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Mental health aspects of women’s

reproductive health
A global review of the literature

Mental health aspects of women’s
reproductive health

A global review of the literature

either expressed or implied. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. Errors and omissions excepted. Switzerland (tel.Mental health. 4. 20 Avenue Appia. In no event shall the World Health Organization be liable for damages arising from its use. The responsibility for the interpretation and use of the material lies with the reader. e-mail: permissions@who. Publications of the World Health Organization can be obtained from WHO Press.Mental disorders . I. the published material is being distributed without warranty of any kind. city or area or of its authorities.United Nations Population Fund.Reproductive behavior. the names of proprietary products are distinguished by initial capital letters. or concerning the delimitation of its frontiers or boundaries.Women.int). Requests for permission to reproduce or translate WHO publica- tions – whether for sale or for noncommercial distribution – should be addressed to WHO Press. e-mail: bookorders@who. World Health Organization.: +41 22 791 3264. However. 1211 Geneva 27.int). ISBN 978 92 4 156356 7 (NLM classification: WA 309) © World Health Organization 2009 All rights reserved. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication.complications. fax: +41 22 791 4857. II. .World Health Organization. The mention of specific companies or of certain manufacturers’ products does not imply that they are en- dorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. at the above address (fax: +41 22 791 4806. 3.Reproductive health services.WHO Library Cataloguing-in-Publication Data Mental health aspects of women’s reproductive health : a global review of the literature 1. The designations employed and the presentation of the material in this publication do not imply the expres- sion of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country. 5. 2. territory.

Contents

Acknowledgements v

Foreword vii

Chapter 1 Overview of key issues 1
The global burden of reproductive ill-health 2
Researchers’ views 3
Women’s views 4
Focus and framework of the current review 4
Reproductive rights 4
Gender, rights and reproductive mental health 5
Chapter 2 Pregnancy, childbirth and the postpartum period 8
Mental health and maternal mortality 9
Maternal deaths by inflicted violence 11
Mental health and antenatal morbidity 12
Mental health and postpartum morbidity 15
Biological risk factors for postpartum depression 18
Psychosocial risk factors for postpartum depression 18
Maternal mental health, infant development and the mother-infant
relationship 27
Summary 30
Chapter 3 Psychosocial aspects of fertility regulation 44
Contraceptive use and mental health 45
Mental health and elective abortion 51
Summary 59
Chapter 4 Spontaneous pregnancy loss 67
Mental health and spontaneous pregnancy loss 67
Medical treatment of spontaneous pregnancy loss 71
Summary 74
Chapter 5 Menopause 79
Mental health and the perimenopausal period 79
Menopause: a time of increased risk for poor mental health 81
Well-being in midlife and the importance of the life course 84
Summary 86
Chapter 6 Gynaecological conditions 89
Non-infectious gynaecological conditions 89
Infectious gynaecological conditions 92
Malignant conditions 100
Summary 104

Chapter 7 Women’s mental health in the context of HIV/AIDS 113
Gender and the risk of contracting HIV/AIDS 113
Gender-based violence and HIV/AIDS 115
Migration and HIV/AIDS 117
Mental health and HIV/AIDS 118
Summary 121
Chapter 8 Infertility and assisted reproduction 128
Causes of infertility 129
Psychological causation of infertility 130
Psychological impact of fertility 131
Psychological aspects of treatment of infertility using assisted
reproductive technology 133
Psychological aspects of pregnancy, childbirth and the postpartum
period after assisted conception 136
Parenthood after infertility and assisted reproduction 138
New technologies and their implications 139
Summary 140
Chapter 9 Female genital mutilation 147
Health effects of female genital mutilation 148
Summary 154
Chapter 10 Conclusions 158
Overview of key areas discussed 160
Annex WHO survey questionnaire on the mental health aspects of
reproductive health 167

Photo credits
Cover © River of Life Photo Competition (2004) WHO/ Liba Taylor
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page 25 © River of Life Photo Competition (2004) WHO/ Dinesh Shukla
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Acknowledgements

T he World Health Organization, the Key Centre for Women’s Health in Society, WHO Collaborating
Centre, Australia, and the United Nations Population Fund wish to express their deep gratitude to
the numerous experts who contributed to the development and finalization of this project starting with
the main authors of this Review who are: Susie Allanson, Fertility Control Clinic, Wellington Parade,
East Melbourne, Australia; Jill Astbury, School of Psychology, Victoria University, Australia; Mridula
Bandyopadhyay, Mother & Child Health Research, Faculty of Health Sciences, La Trobe University,
Australia; Meena Cabral de Mello, Department of Child and Adolescent Health and Development, World
Health Organization; Jane Fisher, Key Centre for Women’s Health in Society, WHO Collaborating Centre
in Women’s Health, University of Melbourne, Australia; Takashi Izutsu, Technical Support Division,
United Nations Population Fund; Lenore Manderson, Key Centre for Women’s Health in Society, WHO
Collaborating Centre in Women’s Health, University of Melbourne, Australia; Heather Rowe, Key Centre
for Women’s Health in Society, WHO Collaborating Centre in Women’s Health, University of Melbourne,
Australia; Shekhar Saxena, Department of Mental Health and Substance Dependence, World Health
Organization; and Narelle Warren, Key Centre for Women’s Health in Society, WHO Collaborating Centre
in Women’s Health, University of Melbourne, Australia.

The respondents of a mail survey who contributed directly or indirectly to the research evidence included
in this Review are gratefully acknowledged. They are: Ahmed G Abou El-Azayem, Eastern Mediterranean
Regional Council of the World Federation for Mental Health, Egypt; Mlay Akwillina, Reproductive
Health Project, Tanzania; Mary Jane Alexander, Nathan Kline Institute for Psychiatric Research, USA;
Faiza Anwar, Women’s Health Educator, Australia; Victor Aparicio Basauri, WHO Collaborating Centre,
Spain; Lara Asuncion Ramon de la Fuente, National Institute of Psychiatry, Mexico; Carlos Augusto de
Mendonça Lima, Service Universitaire de Psychogériatrie, Switzerland; Christine Brautigam, Division for
the Advancement of Women, United Nations; Jacquelyn C Campbell, Johns Hopkins University, USA;
Amnon Carmi, International Center for Health Law and Ethics, Haifa University, Israel; Rebecca J Cook,
University of Toronto, Canada; Dilbera, DAJA Organization, Macedonia; Mary Ellsberg, Violence and
Human Rights Program at PATH, USA; Sofia Gruskin, Francois-Xavier Bagnoud Center for Health and
Human Rights Harvard University School of Public Health, USA; Emma Margarita Iriarte, Tegucigalpa,
Honduras; Els Kocken, WFP, Colombia; Pirkko Lahti, World Federation for Mental Health, Finland; Els
Leye, International Centre for Reproductive Health, University Hospital, Belgium; Regine Meyer, Health
& Population Section, GTZ, Germany; Alberto Minoletti, Ministerio de Salud, Chile; Jacek Moskalewicz,
Institute of Psychiatry and Neurology, Poland; Vikram Patel, London School of Hygiene and Tropical
Medicine, UK; Pennell Initiative, University of Manchester, UK; Ingrid Philpot, Ministry of Women’s
Affairs, New Zealand; Joan Raphael-Leff, Centre for Psychoanalytic Studies, University of Essex, UK;
Tiphaine Ravenel Bonetti, Reproductive Health, Kathmandu, Nepal; Jacqueline Sherris, Reproductive
Health, PATH, USA; Johanne Sundby, University of Oslo, Norway; Susan Weidman Schneider, LILITH
Magazine, USA; and Susan Wilson, National Research Institute, Curtin University of Technology,
Australia.

The following peer reviewers provided much constructive critical assessment during the long development
phase: this work has benefited greatly from their comments, suggestions and generous advice. Natalie
Broutet, Department of Reproductive Health and Research, World Health Organization; Meena Cabral
de Mello, Department of Child and Adolescent Health, World Health Organization; Jane Cottingham,
Department of Reproductive Health and Research, World Health Organization; Lindsay Edouard,
Technical Support Division, United Nations Population Fund; Jane Fisher, Key Centre for Women’s
Health in Society, WHO Collaborating Centre in Women’s Health, University of Melbourne, Australia;
Sharon Fonn, University of the Witwatersrand, South Africa; Takashi Izutsu, Technical Support Division,
United Nations Population Fund; Elise Johansen, Department of Reproductive Health and Research,
World Health Organization; Paul Van Look, Department of Reproductive Health and Research, World
Health Organization; Lenore Manderson, WHO Collaborating Centre for Women’s Health, Department of

v

Australia. and Vikram Patel.Public Health. NY. Technical Support Division.int website: http://www. UK.int website: http://www.int/mental-health Department of Reproductive Health and Research World Health Organization Avenue Appia 20.unfpa. World Health Organization. 1211 Geneva 27. Department of Chronic Diseases and Health Promotion. and Chairperson. Shekhar Saxena.int/child-adolescent-health United Nations Population Fund 220 East 42nd Street.who. Department of Reproductive Health and Research. This production of this publication would not have been possible without the funding support extended by the United Nations Population Fund. NY 10017 Tel: 1-212-297-2706 email: izutsu@unfpa. World Health Organization. We are indebted to Pat Butler. World Health Organization.edu.unimelb. India. Department of Mental Health and Substance Abuse. Key Centre for Women’s Health in Society. United Nations Population Fund.edu. fax: +61 3 9347 9824 email: enquiries-kcwhs@unimelb. Switzerland Tel: +41 22 791 4447.org vi . provided much research assistance and Kathleen Nolan. WHO consultant for patiently editing this publication. Fax: +41 22 791 4171 email: reproductivehealth@who. Australia. 1211 Geneva 27.who. Fax: +41 22 791 4853 email: cah@who. Department of Reproductive Health and Research.au Department of Mental Health and Substance Abuse World Health Organization Avenue Appia 20. Iqbal Shah. Japan. Switzerland Tel: +41 22 791 21 11. For further information and feedback. Andreas Ullrich. National Institute of Mental Health. fax: +41 22 791 41 60 email: mnh@who. Arletty Pinel. 1211 Geneva 27.au website: http://www. and Effy Vayena. Sangath.kcwh. The University of Melbourne.who.int/reproductive-health Department of Child and Adolescent Health and Development World Health Organization Avenue Appia 20. Atsuro Tsutsumi. World Health Organization. Switzerland Tel: +41 22 791 3281. please contact: Key Centre for Women’s Health in Society WHO Collaborating Centre in Women’s Health School of Population Health University of Melbourne Australia Tel: +61 3 8344 4333. Hope Kelaher. WHO intern. Goa. assisted with the editorial process.int website: http://www. London School of Hygiene and Tropical Medicine.org website: http://www.

This review is our unique contribution towards raising awareness on an emerging issue of major importance to public health. Mental health is closely interwoven with physical health. delivery and postpartum care. married women of reproductive age. the central contribut- ing factors to disparities in reproductive health have been identified as: reproductive choice. vii . It includes a discussion of the bio-psycho-social factors that increase vulnerability to poor mental health. However. pregnancy related illness and complications of childbirth. Dramatic contrasts are apparent between industrialized and developing countries in terms of reproductive health services and status. A complete review would examine all mental health aspects of reproductive health and functioning throughout the lifespan for both men and women. Its purpose is to provide information on the often neglected interlinks between these two areas so that public health professionals. nutritional and social status. policy makers. the potential scope of the topic of reproduc- tive mental health far outstrips the available evidence base. Depression after childbirth is associated with maternal physical morbidity. information needs. unsafe abortion. Mental health problems may develop as a consequence of reproductive health problems or events. especially reproductive rights. These include access to contraception. Foreword T he World Health Organization and the United Nations Population Fund in collaboration with the Key Centre for Women’s Health in Society. The review comprises the most recent information on the ways in which mental health concerns intersect with women’s reproductive health. childbirth and the puerperium. The framework for analysis employed here is informed by two interconnected concepts: gender and human rights. premature birth or fistula. in the School of Population Health at the University of Melbourne. sociodemographic. and care for unsafe or unintended pregnancy. access to health system and serv- ices and the training and skill of health workers. including persistent unhealed abdominal or perineal wounds and inconti- nence. very limited consideration of mental health as a determinant of reproductive mortality and morbidity especially in the developing regions of the world. A more comprehensive review is thus not possible yet. The most prominent risks to life are identified as those directly associated with pregnancy. It is generally worse when physical health including nutritional status is poor. Most research into the mental health implica- tions of reproductive health has focussed on a relatively small number of reproductive health conditions experienced worldwide and has investigated most usually. antenatal care. Australia are pleased to present this joint publication of available evidence on the intricate relationship between women’s mental and reproductive health. stillbirth. the diagnosis and treat- ment of sexually transmitted infections (STIs) including HIV. unsafe abortion. reproductive health initiatives aim to address the complex of economic. infertility and pregnancy complications such as miscarriage.and low-income countries on the ways in which women’s mental health intersects with their reproductive health. co-incidental infectious diseases. planners. There is however. The review comprises the most recent data from both high. infertility treatment. infection. unintended pregnancy. sexually trans- missible infections including HIV. health status and health service factors associated with elevated risk of mor- bidity and mortality related to reproductive events during the life course. including haemorrhage. At present. those that might be protective and the types of programmes that could mitigate adverse effects and pro- mote mental health. The focus on women in this review is not only because of the lack of evidence and data on men’s reproductive mental health but also because reproductive health conditions impose a considerably greater burden on women’s health and lives. Around the world. safe facilities in which to give birth and trained staff to provide pregnancy. These include lack of choice in reproductive decisions. and pro- gramme managers may engage in dialogue to consider policies and interventions that address the multiple dimensions of reproductive health in an integrated way.

anxiety. family life and parenting. care and support.to four-fold. Poor mental health can be associated with risky sexual behaviour and substance abuse through impaired judgement and decision-making which can have dramatic consequences on reproductive health including height- ened vulnerability to unintended pregnancy. as a result. the number of women having access to care that incorporates their mental health concerns is quite dismal. They are also more prone to self harm and suicide attempts. sexual abuse and forced marriage. People living with HIV/AIDS have higher suicide rates. There is consistent evidence that women are at least twice as likely to experience depression and anxiety than men are. for example in Viet Nam. There is new evidence sug- gesting that maternal depression in developing countries may contribute to infant risk of growth impair- ment and illness through inadvertent reduced attention to and care of children’s needs. At present. social change to prevent problems and develop acceptable treatments are under-investigated. More recently the adverse effects of poor maternal mental health have become the subject of renewed at- tention and concern because of increased awareness of the high rates of depression in mothers with small children in impoverished communities. Women are at higher risk of mental health prob- lems because they:  carry a disproportionate unpaid workload of care for children or other dependent relations and house- hold tasks. and a proportion of women commit suicide. it is well recognized that mental health promotion. About 10-15% of women in industrialized countries. as are women suffering from fistula. They compromise women’s capacity to provide sensitive.  are more likely to experience violence and coercion from an intimate partner than are men. Even though the relationship between mental health problems and reproductive functions in women has fascinated the scientific community for some time. commonly cause mental viii . trafficking of girls/women. responsive and stimulating care. Feelings about hysterectomy or the loss or termination of a pregnancy may have a major impact on reproductive choices and well being. Children of depressed mothers have poorer emotional. loss of physical and financial independence. and  are less likely to have access to the protective factors of full participation in education. This is particularly true for developing countries where the intersecting determinants of reproductive events or conditions and the mental health problems faced by women are simply not recognized. the risk of depression and anxiety disorders increases three. stigma and discrimination. paid employ- ment and political decision-making. Survivors of gender-based violence commonly experience fear. These conditions have a pervasive adverse impact on women’s health and wellbeing and caretak- ing capacity. STIs including HIV. anxiety and demoralization are amplified in the context of social adversity and poverty. The effects of depression. Other types of gender-based violence such as female genital mutilation (FGM). shame. Adolescent girls with unplanned pregnancies are at elevated risk of suicide. con- traceptive technologies. sexually transmitted infections. Perinatal depression is one of the most prevalent and severe complications of pregnancy and childbirth. Health care behaviours including compliance with medical regimens such as anti-retroviral therapy (ARV) or appropriate use of contraceptives are diminished in the context of mental health problems. particularly if they have expe- rienced childhood abuse or sexual or domestic violence. about a third of rape victims develop post traumatic stress disorder. anger and stigma. up to 14% of pregnancy-related deaths are by suicide. and lack of treatment. which stem from factors such as multiple bereavements. which is especially important for infants and children. guilt. and gender-based violence. and between 20-40 % of women in developing countries experience depression during pregnancy or after childbirth. Sexual abuse is a frequent feature in the history of women with co-occurring mental health problems but is not addressed systematically. infertility and menopause.  are more likely to be poor and not to be able to influence financial decision-making. cognitive and social development than infants and children of non depressed mothers especially when the depression is severe and chronic and occurs in conjunction with other risks such as socioeconomic adversity.Mental health is also governed by social circumstances. Suicide is a significant but often unrecognised contributor to maternal mortality. with effects on the home environment. a childbirth injury caused by lack of emer- gency obstetric care. pregnancy. For example many women have questions and concerns about the psychological aspects of menstruation.

Not only are feasible and cost effective interventions possible. The social environment. but early detection and diagnosis of mental health problems can be undertaken by trained primary health care workers. newborn and child health. and of providing support and training to health workers for recognition. for example. This lack of awareness compounded by women’s low status has resulted in women considering their problems to be ’normal’. interpersonal. the mental health aspects of reproductive health are critical to achieving Millennium Development Goal (MDG) 1 on poverty reduction. and  the treatment of depression. we must address the needs of those who are already victims and afflicted with these conditions. psychotropic medications can be delivered through primary health care services for the treatment of many mental health problems.and low-income countries. quality of life and social functioning of survivors of domestic violence. formulate programmes and reorient services to meet the mental ix . that:  the treatment of maternal depression can reduce the likelihood of maternal physical morbidity and mortality along with the likelihood of physical and mental or behavioural disorders in their chil- dren. culture-bound religious or other healing rituals which have shown to be effective can also play an important role. cognitive-behavioural and brief solution focused therapies and when needed. suggestions have been made regarding the most feasible ways in which health authorities could advance policies. The World Health Report 2005: Make Every Mother and Child Count (WHO. assessment and treatment of mothers with metal health problems. unintended pregnancy and gender-based violence. It has been shown. partner and peers in supporting women as agents of change in the family environment. In response to these mandates. and community organizations can be made more aware and receptive to the mental health problems of women and families. MDG 3 on gender equality. There is tremendous under-recognition of these experiences and conditions by the health professionals as well as by society at large.  the reduction of illicit drug-injection or the treatment of mood disorders can reduce the risk for HIV and AIDS and other STIs. especially as it relates to maternal depression and suicide. Health care providers can involve the family. Moreover. In addition. The International Conference on Population and Development (ICPD) Programme of Action and the Beijing Platform for Action urged member states to take action on the mental health consequences of gender-based violence and unsafe abortion in particular so that such major threats to the health and lives of women could be understood and addressed better. Evidence from peer-reviewed journals has been used wherever possible but has been augmented with results of a specific survey initiated to gather state of the art information on reproductive and mental health issues from a variety of researchers and interested parties. national programme evaluations and postgraduate research work was also compiled. Social and Cultural Rights. Besides encouraging the non tolerance of these practices. In many settings. the present document has reviewed the research undertaken on a broad range of reproductive health issues and their mental health determinants/consequences over the last 15 years from both high. MDG 4 on child mortality reduction. including health systems. The social stigma attached to the expression of emotional distress and mental health problems leads women to accept them as part of being female and to fear being labeled as abnormal if they are unable to function. MDG 5 on improving maternal health and MDG 6 on the fight against HIV and AIDS and other communicable diseases.health problems. Women’s sexuality and reproductive health needs to be considered comprehensively with due consideration to the critical contribution of social and contextual factors. 2005) recognizes the importance of mental health in maternal. Both simple psychological in- terventions such as supportive. humans are emotional beings and reproductive health can only be achieved when mental health is fully addressed as informed by the WHO’s definition of health and the definition of right to health in the International Covenant of Economic. Valuable data from consultant reports. analyzed and synthesized. Where evidence exists. anxiety and trauma reactions results in better physical health.

United Nations Population Fund Shekhar Saxena. Jill Astbury. It is noteworthy that the evidence base everywhere. Australia Takashi Izutsu. Policy makers as well as service providers face a dual challenge: address the inseparable and inevitable mental health dimensions of many reproductive health conditions and improve the ways in which women are treated within reproductive health services. Reproductive Rights. Key Center for Women’s Health in Society. Reproductive Health Branch. stimulate much needed additional research and assist in advocating for policy makers and reproductive health service providers to expand the scope of existing services to embrace a mental health perspective. Sexual Health and Adolescence. University of Melbourne.health needs of women during their reproductive lives.and low-income countries. Technical Support Division. WHO Jane Cottingham. recommendations are made about the areas and topics of research that need to be investigated. Chief. has major gaps but there is a large divide between the amount of research undertaken and the health conditions chosen for research in low income compared with middle and high income countries. both of which have profound implications for mental as well as physical health. Technical Analyst. School of Psychology. Australia Meena Cabral de Mello. It is important that lack of evidence and research on the mental health effects of such conditions predominantly affecting women in low income countries is not taken as implying that there are no mental health consequences of these conditions. WHO Jane Fisher. There is lack of information on chronic morbidities that are experienced disproportionately by women living in resource-poor and research-poor settings. We hope that this review will draw attention to the substantial and important overlap between mental health and reproductive health. Associate Professor. Department of Child and adolescent Health and Development. Coordinator. in both high. WHO x . Scientist. All these facts justify the necessity of investigating and understanding the mental health determinants and consequences of reproductive health and the mechanisms through which the common mental health problems such as depression and anxiety disorders can be prevented and managed in low income countries as a matter of priority. University of Victoria. Research Professor. United Nations Population Fund Arletty Pinel. It is time that all reproductive health providers become sensitized to the fact that reproductive life events have mental health consequences and that without mental health there is no health. Gender. Where gaps in the evidence are identified. Department of Mental Health and Substance Abuse.

Reproductive health therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if. of reproductive age are expected to increase in tal health and reproductive health to the global developing countries. 1 Chapter Overview of key issues Jill Astbury “Reproductive health is a state of complete physical. 1994) M ental health as a component of reproduc- tive health has generally been . Hotopf et al.. and incorporate activities 1996). Depression occurs approximately twice to address them in their services. 1998. More than 150 million people wide. effective. unipolar major depression will be the leading cause of DALYs lost by women (Murray Of the ten leading causes of disability world. Reproductive health conditions also make a toms. knowledge the importance of mental health justed life-years (DALYs) lost (Murray & Lopez. depression is the most common. five are neuropsychiatric disorders. mental and social well-being and not merely the absence of disease or infirmity. Reproductive health programmes need to ac- counting for more than one in ten disability-ad. Programme of Action of the International Conference on Population and Development.inconspicuous. Implicit in this last condition are the right of men and women to be informed and to have access to safe. techniques and services that contribute to reproductive health and well-being by preventing and solving reproductive health problems. & Lopez. reproductive health care is defined as the constellation of methods. particularly for women. diz. burden of disease and disability. problem overall. major contribution to the global burden of dis- ziness. peripheral and marginal. Rates of depression in women given the significant contributions of both men. 1998). and commonly presents with unexplained physical symp. The & Walker. problems for women. and it is predicted that. para 7. in all matters relating to the reproductive system and to its functions and processes. 1996). Of experience depression each year worldwide. palpitations and sleep problems (Katon ability. It is the most frequently encountered women’s mental health problem and the leading women’s health lack of attention it has received is unfortunate. and not merely counselling and care related to reproduction and sexually transmitted diseases”. affordable and acceptable methods of family planning of their choice. and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. aches and pains. ac. these. as well as other methods of their choice for regulation of fertility which are not against the law. It also includes sexual health. the purpose of which is the enhancement of life and personal relations. such as tiredness. by 2020. accounting for 1 .and still is .2 (UNFPA. as often in women as in men. In line with the above definition of reproductive health. when and how often to do so.

may reflect an enduring intellectual habit of tum into the vagina). psychological issues related to pregnancy. and community and of reproductive health employed (Murray & societal factors. Second. 1998). For example. more than 529 000 women die rigidly separated from the study of their minds.and high-income ones. sterilization. Mental health aspects of women’s reproductive health 21. mores Lopez. child- birth and the postpartum period. but none on depression health and reproductive health: for example. suffering serious or long-term complications. programmatic search for papers published between 1992 and and research endeavours. adverse maternal outcomes. including cultural values. and infertility (Family Care International. the evidence base everywhere . Such a review would consider in ill-health detail the relationships between mental and re- Reproductive health conditions are estimated to productive health at all levels. perineal tears or poorly performed epi- ficiency virus (HIV) infection and acquired im. Even the higher figure is likely to 2 . surgery on and removal compared with middle. 300 million There are several possible reasons for the lack of women are suffering from pregnancy-related a comprehensive database on reproductive men- health problems and disabilities.has significant gaps.9% of DALYs lost for women annually com. and the mental Third. Thus. ies and reproductive events has generally been 1998). including anae. there is a significant divide between the health effects of violence. uterine prolapse. The study of women’s bod- ease. beginning with account for between 5% and 15% of the over- the individual and encompassing the effects of all disease burden. spond to these events and experiences. the obvious lack of integration mia. are much munodeficiency syndrome (AIDS). fistulae (holes in the birth between mental health and reproductive health canal that allow leakage from the bladder or rec.1% for men (Murray & Lopez. amount of research undertaken and the health lence.and low-income countries . mind-body dualism. review is impossible at present. depending on the definition interpersonal relationships. pelvic inflammatory dis. feel and re- 2006). tions of reproductive health have focused on a productive health and mental health is poten. conditions studied in low-income countries. there are March 2006 found more than 1500 papers on multiple points of intersection between mental postnatal depression. of pregnancy-related causes each year (WHO. human immunode. of reproductive organs. siotomies. efforts to examine the mental health implica- A global review of the interaction between re. premarital Chronic morbidities. Further. A complete review would examine all mental health aspects of reproductive health and func- tioning throughout the lifespan for both men The global burden of reproductive and women. because the nec- lems directly related to the pregnancy. births and miscarriage. including how women might think. and severity of reproductive mental health prob- 1998). with 15% essary evidence is simply not available. Such a (50 million per year) experience health prob. since each is in itself a tive health conditions. poor and research-poor settings. menopause more common among women living in resource- and infertility (Patel & Oomman. 1999). It is important to bear in mind that the lack of evidence and re- search on the mental health effects of conditions that predominantly affect women in low-income countries does not imply that there are no men- tal health consequences of these conditions. relatively small number of sexual and reproduc- tially a vast undertaking. First. including sexual vio. at any given time. tal health. a Medline large.in both high. and laws. Fourth. It would seek to explain the prevalence pared with only 3. An estimated 40% of pregnant women lems and their intercountry variations. Moreover. the true impact on women’s mental health of the multiple reproductive health con- ditions experienced over the course of their life cannot currently be ascertained. fistula. and uterovaginal prolapse. specialized field of clinical. such as still. As a consequence. including vesicovaginal pregnancies in adolescents. following vaginal fistula.

multiple pregnancies. Second. especially in low-income countries. and pregnancy-related issues. Third. that they had investigated the impact of repro- tries. and to suggest which aspects of re- quantify (Murray & Lopez. ductive health on mental health. cervical cancer preven- tive health has predominantly been carried out tion. however. These health conditions comes overwhelmingly from responses supported the view that reproductive middle. for several reasons.a The available evidence on reproductive mental very low response rate of just over 12%. determi- ities. pregnancy. have not to 246 researchers around the world. Mental health ual health as a result of violence and abuse. there is a lack To augment the evidence obtained from peer- of data on the epidemiology of important non. being undertaken on the epidemiology. These include fistulae. working in been assessed in terms of their contribution to either reproductive health or mental health. nal discharge. these areas. mental health (Annex 1). and maternal morbidity and gy- no support or assistance in this regard. ado. non-sexu. Less than a the false impression that such conditions do not quarter (8/31) of those who responded reported affect or concern women in low-income coun. and to obtain further information on co-morbidities. Premenstrual tension and menopause were lescent girls. First. Moreover. the mental Just over half of the respondents (16/31) identi- health effects of these reproductive health condi. underinvestigated. initiated by obstructed labour resulting in nants and outcomes of reproductive health and organ prolapse or fistula.and high-income countries. services addressing both women’s mental health receive significant attention in low-income coun. Certain physical aspects of women’s repro. including fertility and had been involved in policy. is extremely difficult to the review. such as the combination of poor unmet research needs. The two most im- mental health and emotional needs of women portant broad areas suggested for further inquiry are seen as being outside the scope of reproduc. including HIV. Evidence of childbirth. The required increased attention. to ascertain the extent of fatal health conditions. Within in Safe Motherhood Initiatives. were gender-based violence. such as fear on married women of childbearing age. ally transmitted reproductive tract infections. fistula. health and the inter-relationships between wom- culations. The DALYs. productive mental health required increased attention. and women past the age of child. specifically domestic tive health services. Dependent co-disability. programmes or its control. and often appears to be considered an unaffordable lack of control over contraceptive choice and the “luxury” for women in resource-poor settings. menstrual disorders. Respondents were asked to send copies of any whereby one disability increases the likelihood relevant reports or publications to assist with of another developing. Unfortunately. conveying mental health is underinvestigated. Overview of key issues be an underestimate. often in line with the narrow goals of popu- lation control policies. incontinence. and the links including access to safe abortion in the context between safe reproductive health care practices. Gynaecological topics requiring Another deficiency in the existing evidence base further investigation included unexplained vagi- derives from the fact that research on reproduc. mentioned as problems of the female reproduc- 3 . den of disease and disability in such a context is particularly difficult. rowly defined as physical safety. prevention of sexually transmissible infections. impairment of sex- mothers are rarely considered. men’s reproductive number of conditions are not included in the cal. Chapter 1. such as those mentioned overlap between mental and reproductive health above. 1996). a bearing is meagre. “safety” is nar. a questionnaire was sent mental and poor reproductive health. Only 31 responses were received . reviewed journals. tries. childbirth and lactation. and reproductive health morbidities associated with violence. and only four ductive health. research. and their reproductive health. For example. of the threat of violence towards women seeking treatments or services and the mental health of a termination of pregnancy. Researchers’ views as Murray & Lopez (1996) note. Even naecological conditions generally (5/31). en’s and men’s reproductive health are seriously uterine prolapse. which consequently provide violence (7/31). fied aspects of reproductive mental health that tions are neither considered nor measured. the calculation of bur. fe- male genital mutilation. suicidal ideation may be questionnaire sought information about research the outcome of a calamitous sequence of disabil. a number of concerns were raised. ity. and infertil- on the reproductive health of single women.

en. of ill-health/disease. education. women living in rural or remote areas. and articulated concepts 4 . acknowledged women’s right to have control nificant burden that reproductive health condi. sexually transmitted dis- ductive health conditions impose a considerably eases and adolescent reproductive health. sex education and high-risk the analysis is informed by two interconnected behaviour in relation to both unwanted preg. West  the social and cultural determinants Africa. persons with disabilities and those belonging to stigmatized or margin. severity and fre- women’s interest in mental health concerns ac- quency of disease. tigating all reproductive mental health topics The public health goal of ensuring the conditions with due regard to the psychosocial context in in which people can be healthy overlaps with the which they arose and an awareness of the ad.. as well as health tually outweighed their interest in reproductive outcomes. well-being (Mann et al. objective of reproductive health programmes. Such groups included indigenous wom. This greater burden on women’s health and lives. protect mental and physical health. including women with mental how and why gender-based differences health problems who were also parents. emotional responsibility for children. Reproductive rights comprise a constellation cus of participants’ concerns (Napravnik et al. The framework used for adolescent health. mental health and well-being was the main fo. human rights goal of identifying. influence reproductive mental health. and related to people’s abil- ity to make decisions that affect their sexual and reproductive health (Sundari Ravindran. heavy workloads and a strict gender-based division of labour that put a disproportionate burden on Reproductive rights them. it is imperative to identify and some respondents urged a stronger focus on the relevant risk factors. Women attributed their psychosocial  the roles of women and men as formal distress to financial insecurity. Gender analysis is necessary to elucidate alized groups. Mental health aspects of women’s reproductive health tive cycle that warranted further investigation. ceptions of their mental health or on their health including information. established by international human 2000). For women themselves. In another study of HIV-positive women.. 1999). Areas for study include: Women’s views  risk and protective factors. especially nancies and infections. mental health technology and services. over their sexuality. the homeless. is critically important. concerns.. the elderly. priorities. which and poor mental health associated with the sig. of rights. The first was the International Conference on Population The mental health aspects of women’s reproduc- and Development (ICPD). held in Cairo in 1994. One respondent urged reproductive rights. in Beijing in 1995. the latter must be taken into account in any at- Others commented on the importance of inves. promoting and ditional problems faced by particular groups of protecting the societal determinants of human women. not only which produced a “Programme of Action” raising because of the lack of evidence on men’s repro- issues of reproductive rights and health concern- ductive mental health but also because repro- ing family planning. health. tempt to understand reproductive mental health. Focus and framework of the current 2001). Because of the inextricable that sexual enjoyment for women should be an relationship between health and human rights.  access to resources that promote and Little research is available on women’s own per. in their study of women in the Volta region of Ghana. Avotri & Walters (1999). One study reported that  the manifestations. rights documents. ed to a heavy burden of work and a high level  the response of health systems and of worry predominated over reproductive health services. Two conferences in the 1990s were criti- review cal in promoting reproductive rights. concepts: gender and human rights. was followed by the Fourth World Conference To identify and reduce the emotional distress on Women (FWCW). tive health are the focus of this review. tions place on women. found that psychosocial problems relat. financial and and informal health care providers.

