1 Hospital for Children and Adolescents, Helsinki University Central Hospital, Finland 2 Department of Psychology, University of Tampere, 3 Department of Obstetrics and Gynaecology, Helsinki University Central Hospital, 4 Infertility Clinic, The Family Federation of Finland and 5 Save the Children, Finland, Helsinki
6 To whom correspondence should be addressed. E-mail: leena.repokari{at}helsinki.fi
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Abstract |
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Key words: assisted reproduction techniques/infertility/mental health/social and child-related stress
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Introduction |
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Becoming a parent is among the major interpersonal transitions during adulthood for both genders. It demands learning new skills and acquiring new responsibilities. Preparing for parenthood is therefore often a period of working through intensely ambivalent feelings. These changes can contribute to personal growth, but they can also predispose individuals to mental disorders. Maternal postpartum depression is a common condition affecting 1015% of women (Harris et al., 1989; Ballard et al., 1994
; Matthey et al., 2000
) and it seems to be associated with paternal depressive symptoms (Ballard et al., 1994
; Matthey et al., 2000
). Pregnancy after infertility represents the fulfilment of a dream but may not be unproblematic. In some studies, couples undergoing treatment with assisted reproduction techniques (ART) have been reported to continue to be at increased risk of depression, anxiety and psychological distress during pregnancy (Beaurepaire et al., 1994
; Bernstein et al., 1994
; van Balen et al., 1996
; McMahon et al., 1997
; Guerra et al., 1998
; Eugster and Vingerhoets, 1999
), while in other studies no differences in the levels of depression or anxiety symptoms (Reading et al., 1989
, Klock and Greenfeld, 2000
, Gibson et al., 2000
) have been observed. Furthermore, Abbey et al. (1994)
found that previously infertile women experience less stress and better global life quality after having a baby than their fertile controls. However, becoming a parent did not have the same effect on their husbands, who did not report positive effects on their global life quality to the same extent (Abbey et al., 1994
). Information about the mental health of previously infertile men during their partners pregnancies is very limited. In a Swedish study, infertile male partners experienced more somatic anxiety and indirect aggression and were also more anxious about the progress of their partners pregnancies than fertile men after their partners spontaneous pregnancies (Hjelmstedt et al., 2003
). A higher level of trait anxiety and lower self-esteem has been found in IVF fathers during pregnancy compared to their fertile controls (McMahon and Gibson, 2002
). At 4 months postpartum, however, no differences could be found in anxiety or depression (McMahon and Gibson 2002
).
Generally, mental health problems during the transition to parenthood are also affected by various social factors; for example low economic status, stressful life events and lack of social support from spouse, friends or family are known to be risk factors for postpartum depression (Martin et al., 1989; Evans et al., 2001
). In addition, child-related factors such as health of the child and worry about the child are important determinants of parental mental health (Stowe and Nemeroff, 1995
; Cicchetti et al., 1998).
This prospective controlled longitudinal study was planned to discover whether the occurrence of depressive and anxiety symptoms, sleeping difficulties and/or social dysfunction differed between couples undergoing ART versus control couples during the second trimester of pregnancy (T1), when the child was 2 months old (T2) and 12 months old (T3).In addition, we compared the impact of social and child-related factors on mental health in ART and control groups.
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Materials and methods |
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Measures
The measures applied in the questionnaires at different time points are given in Table I.
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Mental health was assessed by means of the General Health Questionnaire (GHQ-36) which gives an effective measure of psychiatric disorders in the general population (Goldberg, 1972; Goldberg and Hiller, 1979
; Ferdinand and Verhulst, 1994
), including Finland (Rantakallio, 1988
). The questionnaire consists of 36 items, and the respondent estimates how the symptom descriptions match his/her current state (1 = not at all; 4 = much more than usual). Mean sum scores were created separately for symptoms of depression (11 items) and anxiety (11 items ), social dysfunction (eight items), and sleeping difficulties (six items) (Table I). The depression scale measures feelings of hopelessness and suicidal ideation, and the anxiety scale feelings of being under constant pressure and panicking. Social dysfunction scale describes feelings of inability to perform everyday tasks and social activity. The sleeping difficulties refer, for example, to difficulties in falling asleep, and waking up in the night. In this sample, reliabilities (Cronbach
ranged between 0.70 (T2 womens sleeping difficulties) and 0.91 (T3 mens anxiety).
