girls we examined, the pregnant woman herself was a commodity, a selling point for the app. The foetus was also frequently commodified in its representation as an aestheticised entity and the employment of its image (either as an ultrasound or other visual representations) or identity to market apps such as the girls’ games, apps for manipulating ultrasound images, games for predicting the foetus’ sex and choosing its name, and prank apps using fake ultrasounds purporting to reveal a foetus inside a person’s body. As the pregnant user engages in apps, she becomes a commodity in yet another way: the generator of personal data that are marketable in themselves. In this era of the digital data knowledge economy, the personal information about people gathered from their online interactions and content creation has become highly profitable for third parties (Andrejevic; van Dijck). Given that pregnant women are usually in the market for many new goods and services, their personal data is a key target for data mining companies, who harvest it to sell to advertisers (Marwick).To conclude, our analysis suggests that gamification and ludification strategies directed at pregnancy and childbirth can serve to obfuscate the societal pressures that expect and seek to motivate pregnant women to maintain physical fitness and attractiveness, simultaneously ensuring that they protect their foetuses from all possible risks. In achieving both ends, women are encouraged to engage in intense self-monitoring and regulation of their bodies. These apps also reproduce concepts of the unborn entity as a precious and beautiful already-human. These types of portrayals have important implications for how young girls learn about pregnancy and childbirth, for pregnant women’s experiences and for concepts of foetal personhood that in turn may influence women’s reproductive rights and abortion politics.ReferencesAndrejevic, Mark. Infoglut: How Too Much Information Is Changing the Way We Think and Know. New York: Routledge, 2013. Print.Bogost, Ian. "Why Gamification Is Bullshit." The Gameful World: Approaches, Issues, Applications. Eds. Steffen Walz and Sebastian Deterding. Boston, MA: MIT Press, 2015. 65-80. Print.Declercq, E.R., et al. Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection, 2013. Print.Derbyshire, Emma, and Darren Dancey. 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Photo by Alexander Grey on Unsplash ABSTRACT Current studies show that about half of transgender and gender-diverse (TGD) people wish to have children in the future. TGD patients who pursue gender-affirmation interventions must be aware of the impact that various treatments can have on fertility, as gender-affirming care through medical or surgical treatment can limit or alter reproductive potential. Many medical professional societies encourage providers to educate and counsel patients about the consequences of treatment and viable options for fertility preservation (FP) as early as possible, though patients may not be aware of all the family formation methods available. There is a significant need for a tool that thoroughly details not only the various opportunities for parenthood but the perceived cost, rates of success, and risks associated with each option. A fertility decision-aid would allow for a more robust informed consent process and shared decision-making for all individuals pursuing gender-affirming care. INTRODUCTION Over 1.6 million adults and youth in the United States, or about 0.6 percent of those age 13 and over, identify as transgender, according to a report released by The Williams Institute in June 2022.[1] Current studies show that approximately half of transgender and gender-diverse (TGD) people wish to have children in the future, which aligns with the rate of cisgender individuals who desire parenthood in some form.[2] Studies on parenthood show improved quality of life and mental health in TGD adults and decreased incidence of suicide in TGD women.[3] In one study, almost half of the TGD individuals who indicated an interest in parenthood said they wanted genetically related offspring.[4] However, medical or surgical therapies can limit reproductive potential.[5] Recent findings indicate that some TGD adults who underwent medical or surgical paths to affirmation regret decisions that may have led to their inability to have genetic children. Perhaps they did not know it was an option, faced barriers to care, or were not interested at the time.[6] Many medical professional societies, including the World Professional Association for Transgender Health (WPATH), the Endocrine Society, and the American College of Obstetrics and Gynecology, encourage providers to educate and counsel patients about the consequences of treatment and viable options for fertility preservation as early as possible.[7] This paper argues that TGD patients who pursue gender-affirmation interventions must be aware of the impact treatments can have on fertility and, ultimately, parenthood and that a design tool may help them understand the risks and make informed decisions. l. Gender Affirmation Options Some TGD individuals do not use medical or surgical therapies to feel affirmed in their identity.[8] Non-medical paths to affirmation include social and legal measures.[9] These reversible paths do not impact the individual’s future fertility potential. TGD individuals can follow different paths of gender-affirming care through social, legal, medical, and surgical affirmation.