5 . receive and impart their vulnerability to a range of human rights information (informed choices). move away from a stereotyped conceptualiza- tion of reproductive health problems as “wom. and is affected by. Identifying and analysing violations of morbidities. anxiety ciated with pregnancy. with. rights and reproductive rights documents (UNFPA. This focus is based on infection. They also include their right to make decisions concerning reproduction free of discrimination. including reproductive mental health. Research that looks only at socio. the higher risk of depression means to do so. rights in relation to health contributes a new perspective to the socioeconomic and structural factors usually considered within a social mod- el of health. of using a gender and rights perspective. among women clearly underlines the importance sible standard of sexual and reproductive health. tion). rather it  the right to non-discrimination (rec- considers how biological vulnerability interacts ognition of gender biases). 2001). as expressed in human Gender. divorce. violations.  the right to equality in marriage and tion of women as the “weaker sex”.. 2001). improvements in wom-  the right to health (occupational. are potentially preventable or tant mental health condition for women world- treatable (Berg et al. The use of a rights-based approach offers a  rights to bodily integrity and secu- powerful lens to examine those normative orders rity of the person (against sexual vio- and how they hamper women (in this instance) lence. 2001). en- en’s reproductive mental health are contingent vironmental). A denial of the right wide and makes a significant contribution to the to timely and appropriate reproductive health global burden of disease. This perspec. From a gender self). services). control of reproduc- moves beyond biological explanations of wom. tors. 2001) ability including gender power imbalances.g. development of sexuality and the qualities in power and resources. Women suffer more care is a critical factor in increasing mortality often than men from the common disorders of and morbidity rates among women of reproduc- depression and anxiety. spacing and timing relation to their human rights (Astbury. Adding a gender and rights perspective helps to  the right to privacy (in relation to sexuality). and somatic complaints. denial of family planning relation to reproduction (WHO. in responsibly the number. A gender and rights perspective progress (e. 2001). This vulnerability has little to do with  the right to education (to allow full biology and much to do with gender-based ine. compelled sterilization in realizing their right to good mental health in or abortion. and to attain the highest pos. coercion and violence. and how these can be remedied (WHO. there have been sur- Reproductive rights include the basic rights of prisingly few investigations of women’s mental all couples and individuals to decide freely and health. mental health The current review focuses on the common All the major causes of death and disability asso- mental disorders. assault. 2005). obstructed labour and the evidence that depression is the most impor- unsafe abortion.  the right to the benefits of scientific en’s troubles”. of their children. other sources of vulner. on the promotion and protection of women’s hu- man rights rather than the paternalistic protec. to have the information and Nevertheless. Reproductive rights include: economic indicators of risk fails to examine the “normative orders” that influence those indica. and rights perspective. 1994 (para 7. including haemorrhage. (Sundari Ravindran.3)). Overview of key issues of reproductive rights and health (Sundari Although human rights violations are recog- Ravindran. both singly and as co- tive age. 2001). eclampsia.  the right to life. tive does not deny the role of biology. Chapter 1. nized as having a negative impact on mental health (Tarantola. such as depression. en’s vulnerability to mental disorder to consider  the right to seek.

Geneva. Murray CJL. Oomman NM (1999) Mental health matters too: gynaecological morbidity and depression in South Asia. 173:255-261. Geneva. Social Science and Medicine. and Science. Results of a statewide review. rather it is a first step in bringing this im- portant but neglected issue to the attention of a Berer M. Journal mental health of women of Clinical Psychiatry. Routledge. Mental health aspects of women’s reproductive health The gender-related nature of the most common References mental disorders becomes even clearer when it is Astbury J (2001) Gender disparities in mental appreciated that high rates of depression. 20): 15-21. Health and human rights. stressful life events. If these risks serve as Family Care International (1998) Safe motherhood markers of multiple violations of women’s hu. anxi. (1998) Temporal relationships between physical symptoms and psychiatric disorder: results from a national birth cohort. Ravindran TK. Ghanaian women’s accounts of their work and health. Boston. it is imperative to name these viola. eliminated or reduced. 6 . Harvard School of Public tion and elective abortion. Murray CJL. 106:1228-1234. impacts on a wide range of reproductive health conditions (Berer & Ravindran. mental health: an evidence based review. (1999) Health and human rights. 2000). 59 (Suppl. Lopez AD (1996) The global burden  Psychological aspects of contracep. 14: 411-420. World Health to gender-based violence and socioeconomic Organization. (2000) HIV-1 infected women AIDS. disadvantage. the World Bank). These same factors have pronounced negative World Health Organization. Harvard School of Public Health (for the World Health  Gynaecological morbidity and its im- Organization and World Bank) (Global Burden pact on mental health. Vol. eds. Health (for the World Health Organization and  Mental health consequences of mis. Walker EA (1998) Medically aspects of the reproductive health and unexplained symptoms in primary care. 1999. This review addresses the following Katon WJ. health. British Journal of Psychiatry. eds (1999) Safe wide readership. tilation. 48:1123- hensive examination of reproductive mental 1133. 2000). of disease. It is in their remedy that many risks for Technical Consultation held in Sri Lanka. period. Hotopf M et al. women’s reproductive mental health will be October 1997. AIDS Patient Care & STDs. Astbury & Obstetrics and Gynecology. adverse life experiences that are more common Berg M et al (2005) Preventability of pregnancy- for women and that also affect their reproduc. sion is closely linked with a disproportionate ex. and prenatal care utilization: Barriers and  Infertility and assisted reproduction. Evidence indicates that depres. motherhood initiatives: critical issues.  Mental health in the context of HIV/ Napravnik S et al. man rights. In:  Mental health dimensions of preg. London: Blackwell posure to risk factors. of Disease and Injury Series. health. Reproductive Health Matters. carriage.. Reproductive Health Matters. facilitators. related deaths. A summary report of the Safe Motherhood tions. Cabral de Mello. 7: 30-38. tive health (Patel & Oomman. Mann JM et al. situations that predominantly af- Astbury J. of sex and reproduction. In: Mental health: a call for action by ety and co-morbidity are significantly linked world health ministers. Lopez AD (1998) Health dimensions  Menopause and depression. III). 1999). Cabral de Mello M (2000) Women’s fect women (Astbury & Cabral de Mello. nancy. Avotri JY. Mann JM et al. action agenda: priorities for the next decade. Patel V. Walters V (1999) “You just look at our work and see if you have any freedom on earth”: The current review does not attempt a compre. childbirth and the postpartum New York and London. Boston.  Mental health and female genital mu.

Organization.pdf). Agenda item 12. Geneva. 57th programme managers. United Nations Population Fund. Tarantola D (2001) Agenda item 10. Geneva. A training curriculum for health the World Health Organization. (2001) Transforming WHO (2001) Integration of the human rights of health systems: gender and rights in reproductive women and the gender perspective. Statement by Strategic approach to improving maternal and Dr Daniel Tarantola. Chapter 1. World to the Director-General World Health Health Organization (http://www. Overview of key issues Sundari Ravindran TK. WHO (2006) Making a difference in countries: Social and Cultural Rights. Senior Policy Advisor newborn survival and health. Human Rights. ed.who. Statement of health. int/making_pregnancy_safer/publications/ StrategicApproach2006. New York. UNFPA (1994) Programme of Action of the International Conference on Population and Development. Cairo. 5-13 September 1994. Geneva. 7 . World Health Session of the United Nations Commission on Organization. Economic.

in the clinical and research communities of tions. 8 . and United Nations Population pregnancy. 2001). nutritional status. These reports stimulated factors associated with an elevated the substantial research of the past risk of death related to pregnancy. Canada. however. of mental ill-health carried by individuals. 1964) and in 1968 Pitt (1968) de- tiative aimed to address the com. Dramatic was not until the 1960s that systematic reports contrasts were apparent between industrialized were published of elevated rates of admission to and developing countries in terms of access to psychiatric hospital in the month after parturi- contraception. Takashi Izutsu I n 1997. cal facilities for childbirth. awareness has grown countries. tion (Robinson & Stewart. gave very limited consideration search has been conducted in Australia. sociodemographic. communities and societies. including the World Health Organization. including haem. and training and skill of are now the subject of considerable health workers (Lissner. antenatal care. servable in some women following health status and health service childbirth. rela- mortality or morbidity tively little evidence is available from developing countries. The determi- ductive choice. Paffenberger reported the trained medical and nursing staff nature and course of psychoses fol- to provide pregnancy and obstetric lowing childbirth (Paffenberger. infection. The ini. 1993). and In 1964. 1993). unsafe abortion. health care. The 2001 The most prominent risks to life were identi. access to childbirth and the postpartum year services. mental health during pregnancy. four decades into the nosology of Centrally important contributing psychiatric illness associated with factors were identified as: repro. medi. it Initiative (Tinker & Koblinsky. and the need for orrhage. psychological factors associated with health in World Bank. While there are historical references to dis- the Making Pregnancy Safer (Safe Motherhood) turbed behaviour associated with childbirth. childbirth and the postpartum pe- Fund. and the United States of America. 2001). and treatment strategies (WHO. fami- childbirth and the puerperium. Most re- tiative. and government agencies established riod. attention and concern. scribed an atypical depression ob- plex economic. nants and adverse effects of poor co-existing infectious diseases. 2 Chapter Pregnancy. to mental health as a determinant of maternal Europe. The multifaceted ini. pregnancy accurate understanding of risk factors and prev- illnesses. Meena Cabral de Mello. lies. childbirth and the postpartum period Jane Fisher. World Health Report was devoted to the burden fied as those directly associated with pregnancy. a number of international organiza. as pregnancy and childbirth have become safer and maternal mor- tality rates have declined. and complications of delivery. human reproduction. access to information. following a conference to address the gross disparities in maternal mortality rates between resource-poor and industrialized In the industrialized world. such as pre-eclampsia and gestational alence in order to introduce effective prevention diabetes.

Overall. apparent intercountry variations in rates of sui- cide. 2002. Chapter 2. Kumar. Women aged 10-19 years in a 10-year period in Vellore. 2004). 1997). It is suggested health services needed to address them (Stokoe. use of instru- 9 . Brockington. 1994.. restricted autonomy and greater likelihood of bour. 1994). violence .. because of lower risk of suicide than non-pregnant women the extent to which the problem is underesti. rates and determi. 2001. the stigma associated with births to unmarried aminations after suicide do not always include women (Kendell. Cerulli & Maine. (Marzuk et al. women often have more limited edu- The predominant focus in endeavours to reduce cational opportunities than men. especially among younger women.. Frautschi. the termination of pregnancy. 2003). Pregnancy. Pearson et al. of adverse pregnancy outcomes . 1997. a change (Brockington. In indus. 1991. who do this by self-poisoning. or men (Lee. Postmortem ex. sure to violence and suicide (WHO. Goodburn & mental health and higher risk of despair and Campbell. rates of suicide in pregnancy death or because systematic data are unavailable have declined over the past 50 years. Sharma. a highly significant relationship between expo.in the & Pasha.. at have proved difficult to determine. the uterine examination necessary to confirm pregnancy and studies that have examined pri- mary records in addition to death certificates Summary reviews have found that suicide have identified significant under-recognition in pregnancy is not common. Frautschi. 2001). and reduction in Filippi & Ronsmans. 1991. Socially stigmatized causes attributed to the increased availability of con- of death are less reliably recorded and probably traception. resort for women with an unwanted pregnancy trialized countries. herbicides. In particular. male to female deaths by suicide (Brockington. 1999. suicide tion. Maternal mortality data combine records of deaths occurring during pregnancy and up to 42 days after the end of a pregnancy and. Ji. Investigations when it happens. who lack the financial means to pay for an abor- Phillips. in particular self-poisoning by pesticides and ternal mortality (Frautschi. 2005). Frautschi et al. 2002. 2000. there is generally an excess of in settings where reproductive choice is limited. 2002). Ji. Fleischman et al. 2001). 1994).. 2001. Maine & Rosenfield.obstructed la. the ratio cy termination services are unavailable (Appleby.. paid to mental health as a contributing factor to Kleinman & Becker 2001. There are substantial Cerulli & Maine. Batra. 2003). with unwanted pregnancy or entrapment cy status or consider it as an explanatory factor in situations of sexual or physical abuse (Hjelmeland et al. for example. 1984. which are readily accessible in ru- 1994). under-recognized as a contributing factor to ma. specific data regarding suicide or par. Completion form of self-harm or of harm inflicted by others of suicide in South and East Asia is related in . or poverty (Brockington. Kleinman & Becker. In these settings. and appears to be the last asuicide in pregnancy are unavailable. 2001). Much less attention has been consequent self-harm (Brockington. 2004. In indus- mated or obscured in recording of causes of trialized countries.and on the being threatened with violence. however. less access to maternal deaths has been on the direct causes financial resources and control of expenditure. is reversed. 2001). Fikree maternal deaths. of stable mood and relative emotional well-be- nants of suicide in pregnancy or after childbirth ing and that pregnant women are. The 2001 World Health Report identified ral farming communities (Pearson et al. Graham.. (Weir. and legal pregnan- East Asia for which data are available. 2002. adolescent pregnancy. haemorrhage and infection . it is primarily associated of suicide in women often fail to report pregnan. in many Suicide is disproportionately associated with settings. Li & Zhang. Cerulli & Maine. However. childbirth and the postpartum period Mental health and maternal mortality Southern India (Aaron et al. 2003. 1994). therefore. that these gender disparities are linked to poorer 1991. in the countries of South and able to obtain contraceptives.during pregnancy or after childbirth has been part to the lethality of the method of self-harm. 2001. Hicks & Bhugra. It has been argued that pregnancy is a period Despite close investigation. affordable and accessible services for under-reported (Radovanovic. or who cannot obtain a legal abortion may accounted for 50-75% of all deaths in women attempt to induce abortion themselves. where single women are not legally 2001). Young who have suicide rates up to 25% higher than women who fear parental or social sanction. 1996).

compared from abortion-related complications was dis. recommend that the definition of maternal death partum period (Yip. deaths from hypertensive parisons indicate and found that 20% were due to suicide or ac- disorders of pregnancy that the rate of sui. There have been very few systematic studies and usually associated with severe depression of suicide after childbirth in developing coun- or postpartum psychosis (Appleby. which may occur much later in the post. Zacarias & Bergstrom when data collection was cide among women (2002). loss of pregnancy (Gissler & Hemminki. and was associated with age compared with mothers aged over 20 years under 25 years and being unmarried. or herbal and folk deaths in the United Kingdom in 1997-99 . espe- to use untrained service providers. proportionately higher among adolescents. teenage mothers aged under 17 years districts in Turkey found that suicide was one of were found to be at elevated risk of premature the five leading causes of death among women death. College of Obstetricians and Gynecologists now cide. 1998). deaths among 9894 women who had given birth were at least as prevalent as tion-based com. The deaths status was not reported (Tezcan & Guciz Dogan. (Hieu et al. but popula. cidental burns. In a detailed classification of cause of & Faragher. young women of low a number of adolescents had committed suicide socioeconomic status. of suicide after childbirth. Maternal United Kingdom. 2004). In the Health. the report of the Confidential suicide is associ. self-inflicted trauma. Mental health aspects of women’s reproductive health ments. in a review of pregnancy-related deaths extended to twelve months who have just given at Maputo Central Hospital. domestic violence. Reardon There has been relatively limited investigation et al.. more strongly. Lal et al. Two in Maharashtra. be. murder and sui- Deaths found that maternal suicide in mothers of cide. with childbirth. 2002). 1998). The Centers for the first 6 weeks postpartum probably leads to Disease Control and Prevention and the American underestimation of maternal mortality from sui. 1999. India. and that. including suicide. birth is not signifi. but in industrialized countries reported rates are lower than expected. India. accounted for 28% of maternal 10 . Hemminki & Lonnqvist. Seven of the nine suicide deaths death (Department of suicide rate (Oates. in three rural areas of Haryana. Mozambique. most probably groups are at increased risk of suicide in preg. 2003a). that all maternal deaths should be classified ened risk of infanticide (Brockington. Overall 14% of the deaths were by suicide deaths from psychological newborns (Appleby.. as occurring by violent or non-violent means Confining assessment of maternal mortality to (Department of Health. Granja. nation of the pregnancy. 2003b). 1999). miscarriage and. pregnancy (Otterblad Olausson et al. In adventure (Smith. in a population ness. Enquiries into Maternal Deaths recommended ated with a height. 1999).. 2001). 1991). particularly classified as to whether or not they occurred by substance abuse. 1996. and alcohol abuse of reproductive age. were in women aged less than 25 years. most usually suicide. 2002). In addition. in 1992. in postpartum.more remedies are at increased risk of death by mis. 2882 deaths during pregnancy or up to 42 days Attachment to the postpartum. than any other single cause (Oates. were not only associated with severe mental ill- 1990). should include any death of a woman while she is pregnant or within one calendar year of termi- Suicide in combination with other deaths at. 1999). suicide was the cantly different from attributable to pregnancy or coincidental illness leading cause of maternal the general female were by suicide. Gissler. Investigations in three Sweden. but were also related to domestic violence survey of mortality associated with abortion and the complications of substance abuse. Chung & Lee. found that death rates large data linkage studies found that. including accidents. These findings were at- to preserve the family honour without seeking tributed to either a risk factor common to both abortion. Ganatra & Hirve (2002). 1991-1995. and that these should be tributable to psychiatric problems. 1997). (1995) reviewed 219 causes. or depression associated with nancy (Church & Scanlan. pregnancy termination were associated with in- cause they were more likely than older women creased suicide risk in the following year. found that 9 of 27 (33%) deaths not overall. in three provinces in Viet Nam in The British Confidential infant appears to 1994-1995. Mortensen tries. Young women from minority ethnic depression and induced abortion. the leading cause (29%) was exter- Enquiries into Maternal reduce the risk of nal events. cially among unmarried.

which is limited to pregnancy 1999). 1996). 2002) argue that maternal concerns for infant well- being are protective. Holden. from unanticipated surgery (Farhi. from causes are significantly more likely to have been subject not related to or aggravated by the pregnancy or to domestic violence (Stark & Flitcraft. 20% lent in women than men in most countries. Violence- related maternal deaths are under-reported in Appleby & Turnbull (1995) found that rates of routine data collection and are often inaccurately self-harm treated in hospital in the first postna. and recovery Herbert & Reviere. studies using this instrument have not presented 1992. In ad. Stark & Parasuicide rates are 93 times higher in the Flitcraft. Pregnancy. is associated with low education and socioeco- nomic status. 1995. includ- on postpartum parasuicide in developing coun.. 1992. gested that parasuicide and suicide may also be nancy (Farber. Viet Nam. unwanted pregnancy and parasuicide are more common in adolescents without a psychiatric history who have experienced physical or sexual Maternal deaths by inflicted violence “dating violence” (Silverman et al. Dannenberg et al. and Zacarias & Bergstrom. Chapter 2. Fildes et al. Adamson (1996) has sug- history to have attempted suicide prior to preg.thoughts of suicide and attempts to that. 1999. Ben-Rafael & tory of sexual and physical abuse in childhood Dicker. par. Timar & Susanszky. et al. Most ings (Dannenberg et al. (1992) found that the leading cause of 1994) has reported that women who are severely death during pregnancy or after childbirth in depressed commonly have a positive score on one American county (accounting for 46. has a specific item and hospital records in addition to death cer- assessing the presence and intensity of suicidal tificates. companies vesicovaginal fistula in women in cy in adolescence (Adams & East. 1987). women who attempt suicide in pregnancy days of termination of pregnancy. 2001. Deaths from inflicted violence have been likely to occur in the early weeks of an unwel. 1996). 2003). Gissler & Hemminki. scrutiny of primary health. are termed pregnancy-related and suicide attempts by self-poisoning are most deaths. 1991. It acknowledged thoughts of wanting to die. 1999). but predominantly with childhood Intense grief reactions can accompany preg- sexual and physical abuse. coronor’s court ing and research instrument. 1999). but one of Cheng. regarded as incidental or chance events (Granja. Holden & Sagovsky. 1995). Wells & Holford. Herbert & Reviere.is up to 20 times more common attending infant health clinics six weeks post- (Brockington.3% of it. Women with a his. which suggests that it is not uncommon. 1995). using detailed Depression Scale (EPDS). mestic violence (Brockington. underascertained in standard recording of ma- come pregnancy (Czeizel.. childbirth and the postpartum period violent means (American College of Obstericians children and living in refugee camps in the and Gynecologists. 2001. its management. and the first 42 days postpartum. In pregnancy.. (1995) reported that 39% of Rahman & Hafeez (2003) report that more than deaths of pregnant or newly delivered women in one-third (36%) of mothers caring for young New York City were not directly related to the 11 . among a consecutive cohort of 506 women self-harm . 2001). Farber. Past consequences of the profound distress that ac- physical abuse is itself a risk factor for pregnan. Parsons & Harper. 2001). The Edinburgh Postnatal A number of meticulous studies. Both some developing countries. Although no systematic evidence are also more likely that those without such a is currently available. a widely used screen. Deaths of women during pregnancy or within 42 dition. ing homicide (57% of them) and suicide (9%). as well as damage to self-regard. 1994). There is a small emerging body of literature pregnancy-related deaths) was trauma. tal year were low in the United Kingdom. ternal mortality. Fisher et al. suicidal ideation year after treatment for ectopic pregnancy than and attempts at self-harm are significantly more among non-pregnant age-matched controls. common in women with a history of childhood this is interpreted as a response to the loss of sexual abuse than those without such a histo. have had remarkably consistent find- ideation (Cox. Fildes the scale’s developers (Holden. nancy loss and may increase parasuicide rates. had suicidal thoughts. Horon & data specifically related to this item. North West Frontier Province of Pakistan had a mental disorder and that 91% of these women Although completed suicide may be rare. tries. the pregnancy and the potential loss of fertility ry (Bayatpour. and sexual and do. Parasuicide is more preva. partum in Ho Chi Minh City. (2004) found asuicide .

. 1997). with a homicide. in terms of adverse cant depressive symptoms. In general. including unwanted conception. with torture by in-laws the most common 1997). 1987). In contrast to the substantial investigations of Only a few studies of the prevalence of antenatal women’s psychological functioning after child- depression in South and East Asian.. Gissler Depression in pregnancy & Hemminki (1999) reported that one-third of deaths in Finland in the year after childbirth or Llewellyn et al. her partner.. Batra (2003). Pregnancy was not record. and her wider social group. and that tive disorder was not diminished in pregnancy. Research antenatal clinics at a Singapore obstetric hospi- has generally focused on the risks for the fetus of tal. appear to sive symptoms have been nancy-related deaths in their investigation in increase depressive found among pregnant and Mozambique were by homicide and 22% were symptoms and con- non-pregnant women. Josefsson et al. Maryland. Parsons & Harper (1999) (Sharma. Otterblad Olausson libido. these studies concluded that maternal in pregnancy: the Da Costa et al.. are considered “normal” in pregnancy et al. including same-age peers Mental health and antenatal (Berthiaume et al.. more commonly following induced lowered energy. which was the leading cause of such lower rate of hospital admissions for psychiatric deaths in 1993-1998.. Chen et specifically to mental health during pregnancy al.. unmarried status. obstetric care providers were not aware of the severe risks faced by these individuals. 1989. women from minority ethnic ure to attend antenatal clinics. Zacarias called conflict and comparable rates of depres- & Bergstrom (2002) found that 37% of preg. risky women with complicated pregnancies were at 12 . including appetite change. (1997) suggest that certain symp- termination of pregnancy were attributable to toms of depression. USA. Three sourc- as high or higher than rates explanatory factor. Brugha et al. Kendell. homicide. although systematic representative interna. illness (Oppenheim. et al. es of support appear of postpartum depression to influence mood (Zuckerman et al. Stowe & Nemeroff. A range of psychosocial factors premature mortality later in life. 2001). 2001. morbidity Pajulo et al. 1989). in particular substance abuse. (2004) showed that violence inflicted on and their psychological significance is therefore adolescent mothers contributed to increased underestimated. the family of origin. in describing deaths tribute to reduced systematic studies have from burning among young married women in personal resources shown that rates of depres- India.8% of the deaths were sui. in particular 2001). relatively little research has been devoted South American countries are available. Conventionally. Granja. her mother. 2000. intimate partner vio. in particular re- well-being in pregnancy.. causes of death were expanded to include deaths ents. and reported that 20% had clinically signifi- poor maternal mental health. noted that 47. African or birth. Viguera et al.. reduced risk of suicide (Marzuk of multiple vital records was essential for ac. (2002) found that 51% of non-maternal deaths in North reported that risk of recurrence of bipolar affec- Carolina followed domestic violence. compared with has been associated with depression in pregnan- older mothers. However. 63% of which were by homicide and behaviours. due to violence inflicted by self or others. Mental health aspects of women’s reproductive health pregnancy.. (Bernazzani et al. fail- 13% by suicide. Young women and alterations to the intrauterine environment. so linkage & Platz. Despite the impression of ity. al. 1996. unemployment and low income (Pajulo et In developing countries. Certain early lence or violence from other family members experiences within is associated with increased maternal mortal. cy.. 1985. tional studies are unavailable. (2004) surveyed pregnant women attending (Llewellyn. Chalmers ed on 50% of the death certificates. sion in late pregnancy are cide. Horon & Cheng (2001) found pregnancy has been regarded as a period of gen- that 20% of all pregnancy-related deaths were by eral psychological well-being for women. In the county of of adverse obstetric outcome. Large accidents. Zuckerman et al. 1997) and lower rates of panic disorder curate identification. 1998. Evans mortality could be accurately ascertained only if woman’s own par- et al. 1997). and increased risk groups were at heightened risk. 2001. divorce. sleep disturbance and reduced abortion than a live birth.

stance abuse in pregnant adolescents (Bayatpour. recent investigations have re. bid diagnosis of post-traumatic stress disorder ternal stress or anxiety influenced either neona. 1989). en of low socioeconomic status (Glazer. 1983).. and the recommen- ety in pregnancy is harmful to the fetus and dations have been criticised for failing to take contributes to adverse obstetric outcomes. 1980). community in Tamil Nadu. (PTSD) are more likely than those without PTSD tal health or obstetric outcome.. Anxiety in pregnancy is violence and financial concerns (Kitamura et al. exercise (but not to excess). Subclinical levels of themselves if they are poor or have restricted ac- anxiety vary normally through pregnancy. associated with depression arising from conflict being and childbirth (Lubin. 2002. In a detailed and comprehensive review. Elliott et al. Pregnant women are generally encouraged to Risk was increased among the poorest women modify their self-care and personal habits to and those experiencing coincidental adverse life ensure optimal maternal and fetal health. Chapter 2. less well-educated wom. 2001).. Pajulo et al. 1990). India. rest. & Glover. 2000).. a previous termination of anxiety in the last trimester of pregnancy. and found (1989) demonstrated that smoking in pregnancy that 16.. (1998) found that 12% were de. in marital and family relationships. Fisk & Glover. Gardener & Roth. 1992)..4% nal anxiety in pregnancy has adverse effects on of 157 Hong Kong Chinese women in advanced birth weight (Texiera. edge of the health and development of her baby Da Silva et al. with suggestions that mater- 13 . Both maturational force in impelling women to pre. age and reproductive choice in attributing and delay in accessing antenatal care are linked poor pregnancy outcomes to women’s mental to insufficient social support (Webster et al. Adeyemi & on later behavioural and emotional problems Oladimeji (2004) found higher rates of depres. (Perkin. cult for women to ensure adequate nutrition for nant (Diket & Nolan. Fatoye. Anxiety is likely pressed in late pregnancy. 2001). acquired through antenatal care. O’Connor. Pregnancy. 1980). These recent stud- Nigeria. and are Smoking and substance abuse in pregnancy are specifically focused on infant health and well. (2004a) found that 6. Iqbal & Harrington (2003) established and that psychological and social factors had no that 25% of pregnant women attending services direct effect independent of smoking. Istvan Wells & Holford. (Moylan et al. (2002) found that (2002) interviewed a consecutive cohort of 359 maternal anxiety did not affect fetal movements women registered for antenatal care in a rural or fetal heart rate in late pregnancy. Brooke et al. Bullock et al. ma. Glover & sive and anxious symptoms in pregnant wom. Women who smoke in pregnancy have poorer Elevated anxiety may have adaptive value as a nutritional intake (Haste et al. and that depression to be higher in women who know that their in- was associated with insufficient support from fant’s intrauterine development is compromised the partner and lower parity. It is diffi- pregnant women and those who are not preg. 1997). includes advice to alter their diet. Lee et al. and a previous caesarean birth. avoid alcohol. Chandran et al.. 1999) and pregnancy were depressed. Sjostrom et al. relax and have regular health checks. This events. 1996. in Kahuta.. O’Connor. The into account personal circumstances and social incidence of anxiety disorders is the same in realities (Lumley & Astbury. domestic 1975. Pregnant women who (1986) concluded that there was little evidence are dependent on opiates and have a co-mor- to support the contention that. However. stop smoking cigarettes. were depressed in the third trimester of pregnancy. in humans. In a failed to take into account the mother’s knowl- small study of 33 low-income Brazilian women. Heron. gain a specified amount Anxiety in pregnancy of weight. in the children (Glover et al. in assessing a polygamous partner. with cess to shared resources (Nga & Morrow. 2002.2% were depressed in the last trimester. visited the issue. peaks in the first and third trimester. was the main determinant of low birth weight Rahman. perienced severe conflict in their family of origin count for the complex interactive effects of pov. childbirth and the postpartum period elevated risk. Poorer health in pregnancy erty. O’Connor et al. physical and sexual abuse are predictive of sub- pare for a major life transition (Astbury. 1999). health. en than in matched non-pregnant women in 2002. 2002). Depression was associated with having ies have been criticised because. He commented to have a history of sexual abuse and to have ex- further that previous research had failed to ac.. 2001. The evidence for There has been a widely held belief that anxi. some of this advice is poor. higher among younger. they pregnancy. 1999). a rural community in Pakistan.