Trait anxiety was measured by means of the Spielberger Trait Anxiety Inventory (STAI, Spielberger et al., 1970), involving 20 items. Trait anxiety refers to a respondents general predisposition to feelings of anxiety. The respondent estimated how the descriptions matched their general feelings stated on a four-point scale: 0 = not at all; 1 = to some extent; 2 = much; 3 = completely. The scale contains both positively worded (e.g. I am calm) and negatively worded items (I am nervous and restless). As recommended by Spielberger et al. (1980)
, separate sum variables were formed for an Anxiety Present (AP) variable that consists of 11 anxiety-indicating items, and an Anxiety Absent variable referring to nine positive feelings. In this analysis, only AP scales for women and men were used. The STAI is a widely used, valid and reliable tool to measure trait anxiety across cultures (Spielberger et al., 1970
), including Finland (Tasmuth et al., 1996
). The reliabilities (Cronbach
) were 0.75 for women and 0.83 for men.
Socio-economic status (SES) was assessed via education, profession, and the jobs of both spouses in five categories: (1) director, manager, professionals in leading positions; (2) entrepreneur, works manager, trade, nurse; (3) shop assistant, clerk, skilled worker, nursing assistant; (4) shop trainee, unskilled worker, hospital orderly; (5) unskilled worker, and no paid job outside the home, including students. The scale is from the Finnish Statistical Office, and has been widely used in Finnish epidemiological studies (Almqvist et al., 1999). Inter-rater reliability of coding was calculated for 45 cases, and kappa values were 0.90 for women and 0.93 for men.
Family factors:Couples children before the current pregnancy were scored no = 0; yes = 1. Age and duration of marriage/cohabiting partnership are continuous variables (years) based on the participants information. Number of previous partnerships was scored as 0/1/2 or more.
Stressful life-events were measured by means of a checklist of nine changes and stressors, conceptualized by Holmes and Rahe (1967). The events were related to family health (spouses and own), and changes in residency, work and family relationships (e.g. divorce). The respondent answered whether she/he had experienced any of the stressors since the birth of the child. A dichotomous score indicates the presence or absence of stressful life events.
Child-related factors: As regards health at the age of 2 months a single question was posed: Is the childs health now good (0) or problematic (1)? The parents also reported the nature of the infants health problems, but the information is not considered here. Child worry measured at 2 months covered four areas of concern (childs illness, development and growth, uncontrollable crying and anything else). The parents were instructed to indicate none, or one or more worries that they had. For the anything else alternative there was an open space to report worries other than those mentioned. A dichotomous score was constructed to indicate the absence of worry and the presence of worry.
Statistics
Statistical analyses were performed using SPSS-10 software. Bivariate analyses included 2-tests and Fishers exact tests for categorical variables and Students t-tests for continuous variables. To examine the determinants and change of mental health across the transition to parenthood, 2 (Group) x4 (SES) x2 (Stressful life events) x2 (Couples children) x 2 (Child health) x 2 (Child worry) x 3 (Time) repeated measures multiple analysis of covariance (MANCOVA) with time as the repeated measure were applied. Age and trait-anxiety were entered as covariates. Only specific two-way interactions were tested between Group and Stressful life events and Group and Child worry. The number of interactions was limited for conceptual and technical reasons (numbers in cells). The dependent variables were depressive and anxiety symptoms, sleeping difficulties and social dysfunction. Polynomial contrasts (F-Within-subject Contrasts) were applied to specify whether the changes were linear (decrease or increase), U-shaped (decrease from T1 to T2 and increase from T2 to T3) or reversed U-shaped (increase from T1 to T2 and decrease from T2 to T3).
The analyses were separately run for women and men. P < 0.05 was considered significant.