[10] Social affirmation can include using gender-affirming pronouns, names, and clothing.[11] Legal affirmation can include changing the gender and name on a birth certificate and other records in states where this is permissible.[12] Social and legal affirmations are reversible and do not impact fertility potential. Medical affirmation involves the use of gender-affirming hormone therapy. Feminizing or masculinizing hormone therapy allows for the development of secondary sex characteristics that more closely align with the individual's gender identity.[13] No set regimen for treatment exists, as a patient’s goals will determine their individualized plan.[14] Some standard feminizing agents include estrogen, androgen-reducing medications, and progestins, while the common masculinizing agent is testosterone.[15] Gender-affirming hormone therapy is not currently seen as a definitive cause of infertility, as it is possible to discontinue treatment and see a noted reversal of intended effects.[16] Research findings suggest that hormone therapy should stop for a minimum of three months to reverse any treatment effects.[17] The only available data on long-term hormonal therapy use is inconsistent, based on observational studies with varying duration and doses.[18] Individuals can stop gender-affirming hormone therapy, but its lasting impact on fertility is unknown.[19] A TGD individual may choose to undergo surgical interventions that do not impact fertility. These interventions can masculinize or feminize body parts to allow a patient’s physical appearance to align with their gender identity.[20] This care could include breast augmentation for TGD women and Adam’s apple reduction or breast reduction for TGD men.[21] Other surgical interventions will impact TGD individuals’ fertility. Genital surgery for a TGD woman can include the removal of the penis and scrotum (penectomy and orchiectomy) and the construction of a vagina and labia (vaginoplasty and valvuloplasty).[22] A TGD man can have removal of the ovaries and uterus (oophorectomy and hysterectomy) and construction of a penis and scrotum (metoidioplasty, phalloplasty, and scrotoplasty).[23] Following these gender-affirming surgeries, individuals are infertile due to the removal of their reproductive organs.[24] These procedures are irreversible and directly impact reproductive capacity in TGD individuals. ll. Fertility Counseling to Explain Paths to Parenthood Patients receiving gender-affirming care should have the opportunity to learn about the various ways to achieve parenthood, including fertility preservation. Family formation methods include sexual intercourse, artificial insemination, surrogacy, and adoption or foster care.[25] These methods apply to non-TGD people as well. Patients may not be aware of the various means of family-building, so accurate and expansive fertility counseling is essential before initiating medical or surgical affirming care. The frequency with which TGD individuals receive fertility counseling and how thorough it is, is unclear. When surveyed about fertility preservation, healthcare providers reported a lack of confidence in discussing fertility preservation with patients due to gaps in their knowledge on best practices, success rates, and regret rates in patients who did not preserve fertility. They also had varied perceptions of their role in treating patients and whether they should discuss family planning.[26] Patients have reported receiving an overview of fertility options from their primary transgender-healthcare providers before being referred to reproductive specialists.[27] While this is an essential step for patients seeking more information about their opportunities for parenthood, only 16 percent of Society for Assisted Reproductive Technology member clinics share information about options for transgender individuals on their websites.[28] Providers of transgender health care do not, and may not be trained to, provide adequate counsel to patients. Patients also cannot give informed consent for fertility or gender-affirming care interventions without more information on the benefits and burdens of all available treatments. Current literature demonstrates a need for a decision aid that thoroughly details not only the opportunities for parenthood but the perceived cost, rates of success, and risks associated with each option.[29] This tool could foster a more informed dialogue between an individual and their care team. A fertility decision aid would also allow for a more robust informed consent process for all individuals pursuing gender-affirming care. Regardless of the affirmation path chosen, a TGD individual should have early and frequent conversations with their care team regarding fertility. The World Professional Association for Transgender Health (WPATH) asserts that healthcare professionals should discuss fertility preservation options before initiating gender-affirming hormone therapy or surgery. The American College of Obstetrics and Gynecology states that “fertility and parenting desires should be discussed early in the process of transition, before the initiation of hormone therapy or gender affirmation surgery.”[30] The Endocrine Society writes that “all individuals seeking gender-affirming medical treatment should receive information and counsel on options for fertility preservation prior to initiating puberty suppression in adolescents and prior to treating with hormonal therapy in both adolescents and adults."