2003). prohibits this practice. tion of pregnancy for fetal abnormality. 1997)... 1998.5% in an American logical consequences of first trimester termina.. 1997). it is therefore reasonable to tal abnormality. Most re. the other. and during pregnancy on the overall experience of chorionic villus sampling to determine fetal sex. Rahman. and 22% among women 14 . which may still be evident 2-6 years after the birth (Hall. the psychological conse- focused on the determinants of informed. Iqbal & late pregnancy loss (after 20 weeks) due to fe. Women can be blamed for sex determination Termination of pregnancy for fetal abnormality is and may not be able to make a free choice about relatively rare. 1990a).. have a modest adverse pregnancy effect on parental adjustment. there is a preference for sons Marteau. amniocentesis. 1998). also generate anxiety (Green. Hunfeld et al. 15. Those with prior pregnancy loss social reaction to the conception of a daughter. Decision-making about first-trimester 1990a). screening may be beneficial. participation in prenatal genetic screening and India and the Republic of Korea (Fathalla. and is likely to have a different meaning. it is known to persist. Systematic and female fetuses may subsequently be aborted investigations are difficult because services are selectively (Kristof. in settings with restrictions on family effective reassurance (Marteau et al. Inflicted violence and mental health in terpreted as re-evoked grief about the previous pregnancy loss. and 8% of pregnancies (Petersen et al. pregnancy and the postnatal period.. (Cokkinides et al. ing psychological consequences (Green. 2003). but can have significant and last. 1993). au. Although legislation changing rapidly. encouraging parents to believe they are giving Cultural preferences and mental health in birth to a healthy child. Hunfeld et al. 1999).7% among women attending an ante- search on first-trimester abortion has focused on natal clinic in a hospital in Hong Kong. 2002. 1999). 2001). (1997) compared 27 women with a history of 2002. China (Leung et al. 2000). Bobrow & In many cultures. and little is known about the psycho. the fact that many affected pregnancies.. diagnosis. The birth of a There is little social understanding or support daughter was found to contribute independently for either parents or the health professionals in. and research is worse if there is a long interval between the findings for one group cannot be generalized to test and the result becoming available (Green. with 27 mothers of newborns without may also be adversely affected by the family and such a history. been systematically investigated. but may persist (Keenan et al. if left. 1998. Rodrigues & DeSouza. Although will terminate spontaneously (McFadyen et al. 1990a).. Bandyopadhyay. prenatal care programme (Covington et al. Clinicians can use tech- psychological impact of increased surveillance niques such as ultrasound. Mental health aspects of women’s reproductive health In addition to social factors. who subsequently had a live speculate that mental health during pregnancy birth. and Pakistan (Patel. continuing or terminating a pregnancy (Fathalla. 2003).. 1991).. This oc. Prenatal screening although higher rates have been reported: 11% and diagnosis can now be carried out early in in South Carolina between 1993 and 1995 pregnancy. Termination of a planned and wanted pregnancy curs independently of the results of the test. Normal or pregnancy termination associated with sex results in follow-up tests do not always provide selection. In the past decade. size and a preference for male children. There is currently no evidence of the Bandyopadhyay. Wladimiroff & Passchier. this was in. 13.. Chandran et al. had significantly greater anxiety and depression than women without such a history. False-negative results of prenatal screening. anxieties are un. to postpartum depression in women in India volved (Kolker & Burke. participation in those carried out for social reasons. after which prenatal genetic screening and diagnosis can psychological morbidity is low (Adler. 2000). women whose fetus is actually healthy. Country-level ices. quences of this for pregnant women have not tonomous decision making and uptake of serv. 1993). They also perceived their infants as having more problems and were more anxious about Violence is estimated to occur in between 4% infant care (Hunfeld. There is no evidence on the psychologi- necessarily aroused by false-positive results for cal aspects of forced termination of pregnancy. Harrington. research has rather than daughters. The anxiety can be modified by skilled abortion for fetal abnormality is complicated by genetic counselling and psychosocial support. but not on the emotional consequences of sex ratios are skewed in favour of males in China. 1994. 1992).

5% The birth of an infant relinquish her autonomy. The adaptation to her ited evidence is new required roles. the extent to which perinatal psychological dis- order should be regarded as a normal process. in a sample of demands a dramatic cupational identity. 1994). major responsibilities. heightened sensitivity. adaptation by come. morbidity (1997) reported In becoming a mother. poor concentration. and of natal outcomes.anorexia nervosa or bulimia nervosa bility (Yalom et al. They are at increased risk of reality and detachment from the baby have also miscarriage and intrauterine growth retardation. childbirth and the postpartum period attending a routine antenatal clinic in Nagpur.may be unwilling to disclose these conditions sleep (Wilkie & Shapiro. and psychosocial factors. while Webster. capacity to generate an in. childbirth and that some women experience psy- nificantly more likely to rate their relationship chiatric illness. Chapter 2. parent generation. in the days immediately following childbirth (Pitt. 1968. cal case of psychiatric morbidity using the WHO Psychological disequilibrium is normal during Self Reporting Questionnaire on the second day life transitions and in adapting to change. personal liberty. for some. There is now a consist- Shumway et al. Investigations have focused on the links after childbirth are clinically distinct from those between violence and adverse maternal and neo. Debate continues about whether with their male partner as poor (Cloutier et al. anxiety and irrita- disorder . feelings of un- during routine care. are sig. 1986). The syn- Eating disorders and pregnancy drome is characterized by a range of symptoms.. However Muhajarine & ent view that psychological disturbance follow- D’Arcy (1999) found that women who had ex. 15 . 2000). 24. available about ing from being in the childless generation to the postpartum blues in developing countries. Stewart & disturbance Cecutti (1993) found that abused women in a range of prenatal care settings were significantly Maternity. depression events. which have reported rates in non-Anglophone countries ranging from 13% to Mental health and postpartum 50% (Howard. a woman often has to a rate of 42. of differing se- higher stress and more coincidental adverse life verity: transient mood disturbance. increased unpaid workload Davidson (1972) reported that 60% of newly de- and.5% of Arab women met the criteria for a clini- logical resources and on existing relationships. 1999). and after birth. and may have co-morbid depression and anxiety There have been a small number of specific tran- (Franko & Spurrell.. Stein. Pregnancy. scultural studies of the nature and incidence of postpartum blues. 1993). Kumar. there is continuing theoretical consideration of India (Purwar et al. third day or postpartum blues are a more emotionally distressed than non-abused phenomenon occurring in up to 80% of women women. tear- psychological conditions in pregnancy. most commonly a lability of mood between eu- There has been much less exploration of other phoria and misery. been reported (Robinson & Stewart. fulness often without associated sadness. Very lim. psychiatric illnesses occurring in pregnancy or 2002). 1997. there is now substantial evidence that during pregnancy.. rest- there is evidence that women with an eating lessness. & Battistutta and psychotic illness. including verbal aggression women’s mental health can be compromised by and minor and severe physical abuse. Chandler. 1992). However. ing childbirth can be conceptualized as fitting perienced physical abuse in pregnancy reported one of three distinct conditions. Women who are the victims of domestic violence However. oc. 1993. Disturbed . 1973. observed at other phases of the life cycle.. with relatively little emphasis the relative etiological contributions of biological to date on mental health (Petersen et al. (1996) reported that they were more likely to be taking antidepressant medication than women Postpartum blues or mild transient mood who had not experienced violence. of caring for the infant. harm to bodily integrity through livered women in Jamaica were tearful or sad. and social and leisure activities in favour ers. unexpected adverse reproductive events places while Ghubash & Abou-Saleh (1997) found that great demands both on individual psycho. 1982). Kennerley & Gath. 1999). mov. Sutter et al. French moth.. women.

patterns may reflect intercountry differences rates of schizophrenic psychotic episodes are not in diagnostic criteria (Howard. ted to hospital with postpartum mental illness turbed behaviour and confusion (Marks et al.. ated with organic illness. including confusional 16 . of postnatal psychotic illnesses. 1982. but Postpartum psychotic illness there is some evidence that caesarean delivery increases the risk of postpartum psychosis and A very small group of women (approximately of relapse after subsequent births (Kendell et 1 or 2 per 1000) develop an acute psychosis al. However. cal limitations in existing studies (Pfuhlmann. 1993. obstetric factors (Condon & Watson. Both Howard (1993) and Kumar (1994) Dean. predict later development the precipitating factor (Pfuhlmann. birth have been identified (Howard. 1991) to the incidence or sever. America report higher rates of puerperal psycho- Scottish Intercollegiate Guidelines Network. diagnose. in some women a more per. 1998). Mental health aspects of women’s reproductive health The coincidence of the maternity blues with the ment is similar.. However. delusions. Pfuhlmann.. Similarly. Investigations of women admit- thought disorder. dis. 1987). Kumar. Kendell. tion. and usually psychoses and the possibilities of meta-analysis resolves spontaneously without specialist inter. Postpartum psychosis has 1997). with mania and elation as well as sadness. sis. Stoeber & Beckmann. Winokur & 1994). highlighted the higher incidence in develop- Brockington. Relative lifetime risk and incidence of psychotic episodes and by marital difficulties are usually calculated in terms of psychiatric (Marks et al. unmarried predict. 2002). However. prevent. ing childbirth (Kendell. individual with an existing diagnosis of bipolar cal basis to the condition. Kendell. Sutter et al. family history blues.. but these construed as episodes of cycloid affective illness. Chalmers & Platz. to whether puerperal psychotic episodes in an rition has led investigators to look for a biologi. 1993. 1988). 1994). Steiner’s (1998) summary review con. Systematic international comparisons of the encing a psychotic illness is highly elevated for prevalence.. McNeil & Blenow. 1980). with childbirth as unable to stop crying.. Chalmers & Platz.. personal or cluded that the evidence base was insufficient to family history of affective psychosis. the same as first episodes following childbirth Steiner. Kumar. the some evidence that the more severe symptoms of timing of onset of the illness. 1988). 1994. 1987. veloping countries. 2002). 1991. Stoeber & 1987. hallucinations. Chalmers & Platz. been associated with primiparity. ing countries of puerperal psychoses associ- Stoeber & Beckmann. 1995). are not available. Pfuhlmann. to elucidate this are restricted by methodologi- vention.. for two years follow. admissions for treatment of psychotic illness after childbirth. there is no consistent (Pfuhlmann. or personal or family history of mood disorder There is continuing conjecture about the relative (O’Hara et al. Beckmann. contributions of biological and psychosocial etio- ity of the condition. this is the Puerperal and non-puerperal episodes of psy- most severe psychiatric illness associated with chosis are predicted most strongly by a history childbirth. 1987. 1992. psychotic illnesses following child- include acute onset and extreme affective varia. Nott.. Oakley. sistent and severe depression develops. status and perinatal death of an infant (Kendell. 1981. but at a lower rate. 2002). 1992). in all countries in which studies have been McNeil & Blenow. within the first month postpartum. 2002. in countries outside Western Europe and North 1992. Stoeber & Beckmann. 1985. The distress peaks between logical factors to the development of postpartum three and five days postpartum. hospital or home as place Beckmann. including early self-reports of feeling de. elevated postnatally (Brockington. treat or give prognos. Schizophrenia is reported more commonly 2002). having thoughts about death or being derlying biological etiology. including in de- evated. Stoeber & of depression (O’Hara et al. affective disorder should be understood to be erally inconsistent (Robinson & Stewart. There is Stoeber & Beckmann. there is a divergence of views as major hormonal changes associated with partu. clinical characteristics and course the first thirty days postpartum and remains el. 2002). tic indicators for the maternity blues. Kumar. 1981. Although treat. Postpartum psychoses are most accurately than affective illness in those settings. but findings are gen. and molecular genetic studies support an un- pressed. Clinical characteristics conducted. Pop et al. 1993. between 51% and 69% (Pfuhlmann. of delivery (Kendell et al. 1981). Risk evidence for the contribution of parity (Kendell of recurrence after subsequent pregnancies is et al. The risk for women of experi. The contribution of obstetric factors is not clear. 2002). 1982.

Nimgaonkar. IV) (American Psychiatric Association 1994). and many are parents (McGrath et al. course and cally postnatal in onset (Cooper & Murray. frequency of sexual activity may be & Chapman. Although on- reported in industrialized countries. Postpartum depression Over the lifespan. or first occurs and young children (Epperson. There is a clustering of new cases around childbirth. 2000). 1997. 2002). of women with pre-existing chronic severe men- tal illness (Kumar. childbirth and the postpartum period states related to fever from infections or to poor category of postpartum depression. there is consistent evidence that 10-15% ilies. The children of parents with psychiatric illnesses are at increased risk of ne- glect or inadequate care and the later develop- ment of psychopathology (Kumar. 1993.. dition. co-exist. women experi- ence major depression between 1. in the first five weeks postpartum (Cox. Cole. episode of either mild (four symptoms). Pregnancy. Severe depression. This difference is most It is still not clear whether postnatal depression is apparent in the life phase of caring for infants a continuation of an existing state. which is argued to be distinc- Postpartum depression is a clinical and research tive (Cramer. moder- chosis within six weeks of giving birth in the ate (five symptoms).6 and 2. Ndosi & Mtawali (2002) described fies depression after childbirth as a depressive a case series of 86 women who developed psy. this effect is less marked for women than of women in industrialized countries will expe- for men.6 times more often than men. 1998. and there is now an extensive literature delivery a depression can be regarded as specifi- on its nature. Paykel. The after childbirth (O’Hara & Zekoski. with agitation. reproductive mental and physical health needs 2002). occurs in 3-7% of women promised (Thomas et al. Murray tal illness. 2000). associations with risk and protective factors. 1994). 1993). Nimgoankar et al. pression in the fourth edition of the Diagnostic mon and 80% of the illnesses were categorized and Statistical Manual of Mental Disorders (DSM as organic psychoses. and classi- nutrition. Paykel. The 9 months postpartum. prevalence. 2002). 1999. rience non-psychotic clinical depression in the 1999. While there is debate about whether depression Although people with schizophrenic illnesses following childbirth is a clinically distinct con- appear to have reduced fertility and smaller fam. inpatient treatment. after delivery..8% of cases of depression (WHO. 1996. Epperson. normal. O’Hara & Swain. Chaudron et al..2 per 1000 was approximately double that guilt or suicidal thoughts or acts).. Nimgoankar et al. (2001) International Classification of Diseases (ICD 10) demonstrated that 5. feelings of worthlessness or of 3. year after giving birth. but Nott (1987) found that jor or minor depression arising after childbirth the highest incidence of new cases occurred 3- (Cox. Most of the set within one month of giving birth is specified women were young and primiparous. Paykel. 1997. Astbury. 1988). 1994. 1992) does not have a specific diagnostic identified at four months postpartum were not 17 . Cole. with most developing it 1997). Chapter 2. Depression arising after childbirth has at. month of parturition. 1996. how long the postpartum period should be con- tracted substantial research interest in the past sidered to last. it is not distinguished nosologically from depres- There is much less evidence about the complex sive episodes in general (Cramer. for an episode to be labelled as postpartum de- ing anaemia and infectious illnesses were com. Hipwell & Lawson. Oates. multiple psychosocial difficulties experienced by those with severe chronic mental illnesses can have adverse effects on the formation of mother- infant attachment. and therefore for how long after 40 years. prediction. but contraceptive use may be lower and Epperson. or severe (at least five symp- United Republic of Tanzania. 1993. 1999). 1989. needing autonomous reproductive decision-making com. Hipwell & Lawson. Among those with severe chronic men. DSM IV specifies within a construct used to describe an episode of ma. 1994. on average. There is also a lack of clarity over 2001). the incidence rate toms. 1999.

Scottish Intercollegiate weeks of cognitive and affec. in which individuals Nemeroff. of adjustment ex.. ing transient dys. can be observed in tered mood after childbirth. O’Hara & Swain. Most conceptualizations in support of a biological etiology (Stowe & take a categorical approach. Romito. However. Altshuler & Suri. elevated anxiety. 1998. although cal case. 2002). Postpartum depression is of se. iron deficiency anaemia. netic vulnerability. 1998. not be attributed to “over-simplistic biological or hormonal explanations for the female excess be- Biological risk factors for postpartum cause few biological parameters show this degree depression of variability”. Postpartum 1991). tive symptoms including: low phoria and symp- mood. 2002). 1998. Fisher. 1999). most women post. Links between postpartum number of risk and protective factors (Cramer. includ. loss are linked to hyperthyroidism. tribution is derived from a number of sources. population) (Hendrick. drawal. ent presence for at least two processes. In prac- tice. fective disorder. gue that adjustment strated (Robinson & Stewart. Scottish Intercollegiate Guidelines fective illness and alcohol dependence are cited Network. function. Some authors. 1996. Evidence that a range of psychological. Wilson et al. tional well-being or Epperson. He concludes that women’s vul- nerability to depression is attributable to social. 1996. The causes of depression in the postpartum peri. 2002).. 1999). ment of maternal confidence and the cognitive. 1997. Mental health aspects of women’s reproductive health apparent at one month. Two medical conditions may contribute to al- self-deprecation. 18 . 2001. tematic reviews have concluded that. despondency. summary and sys- are classified as satisfying the criteria for a clini. The prevalence of schizophrenia and bipolar af- rious public health concern because of its dem. 1998. Mood in the first haemorrhage and lactation are associated with year after child. 1989. and that a months postpartum (7% versus 3% in the wider rumination and social with. partum. fatigue. Nevertheless. depression and a history of premenstrual mood 1993. Altshuler & Suri. partum depression is more substantial than that social factors. The somatic symp. a direct link Feekery & Rowe. guilt. normal thyroid function is higher in the first six ritability. Beck. lowered mood and impaired but are not uncommon in periences may be volition have been associated with hypothy- normal postpartum adjust. ir. 2001). Evans et al. and there hormonal changes that follow childbirth and are is a general view that postpartum depression is involved in lactation may precipitate or maintain unlikely to be attributable to a single cause. for biological explanatory models. change or increased familial vulnerability to af. toms of depression. research.. ly vulnerable to hormonal change. 1999). Patel (2005) argues cogently that sex differences emotional and social development of their infant in the prevalence of depression and anxiety can- (Murray. continuum of emo. postpartum depression has not yet been demon- characterized by the persist. the arguments concern the social and economic factors contribute to post- relative contributions of biological and psycho. or are regarded as well. between hormones or other neurochemicals and Postpartum depression is Murray. some women may be particularly psychological- however (Green. debate and control. is similar in men and women. associations between risk factors and conditions Biochemical hypotheses hold that the dramatic cannot be interpreted as causal links. a more accurate roidism. Although most women with toms of sleep and appetite a broad spectrum postpartum depression have normal thyroid disturbance are also present. conceptualization. Guidelines Network. 1993. Broadly. & Chaloner. for which there is evidence of ge- onstrated adverse consequences on the develop. 1995). while agitation and excessive weight ment (Campbell & Cohn. Hendrick. ar. it is common for any episode of depression Psychosocial risk factors for during this period to be regarded as linked to the birth (Scottish Intercollegiate Guidelines postpartum depression Network. economic and cultural factors beyond individual od are still the subject of controversy. and determined by multiple factors (Gjerdingen These conditions are often under-recognized. which contributes to birth is dynamic fatigue and lowered mood (Epperson. 2002). but depression (Hendrick. is probably the outcome of the interaction of a Epperson. 1999). Altshuler & Suri. anhedonia. Murray et al. 1994. The evidence for a biological con. The incidence of ab- impaired concentration.

Men Beck. Chapter 2. 2003).. Douglas. al. the factors that contribute to women are more likely to be irritable and so- disturbed affect in women are not well under. low sat..variously described as inability to confide in an chological symptoms was during mid-pregnancy. and 2. previous has been found to distinguish depressed from psychiatric hospitalization. 1996. They found that the greatest level of psy- . Very ever systematic prospective studies of men’s psy- similar findings have emerged from transcultur. intimate partner or lack of support. Dimitrovsky. 1994. 3% port (Paykel et al.... ship have been variously conceptualized as: Rates of depression among men in the post- increased marital conflict (Kumar & Robson. 2000). (Stowe & Nemeroff. 1998. Pakistan (Rahman. 2002. among fathers in the Avon Longitudinal Study Hirshberg & Istkowitz.. found to be predictive of postpartum depres. in infant care (Romito. The alternative and childhood sexual and physical abuse (Buist proposition . The relationship with the partner also of fathers (Skari et al. 1994). relationship between mother and infant. Although this phenomenon is Some authors have suggested that depressed widely observed. themselves become depressed or anxious. Boyce. Iqbal sion (O’Hara et al. Scottish Intercollegiate Guidelines Network. non-depressed women in Hong Kong. 2001). Wilson et al. 1980. 1991. 1995. Webster et al.2% among Irish fathers port (O’Hara.. 2003) and Viet Nam (Fisher et al. Scottish Intercollegiate Guidelines are not at elevated risk of psychotic illness after Network. (Areias et al.. responses from her intimate”. the birth of a baby (Marks & Lovestone. 1991. in particular mood disorder may be providing less care for their partners. poor adjustment of Pregnancy and Childhood (Deater-Deckard et or unhappiness (Webster et al. symptoms were found in 9% of mothers and 2% 1996). insufficient involvement four months postpartum (Matthey et al. O’Hara & Swain. ated with postpartum mood disorders.. overall there mate parenting to their infants (Douglas. & Harrington. 2002). ed that men may feel excluded from the intimate tor of depression after childbirth (Romito. 1997). into whether men’s mental health might also be dren’s safety and feel inhibited in providing inti. 1996. childbirth and the postpartum period A personal history of mood disorder. 2004). 2001. or arguments and that there was actually some improvement and tension in the relationship . 2002). A poor quality of marital relationship fathers. 2002). and that for this reason they stood. especially poor maternal choose a partner incapable of providing care care and neglect in childhood (Boyce. 1995). Marks & Lovestone (1995) postulat- her partner is now regarded as a major predic. chological well-being. 2002).is centrally re. 1998). Beck. Pregnancy. 2000). and providing insufficient practical sup... Rodrigues et al. and only 1. Women who have been sexually abused in childhood Although there have been some investigations have increased anxiety about their own chil. and anxious or de. lated to women’s mental health postpartum. Condon. 2003). China pressed mood in pregnancy are consistently (Chan et al. and O’Hara & Swain. a woman who is depressed postnatally “may be However. Boyce et al. Studies consistently assess prevalence of may be difficult for their partners to relate to. 1993). involving 312 first-time al studies. men being less available after deliv. Brazil (Da Silva et al. usually been considered.. severe postpartum intrusive stress traditional sex role expectations (Wilson et al. six weeks postpartum (Lane et al.. 1989. or and alcohol dependence in the family of origin may perceive their relationship as poor (Cramer. particularly incapable of evoking additional care lence have rarely been considered or assessed. has been much less systematic examination of perinatal psychological functioning in men than A poor relationship between the woman and in women. and holding rigid In one study.. 1. 1996.. histories of abuse or exposure to vio.. 1997. 1987). 1994). partum period appear to be low: less than 5% 1984). Boyce & appears to significantly affect the time taken to Corkindale (2004) conducted one of the first- recover (Gjerdingen & Chaloner. 2001) contrib. ners contributes to maternal depression .9% of the sample had a clinically signifi- 19 . adversely affected by childbirth. 1995).8% among Australian fathers isfaction (Beck. 1986) or poor emotional sup. 1996). 2000). 2001. Cooper & Murray. or psychiatric illness. Overall. 1989). and report elevat. Perez. cially withdrawn. The problems in this relation. and support from her partner” or “may tend to Poor parental care. Hickie & Parker (1991) stated that ed rates in those with postpartum depression. in mood by three months postpartum. India (Chandran et al. Buist & Janson..that the behaviour of male part- & Barnett. Hickie & or to behave in a way which elicits uncaring Parker. among Portuguese fathers 12 weeks postpartum ery.has not ute to adult depression and appear to be associ.

Beck. Chaudron scores on the EPDS were reported 2-3 days after et al. Webster et al. A prospective cohort study of been found to be more common among young 838 parturient Chinese women in Hong Kong. identified a are depressed than those who are not depressed tendency to promote the idea of “female maso- (Mills. Scottish Intercollegiate Guidelines timidation and actual experience of abuse were Network. The authors suggest that distress may be literature has generally failed to acknowledge or expressed in other ways. 1-2 days after discharge from hospital. especially if compounded by being terms of sociodemographic factors. have babies at a different time than most of their and six weeks postpartum than among those peers have social needs that are not met.. 2002. China (Leung et al.. 2001). 2002. 1998. 2002. Stewart & Robinson (1996). & Gath. General dissatisfac- Parker. is related using the Intimate Bonds Measure (Wilhelm & to postpartum depression. 2001). and that screening instruments may require different cut-off scores to detect clinically significant symptoms in men and in women. ships and lack of assistance in crises.. fear of in. Cooper. using the Abuse Feggetter. although the unable to speak the local language and under- abused women were more likely to report that stand and obtain local services. Unfortunately.. 2002). experienced an act of physical violence in the International studies have also found that a lack previous year. Parvin. Inandi et al. (2000). 1989. Chandran et chism … [suggesting] that women are in some al. 1994. pression after childbirth. control. 1993. coercion. Schweitzer.. Lehert & who had experienced domestic violence. leaving violent relationships. in a riod. and verbal or physical violence by an intimate partner on whom the woman is de- pendent. Among women has also been implicated (Dennerstein. including as critical and coercive (Fisher. or if they percieved their partners of practical assistance from family. tion with available support. 2004). 1994. humiliation. Women the risk of difficulties in adjusting to parenthood admitted to an early parenting service were sig. However. but that men actually dependence and desire to maintain the integrity experience little mood change during the period of their relationship.. found that women whose partner. intimida. rather than specific ships were characterized by high levels of con.. Social with no experience of violence.6% had been 1994). and it is possible that women who delivery. Boyce. Matthey et al. perhaps as increased examine the social factors. is more commonly reported by women who review of the literature on violence. Logan & cluding having few friends or confiding relation- Strassberg (1992). Iqbal & 20 . including financial alcohol use or irritability. is causally linked to depression and anxiety (Astbury. Astbury et al. also heightens their pregnancy had been unplanned. mothers and single women (Paykel et al. Jones & Hull.. Poor social support.. The birth. Feekery & Rowe- dedicated care during the early postpartum pe- Murray. 2001. Webster et al. 1981. Fisher et nificantly more likely to be depressed if they had al. 2002). that prevent women from of their partner’s pregnancy and after the birth.. 1980. of postpartum depression. appears to be relevant (Boyce et al. Postpartum depression has not ascertained. Finchilescu & Lea. 1995. in- Hickie & Parker (1991). There was no disruption associated with recent immigration difference between the two groups of women in or relocation. most re- search on the etiology of postpartum depression has not assessed the effect of coercion. higher Riphagen. Having a first child at over 30 years of age abused in the previous year. Rahman. (Howard. Assessment Screen. Violence against women by their intimate part- ners has been described as “the most prevalent … gender-based cause of depression in women” (Astbury. found that 16. and Matthey et al. 2002). 2001). (2001) suggest that distress may be under-reported by men. Criticism. 1988). Mental health aspects of women’s reproductive health cant score on the EPDS at three months after the way responsible for their own victimisation”. Broader social factors are also associated with de- tion and violence by the intimate partner. characteristics or number or quality of relation- trol and low levels of care were at increased risk ships.