Analysis of study sample
Altogether, the participation rate was 69.8% (full response rate, T1 + T2 + T3). Drop-out analysis (attrition analysis) revealed that the parents in the ART group had a greater full response rate than the control group (73.6 versus 66.2%, P = 0.001). Further analysis showed that for men a lower SES and increased number of marriages/cohabiting partnerships were associated with a lower participation rate (P< 0.05) compared with men of a higher SES and no previous marriages/cohabiting partnerships. For women no specific factor associated with response rate was found amongSES, age, number of children, duration of partnership, number of previous partnerships, preterm or full term pregnancy, trait anxiety, depressive symptoms or social dysfunction.
The mean age of the women was similar in the ART and control groups [33.2 ± 4.4 (SD) versus 33.3 ± 3.0], but men in the ART group were older than men in the control group (35.2 ± 5.8 versus 34.1 ± 5.4, P< 0.01). The length of marriage or cohabiting partnership was longer in the ART group than in the control group (9.63 ± 4.5 versus 7.67 ± 4.4 years, P = 0.0001). The groups did not differ in term delivery rate (delivery between gestational weeks 37 and 42; 96.9% in the ART group versus 97.6% in the control group) or low birthweight of the child (<2500 g; 96.5 versus 98.7% respectively). Social and child-related variables by gender in the groups are given in Table II. The men in the ART group had a lower socio-economic status than those in the control group [2(3, 733) = 7.84, P < 0.03]. The control couples had more children than the ART couples [
2(3, 754) = 67.13, P < 0.0001].
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Results |
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Anxiety symptoms of women according to group, social and child-related factors are given in Table III. Anxiety symptoms showed a reversed U-shaped trend among control women (P < 0.05) (Figure 1), whereas in the ART group anxiety symptoms were stable across the transition to parenthood. Child health had a different kind of impact on changes in anxiety symptoms among women in the ART group versus control women (Figure 2). Control women with a child with a health problem were most anxious at T2, and anxiety diminished by T3 (P < 0.01), whereas child health had no impact on anxiety in women in the ART group. Worry about the child was associated with the level of anxiety (P < 0.0001) and with an increase in anxiety across the transition to parenthood (P < 0.0001) among both the ART and control group women. Trait anxiety predicted both an increase in anxiety across the transition to parenthood and generally high levels of anxiety in both groups.
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Sleeping difficulties of women according to group, social and child-related factors are given in Table III. No differences between ART group and control women were found in the level or change of sleeping difficulties during the transition to parenthood. Among control women, stressful life events (P < 0.01) and worry about the child (P < 0.01) had a negative impact on sleeping difficulties, whereas among women in the ART group with these stressors and worries there was a decreasing trend. In both groups, trait anxiety was associated with high levels of sleeping difficulties.
Symptoms of social dysfunction of women according to group, social and child-related factors are given in Table III. In the ART group and control group women, there was no difference in the level of social dysfunction. In control women, stressful life events were associated with a high level of social dysfunction (P < 0.0001), but this was not the case among women in the ART group. In general, worry about the child was associated with a high level of social dysfunction among women (P < 0.0001), regardless of fertility.
Mens mental health
Depressive symptoms of men according to group, social and child-related factors are given in Table IV. The significant between-subject effects indicate that men in the control group reported higher levels of depressive symptoms than men in the ART group (P < 0.01) (Figure 3). Among ART men in both groups, depressive symptoms increased after the baby was born (P < 0.05). In both groups, fathering the first child was associated with generally lower levels of depressive symptoms (P < 0.001). Especially among couples with a second or third child, mens depressive symptoms increased linearly after delivery in both the ART and control groups (P < 0.01). When there were problems with the childs health, depressive symptoms increased substantially in the control group men across the transition to fatherhood (P < 0.05), whereas no impact was found among men in the ART group (Figure 4). Trait anxiety was associated with a reversed U-shaped change and a generally elevated level of depressive symptoms in both groups.
