Resilience as a protective factor in pregnancy and puerperium: Its relationship with the psychological state, and with Hair Cortisol Concentrations
Introduction
Pregnancy is a sensitive period in which exposure to risk factors can have negative consequences for both the physical and psychological health of the mother and the baby, and their subsequent development. Several systematic reviews show that high levels of stress during pregnancy, as a consequence of exposure to life events (e.g., natural catastrophe, death of a relative, etc.), or even chronic stress or financial stress, are related to maternal and neonatal adverse outcomes, such as a higher risk of preterm delivery, an increased risk of miscarriage, low birth weight, or intrauterine growth restriction (IUGR) (Beydoun and Saftlas, 2008, Schetter and Tanner, 2012, Shapiro et al., 2013, Staneva et al., 2015). In addition, pregnancy-specific stress, a distinctive syndrome characterized by concerns about the health and wellbeing of the neonate, medical symptoms, birth and delivery, and the maternal role, are predictors of adverse maternal and infant outcomes (Caparros-Gonzalez et al., 2017, Schetter and Tanner, 2012).
Post-traumatic stress disorder (PTSD) during the puerperium, depression or anxiety appear as the main adverse consequences related to maternal mental health derived from stress during pregnancy. In fact, the main psychopathological symptoms that have been studied during pregnancy are depression and anxiety, which have been shown to have a great influence on the neonate neurodevelopment. Results also show a relation between anxiety, depression and psychopathological symptoms during pregnancy are associated with low-birth-weight (LBW), preterm birth (Schetter and Tanner, 2012) and a higher incidence of postpartum depression (Caparros-Gonzalez et al., 2017, Field et al., 2010, Flynn et al., 2006). At this level, it is noteworthy that postpartum depression is the psychological disorder with the highest incidence in pregnant women after delivery, with an incidence ranging from 10 to 15%, and postpartum depression also is a risk factor for the health and wellbeing of the mother and the development of the neonate (Yim et al., 2015).
The hypothalamic-pituitary-adrenal (HPA) axis, which is involved in the stress response, is altered during pregnancy by the presence of the placenta, a major endocrine organ of fetal origin. The HPA axis produces the release of cortisol from the adrenal glands through the increase of corticotropin-releasing hormone (CRH) from the placenta (Glynn et al., 2013). Besides, mood disorders during pregnancy can modify the activation of the maternal HPA axis, which can subsequently affect the functioning of the neonatal HPA axis (Charil et al., 2010, Glover, 2014, Lara-Cinisomo et al., 2017, Romero-Gonzalez et al., 2018) and the psychological wellbeing of the mother (Schetter and Tanner, 2012). Cortisol levels during the first and third trimester of pregnancy are related to postpartum depression (PPD) (Caparros-Gonzalez et al., 2017). These findings support the fact that maternal subjective experience of stress and the HPA axis are associated with maternal and neonatal health.
Cortisol levels, as a measure of the stress response, have been generally assessed from urine, saliva, blood, or amniotic fluid samples in pregnant women (Bergman et al., 2010, De Rezende et al., 2016). Those samples offer information about the stress levels the women were experiencing at the time the sample was taken, these assessment methods require a relatively invasive technique and can be affected by situational variables or circadian rhythms (Stalder and Kirschbaum, 2012). Alternatively, testing via hair cortisol levels is an innovative technique that offers a retrospectively chronic stress measure of the preceding 3 months by collecting a 3 cm segment of hair (assuming an average growth rate of 1 cm per month), is not invasive, is not affected by the time of the day, and is easy to transport and preserve (Wikenius et al., 2016, Wosu et al., 2013).
Resilience represents a set of personal resources that protect the individual from the negative effects of stressors (Fletcher and Sarkar, 2013). Resilience is a very important factor that acts as a protector against stress in the general population (Oken et al., 2015). However, to our knowledge, studies regarding resilience and pregnant women have only focus on the protective role of resilience against psychopathology in pregnant women who have experienced highly traumatic events, such as hurricanes (Harville et al., 2010), violence (Gagnon and Stewart, 2014), or child abuse (Sexton et al., 2015). Only one study evaluating resilience levels, and its association with stress levels and sleep quality of pregnant women found women with high levels of resilience resulted to have low stress levels during pregnancy (Li et al., 2016). According this, maternal resilience may have a protective role against maternal stress during pregnancy and its negative consequences.
Despite the existing association between maternal stress and maternal mental health during pregnancy, to our knowledge, there are no studies investigating the role of resilience as a protective factor against maternal stress during pregnancy and the puerperium. The aim of this study was to determine whether there were differences between pregnant women with high and low resilience in their levels of perceived stress, pregnancy-specific stress, psychopathological symptoms, psychological wellbeing and Hair Cortisol Concentrations (HCC) before and after delivery. Postpartum depression was also compared between both groups (high and low resilience levels).
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Participants
A total of 151 pregnant women in the third trimester of pregnancy (M = 34.94 weeks of gestation, SD = 3.34) participated in this study. The inclusion criteria were a low risk pregnancy, over 18 years of age, and proficiency of the Spanish language. The exclusion criterion was the presence of clinical psychopathology before or during pregnancy. In order to minimize the confounding effects of risk variables, additional exclusion criteria were pregnant women with Cushing disease, asthma, steroid
Description of the sample: main sociodemographic and obstetric variables
A total of 151 pregnant women with an age ranging from 22 to 44 years (M = 33.01, SD = 4.42) participated in the study. Table 1 shows through the Student's T-test and Chi-square analyses that both groups (women with high resilience vs. women with low resilience) are equivalent in the main sociodemographic, obstetric and hair characteristics variables except in the number of previous miscarriages (t = 8.44, p = .005), with a higher number of miscarriages in the low resilience group of pregnant
Discussion
In accounting for the importance of the impact of stress and related variables to pregnant woman and nenoates, the aim of this study was to verify whether maternal resilience during pregancy is a protective factor related to psychopathological symptoms, psychological stress, pregnancy-specific stress, psychological well-being, and HCC before and after childbirth. To achieve this, we divided the sample of pregnant women into two groups, a high resilience group and a low resilience group. Both
Funding
This research is part of a doctoral thesis. It has been economically supported by the “PSI2015-63494-P” I+D Project of the Spanish Ministry of Economy and Competitiveness (MINECO) and FEDER.
Conflict of interest
None declared.
Ethical approval
The University of Granada ethics committee approved the study, number 881.
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