In general there is no correlation such as bereavement. 1996. ness in the family. especially criti. 2003. 2000). 1980. Others have examined the impact of particular Adverse life events coincidental with childbirth. 2002). 1991. crowded living con- found to be more common among women who ditions and lack of privacy are associated with are depressed in both qualitative (Rodrigues et higher rates of maternal depression (Chandran al. including a propensity to be tage exerts pervasive adverse effects that may not uncomplaining.. 1994). Rahman. 1996)... Astbury 21 . using and no access to employment that allow them two approaches. are more likely to be structed composite scores to assess cumulative depressed (Chandran et al. 1998. Social disadvan. Iqbal & et al. 2001. Lee et al.. Scottish Intercollegiate sion (Paykel et al.. 1995. Beck. Rodrigues et al. 1980).. 2004b). Scottish Intercollegiate et al. 2003. 2003. 2002. 2004b). over-eager- to be more likely to be depressed include: partu. poorly educated of sexual violence or forced intercourse to un- women in low-status occupations are less like. A meta-analysis do not have a job to return to after a period of by Beck (2001) identified low self-esteem as an maternity leave (Warner et al. compliant.. 2002. Rubertsson et al. bereavement or serious ill- ships with the partner’s family. and be asso- Although some have argued that socioeconomic ciated with depression (Kumar & Robson. Fisher et al. Inandi et al. the partner not having an in- cal coercion from the mother-in-law. Hickie & Parker.. obsessiveness.. Fatoye.. Problematic relation. The contribution tested accurately since young. between cumulative exposure to obstetric pro- ily. Astbury et al. However. ment in women.. Chaudron Grazioli & Terry. studies. 2004. In al. Chapter 2. 2003. 2000...consistently have a bet.. 2003. who have low education postpartum mood has been considered. 2002. Rahman. 2002).. ter mood in pregnancy and the postpartum year particularly at times of major life transition. procedures. Some investigators have con- time to care for their infant. examined. 1984. These include: heightened (Kermode. 1984. Fisher et Intercollegiate Guidelines Network. Boyce et al.. status is not associated with postpartum depres.. 2004. those who Guidelines Network. Fisher problems. cated in the propensity to become depressed. pregnancy does not necessarily diminish during pregnancy. Boyce & Mason. 2003. Oladimeji.. 1996. 2002). Rodrigues et al.. social and cultural desired or work for more hours than desired factors that contribute to personality develop- (Gjerdingen & Chaloner. 2004). Lee et tress associated with an unwanted or unwelcome al. that maternal mental health is directly affected by poverty in resource-poor countries (Cooper Physical health and postpartum et al. 2002. Patel et al. lack of assertiveness and timidity. 2001. 2005). If this practical ded. exposure to obstetric interventions. conflict with friends... and those independent risk factor for postpartum depres- who have to resume employment sooner than sion. ment to parenthood more difficult and distress- icated support is available from a supportive and ing (Kumar & Robson. Women receiving obstetric care in the private health care sector . Fisher & Jolley. can make the psychological adjust- et al.. Righetti-Veltema et al.. Fisher et al. Fisher et al. 2002. uncritical person. or serious financial cedures and mood (Elliott et al. 2004).who are likely to be of higher Certain aspects of personality are also impli- socioeconomic status . and retained in. 2003. Groups found sensitivity to the opinions of others. 2004). Iqbal & Harrington. the familial. Elliott et al. 2004. in- than those receiving care in the public sector cluding childbirth.. O’Hara and Swain. can persist postpartum. this claim has not been Guidelines Network. Adeyemi & correlated the scores with later mood (Oakley. rient women who are unemployed or in low-sta. it is psychologically protective 1996. 1984. Iqbal Harrington. ness to please.. and then 2002. serious illness in the fam.. and unassertive and be distinguishable in settings where poverty is to have a low sense of entitlement. Inandi et al.) and survey investigations (Chandran et al. Warner et al. there is consistent evidence considered in relation to these findings. 1998. and excessive worrying (Boyce. However. 1984. childbirth and the postpartum period Harrington. Scottish (Rahman. Pregnancy. 1994). The dis- & Harrington. tus unskilled occupations (Zelkowitz & Milet. have been come.. Limited education reduces women’s depression access to paid occupations and secure employ- ment. developing countries. housing difficulties. Lee et al. 2002). 2004. have not been endemic. Women living in poverty and experiencing The contribution of intrapartum experiences to economic difficulties. wanted pregnancy and depression has not been ly to be recruited to..

but evidence is emerging that they may garded as symptomatic of depression (Stowe be more significant than has previously been ac- & Nemeroff. (Fisher et al.. unpaid workload of caring for a newborn baby. 2002). 1998b). is often considered normal or trivial.. Brown & Lumley. Astbury & Smith. soothing and has deregulated sleep.g. lead to depression (Calhoun & Calhoun. Murray & Cooper.. Women with a mul- ently to postpartum depression when other risk tiple gestation have increased risk of ill-health.. 2003). 2002) and may be an early indicator of al. treatment of early parenting difficulties consid- Campbell & Cohn. However. Some authors ten undiagnosed and untreated (Gunn et al. Profound fatigue is widespread relevant to the onset of maternal depression and among mothers of newborns (Brown. Astbury ple births are also associated with increased risk & Smith. 1980. mother-infant interaction have presumed that ciated with prolonged physical recovery and fa. 1994). 1991. but the Infant factors and maternal mental health effect is not direct and appears to be moderated by quality of care and of personal support (Ayers Investigations of both infant development and and Pickering.. despite its These inter-relationships have not yet been well adverse impact on daily functioning (Milligan conceptualized and are generally under-investi- et al. 1995.. 1993. to the birth can persist for months and are of. 1995). disabilities are highly distressing events that can grief and dissatisfaction. 1984). flect parenting factors (Murray & Cooper. 1997). livery does not appear to contribute independ. There is reactions (Fisher & Stocky. factors are taken into account (Johnstone et al. 1998. 1996). 1994. infants are essentially normative and that vari- tigue... Physical problems related & McCloud. undermines birth on physical and psychological recovery maternal confidence and well-being and may be are equivocal. Cross-sectional cohort comparisons have found 2001). 1990b. in all of which are associated with anxiety in preg- particular caesarean section. Rowe-Murray & Fisher. 1998). 1997. who resists effects of length of stay in hospital after child. These have been variously Premature birth and the birth of an infant with conceptualized as depression. 1990).. fect of early discharge from maternity hospital mental intervention in vaginal birth (e..can have adverse of women admitted to a residential service for psychological consequences (Green. Eberhard-Gran Westley & McCloud. 1994. Excessive tiredness has been re. 2001). Armstrong et al. however. In addition to being asso. ers who are not depressed (Milgrom. 1995.. Mental health aspects of women’s reproductive health et al. 2001). emerging evidence that childbirth events can lead to post-traumatic stress disorders. disappointment. 1997. but to disturbances in mother-infant interaction. ations in developmental outcomes primarily re- ment of maternal confidence (Garel et al. 2002). Feekery & Rowe-Murray. can induce acute nancy. mode of de. pregnancy loss and premature or operative birth. Exhaustion may lead to depression in women Babies are born with distinguishable variations whose workload is neither acknowledged nor in intrinsic characteristics or temperament. 2002). for. and shared (Fisher. Because of the competing and major de- stress reactions and disrupt the first encounter mands of caring for more than one infant. 1998).. that mothers who are depressed are significantly more likely to report excessive infant crying and Poor physical health after childbirth contributes disturbed infant sleep and feeding than moth- to poor mental health (Gjerdingen & Chaloner. surgery can also compromise the develop. O’Neill. Righetti-Veltema et al. 1998. have interpreted this as indicating that the be- 1998). 2002). ered that their maternity stay had been too short Hannah et al. but there is consistent evidence that Large community surveys have not found an ef- certain modes of delivery .. lihood of disturbed infant behaviour (Milgrom. Righetti-Veltema et et al... these exert a significant effect on the infant’s in- 22 . Westley. Righetti-Veltema et al. Emergency surgery during childbirth. Not breastfeeding has been associated haviour of depressed mothers increases the like- with increased likelihood of postpartum de. but an alternative view is knowledged (Cramer. 1994. (Brown. Kumar & Robson. 2000). crying infant. but 20% ceps) and caesarean surgery . of postpartum depression and complicated grief Rowe-Murray & Fisher. that it is associated with the unrecognized and 1997. Fisher. Brown. gated. 1992.. multi- between mother and infant (Fisher. Armstrong et al. 1990. 2002). 1992. Thompson et al. pression (Warner et al. Boyce & Todd. 2002). 1996. others acknowledge that the vulnerability (Eberhard-Gran et al. Brown & Lumley. 2001.particularly instru. Murphy & Greene. 1998a. The care of an unsettled.

2003) and intensity of infant crying and fussing in the first year of life (Lehtonen & Barr. Mothers most often attribute infant cries overall mood. Contemporary advice on infant care encourag- es mothers to trust their intuition and do what 23 . and of gastrointestinal pain. Casey & Pinto-Martin. Marcus (1987) compared 25 depressed mothers Inconsolable crying. but gastrointestinal pa- react with great intensity. a startle reaction or in comprehensive interview. and in reality parents have ing patterns. 1993). or distinguishable. and have greater exposure to the nega- tive stimulus of infant crying. especially with feels appropriate. and the widespread contemporary ad- (Oberklaid et al. depressed. vice to “feed on demand” may promote the no- Infants are more temperamentally difficult when tion that babies only cry when hungry (Craig. 1993). Infant feeding difficulties. are easily aroused. frequent small feeds. 2000). they: have little rhythm in sleeping and feed. Up to 25% of mothers of 4-6-month-old natal complications and were less adaptable and infants report that their babies cry for more than fussier than those of the mothers who were not three hours a day (Beebe. 1987). hunger. response to unfamiliar people or to use other contextual and behavioural cues to stimuli. of emotional reactions. 1984). intensity decode them (Craig. such as laughing or responding to soothing. It is not surprising that longitudinal studies have shown Infant crying is highly arousing to carers. 2000). This can reduce their confidence in their ability to parent. and are now thought to be early indica- and religious affiliation. frequent changes of infant formula. ease of adaptation to change. deregulated behaviour and of six-week-old babies with 24 non-depressed resistance to soothing are usually difficult to ex- mothers of the same age.. threshold to reaction. Hopkins. distractibility. Nine dimen. Campbell & thology is rarely found on clinical investigation. 1993). Excessive pro- ing patterns. Pregnancy. 2000). but that infant sleep problems precede maternal de- there is wide individual variation in the amount pression (Lam.. frequently occur in conjunc- tion with deregulated sleep and persistent cry- ing (Barber et al. Confidence can diminish rapidly and they are less likely to experience their infants as a source of positive reinforcement (Beebe. They are told to distinguish caregivers (Oberklaid et al. deterioration in the familial emotional environment.and observation. Chapter 2. Hiscock & Wake. fatigue. 2000). poor mother-infant relationship. They found that the in.. there is little empirical sup- based rating studies of large samples of infants: port for the notion that cries are in fact specific motor activity. Gilbert-Macleod & Lilley. and may increase the likelihood of postpartum de- pression (Mayberry & Affonso. and multiple overnight waking for feeds. and height- ened risk of infant abuse (Wolke. and discern whether these sions of infant temperament have been identified are indicating pain. regularity of sleeping and feed. maternal irritability. Excessive infant crying is associated with earlier cessation of breastfeeding. have difficulty longed crying is often presumed to be because in adapting to changes in the environment. Parents of inconsolable infants receive less positive reinforcement from the infant. 1984. Lehtonen & Barr. childbirth and the postpartum period teractions with the environment. fants of the depressed mothers had more neo. tors of a difficult temperament (Barr & Gunnar. 2000). including refusal of breast or bot- tle. 1994. and persistence to hunger. Gilbert-Macleod & Lilley. 1997). Sanson et al. Mothers can feel ineffective and helpless caring for an inconsolable infant. Casey & Pinto-Martin. socioeconomic status plain. their infant’s cries.. Gray & Meyer. However.

very high rates of depression . 1983). Kleinman. et al. and relief from normal tasks and responsibilities. & Barnett. Chan & evidence of postpartum depression. Ratnam. Saurel- tured peripartum customs are characterized as Cubizolles & Lelong. but 86% had some depressive symp- where such customs were observed showed little toms three months postpartum (Kok. 2002). Despite some variation in the ranking warm clothes and using cotton swabs in the ears of the contribution of different risk factors by to protect the body against “cold”. among those who were not (Fisher et al..6% of dition.were observed. to pression may be manifested as non-specific so. these are instruments. Matthey. Observation of postpar- and Anglo-Celtic women living in south-west tum rituals.. (2002) in developing country contexts challenges the examined small groups of Bangladeshi wom. and in Japan the ing and diagnostic tools to investigate whether incidence was 17% (Yamashita et al. anthropological view that ritual postpartum en living in London and Dhaka with English care protects women. 1981. Barnett & Elliot. 1998) or from parents or the wider so- sion and other mood disturbances are expressed cial circle (Fuggle et al. Fisher et al. 1993. It appears that this asser- women. 1994.. postpartum period. an honoured status. There is little evidence to support the notion that women in developing countries do not experi- A number of studies have compared peripar. establish the incidence and correlates of clinical- matic symptoms (Ng. 2000). 1995. Stern & Kruckman. Stern & Kruckman (1983) partum women satisfied the criteria for a clini- concluded that ethnographic studies in cultures cal case. 1983). tum experiences. 2004). including lying over heat. 1991). in Hong Kong. it appears that six weeks postpartum. The factors in groups of different ethnicity living in finding of high rates of postpartum depression industrialized countries. literacy levels and familiarity with test-taking are taken into Some comparable investigations have been un- account . 1996. Barnett. 24 . range on the EPDS between Vietnamese. 1993. 1999). or in which screening questionnaires have been conducted distress is associated with shame or stigma. 14% in Iceland (Thome. Arabic Fisher et al. and found an overall rate of depression tion may be an oversimplification and warrants of 11.. Mental health aspects of women’s reproductive health Cultural specificity of postpartum mood ability to confide in the partner and insufficient disturbance practical support from the partner (Matthey. more comprehensive and detailed investigation .5% of post- & Kruckman. atric illness (Lee et al.4% in Sweden providing dedicated care. Stuchbery. 2000. Socially struc.structured interviews and screening dertaken in resource-poor countries. & Good. and risk Patel & Andrew. 11. de. can be used cross-culturally beliefs. 2001). In cultures in which Studies using structured clinical interviews or discussion of emotions is proscribed. Stern (Escriba et al. Matthey & There is debate about whether the ways depres.5% in Finland (Affonso et al. 2000). 1997). 2000). Glasser et al. 2001. 1997. 9% in Italy and 11% in France (Romito.. those in industrialized countries . In Europe. the risk factors identified as relevant to Vietnamese women who were depressed than all groups were highly consistent. 2002. In postpartum depression is a culture-bound con.. 3. the following in- partum care for women are psychologically pro. and 14. women had EPDS scores in the clinical range at priate methods of measurement. herbal preparations. cidence rates were found: 8. They were: in.. are universal or culturally determined (Jenkins. (1998) found that 22. Matthey. . with no difference between groups.5% of postpartum women had a diagnosable psychi- More recent studies have used validated screen. 2004).2-3 times (Clifford et al.if the complexities of translation.. ritual may there were no differences in scores in the clinical not be available to all women (Inandi et al.1. in a range of non-English-speaking countries. Barnett. 29. 2000). While there is still debate about appro. and taking ethnic group (Stuchbery. wearing Sydney. 2004). such as the Edinburgh Postnatal summarized in Table 2. & Elliot (1997) reported that Even where it is culturally prescribed. 1999. Small. was no less common among 1998). In Singapore.7% in Malta (Felice tective (Cox. ence depression (Moon Park & Dimigen. China. Israel.7% in Spain (based on clinical case criteria and social seclusion for the mother and her in the General Health Questionnaire (GHQ)) newborn (Howard. Laungani. 1994). Manderson. Kumar. rates of depression. Contrary to previous Depression Scale. It has been argued ly significant depressive symptoms in the early that culturally prescribed ritual forms of peri. Howard. 13. 2004)).. 1999).5%. Fuggle et al.

2004. 2004). including dedicated care during the early ingful and recognizable to women in these stud. 2003. (2002) in Kathmandu (Nepal) rep- resent relatively advantaged women whose rates of poor mental health are likely to be similar to those of women in rich countries... or arguments and tension in the re- Coincidental adverse life events. 2003. housing diffi- of risk factors for postnatal depression.. Chapter 2. ment that allows them time to care for their in- 1995. highly biased and likely to under-represent the Rahman. Rodrigues et et al. culties. In ad- to the range of rates of depression found.. Lee et al. fant are more likely to be depressed (Chandran Rahman. Aderibigbe. childbirth and the postpartum period Still. but as yet the evidence available is lim- et al. 2003. Iqbal method of data collection may have contributed & Harrington. more common among women who are depressed 2004b). Africa the figure is 39. 2004). 2002. especially creased risk of becoming depressed after child- from the woman’s family of origin.7%. 2002.. 2004). factors (Cooper et al. Chandran et al. This relationship is variously described Fisher et al. in both qualitative investigations (Rodrigues et al.. However.. 2004). place in community clinics. or lack of support from. al.. 2003. 2003. Da Silva et al. Women living in poverty with the intimate partner is consistently found and experiencing economic difficulties. Adeyemi & Oladimeji. and Regmi et al.. a lack of practical assistance from the tions assessing psychological state were mean. Fisher et al. 2003. that the city hospital-based samples used by Cox (1983) in Kampala (Uganda). Finchilescu & Lea. therefore. birth. 2003.. only 32.. In contrast. 2002. who to distinguish depressed from non-depressed have low education and no access to employ- women postpartum (Mills. may be pro. Wider family relationships are also impli- tective (Moon Park & Dimigen. rit. problematic relationships with ual care that imposes control and restricts the the partner’s family. while in West protective (Rahman. especially critical coercion woman’s autonomy might actually be harmful from a mother-in-law. For example. Pregnancy. However. is more commonly reported ies (Fisher et al. 2004). et al. physical violence from a partner are at greatly in- practical support for a defined period.. the been specifically assessed in most investigations partner not having an income. Inandi et al. assisted either by family members or by tradi- tional birth attendants.5% of women give birth cated support is available. Inandi et al. have been reported to be (Chan et al. 2002. Fisher et al. dition. as inability to confide in.. Fatoye. Fisher et al. In countries where most by women who are depressed than those who women give birth without being attended by a are not depressed (Mills.. 1995. It is probable. Inandi et al. 2003. Lee et al... 2002.. 2004. 2002. Finchilescu & Lea. Fisher et al. the partner. increased care that provides dedicated.. it is psychologically attended by health professionals. 2002). ques. many of these take Fisher et al. postpartum period.. 2004).. Rodrigues cated. 2002. Chandran et al. 2002.. Limited education reduces women’s access to paid occupations and The first is that a poor quality of relationship secure employment. Most women in these settings give birth at home. Iqbal & Harrington. 2003) and survey investigations (Chandran While differences in instruments. 2005). including be- lationship. Intimate partner violence has not reavement or serious illness in the family.. Chan et al. family.. sampling and et al. and are accessible only to relatively wealthy women (WHO. 2002. 2003. Rodrigues et al.. Rodrigues experiences of the poorest women.. ited. Iqbal & Harrington. (2002) demonstrated unequivocally privacy are also associated with higher rates of that women who are exposed to intimidation or 25 . Iqbal & Harrington. Rahman. If practical dedi- in East Africa. Gureje & Omigbodun (1993) in Ibadan (Nigeria). hospital-based samples are 1995. crowded living conditions and lack of Patel et al. There are striking similarities between the risk factors for depression identified in these investigations and There is consistent evidence that maternal men- those that are well established in the industrial- tal health is also influenced by socioeconomic ized world. 2004). skilled health worker.

32. Comparison group of nurses clinical interview. Patel & Consecutive cohort of 500 Periurban settlement. postpartum 6–8 weeks and 6 months postpartum Chandran et al. 9 months postpartum Fisher et al. Iqbal & Consecutive cohort of 632 Southern Kahuta.. Goldberg’s Standardised Psychiatric 10% depressive illness. 1983 183 parturient women Kasangati Hospital. 40% met SRQ-20 criteria for clinically mothers and infants Pakistan Assets Questionnaire.20. Kathmandu. Gureje & 162 pregnant women University College Hospital. Kampala. 2004 Consecutive cohort of 506 Immunization clinics at Hung Vuong Structured interview including EPDS.. 15. 3 anxiety Uganda Interview. 2002 Cohort of 359 pregnant Tamil Nadu. and structured significant mental distress questionnaires.. EPDS 23% depressive disorder at 6–8 weeks De Souza. 1998 pregnant women Clinical Interview Schedule (85% of which was depression) Cooper et al. a Structured clinical interview for DSM IV. WHO Self-reporting Questionnaire .2% birth in the previous year villages in five relatively undeveloped provinces of eastern and central Turkey Regmi et al.7% major depression periurban township. 14% postpartum psychiatric caseness Omigbodun... 6–12 weeks postpartum 11% women Rahman. General Health Questionnaire 28. in late pregnancy and 12 weeks postpartum Rahman et al. 2002 2514 women who had given Women selected systematically from EPDS score >12 27. EPDS score >12 and DSM-IV structured Prevalence of depression: 12% in postapartum women and Nepal. Viet Nam .8% at weeks postpartum week 8 Nhiwatiwa. Zimbabwe Shona Symptom Questionnaire. United Arab EPDS score ≥12 on day 7. 3 months postpartum disorders Aderibigbe. Pakistan WHO Schedule for Clinical Assessment 28% depressive disorder 12 weeks Harrington. 2003 pregnant women in Neuropsychiatry and structured postpartum Mental health aspects of women’s reproductive health questionnaires.5% (of which 17. 34. India EPDS score >12.5% in 26 40 non-postpartum women and their friends comparison group Patel. Rawalpindi. 2002 pregnant women and Revised Clinical Interview Schedule. Rodrigues & Consecutive cohort of 270 District hospital.8% was 1997 parturient women Emirates State Examination score ≥ 5 at 8 and 30 depression) on day 7. India General Health Questionnaire 12. Goa.1 Postpartum mental health in developing countries Authors Sample Setting Measures Results Cox. Ho Chi Minh City. South Africa 2 months postpartum Inandi et al. Table 2. Ibadan. Revised 16% met criteria for psychiatric case Acuda.. 2002 Consecutive sample of 100 Hospital postnatal clinic. Consecutive cohort of 95 New Dubai Hospital.7% (EPDS score >12) women Obstetrics and Gynaecology Hospital 6 weeks postpartum and Maternal and Child Health and Family Planning Centre. 1999 147 parturient women Obstetric clinics in Khayelitsha. 2003 Consecutive cohort of 172 Immunization clinic. 1993 Nigeria Psychiatric Assessment Schedule at 6–8 weeks postpartum Ghubash & Abou-Saleh. and Present 24. 2–3 months postpartum postpartum women and 12.

1996a).. 2002. 1990). 2002. Research into the determinants A comprehensive assessment of the links be. Examinations of the behaviour of caring for an infant while living in their par. childbirth and the postpartum period maternal depression (Chandran et al. Fatoye. Iqbal & Harrington. 1996a). including companionship and opportuni.. It is known cial expressions. in. positive affect (Field et al. 2004). has been devoted to the nature and prevalence & Meyers. mother. The link 27 . The relevance of post-traumatic stress disorders ties to confide. 1998). is linked to mental health. tory of an eating disorder.. Chapter 2. are only now being able. remain Harrington (2003) demonstrated that women underexplored (Fisher. Inandi et al.. especially in regard to house. Soderquist & Wijma. are more likely to Maternal mental health. in the mother-infant interactions of depressed birth. of postnatal anxiety disorders. Pregnancy. Murray & and psychological complexities faced by women Cooper. development of the infant. 1986. The social pressed or insensitive (Murray. In lower- ed consideration of other relevant expressions risk populations. Social support from (Barnett & Parker. 2004. Iqbal & to evoke post-traumatic stress reactions. the infant’s own sensitiv- preference for sons.. 1992. disrupts the quality and sensitivity of the more common in cultural contexts where wom. including was consistently associated with depression the lowered mood and social behaviour of the (Patel et al. An infant is less likely to form a women who had already given birth to a daughter secure emotional attachment if the mother is de- (Rahman. in particular among The focus on postpartum depression has exclud. which in a number of and responsiveness of the mother to her infant these investigations was associated with a great. poor postpartum health and difficulties in breastfeeding. 1995.. exacerbates the effect of reduced mater- Adeyemi & Oladimeji. who have adverse obstetric experiences. Astbury & Smith. In particular.. and an absence of disparities between a woman and her mother-in. Effects are more marked in socioeconomically disadvantaged populations. Adeyemi & Oladimeji. however. 1997). infants in face-to-face interactions with their de- ents-in-law’s multigenerational household have pressed mothers have reported fewer positive fa- not been systematically examined. 1997. Cohn... Postnatal depres- cluding about use of contraceptive. has not been systematically as.. infant report depressive symptoms in the immediate development and the mother-infant postpartum period (Mills. In cultures with a strong At the same time. to mental health in pregnancy.. there are fewer differences of psychological distress in women after child. 2003. Mills. 2004). through its negative impact on the mother’s interpersonal function- There are also some risk factors that appear to be ing. Two-month- law may restrict her autonomy. 2004). includ- ing operative birth. 2001). of postpartum onset of panic disorder. warmth. peers. Fisher et al. adolescents and those who are single. This can have adverse en face restrictions related to strong gender-role effects on the emotional. acceptance to unwanted pregnancy. 1996a). giving birth to a daughter ity to its interpersonal environment. and the tween reproductive experiences and mental links between maternal experience and a his- health in developing countries is not yet avail.. than comparison infants (Murray et al. Lack of reproductive choice. Fisher et al. of substantial co-morbidity with depression 2003. this may contribute to poor mental more likely to avoid contact with their mothers health (Chan et al. Murray et al. (Murray et al.. relatively little attention and non-depressed mothers (Campbell. Finchilescu & Lea. 2002. higher levels of withdrawal hold finances. protest behaviour. evidence is emerging that women considered. 2002. cognitive and social expectations. more negative expressions and that autonomy. er likelihood of depression (Inandi et al. Fatoye. Stuart et al. 1997. Iqbal & Harrington. relationship 1995. 2004). However.. despite evidence Patel et al. 2002. Chandran et al. 2003). who lacked it were more likely to be depressed. Boyce & Condon.. tial of childbirth and other reproductive events Finchilescu & Lea (1995) and Rahman. 2002. Wijma. Fisher et al. Depression after childbirth.. contributes sion reduces the sensitivity. especially during old infants whose mothers were depressed had the period of increased dependence that follows higher rates of disrupted behaviour and were childbirth. mother-infant interaction. Rahman. and the poten- sessed in many of these studies. particularly for nal sensitivity. Power and avoidance. more fussing. 2004b). Lee et al.