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Anxiety symptoms of men according to group, social and child-related factors are given in Table IV. In both groups, anxiety symptoms significantly changed across the transition to parenthood: mens anxiety symptoms first decreased from pregnancy to the time after delivery, and then increased (U-shape) as the child grew to 1 year of age in both the ART and control groups (P < 0.001). Control men had a higher level of anxiety (P < 0.01) (Figure 3), while no difference was found in the change of anxiety across the transition to parenthood between ART and control group men. Figure 5 illustrates that among the control men with high life stress, anxiety symptoms first decreased and then increased again (P < 0.001), whereas among men in the ART group, life stress did not have an impact on anxiety symptoms. Socio-economic status, number of children and worry about the child predicted a change in anxiety symptoms across the transition to fatherhood in both the ART and control groups: the symptoms decreased from pregnancy to 2 months after delivery, especially among men from the highest and lowest socio-economic status groups (P < 0.01), those fathering their second or third child (P < 0.01) and those not worrying about the child (P < 0.05). Trait anxiety (personality) predicted both an increase in anxiety across the transition to parenthood and generally high levels of anxiety among men in both groups.
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Sleeping difficulties of men according to group, social and child-related factors are given in Table IV. Sleeping difficulties increased after delivery only among the control men during the transition to fatherhood (P < 0.05), the trend being stable among men in the ART group. Worry about the child was generally associated with higher levels of sleeping difficulties among all men (P < 0.001). Among both groups, trait anxiety was associated with high levels of sleeping difficulties.
Symptoms of social dysfunction of men according to group, social and child-related factors are given in Table IV. Men in the ART group reported less social dysfunction than than control men (P < 0.001). In general, worry about the child was associated with a high level of social dysfunction among men in both groups (P < 0.01).
Clinically significant amounts of symptoms according to GHQ-36 total points (depression, anxiety, sleeping difficulties and social dysfunction together) were found among 6.9% of all men at T1, 8.3% at T2 and 7.8% at T3, and among 3.8% of all women at T1, 6.3% at T2 and 6.2% at T3, using a threshold of 9 as recommended when establishing a norm in Finland (Holi et al., 2003).
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Discussion |
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Some limitations deserve mention. First, the results are based on self-reported mental health, which ideally should be complemented by using multi-source methods such as interviews and observations. Self-reports may be vulnerable to social desirability, especially among couples undergoing ART, who may feel that their duty is to be happy and well after successful treatment. Second, attrition analysis showed that women with elevated levels of anxiety and sleeping difficulties at T1 and men of low SES and with multiple earlier partnerships were more likely to drop out of the follow-up study. However, the drop-out rate was similar in the ART and control groups. It is thus important to remember that our results on mental health in the transition to parenthood are based on women with relatively favourable mental health and men of relatively advantageous social status. Epidemiological research results suggest, however, that, in contrast to somatic health, mental health does not directly depend on socio-economic status in European countries (Martikainen et al., 1999). Our results agree; SES was not associated with mental health in women, whereas for men higher SES was protective for mental health.
Third, the ART and control groups were not symmetrical in family construction: the duration of partnership was longer in the ART group, and in the control group families there were more children. In families where children are born after ART there tend to be fewer children, and thus this represents the natural setting. Our results show that depressive and anxiety symptoms increased more and sleeping difficulties decreased less among mothers with their first child. However, non-significant group x number of children interaction effects confirmed that first-time parenting predicted mental health in the same way in both groups. Finally, the control group was gathered from Southern Finland while some of the ART group came from Northern and Western Finland. In both groups, however, there were participants from both rural and urban areas.
Our results showed neutral or positive impacts of successful ART on mental health during the transition to parenthood. Similar to the findings reported by Reading et al. (1989), Klock and Greenfeldt (2000)
and Gibson et al. (2000)
, infertility with successful ART did not predict depression and anxiety during pregnancy or postpartum. In the present study, mothers in the ART group showed lower levels of depressive symptoms in pregnancy, which contradicts some earlier results (e.g. Beaurepaire et al., 1994
; van Balen et al., 1996
; Guerra et al., 1998
; Eugster and Vingerhoets, 1999
). Our research contributes to the scarce knowledge about the mental health of men experiencing infertility and successful treatment outcome. The results showed that ART men had fewer depressive and anxiety symptoms, sleeping difficulties and social dysfunction than control men.