[31] These conversations are essential even if the patient is not interested in parenthood at the time. WPATH addresses the potential for regret, as cases of individuals who received hormone therapy and genital surgery and later desired genetically related children have been identified.[32] TGD patients pursuing gender-affirming care should assess their individual fertility goals to better understand the many ways to build a family. Surveys of TGD adults show that participants want to become parents in various ways. In one study, 31.3 percent of those surveyed wanted to become parents through adoption, 25 percent wanted children through sexual intercourse, 15.6 percent through surrogacy, 12.5 percent using donor sperm, 9.4 percent using a known sperm donor, and 6.3 percent through the foster care system.[33] TGD women showed a significant interest in adoption (75 percent of participants), whereas more than half of TGD men wanted to become parents through sexual intercourse or pregnancy (58.3 percent).[34] These fertility goals should be acknowledged and discussed with the care team to guide decision-making about fertility preservation. lll. Fertility Preservation Individuals who wish to share their genetic makeup with their child will usually need to speak with a reproductive specialist about fertility preservation options. They are the same as those for cisgender individuals using fertility services before cancer treatment or elective preservation.[35] For TGD adults with ovaries, this includes freezing embryos (using donor or partner sperm) or ovarian tissue.[36] While no longer viewed as an experimental treatment, professionals offer tissue freezing to few patients due to a lack of data on its safety and efficacy.[37] For TGD adults with testicles, freezing sperm and preserving testicular tissue can preserve the ability to have biological children.[38] Fertility preservation numbers for TGD adults remain low. A study showed that 76.6 percent of TGD men and 76.1 percent of TGD women considered fertility preservation, but only 3.1 percent and 9.6 percent, respectively, initiated it.[39] Success rate, cost, need for travel, and elevated risk of gender dysphoria likely lead to lower use of fertility preservation.[40] According to the American Society for Reproductive Medicine, the average cost of an IVF cycle in the US is $12,400.[41] Intrauterine insemination can range in cost from a few hundred dollars to $2,000 per cycle.[42] There are also associated costs to freeze and store sperm and eggs.[43] Insurance coverage and physical location impact the costs and how the patient bears the costs.[44] For those who do not have sufficient or any insurance coverage, fertility preservation may not be feasible. Of additional significance for this population, fertility preservation techniques can exacerbate gender dysphoria as the patient must produce gametes associated with the gender they do not recognize.[45] For TGD women, masturbating in a clinical setting or sperm banking for sperm cryopreservation can cause severe distress.[46] Furthermore, fertility preservation for TGD men can be challenging and invasive. A transvaginal ultrasound exam is a requirement for the cryopreservation of embryos and oocytes.[47] This exam can cause significant distress as the procedure does not align with their male identity.[48] Controlled ovarian stimulation cycles require two weeks of daily gonadotropin injections, and the patient is given anesthesia for oocyte retrieval.[49] Furthermore, TGD men undergoing fertility preservation must discontinue testosterone use, and menstruation can resume.[50] lV. Other Paths to Parenthood a. Adoption TGD adults can also pursue parenthood through adoption systems, though foster care is a temporary option. While almost one-third of surveyed TGD adults consider adoption a means to parenthood, cost and fear of discrimination can prevent them from following through.[51] TGD individuals have expressed a reluctance to pursue adoption due to the fear of discrimination by adoption agencies, attorneys, or families.[52] Nineteen states in the US allow child welfare agencies to refuse to provide services to LGBTQ+ families if it conflicts with the religious beliefs of the relevant people in the agency.[53] Nineteen states have no laws about discrimination during the adoption process based on sexual orientation or gender identity.[54] Only 29 states have statutory or regulatory protections against discrimination based on orientation and gender identity.[55] b. Surrogacy There are two types of surrogacies: traditional and gestational.[56] In traditional surrogacy, professionals fertilize the surrogate’s egg by the sperm of an intended parent or a sperm donor through intrauterine insemination. In gestational surrogacy, the surrogate undergoes IVF to implant the fertilized embryo.[57] Egg donation can be used for gestational surrogacy if necessary. Those considering surrogacy need to understand the specific laws in their state, as they can differ significantly.[58] c. Intercourse TGD individuals who have not undergone genital surgery can have intercourse with the intention of causing pregnancy. TGD men who have not had genital surgery can bear children. For those who have initiated hormonal therapy, limited data has been collected on the impact of gender-affirming hormone therapy on conception.[59] TGD men have gotten pregnant after discontinuing testosterone use.