1998). ating factor. 1992. antena- crowded living conditions and infectious dis. 2001). (2001) of normal weight. on child cognitive outcomes are mostly confined cational needs. statistical differences between weight for age were significantly more likely to depressed and non-depressed groups often dis- have a mother who was depressed than infants appear (Murray et al. Young boys findings on the importance of breastfeeding for whose mothers were depressed postnatally were cognitive development are important. other investiga- justment for birth weight and maternal educa. nal depression (Luoma et al. maternal sensitivity is sample of 132 11-year-old children from south reduced and risk of depression is increased if London. 2001). 1993). especially for temperamentally reac- quences of maternal depression in a community tive infants.. When social adversity is taken fants whose weight was 50-80% of the expected into account. et al. 1990). older than one year. 1999). did not alter the effect of (Field et al. as measured by the depressed postnatally (Lyons-Ruth et al. Compared with controls. maternal mood improves. even after ad. 2003). 1996b. and matical reasoning and visuomotor performance. Conversely. There is consistent Sharp et al. Murray et al. because found to have poorer cognitive development and mothers who are depressed are more likely to to display more antisocial behaviour. (1995) found that breastfeeding was evidence of poorer cognitive development in a reliable predictor of intellectual functioning preschool-age children of mothers who were in three-year-old children.. The worst child outcomes were predicted by 8 weeks postpartum on the subsequent growth a combination of prenatal and recurrent mater- and development of infants in Goa. 28 . infants of depressed mothers were more than twice as likely to be A meta-analysis of nine studies (Tatano Beck. 1996b). 1999. 1992.. stop breastfeeding early (Cooper.. Hay et al. especially boys. Murray & cial disadvantage and later mental health prob- Cooper. tally. Desouza & Rodrigues (2003) ioural problems in the children at 8-9 years of examined the impact of maternal depression 6. (2004). maternal depression contributes to infant depression present both during pregnancy and failure to thrive in resource-poor settings (Patel after childbirth was strongly predictive of behav- et al. according to the EPDS. so- the United Kingdom (Murray. Children. India.. the been depressed had significantly lower intelli. whose mothers had Crockenberg & Leerkes. such as parental intelligence. tors have found no association between postna- tion (Patel. 2003) and the United States of America lems in the mothers. They found that eases.and high-income countries. However. the partner behaves aggressively either during chiatric interviews three months postpartum. 2003). Similarly. in a case-control study in a rural in women who are socially advantaged (Murray community in Tamil Nadu. 1986. These Murray. Mental health aspects of women’s reproductive health between postnatal depression and impairment of and more attentional problems than those whose the mother-infant relationship has been reported mothers had been well (Hay et al. pregnancy or postpartum (Leung et al. and in a low-income cohort maternal postnatal depression on the children’s in South Africa (Cooper et al. In general. 2003). long-term adverse effects of maternal depression gence scores. age. underweight at six months of age (30% versus 1998) found small but significant adverse effects 12%) and three times more likely to be short for of maternal postpartum depression on the cog- age (25% versus 8%). (2001) examined the long-term conse. to socioeconomically disadvantaged groups. 1996). and a higher rate of special edu. Sensitive fathers reduce the impact of maternal depression and reduced respon- Hay et al. such as confounders. They also had significantly nitive and emotional development of children lower mental development scores. including difficulties in mathe. Desouza & Rodrigues. (2001) assessed a group of school-age children whose mothers had Independently of the adverse effects of poverty. found that in. overactiv. Murray et al. 1986. mothers were not postnatally depressed (Cogill et al. intellectual status. 2004). Murray & ity and distractibility compared with boys whose Stein.. found that breastfed children of women who had been depressed postpartum did not have verbal These effects do not necessarily remit when or mathematical cognitive deficits. postnatally or currently. Patel. been depressed. are worse for boys. whose mothers had completed psy. Possible in middle..... India.. Sinclair & The sensitivity of fathers is also a crucial medi- Murray. siveness. McCarthy Scales of Children’s Abilities.. Luoma et al. Anoop tal depression and adverse child development et al.

routine primary care found short-term improve- tify women at risk of ments in maternal mood with all treatments. volved family members. of caesarean or forceps-assisted delivery. provide care for mothers of newborns that led Although the quality of a woman’s relationships. Reduction of poverty. Two recent systematic reviews have concluded tive health programmes. Ray & Hodnett.have to be weighed against anxiety. pharmacological approach (O’Hara & Swain. 2002). combining cupational conditions that ac- tested in randomized problem-solving strategies. disorders. especially in areas with that the research base on preventive interven- high rates of poor infant growth. refused to participate (Hoffbrand. supportive empathic knowledge women’s multiple controlled trials. 2001). “Preparation-for-parenthood” in the long term the benefits were not superior groups for women during pregnancy did not to spontaneous remission (Cooper et al. as the attention to the human rights A range of interven. 2000). and while caring ministered during havioural therapy.. only psychodynamic therapy signifi- after childbirth have low positive predictive val. both child health and maternal and reproduc. Chapter 2. Crawley. childbirth and the postpartum period Most of the research into the impact of mater. prevent postpartum depression. & While identification and ef- However. in which women close relationship between the mental health of could talk with a midwife about their experience mothers and the physical and mental develop. either in groups or indi- family-friendly employment a modest or negligi. 2001). 2001. 2001). ues. Most women prefer a non- sonal safety and equality of development of de. most interventions have not in- has been done in developed countries. drug may be transmitted through the placenta of reproductive choice. A randomized trial com- health during pregnancy.. (2002) demonstrated that spe- partners were included in at least one session cifically trained community health visitors could (Gordon & Gordon. a short follow-up period. 1960. treatment did not ing as part of routine antenatal care (Lumley prevent subsequent episodes of depression. and reviewers have concluded that there None of the benefits of treatment were evident is insufficient evidence to introduce screen. The re.usually antide- vulnerable to depression and 1995). pregnancy to iden. Most mild depression in the post. Screening reducing depression. are more effective than routine care in can help ensure good mental ble effect. except when MacArthur et al. sion. Both phar- fective treatment of perinatal vere depression can macological and psychological treatments have psychological disturbance are persist.. 2001. in questionnaires ad. listening. Scottish Intercollegiate Guidelines In spite of the high prevalence of perinatal mood Network. 2003). Psychological approaches. access to education. paring non-directive counselling. pharmacological treatments . and oc- pression have been 1996). 2003). tions is extremely limited. cognitive be- childbirth. of loss to follow-up. the potential harm to the fetus or infant. Elliot et al. did not ment of their children are of vital importance to reduce the rate of depression (Small et al. but many are limited because of high rates partum year resolves as mothers gain more ex. is central to her postpartum compared with women cared for by 29 . Pregnancy. psychodynamic therapy and for a newborn baby. there is relatively little systematic data about the efficacy of prevention and treatment There have been a number of randomized con- strategies (Boath & Henshaw. 1999). and & Austin. emotional well-being during pregnancy and af- nal postnatal depression on child development ter childbirth. Lumley & trolled trials of treatments for postnatal depres- Austin. becoming depressed however. A single session during cent findings in developing countries of the the postpartum hospital stay. Howard. Decisions about prescribing factors that render women (Cooper & Murray. and opportunities to focus on past and roles and provide secure and most have had only present relationships. becoming been found to reduce the severity of symptoms important.. and there is currently no compelling evidence to support the introduc- Prevention and treatment of maternal tion of any of the interventions that have been mental health problems tested in primary prevention trials (Lumley & Austin. to reduced rates of depression at four months in particular with her partner. Koren. more se. vidually. pressant medication . cantly reduced depression (Cooper et al. vital need to reduce the risk from time to time & Sharp. by nine months postpartum. or perience and their potential bias because most eligible respondents confidence grows. 2000). there is an equally chronic or recurring and the duration of depression (Appleby. 2001. per- tions to prevent the and in breast milk.

a disproportionate emphasis has standard care. 2000).. 2003). 1996). 1992. The contribution of intimate partner vio- functioning at 18 months. programmes and recommendations for mental health. China. improved maternal Future research mood (Armstrong et al. (2003). 1999. either in Summary clinics or during home visits. 5. (Brockington. 2000. relatively covering events up to one year postpartum. found that non-directive counselling fos. of psychopathology after childbirth have in a comparison of home visits by professional focused almost exclusively on women. compared with mental health during preg- less perceived stress and improved perception of nancy. At four months. 2002). separation and management ing maternal depression should ascertain of infant needs for attention. This versity. which warrants more comprehensive interpersonal support than controls who did not investigation. and much less on exploring the contribution of 30 . but 2. Risk factors for poor mental health should be ascertained as part of routine primary peri- In conclusion. Short. among those who were experiencing social ad. treatments for postnatal depression. 4. prevalence and correlates of poor ing primary care providers. There is increasing evidence about the pre- generally agreed that a team approach.. borns. is needed conducted in some of the poorest countries. Hiscock & Wake.. Randomized controlled trials are needed of versity than psychodynamic or cognitive behav. benefit was sustained in more positive mater- nal reports of infant emotional and behavioural 7.. 3. 1996) for women at high risk of developing depression (Dennis. countries. with an in- term benefits were also apparent in the pilot test creased risk of misattribution of causality and of a randomized trial of increased peer support victim-blaming (Wilson et al. during pregnancy ioural therapies. and should be included in all future initia- prove maternal health. involving partners may be more effective. dictors. involv. such as play. linked to maternal mortality and morbidity. in various aspects of their relationship with their 6. Mental health aspects of women’s reproductive health health visitors who had not been trained. Barnett & Morgan. Teaching mothers how to soothe their infants and settle them to sleep. been placed on identifying the correlates and consequences of poor maternal mental health. treatments for depression. It is 2. Research attention has focused dispropor- attended weekly support group meetings had tionately on mental health after childbirth. Investigations of infant development follow- infant. mothers who and after childbirth that are suitable for use received counselling reported fewer difficulties in primary care settings. allied health work. compared with and control for the contribution of social ad- those who received routine primary care. there was lence and coercion to women’s perinatal no significant impact of any of the treatments on mental health has been neglected and war- cognitive development or emotional and behav. has been generally neglected in initiatives to im. but these need to be designed and appropri- tered more sensitive mother-infant interactions ately evaluated. In the field of perinatal tives. attend group meetings (Chen et al. few have been designed to improve developmen. women who 1. ioural adjustment at home or in school when the Policy children reached 5 years of age (Murray et al. mental health is inextricably natal health care. Murray et al. Interventions to prevent the development tal outcomes for the child. 2003). However. familial or social factors. postpartum mental health in developing ers and specialist mental health practitioners. but investigations have yet to be as well as a range of health facilities. lower scores on the Beck Depression Inventory. Mental health is integral to safe motherhood. The contribution of maternal mental health While there have been a number of trials of to maternal mortality should be ascertained. In Taiwan. 1. rants inclusion in future investigations. health visitors trained to provide one of three Emerging evidence suggests that strategies psychotherapies to depressed mothers of new. paternal.

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including One of the most serious consequences of un- intended pregnancy is unsafe abortion. the methods them. i. is a simple biological. and inexpensive procedure (WHO. and how a gender-based lack of power or disorder. The second section addresses for the Year 2000 and Beyond (International the psychological aspects of elective abortion. Mexico City. At least unsafe abortions took place in the year 2000. decision-making about the initiation and continuation of contraceptive use may lead This chapter has two sections. carried in two main ways. despite nal mortality and morbidity in developing re- an expressed wish to space or limit the number gions of the world. abortion to about seven live births. women and the psychosocial factors that prevent liefs about gender roles. through ers in a proper medical environment. giving a ratio of one unsafe methods (WHO. and in particular the effects male partners or state reproductive health poli- of discrimination and violence against women. 2003) Second.e. The first summa- to conflict between partners. Safe abortion. Unsafe abortions. The relationship between depression in cision-making is likely to be influenced by be. The contraceptive needs ommendations of the International Symposium of women with severe chronic mental illness are on Contraceptive Research and Development also considered. out by qualified and trained medical practition- selves may have a direct effect on mood. most research in tility are reviewed. Almost all un- safe abortions take place in developing countries Contraceptive use interacts with mental health (Ahman & Shah. mostly in developing tine manner. 1993). Central to this discussion is the field has examined the direct effects of con. in association rizes the evidence on the direct effects of vari- with other social determinants. health. performed by people not trained in their mental health. 3 Chapter Psychosocial aspects of fertility regulation Contraceptive use – Jill Astbury Elective abortion – Susie Allanson T he availability of safe. can contribute ous contraceptive methods on women’s mental to depression and anxiety in women. To date. acceptable and affordable contraceptive methods has a profound impact on women’s health. the question of women’s ability to act independ- traceptive methods on psychological distress ently. are not using contraception. It has been estimated that medicine and usually carried out in a clandes- some 123 million women. It is estimated that 19 million of their births (Ross & Winfrey. 2004). contribute significantly to mater- countries. reliable. and can undermine their mental health and was identified in 1993. as one of the eleven rec. Symposium on “Contraceptive Research & Development for the year 2000 and beyond”. gender roles and gender relationships contraceptive choices. Such de. without duress from their in different cultures. 44 . The need for increased research on and control can affect their freedom to make sexuality. emotional well-being. cies. approximately one in ten pregnancies ended in cess to the full range of modern family planning an unsafe abortion. 350 million couples worldwide do not have ac. biochemical or hormonal pathways. autonomy and women’s or make it difficult for them to control their fer- reproductive rights. 2002). 2002). this. First.

Sri tion for more than 90% of the women surveyed Lanka. Moreover. 1996). gestogen-only pill had adverse effects on sexual ity and reasons for discontinuation of implants. in comparison with non-us. Arowojolu & gain. Arowojolu United States have reported cases of major de. injectable contraceptives. Wagner. enantate. 1994. A study in Scotland and the Philippines found that the pro- London. 2000). provement in well-being in both the centres effects of depression and mood swings. Much of the research on the psychological ef- found an increased likelihood of reporting de. followed by sterilization. 2003). such injectable progestogens in the postnatal period as depot medroxyprogesterone acetate (DMPA). DMPA and A recent survey in five European countries levonorgestrel implants. 1998).. Women are most likely to cease us- who reported high rates of satisfaction (Arshat ing implants because of concerns about weight et al. in a hospital in Johannesburg. the same conclusion. a five-year follow-up post-market- confirmed that oral contraceptives were the ing surveillance study. and female condoms). found no significant in- (France.. between depressive symptoms and two different hormonal contraceptive methods. planning clinics in eight countries (Bangladesh. lected women between 15 and 49 years of age. Colombia. of more than 900 users of contraceptive im- logical disorder and on mood. pression and panic disorder developing in wom- en with no prior psychiatric history (Wagner A placebo-controlled double-blind study in & Berenson.. concluded that women receiving devices (IUDs). and were associated with high levels of satisfac. Italy. In its review of evidence tively. of DMPA in the United States. intrauterine Africa. there was no evidence to suggest that women with a history of depression should be excluded A population-based prospective study of users from using hormonal contraceptives. Larger systematic investigations have not reached itus interruptus and abstinence). out in the 1970s and 1980s. Chile. Egypt. anxiety and depression were similar in women Studies in Malaysia. South emergency hormonal contraception. use or two years of implant use (Kaunitz. Chapter 3. WHO (2000) concluded that contraceptive (Erskine et al. functioning and was associated with some im- found that 5% and 3% of women reported side. China. modern and permanent (male and female sterilization) or traditional (co. Psychosocial aspects of family planning Contraceptive use and mental health to and immediately following discontinuation (Civic et al. 1999). norethisterone modern and reversible (oral contraceptive pills. evaluations in the strual problems (Glantz et al. Nigeria and the West Indies using levonorgestrel implants and in those using did not find any negative psychological sequelae hormonal methods containing estrogen (Fraser among women using contraceptive implants. 2000). to the conclusion that rates of mood disorders.. and Thailand) from 1987 to 1997. A double-blind. and therefore lies ers. headache. Hormonal contra. 1995). 2003). plants (Westhoff et al. and 6% of the women gave mood swings to determine eligibility criteria for use of hormo- as the main reason for discontinuing use of the nal contraceptives. had more severe depressive symptoms prior Rather more research has been conducted on the 45 . includ- pressive symptoms among both DMPA users ing female sterilization and IUDs was carried and discontinuers. and male al. England. 1990. Effects of contraception on mental health placebo-controlled trial on the effect of postnatal administration of the long-acting injectable Methods of contraception can be classified as: progestogen contraceptive. A prospective cohort study ods have different impacts on rates of psycho. Germany. 1998) reported no signif- ceptives have been most thoroughly studied for icant increase in depression scores over 2 years their possible effect on psychological function. Rattray et al. 2000. which explored acceptabil. are at an increased risk of depression (Lawrie et levonorgestrel implants (Norplant). randomized. 1997. A multicentre study on the relationship ing. et al. Indonesia. of use. (Graham et al... came (Skouby.. Different meth. However.. & Ladipo.. which looked specifically at effects on depressive symptoms. raised blood pressure or men- Ladipo. of more than 12 000 randomly se. Women who had discontinued DMPA use outside the timeframe of the current review. fects of other methods of contraception. conducted in 32 family most widely used method of contraception. Spain and the United crease in such symptoms after one year of DMPA Kingdom). 1998). respec. 2004).

ilization counselling emphasize the importance 1999. and those whose marriage was unstable of women’s health throughout the world. without pressure from either part- ners or health care providers (Neuhaus & Bolte. Yet. but that this mood disturbance contraceptive use was more likely to be attributable to coincidental adverse life events. includ. 1985). The before sterilization (Philliber & Philliber. including failure rates and contraception. rather than to side-effects. Psychosocial determinants of cally depressed. Mental health aspects of women’s reproductive health psychological effects of voluntary sterilization. and and restrictions on the types of contraceptive feeling they have been able to make their own methods available. and found that 20% were clini. den Tonkelaar & Oddens. may influence government policy More recent research confirms the importance to and lead to strict criteria regarding eligibility for psychological well-being of women being given government-funded reproductive health care. protect themselves against sexually transmitted joyment once the risk of pregnancy is removed disease is contingent on their status and posi- (Philliber & Philliber. concept of reproductive health goes beyond con- Hence. women who were sterilized im. The right to sexual and reproductive health is ity of the marital relationship after female sterili. relationship problems and a Reproductive rights and family planning family history of psychiatric illness than to the procedure. (Neuhaus & Bolte. North America and Europe exercise their reproductive right to control their (mainly United Kingdom) conducted up to the fertility and to make decisions about whether. tive health care. who have participated in abortion had an increased incidence of psycho. when and how often to become pregnant. ported minimal or negligible change in the qual. Both the International Conference on found among certain groups of women. to lack of confidence in the effectiveness of the and screening for the possibility of poststerili- method. effects on mood were most usually attributable presenting male sterilization as a viable option. In many 46 . or of certain forms of contraception. adverse psychological effects were more sideration of the biological factors involved in re- likely to occur as a consequence of violations of production to encompass the cultural and social reproductive rights. risk of ectopic pregnancy. 1995) sequences of sterilization or who experienced stressed that the empowerment of women and health complications after the procedure. 1996). A comprehensive review of studies in Contraceptives are crucial to women’s ability to Asia. includ- zation and few women regretted being sterilized. The timing of the sterilization procedure ning and provision of family planning services is also relevant. 92% of of providing accurate information regarding the those who had undergone sterilization and 59% actual surgical procedure and possible physical of IUD users were satisfied with these forms of health consequences. Caesarean section or en aged 15–49 years. Khanam. 1995). 2001). Latin America. is based on data collected from married wom- mediately after childbirth. Negative involving both partners in decision-making. Guidelines for prester- In a survey of 1466 German women (Oddens. linked to other important human rights. mid-1980s found that most women do not ex. including the right to accu. Government policies determine who rate health information and the right to give free has access to health care. negative psychological effects were education. and reported general improve. Most women re. zation regret (Association for Voluntary Surgical Mullich & Munib (1993) assessed psychiatric Contraception. those who did not understand the con. Women (FWCW) (United Nations. those the provision of comprehensive reproductive who disagreed with their partner about the steri. Social and religious disapproval than to the procedure itself. They also recommend ments in their sexual relationships. ing economic and social rights and the right to However. symptoms in 100 Bangladeshi women who had been sterilized. decisions. context. 1994) and the Fourth World Conference on lized. ing those who had been coerced into being steri. and some experience increased sexual en. 1985). including reproduc- and informed consent to medical intervention. health services were critical to the improvement lization. of sex outside marriage. Population and Development (ICPD) (UNFPA. which have somatic complaints and depressive symptoms been conducted so far in 70 countries. Much of the evidence that informs the plan- 1995). women’s ability to exercise this right and to ity. perience any significant change in sexual activ. adequate information before the procedure. Demographic and Health Surveys. tion within the family and the broader society.

eastern Turkey) have found increase uptake of reliable contraceptive meth. recent recognition tional distress. Other realization of gender equality in family planning. fined as the number of non-pregnant women ners (Humble. Male in. not being mar- therefore presupposes control of women’s be. Gender inequality persists in most spheres of life (UNDP. This is puzzling. Few contraceptive methods unmet need for contraception. women remain the predominant users of the this discrepancy. many unmarried women who may exacerbate the woman’s risk of violence. Among some women. Moreover. adolescents were once illegal in many countries decision-making and the development of emo- (Eschen & Whittaker. Unmet need. For example. many did not actually programmes is now being increasingly promot. and the magnitude of and reasons for family planning. 1994) and the Beijing Platform who wish to limit family size plus the number for Action (United Nations. depression and other psychologi- of their health needs has led to an increase in cal disorders in women has not been adequately the number of adolescent reproductive health investigated. while services to unmarried interpersonal determinants of contraceptive use. Sexually active unmarried wom. while a majority of women expressed a de- ods. Unmet need has been de- the equality and responsibility of both part. related to pregnancy and sexu. 1993). including decision-making Most research on predictors of contraceptive around contraceptive use and participation in demand. but those who did cited fear of contraceptive methods offered. evidence of the importance of decision-making and control to mental health. Kuwait. The availabil- decide freely and responsibly the number and ity of contraceptive methods may be a necessary spacing and timing of their children and to have condition for their use. Often. 1995). and the impact of an oral serve to increase the level of gender-related con. haviour in relation to contraceptive use. 2003). as well as the disparity between Historically. The ICPD Programme of who are not currently using contraceptives but Action (UNFPA. when the counterparts. women mentioned not having the approval of 47 . over the past ten years. the actual behaviour provision of services to women has become less discriminatory in terms of age and marital sta. has been con- are delivered through systems that emphasize ducted with women. While male involvement in family planning sire to use contraception. the women gave no explanation for ed. Fertility control side-effects. tradition in forming attitudes contributed to the trol over women’s bodies rather than assist in the low uptake of family planning services. Chapter 3. religion and the need for more children. national development objectives. contraceptive intentions and tended to. With this goal. Programmes to in- Male involvement in the control of women’s crease contraceptive use need to be based on an fertility accurate understanding of the multiple determi- nants involved. over contraceptive decision-making. promote participation in family planning and to Nigeria. Psychosocial aspects of family planning countries. women have been the main targets of efforts to Studies in different contexts (India. male involvement only for married women of childbearing age should not be relied on as a means of increasing and for the methods of fertility control offered female compliance with contraceptive use or of by government or donor-funded family planning legitimizing (albeit inadvertently) male control programmes. could benefit from the services offered by family planning programmes may not be adequately at. the information and means to do so …”. male involved is physically. their volvement in family planning programmes may status relative to men. Due to this gap in ally violent towards his partner. and down population growth in order to achieve the reasons for this. do so. Researchers have sought to quantify the extent of unmet need. Somalia. not having a need. that. 1995) articulated of pregnant women who report that the preg- “the basic right of all couples and individuals to nancy was unwanted or untimely. religious teachings. but alone is insufficient. sexually or emotion- ally transmissible infections. good quality evidence is available For the latter to be achieved. However. ried. reproductive health and fam. en face the same health risks as their married male involvement in family planning. is dangerous and data collection. because there is services. women’s stated intention or desire to use con- ily planning programmes have sought to slow traceptives and their subsequent behaviour. The relationship between broader situational and tus.

Women’s designed to further dispossess and eradicate perception of their position in the family was Palestinians. including. including the projects as coercive and a mechanism of war. they exercise preponderant power in nearly every sphere of life.. With specific reference to family planning. Governments should promote equal participation of women and men in all areas of family and household responsibilities. in level and employment status. to increase the participation and sharing of responsibility of men in the actual practice of family planning. At the same time. than women. stating: Men play a key role in bringing about gender equality since. reported that decisions about cation. the husband or a religious leader. Onwudiegwu. refers to the importance of improving access to high quality care in family planning. and “ensuring that men’s and women’s rights and perspectives are taken into account in the planning.. planning. among others. to improve the quality of advice. responsible parenthood. Fear of ies the negative attitudes of husbands and of the the husband’s disapproval is known to be a key women themselves were critical factors in non. prevention of sexually transmitted diseases. Another study. use of birth control and family size. rural Bangladesh. 2003. The objective is to pro- mote gender equality and to encourage and enable men to take responsibility for their sexual and reproductive behaviour and their social and family roles. educational ily size. 2003. information. Selected practice recommendations for contraceptive use (WHO. Turkey.. or a belief ference between husband and wife resulted in that family planning was a sin and that use of women having an ineffective role in decision- contraceptives had side-effects. Shah et al. education. to prevent unwanted pregnancies and reduce the incidence of high-risk pregnancies and morbidity and mortality. 2002. Men predominated in all deci. Orji & tion among women (Jain & Bruce. to make quality services affordable. male status was significantly related to their decision-making partly related to the exercise of control over fam- status. making and a low position in the family. Erci Men’s suspicions about the motives of family (2003) investigated decision-making power and planning campaigns can also determine whether perception of status within the family among their wives are allowed to participate in family more than 300 women in Erzurum. 1994) emphasized the importance of male responsibility and participation. in most societies. Sahin & Sahin. 2003). 1994). Mental health aspects of women’s reproductive health The ICPD Programme of Action (UNFPA. acceptable and accessible to all who need and want them. Men regarded family planning sions related to family planning. 2002). the Programme of Action states: Actions are recommended to help couples and individuals meet their reproductive goals. which was governed by age. Comerasamy et al. counselling and services. A low level of edu. … The publication. Hasna (2003) investigated attitudes Women had lower rates of decision-making than towards family planning in a Palestinian refugee men in almost every domain surveyed. 2003. acceptability of long term contraceptive meth- 48 . management and evaluation of services. except camp and found that men were more suspicious selecting clothes. wives and children. reason for discontinuation of use of contracep- use of contraception (Roy et al. sexual and reproductive behaviour. communication. and shared control in and contribution to family income and children’s welfare. inadequate income and a large age dif. In other stud. promoting the widest availability of different contraceptive methods so that people may select what is most appropriate to their needs and circumstances”.

Chapter 3. Psychosocial aspects of family planning

ods were governed by the number of living male tions (Dixon-Mueller, 1989:147). Various forms
children and by husband’s preferences for more of violence, including verbal abuse and sexual
children (Nayer et al., 2004). coercion, reduce contraceptive use and result
in increased rates of unwanted pregnancy and
The beliefs and behaviour of health care provid- termination of pregnancy (Gazmararian et al.,
ers may also influence contraceptive use. Fears 2000; Jewkes et al., 2001; Rickert et al., 2002;
regarding the side-effects and safety of IUDs Cabral et al., 2003).
were expressed by 44% and 69%, respectively,
of 107 Navajo Indian health service providers, There is substantial evidence that intimate part-
in response to a question about why they did not ner violence, including sexual violence, has mul-
recommend this form of contraception to their tiple negative physical, mental and reproductive
clients (Espey et al., 2003). While most health health effects (Heise & Moreno, 2002; Jewkes,
care providers in a New Delhi health care fa- Purna Sen & Garcia-Moreno, 2002; Krug et al.,
cility were familiar with emergency contracep- 2002). Multiple mental disorders can result from
tion, very few knew about timing of doses or violence, including depression, anxiety, dys-
efficacy (Tripathi, Rathore & Sachdeva, 2003). thymia, stress-related syndromes especially post-
Oral contraceptives are widely used in India, but traumatic stress disorder, phobias, substance
discontinuation rates are high. A low frequency use and suicidal ideas (Kilpatrick, Edmunds,
of field worker visits was found to be strongly & Seymour, 1992; Campbell & Lewandowski,
associated with discontinuation, and 70% of the 1997; Resnick, Acierno & Kilpatrick, 1997;
women who discontinued did not use any other Roberts et al., 1998; Campbell & Soeken, 1999;
contraceptive method, despite wishing to avoid Astbury & Cabral de Mello, 2000). Sexual vio-
pregnancy (Roy et al., 2003). lence, in particular, carries an increased risk of
a range of sexual and reproductive health prob-
It is inaccurate to conclude that inconsistencies lems, including unintended pregnancy, abor-
between intentions to use contraception and ac- tion, sexually transmissible infection including
tual behaviour indicate that “women failed to human papillomavirus and human immuno-
adhere to their intention” (Roy et al., 2003). If deficiency virus (HIV) infection, urinary tract
women’s intentions are the only predictors as- infection, chronic pelvic pain, fibroids, vagi-
sessed, other influences on their contraceptive nal bleeding and cervical dysplasia (Springs &
behaviour may be overlooked. Service providers Friedrich, 1992; Lechner et al., 1993; Plichta &
and researchers need to recognize the potential Abraham, 1996; Resnick, Acierno, & Kilpatrick,
impact of gender and gender inequality and to 1997; Letourneau, Holmes & Chasendunn-
consider whether women possess sufficient in- Roark, 1999; Coker et al., 2000). In addition,
dependence to make and implement decisions sexual violence is associated with decreased
about contraceptive use. It is imperative to de- use of preventive health care, cervical screening
termine whether, in reality, women possess suf- and antenatal care, as well as poorer pregnancy
ficient autonomy and decision-making power outcomes for both the woman and her offspring
and resources to formulate and implement their (Springs & Friedrich, 1992; Coker et al., 2000;
preferences and intentions. Gazmararian et al., 2000).