The main effect models for women suggest that social and child-related stressors are more important determinants of depressive and anxiety symptoms, sleeping difficulties and social dysfunction than infertility and successful treatment. For instance, women with two or more children and worried about their infant reported increased levels of social dysfunction in both groups, and multiparity, poor child health and worry about the infant were generally associated with depressive symptoms. SES, in turn, was not associated with any of the mental health dimensions among women from either the ART or control group. The main effect models for men were similar to those of women, i.e. they suggest that social factors (including SES) are more important in predicting the trends of depressive and anxiety symptoms than the ART/control group affiliation. Child-related factors were relatively important determinants of sleeping difficulties and social dysfunction. High socio-economic status, having the first child, good child health and no worry about the infant predicted a decrease in anxiety symptoms across the transition to fatherhood.
The nature of symptoms is informative in understanding the mental health of couples undergoing ART. Interestingly, while depressive symptoms were at a low level during pregnancy among mothers in the ART group, they reported a high level of sleeping difficulties. This may reflect their concern for the infant and the need to adjust to a new life situation. This observation concurs with research revealing that formerly infertile women show disbelief concerning their pregnancies (Bernstein et al., 1994) and great concern about their own and the childs safety (Reading et al., 1989
; Hjelmstedt et al., 2003
). Similar to results reported by Raoul-Duval et al. (1994)
, differences between women undergoing ART and naturally conceiving women tend to disappear with time. As shown in the present study, the good mental health among women and men undergoing ART may simply reflect their satisfaction with successful treatment and fulfilment of hopes for parenthood. The possibility of ego defence mobilization among women undergoing ART, as a result of a stressful period of infertility treatment could also explain their lack of mental health symptoms compared with their fertile controls, and this is an interesting question for further study.
Our prospective research setting provides an expanded frame to view the cross-sectional results of the effects of infertility (Link and Darling, 1986; van Balen and Trimbos-Kemper, 1993
; Slade et al., 1997
; Kee et al., 2000
). Our results suggest that new parental challenges and concerns for the child become more salient than possible negative experiences of infertility and treatment. This was evident in that stressful life events and worry about the child explain significantly more about a couples mental health than belonging to the ART or control group. Naturally we have to be aware that our focus was solely on symptoms and distress, while other researchers have also studied wider aspects of well-being such as self-esteem and coping capacity (Bernstein et al., 1994
; Dhillon et al., 2000
). It may be easier to recover from symptoms after a successful pregnancy and delivery than to recover from hurt feelings, low self-esteem and a feeling of helplessness (Hjelmstedt et al., 2004
).
It was characteristic of couples undergoing ART that social and child-related stressors did not have as dramatic an impact on their mental health as they had in the control group. There are several possible mediators for this finding. It is possible that the high motivation to have children make the ART parents more resilient for general life stressors. Possibly the procedure of ART makes a selection: those who start and sustain in the treatment are more resilient than those who do not, as was noticed by Olivius et al. (2004), who found in their study that the most common reason for discontinuing ART was psychological stress. The integrity of the ART group contradicts the dynamics found in general research suggesting that earlier hardship and trauma make people more vulnerable in the face of new stress (Cicchetti et al., 1998
; Evans et al., 2001
). We suggest that the experience of infertility positively alters parents ways of responding to stress, disappointments and worries. One philosophical lesson of infertility may be the simultaneous realization of the preciousness and uncontrollability of life, and working through the experience can make individuals more resilient. To sum up, our results oppose portraying formerly infertile and successfully treated couples as highly psychologically vulnerable (Bernstein et al., 1994
; McMahon et al., 1997
), and suggest some positive consequences of resolved trauma and major life stress.
To conclude, our results indicate that mental health among new parents after ART and spontaneous pregnancies should be studied as a dynamically changing situation, in which people are vulnerable in varied ways to social and child-related stressors. Concerning ART pregnancies and parenting, it is informative to learn how differently women and men experience the biological, social and psychological misfortune of infertility.
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Acknowledgements |
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References |
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Submitted on June 18, 2004; resubmitted on March 5, 2005; accepted on June 23, 2005.
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