[60] TGD women who have not had genital surgery can have intercourse with a person with ovaries and produce sperm to fertilize an egg. Gender-affirming hormone therapy possibly affects sperm viability.[61] V. A Decision Aid to Support Informed Consent and Shared Decision Making For individuals pursuing gender-affirming care, time is of the essence when considering fertility preservation. In one review, transgender health doctors reported that most patients did not want to postpone treatment for fertility preservation procedures, even if they wanted children;[62] any delay in treatment can be distressing for those with gender dysphoria.[63] Providers face several challenges when counseling patients about fertility. The WPATH guidelines pose an ethical dilemma for transgender health providers as limited data offers guidance about discussing fertility risks and recommendations with patients.[64] For TGD patients, limited and contradictory data about fertility outcomes before, during, and after gender affirmation exists, particularly for the lasting impact of gender-affirming hormone therapy.[65] For TGD women who have taken estrogen and stopped to pursue fertility preservation, data on sperm quality is mixed.[66] The data on when normal ovarian function resumes is variable for TGD men using testosterone who have stopped to pursue fertility preservation.[67] Much data comes from the oncofertility literature, which indicates that when providers use standardized counseling practices when discussing fertility with their patients, more patients undergo fertility preservation, and patient satisfaction increases.[68] For individuals seeking gender-affirming care, there is a need for a decision aid that providers can utilize across multiple clinics and programs.[69],[70] Patients must be aware of the benefits, risks, and alternatives of any intervention to provide truly informed consent. When discussing fertility for TGD patients, this includes which fertility options are available at each stage of transition and the potential for a live birth with each option.[71] Furthermore, a decision aid would allow for shared decision-making, where the patient is an active participant and co-designer of their treatment plan.[72] Shared decision-making acknowledges the healthcare provider’s beneficence, knowledge, and experience while equally valuing the right to patient autonomy and respecting the ability of the patient to inform the provider.[73] A decision aid can help initiate the conversations between a patient and their provider that allow for a true partnership in decision-making. A recent study investigated the efficacy and impact of a web-based fertility decision aid targeted at TGD adolescents and young adults.[74] This tool, titled Aid for Fertility-Related Medical Decisions (AFFRMED), significantly increased fertility knowledge in both youth and their parents while improving youth’s perceived ability to make fertility decisions.[75] Youth participants and their parents found the tool “feasible, acceptable, and usable.”[76] This initial study was small, with only eight adolescents or young adults and seven parents participating.[77] At large, the effectiveness of the trial will be the next step in determining the legitimacy of the aid for clinical use.[78] A similar decision-making tool designed for TGD adults would also be useful. The tool can present an average range of expected costs as much variability exists and costs change over time. This tool should also include general information on what is required to pursue each path to parenthood. For example, a patient undergoing fertility preservation needs to know what steps are necessary after the cryopreservation of gametes for live birth.[79] CONCLUSION Individuals pursuing gender-affirming care must closely consider the impact of their medical and surgical care on their desire to become parents as early in their affirmation journey as possible. A decision aid can be helpful if it outlines the risks to fertility and options to preserve fertility, with the specific data necessary to make an informed choice. The tool should include the methods of fertility preservation, each step of the protocol and respective risks for each method, the expected timeline from initiation to completion, general success rates, options for remaining gamete disposition, and the average cost of treatment. This should include a list of steps to initiate the process for each method and any potential barriers or obstacles. For surrogacy, the tool should include the two types and the average cost. For intercourse, the aid should include information on risks for discontinuing gender-affirming hormone therapy and general success rates. Clinics and providers could elect to tailor the decision aid for their population to include specific information about local laws and the availability of services. With a standardized fertility decision aid, TGD individuals can have a more thorough understanding of the opportunities and limitations placed on their reproductive capacity. Healthcare providers can feel more confident that their patients have access to relevant information regarding family-building before initiating medical or surgical affirmation. This allows for a more substantial informed consent and shared decision-making process, regardless of the decision made. A trial-tested decision-making tool for TGD adolescents and young adults exists that can serve as a model for creating aid for TGD adults of all ages. 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