Violence and control of contraceptive
The use of coercive control by violent partners
decision-making is known to extend to areas of behaviour that
family planning programmes seek to modify,
Sexuality and sexual violence have been large- such as decision-making around contraception.
ly ignored in family planning programmes A comparative study in the USA on the sexual-
(Sundstrom, 2001). Some of the earliest research ity of college students, the circumstances of first
on the links between contraceptive use and sex- intercourse, including the use of contraceptives,
ual violence was carried out in Latin America. and psychological reactions to first intercourse,
Women reported having little control over their reported highly significant differences between
husband’s use of contraception and anger when men and women. Overall, 38.5% of women, but
they refused to use it. Some of this was related only 8.8% of men said they had felt coerced to
to “a sense of deep depersonalization, humilia- have their first sexual encounter (p ≤ 0.0001);
tion and physical dissatisfaction” because their 63.2% of women and 57.4% of men reported that
husbands mistreated them during sexual rela- they did not use birth control during first inter-

49

Mental health aspects of women’s reproductive health

course. Women did not use contraception be- be used in relationships characterized by a his-
cause the intercourse was unplanned, and men tory of conflict (Cabral et al., 2003).
because contraception was not available to them
(Darling, Davidson & Passarello, 1992). Contraception and women with
serious mental illness, substance use or
In a review of sexual relations among young peo- intellectual disability
ple in developing countries (WHO, 2001a), many
studies highlighted the fact that sexual activity Women who are mentally ill or who abuse alco-
of young women was not always consensual. In hol or drugs may be unable to consent to sexual
the majority of case studies included in the re- activity, are less likely to use contraception effec-
view, between 5% and 15% of young women re- tively, and are at high risk of sexual exploitation
ported a forced or coercive sexual experience. In (Hankoff & Darney, 1993). They are as likely
several case studies, the figure was higher: 21% to be sexually active as women without mental
among adolescents in Selibe Phikwe, Mahalapye illness (Nimgoankar et al., 1997). Hypomanic
and Kang, Botswana (Kgosidintsi, 1997); 20% behaviour is associated with risky sexual behav-
among secondary school students in Lima, iours, including intercourse with multiple part-
Cusco and Iquitos, Peru (Alarcon & Gonzales, ners and rates of unplanned pregnancy are high
2001); and 41% among young women attending in women with severe mental illness (Hankoff &
night study centres in Lima, Peru (Villanueva, Darney, 1993). Compliance with methods that
1992). Among women working in an export require regular self-administration, particularly
zone in the Republic of Korea, 9% reported that oral contraceptives, is lower in women with psy-
their sexual debut had been forced by a fac- chiatric illness. Since some hormonal contracep-
tory supervisor or colleague (Kwon, Jin & Cho, tives may alter mood and contribute to depres-
1994). In a case study in Manila, Philippines, 6% sion, it is recommended that they are not pre-
of unwed mothers reported that their pregnancy scribed to women who are currently depressed
had resulted from rape, and another 7% that it (Hankoff & Darney, 1993). However, health
had resulted from sex in exchange for money to professionals are less likely to discuss contracep-
support a drug habit (Bautista, 2001). In rural tion with women who have serious psychiatric
areas of north and north-east Thailand, three of illness (McCandless & Sladen, 2003), and provi-
11 sexually active adolescent females reported sion of contraception is problematic for groups
that their sexual debut was a result of force or who do not attend routine medical or reproduc-
pressure from their partner (Isarabhakdi, 2001). tive health services.
An investigation in South Africa (Jewkes et al.,
2001) found that pregnant teenagers were sig- The reproductive health, rights and contracep-
nificantly more likely than their non-pregnant tive needs of women with intellectual disabili-
counterparts to have experienced forced sexual ties have been the subject of extensive legal, ethi-
initiation and to have been beaten, and were less cal and health care deliberations in the United
likely to have confronted partners when they States (Paransky & Zurawin, 2003). The con-
discovered they were unfaithful. cerns of parents and carers regarding pregnancy
and menstrual management have in some cases
Inconsistent use of condoms and prescription led to women being surgically sterilized or un-
contraceptives was associated with verbal abuse dergoing hysterectomy (Diekema, 2003). The
of young women, aged between 14 and 26 years, women’s capacity to make autonomous decisions
attending family planning clinics in south-east and to care for children is not always clear, and
Texas, USA. Clients who had used dual contra- the rights and wishes of the individual women
ception (such as a barrier and a hormonal meth- have to be protected as far as possible (Diekema,
od) during the last intercourse were less likely 2003). Newer medical options, including hor-
to have experienced verbal abuse (Rickert et al., monal implants, permit less invasive and revers-
2002). In a study of 600 American women at- ible management of fertility and menstruation
tending sexual health clinics, personal control (Paransky & Zurawin, 2003).
in the relationship was predictive of female con-
dom use when male condoms were not used. Extensive research on the situations that trig-
Male and female condoms were more likely to be ger clinical depression has revealed critical ar-
used in relationships in which women reported eas of overlap with intimate partner violence.
having more control, but both were less likely to Situations or events that engender depression are

50

Chapter 3. Psychosocial aspects of family planning

typically characterised by a sense of loss, defeat, clandestine abortions in both developing and
humiliation and entrapment, diminished self- developed countries are likely to be unrecorded
esteem, and poor coping and decision-making (Huntington, Nawar & Abdel-Hady, 1997; Kaye,
ability. Identical psychological effects are caused 2001; Ahman & Shah, 2002; Rossier, 2003).
by violence (Brown, Harris & Hepworth, 1995; Estimates suggest that 26 million legal abortions
Astbury & Cabral de Mello, 2000). Family plan- and 20 million illegal abortions were performed
ning programmes need to extend their explana- worldwide in 1995, with one pregnancy ter-
tory models for unmet need and non-use or in- mination for every three live births (Henshaw,
consistent use of contraceptives to include the Singh & Haas, 1999). WHO estimates that
possibility that intimate partner violence may be 19.7 million unsafe abortions took place in
a major cause of low rates of contraceptive use 2003, almost all of which were in the developing
and several poor reproductive health outcomes. world, resulting in approximately 66 500 deaths
(WHO, 2007). Some countries, e.g. Ireland and
Women’s decision-making latitude, including Poland, report near-zero legal abortion rates but
their control over participation in family plan- these figures say nothing about the number of
ning programmes and use of contraception, is clandestine abortions and the extent to which
critically linked to their emotional well-being women travel to nearby countries for abortion
and their status in the family. Support from (Henshaw, Singh & Haas, 1999).
health professionals for autonomous decision-
making is associated with fewer psychosomatic The United Nations (1999; 2003) has collected
complaints and depressive symptoms. information on the legal status of abortion in
countries throughout the world, and has com-
pared the legal grounds on which abortion is
Mental health and elective abortion
permitted in developed and developing coun-
The direct and indirect societal and personal tries. The respective percentages of developed
impact of elective abortion varies widely from and developing countries that permit abortion
country to country, because of differences in le- on specific grounds are as follows: to save a
gal, social, political, religious, cultural and med- woman’s life (96% and 99%); to preserve physi-
ical restrictions, stigma and practices (Henshaw, cal health (88% and 56%); to preserve mental
Singh and Haas, 1999). In many countries, wom- health (85% and 54%); in cases of rape or in-
en cannot access legal, safe, timely or affordable cest (83% and 32%); in cases of fetal impairment
abortion, and they resort to unsafe, clandestine (83% and 27%); for socioeconomic reasons (77%
or “backyard” abortions by unqualified practi- and 19%); on request (67% and 15%). Abortion is
tioners, or to unsafe self-inflicted procedures. totally prohibited in four countries, three in the
Unsafe abortion is one of the major causes of developing world and one developed country.
preventable death (WHO, 2005). Safe abortion Laws that permit abortion to protect a woman’s
is a simple and inexpensive procedure (WHO, health, and more specifically her mental health,
2003), with surgical vacuum aspiration the pre- suggest recognition of the potential serious ad-
ferred method in the first twelve weeks of ges- verse impact on women’s mental health of hav-
tation and medical abortion (using mifepristone ing to continue with an unwanted pregnancy.
and a prostaglandin) possible in early pregnancy However, such legislation may be implemented
(WHO, 2003). At abortion providing services leniently, accepting a broad definition of health
with medically trained practitioners, women and mental health, or in a highly restrictive fash-
usually simultaneously access contraceptive and ion, by requiring that women demonstrate sig-
other health services, ultimately decreasing the nificant physical or psychiatric pathology (Aries,
abortion rate and improving their reproductive 2002; de Crespingy & Savulescu, 2004; Pinter,
health (Henshaw, Singh & Haas, 1999). 2002; Whittaker, 2002). Legislation may also
include gestational limits. Little is known about
It is difficult to obtain reliable estimates of abor- the incidence of clandestine early abortions (up
tion rates because there have been few compre- to twelve weeks’ gestation) versus later abortions.
hensive epidemiological studies, the terminol- In countries with liberal abortion legislation,
ogy used to describe elective abortion is often estimates suggest that more than 90% of legal
ambiguous (e.g. induced miscarriage, menstrual abortions are early (British Medical Association,
regulation), induced abortion may not be dis- 2005; Chan & Sage, 2005).
tinguished from spontaneous abortion, and

51

Women’s health advocates have gen- 1997. (Gebreselassie & Fetters. all were poor and all underwent subsequent decision-making and adjustment to high-risk procedures involving the insertion of the pregnancy. (Hessini... A significant minor. unsympathetic treatment from medical a pregnancy experienced difficulties with long. 2002) suggests that the mental health aspects of abortion may be inextricably linked to the particular “abortion milieu” (Stotland. infertility and death (Ba-Thike. Casas- First. Canada. notwithstand. 12 prosecuted excluded. catheters. pelvic inflammatory disease.. Casas-Becerra noted that upper- nation of the impact on women’s mental health and middle-class women could afford a private. 2003) have sought haemorrhage. 2003. and 80 prosecuted for having an pregnancy are not examined. Maternal mortality and morbidity rates have quences including poverty. breaches of their privacy and confidential- term adjustment and mother–infant attachment ity. 2002). Several countries.. 2002) and Kenya es of unsafe or incomplete abortion can include (Onyango. risk is stratified along economic lines. Herrera ciated improvement in mental health may also & Zivy. to reduce complications following unsafe abor- inal injury. toxic tion by improving the medical response post reaction. shame.4 million abortions are abortion (David et al. Of this last group. where an estimated 160 000 to 300 000 pects of abortion is limited in a number of ways. A rigorous. complications. 52 . Women may also face adverse legal. social and psychological conse. with post-abortion complications reported pu- ity of women who were twice denied abortion in nitive. contraceptive fallibility. many were subsequent- conception may have an impact on the woman’s ly imprisoned. 1997. Bandewar & Pisal. sepsis. Where the abortion mi- lieu is legally restricted.. Second. Whittaker. In Mexico. Variations in women’s access to instruments such as knitting needles and rubber contraceptive methods. Boonthai & Warakamin. illegal abortions are performed annually. improved in developing countries that have le- sion and imprisonment. In nineteen other Latin American coun- Czech Republic to examine the effects of denied tries. 2003) found that clandestine and unsafe. studies in India (Duggal. 1997). 2002). 1997). longitudinal study in the doctors. Becerra (1997) reported on 40 women pros- tion following a diagnosed fetal abnormality are ecuted for performing abortions. In Chile. Nevertheless. genital and intra-abdom. and may even be driven galized abortion (Hardy et al. 2005). adverse developmental and emotional conse- quences than those born to a matched cohort of mothers who desired the pregnancy. erally sought reform of restrictive abortion laws Langer et al. Mental health aspects of women’s reproductive health The following discussion of the mental health as. Huntington. 2004. 2001. Sigal (2004) has made similar observations in a 50-year study of unwanted babies in Quebec. the causes of the unintended as accomplices. 1996). The medical consequenc.. Kubicka et al. with poor women more likely to resort to unsafe abortion (Whittaker. 1997. al. 1997. 1988. Abortion milieu An ecological model (Krug et al. David. social exclu. Gupte. an estimated 3. of having their requests to abort a pregnancy confidential procedure performed by trained denied. Mitchell & Nyaga. and the withholding of pain relief (Langer et and their children had higher rates of long-term. Nawar & Abdel-Hady. pain. 136 women women go to great lengths to obtain an abortion who went to a public hospital emergency room when one is initially denied. Third. and vulnerability to the authorities by the public hospital where to violence. the special cases of late abortion and abor. an asso- to commit suicide (Casas-Becerra. 1997. The majority of women were reported education. abortion. 2002). the majority of which are Matejcek. economic security. 2001. abortion. there is no detailed exami. including Ethiopia Herrera & Zivy. may all exert independent effects on they had sought treatment for abortion-related mental health. eight had sought ing the fact that the biopsychosocial context of abortion following rape. staff. Dytrych & performed annually. be expected.

morally blind individuals who kill their own The cost of the abortion may be subsidized by children for convenience” (Fried. Women have complained that who believe once a woman is pregnant she must the hospital camps lack privacy (initial registra. 1997) and elsewhere suggest that tion and restricted abortion access (de Crespigny “legalisation is an imperfect indicator of the & Savulescu. 1997:108). 2003) and indirectly impact on women’s physical and men- the government subsidizes the cost. 2002). in relation to abortion (WHO. Dean. 2003. tal health. verbally abused. with support from the plifying “unrestrained hedonism. in- do not face a threat of death. 2004). In Thailand. niving.. 2001b). Most of the population supports safe. or denied abortion on spurious grounds network of Crisis Pregnancy Centres which (Ramachander & Pelto. tion to abortion outside abortion-providing clin- galized in India in 1972. United States women who have abortions tend an accredited medical facility for a medical have been portrayed by anti-abortion groups as abortion. (Castle & Fisher. an esti. regularly updates its tation” (Whittaker. and gal abortion services (Kelly & Evans. 1997). for abortion. Puerto Rico clarity and the risks run by both women and (Azize-Vargas & Aviles. or vulnerable and needing protection” mated 85 000 women terminate a pregnancy (Abeyesekera. tems and liberal abortion laws. or for the ten-minute surgical abortion “selfish. When limited official support. 1996). intimidation and cost of abortion. information or services accessing abortion providing health clinics. Approximately one and half million abortions vide abortions. Definitions and semantics can im- there is some variation between Australian states plicitly and explicitly reflect value judgements. serious illness or cluding ingestion of poison and violence. use a variety of strategies to delay and dissuade women from terminating a problem pregnancy. Maltbie & Sullivan.. 2002). high rates of contraceptive use and sterilization. In countries with comprehensive health sys. Medical and social assumptions of maternity are stration that continuation of the pregnancy is a embedded in definitions of maternal mortality threat to the woman’s mental or physical health. coerced into surgical steriliza. However. but many clandestine abortions are performed annually in the United States of continue to be performed annually by unquali. denial of public funding. In explain. ics (Clapman. (Hardy et al. scientific community may also serve to restrict 2005). in abortion laws. Reflecting These laws have been criticised for their lack of on the large number of deaths from unsafe abor- 53 . Azize-Vargas & Aviles (1998) point to groups (Cavenar. 2006. 1997. In the government. National Health and Medical availability of services providing safe abortion” Research Council. and women have been in abortion services. Psychosocial aspects of family planning Ramachandar & Pelto. America. each year. this milieu. vice and temp- National Health Service. Fried (1997) has observed American al support from staff. although the national data do not dis- tinguish between procedures following missed Use of certain words and definitions within the abortion and elective abortion (Chan & Sage. 2003).. Dean & Allanson. Woodhouse. 1997: 41). but a low Worldwide. Since abortion was le. unfeeling and procedure under general or local anaesthetic. 2004. “variously assumed to be promiscuous and con- ing an elective abortion. Mozambique abortion providers in terms of potential prosecu- (Hardy et al. Chapter 3. continue the pregnancy no matter what her cir- tion and waiting areas may be in the open air cumstances. ing abortion are under threat from anti-abortion ing this. women were medical and psychological care of women seek. and women turning to unsafe abortion practices. or expand women’s reproductive options. 1998). 1978. family and friends. le. Puerto Rico has one of the world’s most liberal abortion laws. terminations are performed annually in Great anti-abortion rhetoric has labelled women who Britain. have led to a significant reduction and publicly visible). sexually irresponsible. 2001). In Australia. with most requiring demon. The activities of anti-abortion groups. either prosecution. fied practitioners. During parliamentary evidence-based guidelines on best practice in debates on abortion in Sri Lanka. abortion providers and women seek- documented incidence of abortion. Women can receive emotion. Medoff. Rizzardo et al. and no government subsidy for the women can face verbal abuse. An estimated 180 000 pregnancy self-inflicted or inflicted by others. government-run mo. The Royal College of Obstetricians and have an abortion as “morally corrupt” and exem- Gynaecologists (2000). women can at. increased legal restrictions and a well-funded tion. 1982. Most women surveyed believed violence from people protesting their opposi- that abortion was illegal. 1991). bile hospital camps and the private sector pro.

2004. Stotland. Altogether. a reason. while post- the price women are expected to pay for hav. including being held in suspension” (Huntington. A woman’s attitude towards the pregnancy may also be quite distinct from being pregnant The discussion below reflects research on the (Condon. and a relative nificantly lower. of the evidence to other abortion milieus is un- ality. 1979) or “preg- nancy-related deaths” might be a more suitable Abortion and mental health term. Dagg. 1991:10). the traumatic experience they had just survived. earlier research is included. Frommer & Weisberg. Generalizability contraceptive incompetence or impulsive sexu. at two hours. Larsson et al. in developed countries. Mental health aspects of women’s reproductive health tions in Bolivia being described as “maternal assessments have been taken from a few hours deaths”. Studies have not included a specific ter unsafe abortion has overshadowed research mental illness category. enough to pay for a safe abortion. 2004). 1995. woman is pregnant in circumstances unfavour- able to pregnancy continuation. de More is known about women’s emotional health Silva & Gange. Where there are gaps in the recent evi- intended pregnancy” might be preferred where a dence. Geelhoed et al. or incest. clear. Rance (1997) concludes that this “is to two weeks before the procedure. de Silva & Gange. 2003. tioned their own im. and lack of readiness come unwanted. for terminating a pregnancy. methodologi- cal problems have included ideologically moti. 76% endorsement) were: a concern about life abortion research on large samples is scarce and changes if the woman had a baby.. 1990. and that hour to two years after the abortion. the most important College of Obstetricians and ing medical attention. may be- 2004). and such women may or into their mental health. “In trying to understand may not fit within the general health category. Major. The most frequent research in both developing and developed coun. Only 1% said Gynaecologists. Torres & Forrest (1988) asked 1900 women in American abortion facilities about their reasons Because of the stigma associated with abortion. 1997). 2002. al. Accessing abor. Matlin. rela- teristics and contraceptive history of women tionship problems “A pregnancy may have been seeking abortion (Adewole et al. single parenthood. Research into women’s physical health af. research samples commonly com. To refer to a pregnancy as “un. In a study of 386 American women. & Abdel-Hady. Nawar in developing countries (Tornbom et al. similar their concerns about physical recovery were the reasons have been found in more recent studies most salient. qualitative and retrospective. with emotional reactions perhaps across a variety of cultural contexts.. and only 7% gave a health problem as 2002). compared with some hours McGrath et al. while “unplanned” may imply women’s relatively liberal abortion laws. before the abortion. 1985). ity. “reproductive mortality” (Beral. Cozzarelli et vated research seeking to demonstrate that abor. 2002. Turell. cantly higher. 31% nancy may become wanted. (2000) found that depression scores were sig- tion is either harmful or benign. Angulo or a wish to avoid planned and intended yet. Armsworth & Gaa. Pre-abortion baseline mean scores indicated that women felt more re- 54 . a number of reasons. Mental health studies are mostly anecdo. Perera. afford a baby. 2004. 1991. for the responsibil. 2003. hand an unplanned preg- tion is illegal. or those who are wealthy reason. and most important reasons (between 31% and tries has been limited. prise women presenting to public hospitals with of respondents men.. Adelson. 1994. 1990).. and self-esteem scores signifi- scarcity of rigorously designed studies (Adler. However. years after abortion. experiences of women having an unsafe abor- wanted” may suggest fickleness on the part of the tion and research from developed countries with woman. Where abor. One month after abortion. 1985) or “un. Despite significant social differences. those indicating this was pregnancy in this way” (Royal who do not experience complications requir. operative assessments have occurred from one ing transgressed by refusing maternity”. one month and two 1992. The term ‘unwanted’ does not serious complications following unsafe abortion. inability to primarily focused on the demographic charac. on the other tal. In developing countries. for & Guendelman. that the pregnancy tion research samples can pose dangers to both was the result of rape participants and researchers (Herrera & Zivy.. convey the ambivalence felt by Such research obviously has little to say about maturity. “Problem pregnancy” (Baker. 2002. with 11% many women in categorising a women who do not access health facilities. Perera.

that the symptoms were unrelated to the abor- porting dissatisfaction had increased to 16. past or current psychiatric illness ric data were reported. most of the variability in women’s post. 2000. Major et al. high et al. to safe elective abortion. However. the outcome variance has attracted negligible research attention. 59%). were not re. 1997. Cozzarelli. gest that unsafe abortion can be traumatic be- fore. sistently concluded that safe. 1989. (including adolescents) experience heightened cal impact of adverse life events. two-thirds had a pre-abortion dissatisfied and had made the wrong decision. treatment for emotional problems in the past. 1993. (2000) reported on 418 American factory sexual adjustment (74% compared with women two-years after an early elective preg. a rate equal to the national but 87% reported improvement in other relation- rate of depression. The abortion had a ence some degree of dissatisfaction with their very low psychological impact for two-thirds of abortion decision or other psychologically dis- the sample.5%) reported At two-year follow-up. was predictive of poorer mental health and more or recurrence. although qualitative data sug- abortion adjustment was unexplained. elective. safe abortion might protect vulnerable tions at one hour. psychiatric history. 4 (1. the number of women re. Chapter 3.. during and after the abortion. clinical depression. 13 were unsure. 2001). and abortion. No other psychiat. 2001. which is less 96% reported resuming normal work activities than the national rate. In summary. while negative abortion-related emotions and evalua. such feelings do not necessarily signify clin- who had undergone an early pregnancy termina.3%. 29% (63) had a history et al.. early abor- tion does not pose a substantial mental health 55 . Evidence-based reviews have con- of inpatient or outpatient psychiatric treatment. Of tions. Pope. of serious mental ill-health. but show significant three months after the procedure for 96 women improvement on mental health indices after- in Australia (Allanson. of 216 women ant. Eisen & Zellman (1984) reported simi. While unpleas- Greer et al. 2000. Typically. highly significant improvements were ob- abortion reported satisfaction with the decision served in measures of depression and guilt (13% six months later. psychological distress scores in the days prior to Psychiatric sequelae to safe abortion appear to the abortion returned to within normal limits be rare. The stress of facing illness was related to the abortion. an abortion. during the two years following the abortion. tion. and has not been a strong predictor women’s views on whether subsequent mental of adjustment to abortion. This compared with 26% shortly after the abortion. The explained was quite small (generally less than mental health consequences of unsafe abortion 10%). (1976) found that. over half (59. A pre-pregnancy history of depression might be expected to increase the risk of onset. and 19% (42) had received psychiatric treatment all more positive emotions than negative emo. Adler. an unintended pregnancy or unsafe abortion ported. Barnow with 5% being admitted to hospital. this group of women statistically significant. women to scores on a scale measuring the psychologi.. Satisfaction with the marital relationship nancy termination: 20% reported an episode of did not change from before to after the abortion. Adler & Tschann. Overall. Though these relationships were and parenthood. 1% met clinical criteria for ships. England. 10. reported considerable or moderate guilt com- pared with 37% before the abortion) and satis- Major et al. However. 1999): 31% had sought wards (Mueller & Major. elective. and over. 2000). The possibility of mental is apparently rare as a stated reason for elective ill-health being a reason for the abortion. in this case a distress facing a problem pregnancy and prior problem pregnancy and its early termination. while 13% reported deterioration. Three months after the abor- lar findings: 80% of 148 adolescents who had an tion. ically significant mental health problems (Major tion in London.8% reported that they felt these 42 women. of women reporting clinical depression at some stage prior to the pregnancy. while 27% reported some persisting tressing symptoms about their decision to have stress symptoms related to the abortion.9% of the total sample) reported that and 19% said that the abortion was the wrong their symptoms were related to the abortion. Psychosocial aspects of family planning lief than positive or negative emotions. and is likely Previous psychiatric treatment was not related to cause psychological harm. and decision. are not known. one month and two years after women from the long-term stress of pregnancy the abortion. Some post-traumatic stress disorder. and this can increase to up to 20% within two years after abortion. Approximately 10% of women experi- at three months follow-up.

disclosure about the abortion was re- terventions had fewer emotional and physical lated to decreased distress. contrast. In identifying appears that the continuing complex biopsycho. 45% did not disclose because women who had had an abortion. 25% had told their mother and 17% had told all Although adverse mental health impacts of safe three. Linn. or (iii) a control sion and intrusive thoughts were associated with presentation on a therapeutically neutral topic. In-depth interviews with 31 women hospital- tion are not known. Turell. 56 . ized in Egypt with post-abortion complications (Huntington. Cozzarelli. Sumer & of people gossiping about them. (ii) to alter the attribu. conflict were more distressed than if they were just perceived as a source of support. and 8% be- timism. disclosure was more acceptable. Mental health aspects of women’s reproductive health risk and has fewer adverse psychiatric sequelae 85% of women had told their partner about the than childbirth (Adler. 2001. Both suppres- tions for unwanted pregnancy. (1997) investigated blame and lack of understanding from their hus- 617 women’s perceptions of support and conflict band and his family. Major. 1992. and positive well-being one month after abor- ous adverse impacts appear to be quite small. Woo. 1990. irrespective of his support for health after abortion her abortion. mother and friends. the possibility Major & Cozzarelli. Mueller & abortion. 1990). Fine justment appears to be protective (Cozzarelli. Generally. 1992. Nawar & Abdel-Hady.. increased psychological distress over time. perceived personal control and high cause they believed that disclosure would result self-esteem – was strongly associated with better in their partner physically harming them. was related to distress one month after abortion. apparently re. 1990. In a survey of 818 American wom- Pre-abortion optimism about post-abortion ad. and bling issues for the women were the need to re- the characteristics of study samples (Mueller turn immediately to physically demanding work & Major. cope with illness and more likely to seek health sulting from subtle differences in the defini. Major et al. Self-efficacy Major & Gramzow (2001) reported on 442 predicted up to half the variability in post. Dagg. the quality of relationships. as sources of support and reported little conflict. 1998). and child care responsibilities. disclose the abortion to the partner in the preg- Cozzarelli (1993) investigated 291 American nancy. 69% had told a friend. The most trou- tion of support. and criticism. Investigations women’s predicament was made more difficult of social support have indicated considerable by this because women are usually better able to complexity and contradictions. cated that practical and emotional support were cision regarding abortion. en presenting for elective abortion. Sumer & Major. women viewed all these people elective abortion affect a relatively small minor. American women followed for two years after abortion psychological adjustment. but their social net. The longer-term benefits of the interven. & Goetzl (2005) found that 17% chose not to 1993. Of these. Women who felt that they could not Major (1989) randomly assigned 232 women to disclose the abortion suppressed more thoughts receive one of three brief verbal presentations about it and experienced more intrusive thoughts before their abortion: (i) to raise expectations of about it than those in environments in which personal coping capacity. post-abortion adjustment both immediately and three weeks after the procedure. 1998). 1991. and found the relationship had no future. Cozzarelli. not forthcoming. Major et al. Preoperatively. 2003. it tion was predicted by support. Conflict Risk and protective factors for mental with the partner. partner would oppose the abortion. factors contributing to less positive adjustment social environment of abortion and a desire to one month post abortion. 1989. ity and the number of women experiencing seri. Adler. care when socially supported. The authors surmised that works are not always supportive. Stotland. pregnancy and abortion. 21% because the that self-efficacy – defined as pre-abortion op. within three salient relationships: with their partner. Major et al noted that optimise women’s mental health following safe women who perceived their mothers and friends elective abortion has prompted limited research as a source of a high level of support as well as into risk and protective factors. complaints immediately following the termina- tion. 1997) indi- Women often involve other people in their de. 1991. Major. in Women exposed to one of the experimental in.

infertility and isolation. compared with 8% for other gynaecol- 1993. partner (Kaye. Leung et al. tory of sexual abuse. contraception and abortion (Henshaw. however. Glander et al. The authors The very low abortion rate in the Netherlands note. A study of women in Uganda who reported having an abortion were more reported that 39% of 70 women presenting to a likely to report depressive symptoms and lower gynaecological emergency ward with complica- life satisfaction than those who reported that tions of induced abortion gave domestic violence they had not had an abortion (Russo & Denious. but institutionalized “blaming of vic. compared with 25. In a large- Recent research suggests that victimization may sample study in Colombia. physical abuse. mination reported a history of sexual or physi- ception for married women (Gupte. controlled for.9 per 1000 in the USA) health professionals. which include pregnancy resulting that 40% of 486 women seeking pregnancy ter- from rape for single women. and 59% reported more anxiety after Prevalence studies in various countries have the initial examination than before it. Chapter 3. In a study of 818 American women characteristics and background variables were (Woo et al. 1999). Women having a repeat ics and harassment of women seeking abortions. had had an abortion reported violence (includ- pital in Mexico. Cozarelli & Major..0–6. but social milieus that do not provide a hospital abortion service in London (Fisher support for women’s decision about pregnancy et al. rather than comforting. Pallitto & O’Campo play an important role in some women’s decision (2004) documented a moderate relationship be- to seek an abortion. abortion. including attacks on abortion clin. ogy patients and 18% for pregnant women at- 2000). and a shortage of research that goes be.. Cozarelli et al. ner violence towards the woman in her current sions. In this study. In in order to meet legal eligibility requirements the United States. Bandewar & cal abuse.5 per 1000 women aged 15–44 years in ably inhibited the women’s reporting of abuse to 1996. tending antenatal clinics in the same locality. A United Kingdom survey (Keeling. recent and more serious violence.. Pisal. lence were significantly more likely to become Singh & Haas. 1997). 2004) found that 35% of women seeking an abortion reported intimate partner Women’s interpersonal networks can be pro. (2002) found a scarce. of 27%. The authors esti- of violence. abortion were more likely than first-time abor- would be expected to produce negative effects” tion seekers to have suffered violence at some (McGrath et al. documented a high incidence of violence against women may need to lie about their pregnancy women among those seeking an abortion. 2001). 1994. would decrease by 5% (32 000–45 000 abor- yond measuring prevalence. 2004) found tive options and open discussion and acceptance that women with previous or recent partner vio- of sex. impact of mental health. 2005). compared with 14% of those who reported no and constant worry about their children at home. An epidemiological study has been linked to the promotion of reproduc. lifetime prevalence of domestic violence among tims” and withdrawal of social support are likely women seeking abortion in Hong Kong. However. to have adverse effects on self-regard (Waites. and in their abortion-related tween unintended pregnancy and intimate part- mental health. China. Birch & Green. In India. Almost half the women arrived ing physical or sexual assault during childhood at the hospital in a highly anxious state and re. Psychosocial aspects of family planning Langer et al. in Australia (Taft. or adulthood and intimate partner violence) ported fears of dying. Watson & Lee. and failed contra. ing abortion prevent women talking about The women seeking abortion had suffered more their experiences and may worsen outcomes. as the main reason for inducing the abortion 2001). abortion was unrelated to poor pounding. sexual abuse 57 . barriers to women’s disclosure of mated that unintended pregnancies in Colombia violence. abuse. when history of abuse. (1998) found for abortion. however. because of differing definitions or most recent relationship. (1997) discuss the apparently com. while a survey of 1127 women attending tective. It is difficult to draw firm conclu. Empirical research is time in their life. 31% of women who post-abortion medical attention at a public hos. 2005) found that 20% reported intimate may have an adverse impact. A household survey tions) annually if intimate partner violence of 2525 women in the USA found that women were eliminated. Taboo and punitive attitudes surround. pregnant and to report having had an abortion than women without such a history. The women found the medical staff rushed and insensitive. 1999). that cultural influences prob- (4.. “Expressions of partner physical abuse and 27% reported a his- disapproval.

pregnancy complications. small but and protective factors that are predictive of men- statistically significant links were found between tal health following an abortion. ma- (Carlson. and the discussion above suggests that decision ambivalence may reflect many other facets of a problem pregnancy and abortion. Post-abortion these women’s experience of violence (40% re. 1999). 2002). abortion disclosure. mental health appears to be enhanced where ported being physically assaulted. Allanson & Astbury. tural preferences for sons. Rothstein (1977a. Yet. emotional attachment to a pregnancy or anxie- fering past or current physical and/or sexual ties about pregnancy continuation or termina- violence have worse mental and physical health tion. when poorer mental health outcomes three months the abortion is not kept secret from others. 1995). violence may interfere with contra. but may influence Evidence suggests that pregnant women suf. have not been investigated. 1990. ternal attachment to the pregnancy. 1990. ing miscarriage. or may and undermine a woman’s confidence in pro. Lam. 2002) and surgical abortion. there has been only limited inves- tigation of a woman’s relationship with a preg- nancy she is considering terminating (Hunter. 1997). Miller. and 10% reported conflict about the abortion within usually sup- violence from the partner in the pregnancy) and portive relationships or with the partner. 2002). the relationships between elective abortion and support and women’s abortion related mental other adverse reproductive experiences. when there is no assaulted. Sexual assault when the woman has high self-efficacy. Although ambivalence appears to be a risk factor for post-abortion distress. leading to grief and a sense of loss if the pregnancy is ter- minated. assisted conception. Pines. cessibility of safe reproductive and family plan- 58 . In summary. Gupte et al. Based on interviews with 67 women from six villages in India. However. and among 96 Australian women attending for an early abor.. (Krug. In addition. 1991. Turrell. Mental health aspects of women’s reproductive health or both within the previous year was twice as Cultural and social factors that place coercion common among those who did not disclose their on women’s reproductive health. and post-abortion (Allanson. 1995). 2001). (1997) reported that women “who had an abortion after a sex de- termination test were traumatised compared to those who had an abortion for other reasons”. Ambivalence Arguably. Ambivalence in an abortion decision of- ten has been taken as reflecting a woman’s emo- tional attachment to her pregnancy. Research history may increase anxiety around childbirth is needed into other possible risk /protective fac- (Jackson. Allanson & Astbury. 9% reported both. and the ac- sequent pregnancy ambivalence. for example abortion to the partner than among those who social pressures to have only one child or cul- did disclose the abortion. ceeding with a pregnancy. Dagg. 1979. with con. previous mental health and violence is limited (Bruyn. includ- health. may be a normal part of the psychological proc- ceptive use. gynaecological examination tors. may influence mental health after an abortion (Mandal. aggravate relationship instability ess of resolving decisions about abortion. 1977b) suggests that both subtle and blatant coercion either to continue or terminate a pregnancy is linked to a wom- an’s ambivalence about whether or not to have an abortion. Dahlberg et al. 17% sexually there is no history of violence. 1990. such as history of reproductive trauma. Arnmsworth & Gaa. be an expression of low self-efficacy. evidence is emerging about risk tion (Allanson and Astbury. Kung. Leung and Ho. Leung. 2001). there has been little clarity in its definition or meas- urement (Adler et al. 2001. research linking abortion. and caesarean section 2001.

Strategies to increase the involvement of men in family planning programmes are essential if the goal of gender equality is to be realized and women’s safety protected. 4. medical Services and social expectations and infrastructure are 1. Given the high incidence of both safe and traceptive intentions and contraceptive use unsafe abortion. Sexual violence and coercion. Examination of the disparity between con- 3. Family planning programmes need to give attention to sexual enjoyment as well as fer- tility control. as well as for depression. With respect to mental health associated with both safe and unsafe abortion. Chapter 3. needs. violence. should be ascertained in establish accurately needs for contraception. biopsychoso- cial risk and protective factors. uptake of contraceptive meth- ods. Investigations are needed of the level of co- ercion and pressure women experience from family planning programmes regarding child-spacing. cial aspects of abortion care. and health enhancing interventions. Summary 2. 2. The biopsychosocial aspects of sex-selective abortion are at present unknown and need to be systematically investigated. Psychosocial aspects of family planning ning options. and fertility control needs to be sensitively ascertained. termination of Future research pregnancy and contraceptive failure. 3. 2. health professionals need should look beyond women’s “failure” to ad- specific training in medical and psychoso- here to their intentions. A society’s legal. 6. there is a need for methodologically rigorous quali- tative and quantitative investigations into women’s experiences. who may have particular vulnerabilities such as mental illness. religious. anxiety and symptoms of 1. 59 . rather than simply assumed. Strategies to increase women’s self-efficacy regarding reproductive options. medical and support needs of women facing an unintended pregnancy and abortion. as risk fac- tors for unwanted pregnancy. 3. Research needs to explore the counselling. Further participatory research is required to traumatic stress. reproductive trauma. routine care. Implications for policy 1. 5. including sterilization and abortion. Women’s freedom to make decisions about likely have an important bearing on all these participation in family planning programmes factors.

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tral southern Nigeria revealed that the women believed that attempts to control their fertility Responses to miscarriage are shaped by the pat- would result in pregnancy illness and loss. it is argued. health. and terns of socially sanctioned support and mourn- that bleeding in pregnancy was a punishment ing behaviour. The reactions of this group children is desirable for social and economic rea. There has been little cross. ety at both the family and the social level. Only if the crime pregnancy is publicly acknowledged and the could be established and forgiveness received fetus accorded status as a human (Slade. In developed countries. because of a belief that miscarriage may portend bution of blame for pregnancy loss to the woman the failure of the family to extend its lineage. discussion of adverse Mental health and spontaneous pregnancy events. and where high social status is accorded disruption to the harmony between the social to fertile and fecund women. of women to miscarriage reflect anxiety about sons. However. and is a common theme. Religious concerns are focused a man may divorce his wife (Vazquez. or even encourage. beneficial (Jordan. miscarriage creates considerable anxi- pregnancy complications (Asowa-Omorodion. 2002). it is reported that women in some settings. are able to speak candidly about all for individual women are likely to be influenced kinds of pregnancy loss. 1997). when pregnancy loss does occur (Layne. 2002). 2003). 1993. particularly my and control of their bodies during pregnancy where legal. 1993). as well as the time at which for wrongdoing by the woman. and supernatural worlds. for these cultural research on ethnomedical beliefs about women. individual responsibility and at. For example. including those that are not clinically or per. in Australia. healthy tion between miscarriage and induced abortion pregnancy outcome. safe abortion is unavailable. most within the first three months of gestation. is estimated to be much higher emphasizes the desirability of women’s autono- (Mishell. In some countries. It is implicit in this that indi- always possible to make a clear clinical distinc. Societies differ in the degree to which they per- mit. 1994). March. is by culturally specific beliefs and practices sur. In contrast to Western so- pregnancy loss cial conventions. because it is seen as a threat to the existence of cieties pregnancy loss is still grounds on which the clan itself. 2001). which is essential for ducted with Esan women from Edo state in cen. on the loss of a place within the family for the This is especially the case where having many rebirth of a soul. Focus groups con. in the available studies the attri. inheritance and ideas of (1999) conducted in-depth interviews and par- family identity. ticipant observations with Hmong women living tribution of cause. Her findings revealed that. 67 . The actual rate. Rice rounding conception. viduals can personally ensure a happy. in some so. from the offended party would the bleeding stop (Asowa-Omorodion. this can result in self-blame (Vazquez. for example Yucatan (Mexico) The psychosocial repercussions of miscarriage and Nepal. it is not and childbirth. This is 1997). contemporary discourse sonally obvious. which. 4 Chapter Spontaneous pregnancy loss Heather Rowe I t is estimated that 20% of conceptions end spontaneously in miscarriage.

whelmed by the requiring psychiatric ment or support from others.. Slade (1994) suggests an alternative con- Studies in developed countries have identi. have been re. Cordle & Cook. in developed countries. ambivalence. In developing coun. 1996). 1999). Psychoanalytical a significant life crisis (Slade. Garel changes. ings of being over. to expressions of the miscarriage is a minor mishap. 2003) the urge to nur. tively little research on maternal–fetal emotional sumption that the bereavement or loss model attachment in early pregnancy. greater the loss. Lack of social ac. appears to be a diversity discussion of adverse events is discouraged. which are exacerbated by the absence of nonexistent. ceptual framework. Women’s own descriptions of miscarriag. while the “gestational” model recog- other. 1994). helplessness and low self-es- a society where alternative roles are limited or teem. relative an invisible bereavement and disenfranchised alization explains indifference or relief at grief (Cecil & Leslie. 2003). there is also evidence in primary process thinking. where pregnancy loss of all kinds is more pregnancy loss in common. Layne. ence some ambiva- and to assume that women will make a rapid and lence towards the Not all women spontaneous recovery (Layne. Stirtzinger et al. sadness. Kline and an intense narcissistic state may develop. helplessness individuals will respond according to their in- and anger (Frost & Condon. social and cultural meanings (Madden. Cordle & Cook. She pro- rather than psychological morbidity (Maker & poses a model with greater potential explanatory Ogden. 2001.. Nevertheless. an object for which to mourn (Frost & Condon. most women experi- munity tend to minimize the degree of distress. Stirtzinger fetus. characterized by feelings of to the woman the loss of her role as a mother. not all women in every set- ting will experience miscarriage as a profound Moulder (1994) described two models on which loss. 1992. from those requiring psychiatric care riage is based. in emptiness. especially if it represents narcissistic injury. as yet there has carriage itself may be a frightening experience been no empirical investigation of this theoreti- (Prettyman. There has been rela- miscarriage. 1993. where adverse ture and protect a profound loss. Prettyman. 1999. it is arguable that miscarriage may be terms of an intense felt as more profound. there is generally an implicit as. It has been argued (Layne. cal position. as well as tude of loss in terms of the stage of pregnancy at familial. Elevated conceptualizations emphasize the normal psy- rates of psychological morbidity. power. professional care for women having a miscar- actions. Cognitive modifications may accompany these 1993. and there appears to be a diversity of re. perience of pregnancy loss as a stressor. but describes the magni- differences in personal circumstances. but the process 68 . when use of psychotropic medication. including guilt. which are characterized by alterations et al. irrevocable course care at one end of the knowledgement of distress about spontaneous of the pregnancy. to expressions of pregnancy loss may lead women to experience This conceptu. dividual coping style. 1994). which can ambivalence. to which riage. adjustment and resolution women’s responses to pregnancy loss. the 1994). 1994). Finally. relative indifference or relief at the be treated. 1993). from those women may suffer alone without acknowledge. & O’Connor. and Despite a lack of explicit theoretical frameworks the degree of individual investment in the preg- in much research on psychological reactions to nancy (Moulder. 1997). grief reactions to the other. Moulder argues that neither of es have been interpreted as a process involving these models accurately explains the diversity of the stages of turmoil. which is based on an understanding of maternal–fetal emotional attachment. spectrum. 1990. loss. which include depression and anxiety disorders and increased pregnancy as a maturational challenge. tries. which characterizes the ex- fied a range of emotional reactions to miscar. experience miscarriage as that. and there pregnancy and birth outcomes are rare and the coexists with feel. pregnancy is wanted or not. unresolved early conflicts may be re-aroused ported after pregnancy loss (Neugebauer. in particular chological changes in pregnancy. 1996). The mis. of reactions. in which in every setting will et al. Mental health aspects of women’s reproductive health Miscarriage is experienced by many women as is appropriate (Slade. However. shame. The “medical” model assumes that at one end of the spectrum. 1994). Paradoxically. whether the that both health professionals and the lay com. which it occurred: the later the miscarriage.. This variety is likely to be associated with nizes the loss involved. Geller.

but more recent work has generally used standard psychometric measures. during or after treat- 1999. the relationship between grief and depression on the measurement of psychological sequelae is essential to understanding the psychological of miscarriage. which will normally resolve without intervention over time. Meaningful compari- sons between these studies are therefore limited (Slade. However.. 1980). pressive symptoms in women following miscar- entiation of grief from depression. characterized by sistance from professional or lay support groups feelings of sadness. There is also As with other human loss. In addition. the timing of psychological assessment after miscarriage varies. Significantly higher anxiety and depression action” group were twice as likely (P≤ 0. 1995). but has received little theoretical or empiri. Grief has been conceptualized as a nor. differences between study and control groups may confound results. Beutel et al.001) to scores were found in a group of women within 24 have a prior history of depression than those in hours of surgical treatment for miscarriage com- the “grief only” group. carriage. while depressive reactions are more likely is women with uncomplicated pregnancy rather to occur in women with a previous history of than non-pregnant women. 1999). rates of depressive symptoms have been found and with difficult personal relationships and in pregnant women and community samples of poor social circumstances. 69 . of the provision of psychological implications of miscarriage (Stirtzinger et al.. the pregnancy state itself (Lumley. The attachment construct is useful in understanding Despite a lack of consensus regarding the nature the intensity of emotional reactions to pregnancy and etiology of psychological reactions to mis- loss. tomatology. in comparison with women with uncom- (1995) hypothesized that two kinds of reactions plicated pregnancy. or whether participants sought or received as- mal adaptive response to loss. indicating progression measures and comparison groups. emptiness. miscarriage. angry protest and prior to psychological assessment. Anxiety appears actions are preceded by joyful anticipation of to be less well described than depression (Brier. such as counselling. Spontaneous pregnancy loss appears to begin before fetal movements are de. A number of recent. Ritsher & Neugebauer. similar depression and elevated distress in pregnancy. however. there is a body of research describing cal attention in the research literature (Condon. methodologically rigorous action occurs when symptoms remain intense studies. In addition. the incidence and course of psychological symp- 1993). those who were categorized on the basis of standard measures to the “depressive re. munity who are not pregnant. 2003). or with women in the com- to miscarriage can be distinguished. using both standardized psychometric for a prolonged period. Chapter 4. an understanding of the question of the potential confounding effect.. In an ently found significantly elevated rates of de- attempt to demonstrate empirically the differ. motherhood and are of relatively short dura. It is therefore surprising that very few the literature has generally not distinguished studies have reported details of any such care between the symptoms of these reactions (Brier. and to have significantly pared with a control group of pregnant women. a high level of attachment to stressors and greater ambivalence towards the the fetus can coexist with disenchantment about fetus (Beutel et al. ment. Further. that may have been offered to study participants. yearning. 1994. have consist- to major depression (Beutel et al. Stowe & Nemeroff. 2002). Grief re. and there is vari- ation in the extent to which the study methodol- ogy itself may act as a therapeutic intervention. more life tected. 1995). a number of methodological limitations restrict the con- clusions that may be drawn from the studies. For example. Interpretation of these data is ham- pered by the variety of methodologies employed and of measures used to assess symptoms. Neugebauer. 1997). 1999). care. riage. Arguably the relevant comparison group tion. A pathological grief re. In his study of 125 women of a similar age who are not pregnant German women who had recently experienced a (Llewellyn. fewer educational and social resources.

between younger and older & Prettyman. Robinson et al. A differ. 1981). Prettyman.. as assessed by the Diagnostic (Slade.. assessed by the Structured Clinical – may be salient. or in subsequent pregnancies (Statham & Green. using a symp. Cordle & Cook. It has first month after the loss in 72% of cases. 2000). pared it with the risk in a population-based cohort of 230 women drawn from the commu- Follow-up investigations after pregnancy loss nity. Symptoms of depression. Anecdotal reports sug. found 25% prevalence of PTSD ducted study (Neugebauer et al. Onset of symptoms was within the riage (Tunaley. 1996). history of elective abortion (Neugebauer. post-treat- gest that a few women will experience miscar. meaning of miscarriage to an individual woman pressive disorder. occupation and marital status. persisted for 12 months in a group of has been argued that sociodemographic fac- women who miscarried (Beutel et al. Prettyman. A meticulously con- Netherlands. 1997. In this sample. 1996). Major depressive disorder was assessed by have concluded that symptoms of anxiety and the Diagnostic Interview Schedule (Robins et depression resolve spontaneously over time in al.9% and 4. the mean gestational between sociodemographic factors including age was higher in the pregnant group.2%. by marital status. may be to investigate the role of thoughts and was found in 5. Slade & Duncan. 1994). In a tors contribute little to the understanding of the study conducted in the United States. but not psychological distress (Lee & Slade. six weeks after miscar. respectively (relative (Prettyman.. 95% confidence interval (CI). ment interventions aimed at reducing feelings of riage as a traumatizing event. 1992. some of these self-blame and enhancing self-esteem appear to will meet the criteria for acute stress disorder or show promise for improving psychological adap- post-traumatic stress disorder (PTSD). 1996.. Janssen et al. and that a more fruitful approach Interview Schedule (DIS) (Robins et al. Cecil & risk. and major depressive dis..3%. 1. Kline 1994). educational level. Higher age. 1993. declin. in particular understanding of the order in 10. and com- (P<0.. tation to miscarriage (Nikcevic.2–5. 1994). Leslie. 1981). 2001). 2. sistent findings (Tunaley. This also been suggested that individual differences compared with rates of major and minor depres. for the miscarrying and the community wom- ety symptoms are more variable and persistent en were 10. Slade & Duncan. riage (Lee et al. More recently. factors such as gestation and whether the preg- ated with experience of previous miscarriage. the impact of previous adverse A prospective longitudinal study. 1994). 1998). 1997a). 1995).5. cognitions. miscarriage (Thapar & Thapar. 1993). However. respectively. women (Lee. of 229 women. 1992. 6 months after medical explanations of the cause of the miscar- miscarriage. Kuczmierczyk ent model of care may be warranted for these & Nicolaides. 1992. and that anxiety recurs women. 1993).. neither time of 70 . life events on emotional adaptation to pregnancy tom self-reporting scale with 113 women in the loss has been investigated. Bowles et al.9%. The six-month total incidence rates most women. Nevertheless. Mental health aspects of women’s reproductive health the difference persisted for six weeks (Thapar & There is no consistent evidence of a relationship Thapar. Studies that have attempted to Interview for DSM-III-R (Spitzer et al. there is some evidence that anxi. Some women The relative risk for depressive disorder in both have reported that continuing distress influ. 1993. in attributional style – a construct measuring sive disorder of 4. & O’Connor.3% and 1%. groups did not differ between women with prior ences the decision to conceive again (Cordle reproductive loss. miscarrying women assessed the risk of a first ing to 7% at four months.1)..001) (Engelhard et al. pregnancy levels of psychological symptoms were associ.. 2000). Cordle & or infertility and the risk of post-miscarriage Cook. Thapar & Thapar. 1993. 1997) of 229 symptoms one month after miscarriage. 1993). 1992).. Major depressive nal factors over which he or she has less control disorder. China. nancy was planned or wanted or reproductive childlessness and an unplanned pregnancy history including prior abortion. PTSD or recurrent episode of major depressive disor- symptoms were associated with depression der in the six months following loss. Klier. in an individual’s propensity to locate the cause of the community cohort (Neugebauer. 1992) was investigate the role of cognition in psychological found in 12% of a group of 150 Chinese women adaptation to miscarriage have produced incon- in Hong Kong. minor de. Cordle & Cook. In the group of women who had miscarried. an adverse event either internally or with exter- Geller & Neugebauer. It anxiety.

necessarily. experience including been consistently associated with post-pregnan. in the context of clinical sity of routine sur. The sequelae expectant management of miscarriage. haemorrhage uation of different treatment regimens would and intrauterine adhesions (Nanda et al. 1998). may attitudes of health care staff. and the experience of miscarriage warrants specific investigation. the risk of an ep. especially in Among women in both groups.9) for previous 2002). Historically. 1996.2) for having been a victim of violence. care (Hemminki. and the qual- Medical treatment of spontaneous ity of this care may influence women’s emotional pregnancy loss recovery. when it might more are now used with the aim of minimizing mor- accurately be described in some women as a re. especially late miscarriage. Harris & psychological vulnerability among women fol.7–20. The miscarriage experience and its aftermath are almost universally experienced in the context of clinical care (Hemminki. in the postpartum period. of both unsafe induced abortions and surgical nor length of prior warning of the miscarriage treatment of miscarriage consume substantial influenced the risk of major depressive disorder. This finding concurs with proportion of miscarriages are incomplete.. in- promote expulsion of the products of pregnancy cluding cervical trauma and subsequent cervical is gaining acceptance (Lee et al. The interaction between vention (Ashok et al. 2002). and unnecessary surgical inter- arousal of prior trauma. emergency gynaecological services. 1993. 1999). There has been limited discussion in the litera. and about whether plete miscarriage. a personal history treatment. 2001). Nanda et al. which are likely to differ.. the Miscarriage.. and violence. but current treatments for miscarriage are not based There are potential advantages to conservative or on randomized controlled studies. A systematic review of the evidence on miscarriage. and those from studies investigating mood disorders it is therefore probable that many women have at other phases of reproductive life. Hahlin & previous adverse life experiences. Relevant factors include whether the treatment is medical.. Scottish continuing debate universally experienced Intercollegiate Guidelines Network. 1998) and practice guidelines now urge lowing miscarriage or perinatal death. Demasio. un. In particu. and an odds ratio of 7. bidity. in a large data-linkage study in the United States The use of ultrasound could allow active treat- (Seng et al. about the neces. Appropriate and timely services. Hickey & Neilson. There is its aftermath are almost cy depression (O’Hara & Swain. Spontaneous pregnancy loss gestation. not the 71 . This raises the possibility of the causal Medical treatments for incomplete miscarriage misattribution of psychopathology to the mis.3–2. – evacuation of the uterus under general anaes- Smith. Chapter 4. nor attitude towards the pregnancy. women who had an ICD-9 ment to be restricted to women with an incom- code for post-traumatic stress disorder had an plete miscarriage (Vazquez. isode of major depressive disorder was substan- tially higher among those with a history of major Ultrasound examinations indicate that only a depressive disorder. developing countries (Hemminki. undergone surgical lar. Medical man- thetic – has been the treatment of choice for mis- agement using a prostaglandin (misoprostol) to carriage. 2003). There is debate about the relative effi- treatment is necessary to effect complete removal cacy and efficiency of medical and surgical treat- of this tissue from the uterus in cases of incom- ments for early miscarriage. 2003). nosis. odds ratio of 1. mortality. nancy loss is in preparation (Nanda et al. and the availabil- lead to haemorrhage and infection if pregnancy- ity of counselling. 2001). However. have been developed. 1998. 1998). 1993. 2005). support and other follow-up related tissue is retained. and pharmacotherapies carriage experience itself. with its The miscarriage of mood disorder or psychiatric diagnosis has attendant risks. need to investigate the psychological ramifica- There is an international consensus that profes- tions. uterine perforation. sional care is needed following miscarriage. agement versus surgical treatment for early preg- compared with women without such a diag. surgical curettage active treatment is needed at all (Henshaw. gical management ture of the factors that contribute to variations in (Ballagh. The procedure itself carries risks.. Any eval- incompetence. Chung et al.. such as abuse Platz-Christensen. surgical or expectant. 1999.. conservative attitudes (Lagro-Janssen. 2003). 1998).9 (95% CI 1.4 (95% CI the effectiveness and safety of expectant man- 2. Nielsen.

Hickey & Neilson. Cordle & Cook. ameliorated by discussion of their feelings. sufficient recognition by staff of the magnitude cal (misoprostol) versus surgical treatment for of the experience. 1994. 1999. its relatively high failure rate (Lee et al. Satisfaction was measured on a of surgical management. commonly report a desire for it. lated tissue and find the experience traumatic. veloping countries because it is cheap. Kuczmierczyk & Nicolaides. even though women damaged the body. al. why their pregnancy miscarried and the impli- China. which might be the 40% of women who required surgical treat. There were no significant dif. There is evidence from Australia. Moohan. (Vazquez. limit the capacity of primary health care provid- although it carries its own risks. It would appear. 1993. days after treatment may have limited critical or dissatisfied responses (Nielsen.. 1993). There have 72 . analogue scale. A room temperature. its ant with medical management for first-trimester efficacy will need to be improved if its apparent miscarriage. is the avoidance of hospital admis. 1999). It has been argued that the the United Kingdom and the United States that psychological impact of medical management aspects of the primary and hospital care that of miscarriage should not be underestimated. rather than to the sequelae or satisfaction. is shared by many other cultures. Flannelly & Wingfield. insufficient information about early miscarriage. that this finding has widespread application. Hahlin & Platz. Nikcevic.. on several measures. 1994. comparing expect. but women and health (Cuisinier et al. less satisfied than for women in their care (Prettyman. and deficiencies and culturally appropriate outcomes for women in psychological or medical follow-up. However measures When surveyed. been suggested that unhelpful and insensitive ferences between the groups in psychological or attitudes among staff may reflect their own emo- social functioning. chologically informed care are needed. but the fact that of medical therapies in miscarriage may help to it was administered in the treatment setting 14 address this potential flaw. 90% of care providers recog- of client satisfaction. therefore.. Speraw. 1992. for women with uncomplicated misoprostol may prove especially useful in de- miscarriage. pared with 82% of 60 who were given a com- bination of antiprogesterone and prostaglandin Research into the psychological consequences of E. 1994. 1999). conducted in Hong Kong.. The authors argue available. this study investigated the ethno. Harvey. measured two weeks and six tional responses to pregnancy loss (Brier. and report that it is helpful (Prettyman. post-miscarriage complications of miscarriage itself. and may Surgical intervention under general anaesthesia. but there were of potential misattribution of adverse psycho- no differences between the groups in level of logical and physical outcomes to the experience pain. that for whom medical treatment was successful. 1996. Cecil. com. visual. women’s reports clearly fa. 1992). made with due care to limit nized that women were likely to experience emo- under-reporting of dissatisfaction. bleeding. Mental health aspects of women’s reproductive health least of which. months after the procedure. may therefore ers to identify psychological morbidity (Wong et be the preferred treatment option for some wom. and has few systemic effects randomized controlled trial. 1991. Moyle & Creedy.. Paton et al. follow-up professional care after mis- treatments were seen as having devitalized and carriage is not provided. but ment because of failure of medical treatment only 20% felt confident that they could do this were. 1998). the Netherlands. Research into the use single. paid particular attention to psychological cations for future pregnancies. On measures of the degree to which In general. 2001). 2002) However. showed that tional distress after miscarriage. Brier (2005) recommends that practi- en (Sharma. Women report in- A randomized controlled comparison of medi. attend when it is voured medical treatment. In addition. education and training of staff to provide psy- Interestingly. Christensen. Lee & Slade. found that 76% of 62 women had a psychological benefits are not to be attenuated by complete miscarriage without intervention. 2001). 1993). stable at sion and separation from family (Smith. Ashe & Cecil. medical dimension of the treatments for the par- ticipants. It has (Lee et al. 2001). because concern for devitalization of the body Turner. Those receiving pharmacological treatment miscarriage has been hampered by the problem had a longer convalescence time. Cordle & both the surgical treatment group and the group Cook. care staff may see the discharged pregnancy-re. tioners should routinely screen for anxiety and depression after miscarriage. women receive after miscarriage are consistently Pharmacological treatment may shorten the time regarded by them as unhelpful in their recovery to complete miscarriage. 2003).

Women’s responses to miscarriage are likely to that two recent prospective longitudinal studies be mediated by the reactions of others. with other forms of bereavement. 2000). In common The intervention was generally regarded as help. There is general agreement in the literature that psychological distress diminished significantly many women experience miscarriage as highly in both groups over time (Lee. a combination of such screening does not distinguish women for explanation of the medical reasons for miscar. 1996). 1997b). including local health months after miscarriage revealed no significant services. and that rates of subsequent psycho- 1996). proach is needed. Nikcevic. or routine care (no follow-up). They further suggest screening using the one year after miscarriage (Swanson. can potentially precipitate trauma reactions. fect. miscarriage (Nikcevic et al. measures of psychological morbidity (Lee. includ- have found no association between miscarriage ing family members and the broader society in and psychosocial stress. to detect specific features of miscarriage suggest that a individuals who may benefit from additional broader conceptualization of therapeutic ap. cy loss were significantly more likely than those chological debriefing by a female psychologist in who were not depressed to have partners who their own home approximately two weeks after avoided talking about the loss and who were the miscarriage. including depression and anxiety. 1994). Nelson et ity to provide emotional support remains un- al. but are not 73 .. optimism. With the excep- tion of anxiety. al. a form of cri. less supportive (Beutel et al. in the presence of their sis intervention used with survivors of trauma own feelings of loss after miscarriage (Puddifoot (Lee. psychological assistance (Lee. In particular. grief may be less intense and of shorter dura- carriage care that acknowledges that miscarriage tion than that of women (Stinson et al. Slade & Lygo. support from ful. Men appear to grieve the loss of a pregnancy (Conway & Russell.. even for women in the control group (Athey retical conceptualization of miscarriage as sig. This was tested in a & Johnson. distressing. Chapter 4.. 1996). which they live. in this context. which remained above the norm. 1999). a randomized controlled test of a have cancelled out beneficial effects. 2003). 1993. & Spielvogel. The 30-item General Health Questionnaire. The authors suggest that nificant loss. pathology.. Slade & Lygo. but do not counselling intervention by nurses found no sig. but their Lee & Slade (1996) proposed a form of post-mis. and little description of the form that such the study may itself have had a therapeutic ef- follow-up services might take. 1992). 2000. It is interesting to note. present data to support or refute this interpreta- nificant differences in overall mood disturbance tion. and A small qualitative study revealed that men may that gives attention to post-miscarriage anxiety experience confusion about how to behave so- symptoms. This is consistent with findings to the psychological care of women after sponta- of other trials of psychological debriefing in the neous pregnancy loss will be effective in all set- context of reproductive loss or trauma (Small et tings and for all cultural groups.. Medical services are routinely involved in miscarriage or about the implications for future preventing the potential complications of mis- reproductive decision-making. it is unlikely that a single approach & Lygo. 1999. der-explored. grief counselling may be appropri. whom psychological debriefing may be helpful riage and psychological support may ameliorate from those for whom it is not.. in which 39 women were pressed six months after spontaneous pregnan- randomly assigned to either an hour-long psy. 2003b). are briefing in this trial was unable to provide medi. Given the theo. 1997). Rajan. Spontaneous pregnancy loss been few evaluations of post-treatment interven. Priest et al. 1996). Their proposed model of treatment cially. 2000). However. The psychologist who conducted the de. However.. support to their partners. controlled trial. but assessments of all trial participants four broader social networks. or how to provide appropriate emotional includes psychological debriefing. chological reactions of the partners of women metric instruments) or biochemical markers of experiencing miscarriage may limit their capac- stress and anxiety (Milad et al. that the completion of questionnaires as part of tions. possible adverse effects in some women may ate. It may also be carriage through active treatment. elevated in comparison with community sam- cal information about the possible causes of the ples. 2003). 2003a. Women who were still de- small. Slade In practice. may assist in the adaptation to preg- differences between the groups in standardized nancy loss (Rajan & Oakley. depression. 1998. or for whom it the guilt reactions commonly experienced after could be harmful. The extent to which the psy- spouse abuse (measured by validated psycho.

lives. psychological reactions to miscarriage resolve spontaneously in most women. However. It is not Health services should ensure that staff are at- clear whether some or all women would benefit tuned to women’s psychological needs following from this type of intervention. 74 . Although experienced miscarriage should be developed. on a woman’s predisposition to psychological morbidity after miscarriage. and there has been no evaluation empathy and sensitivity. there appears to Services be a role for psychological intervention. and are trained to respond with should take. as well as on the form of care that is appropriate for this group. such as abuse and violence. Mental health aspects of women’s reproductive health perceived to provide psychological support at Policy the time of treatment or at follow-up. There is a need for research on the impact of prior adverse life experiences. miscarriage should more intense psychological reactions have not not be regarded as a routine event in women’s yet been clearly identified. policies for the assessment and short. or what form it miscarriage.and erated by earlier adverse events appears salient long-term psychological care of women who have and warrants additional investigation. there is little agreement in the literature about the form that psychological interventions should take. 2. or which would be of most benefit to women. of existing services. it is acknowledged that women who use health services after losing a pregnancy may benefit from a more psycho- logically informed model of care than currently exists in most settings. More attention needs to be given to the psy- chological component of medical care after miscarriage. The par- ticular factors that predispose some women to Even though it is common. but vulnerability gen. Summary Future research 1. immedi- ately after treatment or in the long term.

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7 years). women outlive men menopause is around 50 years for nonsmokers.8 years). 1994. 1994. (84. 1992.4 years) average life expect. 1992. Rwanda menopause and (38. the average age at In high-income countries. to menopause (Lock. hormonal. 1998. Malawi (39. the perimenopau- countries. Luoto. Sierra Leone beyond. and the meanings they attach vary considerably between countries. Hormonally. ated with an earlier age at menopause (McKinlay. in low-income countries. Brambilla & Posner. Swaziland (39. sal transition is characterized by declining ovar- life expectancy is more than ity of women not ian follicular activity and hormonal fluctuations 80 years. more at menopause has been reported. The problems. Physically. live to menopause include hot flushes. Pitts & 79 . 1994). Leidy. Spain (82. During the perimenopausal ran Africa caused life expectancy to fall to 47 period. 2006). earliest among women who have suffered from less than 40 years. Sweden (82. Women who smoke tend to reach menopause the differential is reduced to 0–3 years (World approximately 18 months earlier. 2003). Menopause is women’s life expectancy is women are liv. As life expectancy In low-income countries. of menstruation. increases. McMaster. 2003).4 years) underline the fact roles help shape women’s expectations of and and Switzerland (82. The increase. These are ing to the age of malnutrition (Khaw. health status may decline and chron- and Zimbabwe (35. that the priority of attitudes towards menopause. by 5–8 years.2 years).6 marked differences in life expectancy Dominant views on fertility.1 years). Wise et al. 2002). Symptoms include Australia (81. life expectancy has fallen in 34 and become unable to conceive and bear chil- countries since 1990 (UNDP. ancy is lower than men’s (UNDP. Kaprio & Uutela. views inform women’s expectations and subjec- mensions.7 years).4 years). global average life expectancy increased from 61 to 67 years. years).9 countries with low physical. conomic position over the lifetime is also associ- Pakistan and Zimbabwe – women’s life expect. Shinberg. A low socioe- Bank. Zambia (33. However.9 years).6 years). an overall earlier age In six African countries. Menopause is defined retrospectively as the end nodeficiency virus (HIV) infection in sub-Saha. dren without assisted reproductive technology. Japan and beyond. such as those ic diseases associated with ageing may appear In high-income developed in sub-Saharan for the first time. women gradually stop menstruating years on average. as a reproductive health problem. was not evenly distrib- Mental health and the perimenopausal period uted. high rates of human immu. For example. however. Even in Menopause is characterized by simultaneous (35. the major. and psychosocial changes.. These mental health di. will tive experiences. ageing and female years). vaginal dryness and sleep France (82. and in three countries – Nepal. In high-income countries. 5 Chapter Menopause Jill Astbury B etween 1980 and 1998. These countries infected by HIV that result in vasomotor instability. and influence the menopause and its social status accorded to women in midlife. women’s average Africa. ancy.

even within countries. found high rates of increased risks of breast cancer (Chlebowski et hot flushes (65%). Again. difficulty al. the majority of partici. 1997. The prevalence of menopausal symptoms var. tion. Conversely. breast tender. 1995). Bosworth et al. paid work may decline. 2003). from its being fewer menopausal symptoms than those in the perceived as a normal and unproblematic part of United States (Boulet et al. Republic of Korea. The relative contributions of 80 . Family comparative research concluded that the major. and psychological symptoms requiring medical treatment and surveillance. few oporosis. 2000). Fu. Women in Japan been identified as playing a significant role in (Lock. re- Survey (Woods & Mitchell.. progestogen. 2003) and problems (44%). the perimenopausal transition takes place in a context that may be marked by A comprehensive review of cross-cultural and significant life changes and upheavals. was associated with significant health risks. in a study of three years early. expectancy for women. Indonesia. In this study only 17% high-income countries on samples of middle reported hot flushes and night sweats. a longitudinal study of Australian women Treating menopause in low-income countries reported an increase in vasomotor symptoms. mood swings (49%) and memory stroke (Wassertheil-Smoller et al. this research women in the Seattle Midlife Women’s Health is not the focus of the current review. trast. For to be completed in 2005. rates of depression. 1997) defined men. Lock (2002) human development and the female life course cautions against dismissing reports of fewer to its being seen as a hormone-deficiency dis. This chapter focuses on the relationship be- cal and psychological distress associated with tween menopause and psychological distress them (Punyahotra & Dennerstein. women’s emotional health and well-being at this ing China (Hong Kong SAR. world’s largest randomized controlled trial in- disease risk or medical care should be expected. volving more than 16 000 women in the USA. Most women viewed menopause as a normal de. carries a high cost and has low public health rel- such as hot flushes. countries in the level and type of menopausal symptoms experienced and the degree of physi. It will consider the factors that have Anderson & Courtney. composition may change through death or di- ity of women do not find menopause a difficult vorce.. require more urgent attention. 2002). In the longitudinal Massachusetts Women’s Health study. oste- towards it (Avis & McKinlay. sults from the Women’s Health Initiative. evance. In con. the opause as a time when increased symptoms. dementia and depression. other reproductive and mental health issues are of more concern. 1994). heart disease. Cultural con. in midlife.. symptoms in these societies simply as learned ease that gives rise to severe. children may leave or return home.. disabling physical cultural expectations. treatments for menopause and the effect of such and held primarily positive or neutral attitudes treatments on breast cancer. In addi- women’s attitudes towards natural menopause tion. Similar findings on parents may become more dependent. Boulet et al. 1994) and other Asian countries. These included years) in North Carolina. (1997) reported much lower rates of symptoms Second. 1992). given for treatment of menopause. 2002). class white women (Standing & Glazer. Malaysia. First. tend to report ceptions of menopause can vary. work status and level of participation in have been reported in the USA (Avis & McKinlay. because analysis revealed sig- perimenopausal American women (aged 45–54 nificantly increased health risks. Psychosocially. Mental health aspects of women’s reproductive health Poyah. This study. 1995). than treatments cant variations between women in different for menopause. night sweats (56%). high maternal mortality rates and low life sal transition (Dennerstein et al. 1997. begun in 1997. While there is a large literature on hormonal pants did not seek medical help for menopause. and Province of time. 2003). Woods & Mitchell poor cognitive functioning (Rapp et al.and Women’s Health Study. but was terminated example. 1994). heart disease (Pradhan et al. menopause research has been criticized for women participating in the Seattle Midlife for being carried out primarily in middle. (2001). night sweats.. includ. and Cross-cultural studies have found signifi. was initially intended ies considerably.. and Singapore. and experience (Lock. indicated that the combination of estrogen and velopmental process.. 2003). sleeping (45%). especially those associated with increased Taiwan). Where there are high rates of HIV infec- ness and vaginal dryness over the perimenopau. the Philippines.

it is gery (hysterectomy) and hormone replacement necessary to clarify through prospective. A stress model of depression is congruent with Despite the fact that the gender difference in de- a multidimensional approach to understanding pression is most marked during the reproductive the pathways to depression in midlife (Woods years. the use of oral con- mediating factor linked to depression. 2003).. and symptoms. menopau- peared after the age of 55 years (Bebbington et sal status. in menstrual patterns and the appearance and Large-scale epidemiological surveys of mental persistence of vasomotor symptoms. hormonal and psychosocial changes to and do not experience depression at this time. study and one country to another. Most research has been such as hot flushes and disturbed sleep. health of Psychiatric Morbidity found that the sex dif- status and health behaviours. For Australian rates of depression? Dennerstein. including parison of population-based rates of depression menopause have more Australia. 2002. insomnia and vaginal dry- ness. 2003). 1997). from researchers. tors. Throughout their reproductive frequent symptoms and the United Kingdom. al. psycho- carried out in high-income countries and the social. though evidence on the age when the sex dif. from the health have found no substantial increase in woman’s life context. and a history of depression (Bosworth et poor settings is largely unknown. such as pregnancy. Kaufert. 2000). years. and from acute or 81 . Kessler. Menopause physical. 2001). and evidence on the relation. negative expectations of countries. Caution in ex. or consequence of high levels of symptoms. may arise traceptives. considerably lower than that Most longitudinal for women aged 18–24 years (11%) (Andrews et studies have used multidimensional models to al.. Stress. depression have received considerable attention These include the role of hormonal changes. do not appear to account for this dif- menopausal transition itself. The United Kingdom National Survey towards and expectations of menopause. trapolating findings from high-income countries is especially warranted with regard to studies In order to investigate whether menopause has from the USA. positive expectations et al. 1997. 2002. 1992). where rates of gynaecological sur. depression was 7%. Cairney & Pevalin. hormone replacement therapy and from a number of different sources: from the menopause. because of changes ference (Stephens & Ross.. over the lifespan. which can have a direct rates of depression among women in midlife.. 1992. but not all. women expe- indicated a U-shaped relationship between age rience depression during the menopausal tran- and depression. as a highly important mones. 2003) and declines from midlife onwards. Chapter 5. socioeconomic and physical health fac- validity of these findings for women in resource. Wadsworth ference ceases to be important varies from one menopause and higher & Hardy. This difference first emerges in pu. menopausal status and menopausal symptoms. a direct or an indirect effect on depression. and hence natural menopause tudinal research whether depression is a cause is by no means a universal experience. al. women experience significantly higher rate these symptoms and the United rates of depression than men. 2002. in- cluding hot flushes. the rate of & Guthrie. as well as the impact of age. 1999). These have been designed to assess the ring in the age group 45–49 years (Kessler et contributions of sociocultural factors. with female:male more negatively than States (Woods & ratios approximately 2:1 (Astbury & Cabral de women who hold Mitchell. and in turn do such et al. Glazer berty (Wade. 1997. Kessler. experiences related to changes in sex hor- & Mitchell. an increasing Menopause: a time of increased risk number of such stud- for poor mental health? ies have been carried out in high-income Do women with Evidence from national surveys permits com. longi- therapy are high. 2001. Canada. negative experiences of Kuh. 2002). Lehert women aged between 45 and 54 years.. attitudes al. and history of de- ference in the prevalence of depression disap- pression. with the lowest rates occur- sition.. Two national surveys in the USA have investigate why some. Over the past decade or so. Yet impact on mood but is also influenced by nega- researchers remain interested in identifying the tive socialization experiences and attitudes to factors that distinguish between women who do menopause and poor health. ships will be reviewed. al. women have more Gilbert & Tate. Avis Mello.

Hypothesis 3. Anxiety was also physical health status and health behaviours. there is little evidence that menopausal were important too. The central question is: to what extent do classical determinants of depression. Avis et al. Rather. the evidence supports a better predictor of poor health outcomes than a “domino” hypothesis that an increased level of menopausal status. difficulty sleeping. The main ques- tion related to this hypothesis is whether high rates of menopausal symptoms predict increased depression and reduced emotional well-being. re. No effect Menopause and its associated hormonal changes are largely irrelevant in explaining depression among women in midlife. also found that troublesome menopausal symptoms. Loss of resources and low context factors such as psychosocial adversity. Estradiol had Using this multidimensional framework. and menopausal change in hormonal status will have direct effects on depression. such as low socio- economic status. as indicated by loss of resources. The specific questions arising from this view include whether lower estrogen levels are associated with increased rates of depression and whether de- creases in estrogen bring about neurochemical changes that lead to depression. negative life events and high levels of past or current stress account for depression in midlife? chronic health conditions and thus the physical symptoms such as hot flushes. symptoms. Direct effect There is a close relationship between hormones and mood. previous history of depression. lack of social support and a confiding relationship with a partner. The stres. however. but not with menopausal sta- tus or change in estradiol levels. Implicit in this view is a criticism of other research on menopause that does not include all the previously identified predictors of depression. Glazer et al. (2001). and menopausal status and symptoms make no meaningful additional contribution. life depression in midlife. no direct effect on depression independent of searchers have investigated the different contri. unemploy- ment. Indirect effect Depression is a consequence of menopausal symptoms (the “domino” hypothesis). negative socialization and of depression – were. predicted by loss of resources but the effective- ness of women’s coping strategies and education Overall. Hypothesis 2. Mental health aspects of women’s reproductive health Three main hypotheses have been proposed regarding the relationship between menopause and depression for women in midlife: Hypothesis 1. level of education – both classical determinants negative life events. age. in a longitudinal study. The researchers concluded or hormonal status exerts a strong or direct ef. (2002). (2001) conducted a cross-sec- that depression was positively associated with tional study of a random sample of women aged 82 . distressing symptoms is a cause of depression. found Bosworth et al. that stress. strongly predic- attitudes towards menopause. in the longitudi- butions of various stressors to depression and nal Ohio Midlife Women’s Study. Depression during menopause can be primarily accounted for by the classical determinants of depression over the life course. was fect on depression. as well as general tive of depression in this cohort. night sweats and and psychological health status and history. menopausal status did not significantly predict sors have included menopausal status.

death of a ual pleasure and satisfaction. USA (Avis et al. However. and poor physical 1992).. Women who experienced more Studies –Depression Scale (CES-D). portant factor for explaining decreased sexual ing from early to late phases of the menopausal functioning (Hallstrom & Samuelsson. An obvious difficulty of a child – conferred particularly high risks for research in this area is separating the effect of depression in midlife. Rates of depression. & Mitchell (1997) found that most were uncer- count. Woods sion. insomnia. non-confiding re- and experienced increased satisfaction in work. On the other hand. status. 2000. Sources of stress included mari. Some studies have partner or child. Avis. associated with having more severe vasomo- ured by the abbreviated Centre for Epidemiologic tor symptoms. financial problems. creased from pre. Dudley & Burger. Massachussetts. es in the frequency of sex or in the level of sex- ability to work. One Dennerstein. The major explanatory role assigned to attitudes ported ever using HRT. particularly when factors for decreased sexual desire included lack a woman formed a new marriage or partnership of a sexual partner. other Another possible risk factor for depression dur- risk factors significantly associated with depres. ing menopause is sexual functioning and chang- sion in this study included unemployment. Dennerstein. a poor. of increasing age from menopausal status. Overall 164 women (28%) were using hormone replacement therapy (HRT). Avis. 1994) and negative attitudes towards menopause. time in midlife. in an interview-based study of Knottnerus & Pop (2002) found that stage of more than 500 premenopausal women with menopausal transition in Dutch women was sig. menopausal status. all of which had higher odds ratios age. Dennerstein. found that negative attitudes towards women. transition. but ity of women formed these attitudes earlier in there was no significant difference in menopau. 2000. and a previous episode of de. insufficient support. stressful life events and circumstances or psychological health also contribute to de- were found to be strongly associated with de. hot flushes. difficulties with tors are also predictive of depression. participating in the nificantly and independently related to depres. creased sexual desire and functioning in midlife pression persisting or occurring for the first (Hallstrom & Samuelsson. or dissatisfaction with sexual functioning can ily. Chapter 5. as measured by the tain about their expectations of their own meno- Edinburgh Depression Scale. reported a decrease in sexual functioning with pression. there was an improvement in well-be. previous Manitoba. and again from peri. Psychosocial variables were most sig.to postmenopause. In addition to age and menopausal status. health tive expectations for midlife and poorer health behaviour and markers of socioeconomic status. Canada (Kaufert. 2001). level of sexual functioning. Stressors. Gilbert & Tate. Almost one-third (29%) and expectations of menopause in the develop- of women in the sample had CES-D scores in. Stressful life context was significantly Carolina. sion. and demands from friends and fam. employment. which becomes more marked in midlife than any stage of the menopausal transition. and 236 (41%) re. significantly in. These fac- tal and relationship problems. 1990. was the im- rather.to perimenopause. (Palacios et al. rather than age. memory tom reporting during menopause and depres- loss/forgetfulness and mood swings. after other risk factors were taken into ac. effects of these two factors and reported that strable effect on women’s well-being over time. 1995. However. in a longitudinal sal status between depressed and non-depressed study. lationship with the sexual partner. Woods & Mitchell (1997) reported add to stress during the menopausal transition. Variables included depression (meas. a median age of 41 years. North mood. pause. alcohol dependence and the partner’s In population-based longitudinal studies in own sexual difficulties. Menopause 45–54 years residing in Durham County. Difficulties children. life. Similarly. in. 2001). perceived menopausal changes tended to have more nega- menopausal stage. 1990). Depressed women had higher rates of menopause predicted both subsequent symp- night sweats. ment of depression presupposes that the major- dicating significant depressive symptoms. risk nificant in determining this. Two of these – unemployment and the death Dudley & Burger. Maartens.. Seattle Midlife Women’s Health Study. Avis & McKinlay (1991). climacteric symptoms. Lehert & Guthrie (2002) found longitudinal Swedish study disentangled the that menopausal symptoms exerted no demon. that a stressful life context and poor health sta- tus had significant direct effects on depressed 83 .

adult health. lifestyle and cur- In addition to investigating the predictors of rent life stress. tear. and physical disability at 43 years. en whose children were teenagers or younger. reported health problems at 36 years ing or are already experiencing the perimeno. other studies. and high psychological symptom scores. Women living in life) and mental health in midlife. who A significant inverse relationship was found investigated the links between earlier experi. These included level of neurot- who were under. health behaviour and current life stress assessed retrospectively and are therefore sus. Wadsworth & Hardy (1997) had mothers who had high scores on a meas- also found that women who were obese had the ure of neuroticism. No variation was found in psycho- transition. Wadsworth & Hardy (1997). Risk factors were grouped in in a crisis were associated with low symptom 84 . adult socioeconomic circumstances. tive life events. Mental health aspects of women’s reproductive health Well-being in midlife and the six clusters: family background. social adversity. ceptible to recall bias. Data on midlife were those who were married or single. had higher symptom scores than Development (MRCNSHD). divorced or sepa- population born in 1946 and assessed repeatedly rated women had a higher symptom score than over subsequent decades. negative events and experiences over the course being during this period. Pathways through which risk fac- depression in midlife. characteristics importance of the life course of the child. In general. was associated with only two variables following multivariate analysis: a change in Following multivariate analysis. From these data. This study. This means that potentially like many others. a prospective cohort those from non-manual-labour households or study of a representative sample of the British with higher income. among women who had pausal stage. social support. Kuh. irritability. Certain characteristics of the highest rates of psychological symptoms. included cumulative losses. but this was and work life. while women during childhood and adolescence were women who were of normal weight had lower significantly associated with adult psychological levels of self-reported symptoms than women symptom scores. anxiety and depression menopause recruit women who are approach. in keeping with the results of most initially rated their health as better than aver. Dennerstein. Dudley of the women’s lives. Higher social support. likelihood of poor mental health at the time of Of particular note were psychological illness be- menopause. educational qualifications ences (in childhood. Women with higher psychological symptom As these studies illustrate. social relation- occurred earlier in the life course can only be ships. factors preceding scores in midlife were significantly more likely menopause can exert a strong influence on the to have had health problems earlier in adult life. The importance of nega- & Guthrie (2003) noted a small decline in self. Similarly. good social networks and access to help score (range 0–12). depression. Although collected over a 6-year period when participants the number of children exercised no effect on were aged between 47 and 52 years. three signifi- weight and a change in libido and feelings for cant associations remained between family the partner. a number of researchers tors determined psychological distress in midlife have sought to identify and understand the de. A decline in self-rated health eight logical symptoms in midlife according to meno- years after enrolment. A notable exception is the study by Kuh. such as adverse changes in family rated health with increasing age. pausal transition. fulness and feelings of panic. between social class.or overweight. Women who were psychologi- were significantly more likely than other women cally distressed were more likely to have lived in to have had an operation or procedure in the council housing. had parents who divorced. Women who reported a decline in background variables and symptoms of psycho- self-rated health and were in paid employment logical distress. Participants households where the income was earned by in this research were part of the larger Medical manual labour. and terminants of positive health and general well. longitudinal studies of tween 15 and 32 years. the scores were worse in wom- collected on anxiety. found significant relationships important risk factors for depression that have between adult circumstances. Data were symptom scores. icism and antisocial behaviour in adolescence. adolescence or earlier adult and psychological symptoms. or who were themselves on a Research Council National Survey of Health and low income. including emotional sup- researchers calculated an overall psychological port. for mental health was confirmed not attributable to the effect of the menopausal in this study. age. at 36 years. and previous year.

especially if there is a low response rate to of some kind in childhood. This limited meas. studies are needed to document time-related cluding depression. for multiple health out. bias remains a problem for more distant longer independently associated with midlife events and past experiences. scores. raise new issues that can affect women’s sion in midlife and possible risk factors. significant social and cultural changes can ing experienced some form of domestic violence occur over a single generation. ables. variables. decreased fertility rates and increased participation by women in paid Research into the relationship between depres. faces a number of methodological chal. symptoms between individual women. Only the life course symptoms. not all important cov- cal. All 2000). were under. but such in midlife. sense of well-being in midlife. there is a well documented link between remain in a longitudinal study. such as depression. Menopause scores. such as smok. Prospective number of adverse mental health outcomes. They commented further that a studies do not consider the impact of cultural retrospective question. prospective study by Kuh. some have psychological distress in midlife. in a cross-sectional study. and most in their study. or physi. Guthrie. includ. and choice of instruments physical activity were not systematically related for measuring risk factors and outcome vari- to symptom scores. Some health risks. However. in. the comparison of findings across smokers had intermediate scores. As further attrition in prospec- tive samples occurs with time. Chapter 5. including in- lifetime. tion. ance on recall for contemporary events and expe- ment of all risk factors. studies is limited by differences in methodologi- mal weight had lower scores than women who cal approach. For example. differences in re- had the highest scores. tempt to recruit participants is needed. Women of nor. Wadsworth & Hardy ing and weight. 1998). and was Project was only 56% (Dennerstein. Studies also vary in the choice of methods for defining.. sexual or emotional – during their cial organization and gender roles. In addi. As a result. were related to symptom scores (1997) avoided recall bias altogether. Alcohol intake and past cruitment strategies. after simultaneous adjust.5% (101/362) reported hav. the response rate to the invitation to partici- ciated with midlife psychological distress after pate in the Melbourne Women’s Midlife Health adjusting for all other early experiences. Changes in so- – physical. similar to the general population than those who tion. hormonal. Women in the sixth year of follow-up for of these may influence and help to explain vari- the Melbourne Women’s Midlife Health Project ations in menopausal symptoms and depressive completed a questionnaire on lifetime experi. work. However. detecting and measuring outcome The researchers concluded that markedly differ. where only one at- including sexual abuse. women might differ from earlier cohorts in the toms. parental indifference. Recent cohorts of ing menopausal and hormonal status and symp. No measures of There are differences in the age groups of women parental conflict. Smokers had the highest symptom longitudinal studies are extremely costly to run. In addi- ence of violence: 28. sample bias is Other research has confirmed the importance compounded. including recent stress disorder (Astbury & Cabral de Mello. ure of parental maltreatment was strongly asso. asked when the women factors. the initial invitation to participate. anxiety and post-traumatic changes in indicators of health. recruited to the studies.or overweight. Some studies have ent life course trajectories were associated with measured symptoms of depression. while obese women the method of sample selection. creased rates of divorce. and others have may be even more important than their findings used non-standardized self-report measures. significance they assign to work and personal lenges. lifelong non-smokers the lowest and ex. social and psychological changes. and argued that used standardized measures that permit diag- the relationship between the woman’s parents nostic criteria to be applied. While prospective studies minimize reli- 85 . sexual or psychological abuse were included ariables are taken into consideration. ranging from the research design. Lehert & mediated by mental health status in adult life. on parental divorce suggested. The sample in a longitudinal study is not were 42 years old. cross- childhood sexual abuse and intimate partner sectional studies cannot disentangle cause from violence in adult life and increased rates of a effect or capture temporal changes. are more comes in adult life (Felitti et al. 2002). social networks were no riences. It may be that those participating of different forms of adversity in childhood. identified a small number necessarily representative of the general popula- who may have suffered abuse or serious neglect tion.

causes of depression 3. What sources of assistance do women in low. based policies on women’s health. current levels of emotional distress.and middle-income countries. and and on women’s expectations and experiences should be taken into account. or 1. Mental health aspects of women’s reproductive health achievement in their lives (Woods & Mitchell. Research to date has the following implications tive life events. approach is necessary to understand emo- cessful only if they simultaneously address the tional distress in midlife. The classical social and contex. It is important to evaluate the sources and and menopause are more limited. of distressing menopausal symptoms than a cause of them. It is necessary to look beyond menopau- lack of a confiding relationship with a partner. data on the links between mental health 5. Answers to the above questions are essential to Overall. who can function as conduits of the following questions should be addressed: stress as well as sources of positive social 1. In particular. Services tual determinants of depression. cultural or interpersonal factors play a significant role? 3. such as un- employment. Research on impact of stress. sion in midlife are related. Health promotion programmes that seek to reduce these high-risk 2. therefore. A history of depression and high levels of While there is considerable anthropological lit. psychosocial adversity may be more impor- erature on the cultural construction of meno. A life-course. Are the factors identified in high-income support. sal status. are likely to con- tribute to dysphoria and depression. countries as critical to women’s mental life in midlife equally important for the mental health and well-being of women in low. The “classical” social determinants of de- pression.and middle-income countries? 2. Policy 1997). This may specific data for decision-making at programme. lack of social support. nega. including Depression is more likely to be a consequence their mental health in midlife. Obesity. behaviours among women in midlife will be suc.and middle-income countries have for health problems and physically or psycho- logically distressing symptoms related to menopause? 4. and of social support. include stressful demands from family and policy and service-provision levels. as well as the presence of distress- ing somatic symptoms and decreased sexual Summary functioning and pleasure. on this relationship is needed to provide culturally women’s emotional well-being. multidimensional models provide data for the development of evidence- are needed to explain depression in midlife. tant than menopausal status in explaining pause in low. rather than a cross-sectional. How satisfied are women with these sourc- es? What additional sources of assistance or services would they like to have? Do they think such services should be integrated in existing reproductive health services or stand alone? 86 . If not. what other socioeconomic. smoking and depres- mood in women at midlife. hormone levels and menopausal continue to exercise a powerful influence dur- symptoms to adequately explain depressed ing menopause. friends. socioeconomic adversity. loss of for services and health care providers: partner through bereavement or separation. Further research 4. of it.

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Social Science and Medicine. Ross N (2002) The relationship Finland. American Medical Association. Wassertheil-Smoller S et al. (2003) Effect of estrogen plus longitudinal data. progestin on global cognitive function in 81: 623-632. Maturitas. Luoto R. 289: 2663-2672. Journal of the Health Study. 42: 195-200. 88 . Maturitas. Punyahotra S. Journal of the American Medical Washington. American Journal of Epidemiology. Journal of the American Academy for normal menopause transition. Wise LA et al. prospective study. (2002) Lifetime socioeconomic position in relation to onset of perimenopause. British Menopause Society. Uutela A (1994) Age at menopause and sociodemographic status in Stephens C. Millennium Development Goals: A compact among nations to end human poverty. Pitts M. Journal of the American developing country: there is a time for Medical Association. Knottnerus JA. psychological symptoms: no effects found in a New Zealand sample. 56: 851-860. Menopausal transition and increased depressive symptomataology: a community based UNDP (2003) Human Development Report 2003. Health Care for Women Maartens LW. (2002) Inflammatory to depressed mood for midlife women: biomarkers. Maturitas. 103-115. 13: 271- 280. after menopause: effects of tibolone. Shinberg D (1998) An event history of age at last menstrual period: Correlates of natural and surgical menopause among midlife Wisconsin women. Association. Pop VJ (2002) International. Journal of the income clinic patients toward menopause. Mental health aspects of women’s reproductive health Lock M (2002) Symptom reporting at menopause: Standing TS. 26: 9-14. 288: 980-987. sexual and Oxford. 14(2): Child and Adolescent Psychiatry. 23: 408-414. Poyah G (1997) The of estrogen plus progestin on stroke in menopausal experiences of women in a postmenopausal women. and observations from the Seattle Midlife Women’s incident coronary heart disease. Oxford University Press. Pevalin DJ (2002) Emergence Medical Journal of Australia. 20: 119-129. 175: 199-201. Acta Obstetrica Scandanavica. controlled trial. to be a teenager. Cairney J. emotional violence history of middle aged women: a community based prevalence study. Wade TJ. 8: 132-136. Mitchell ES (1997) Pathways Pradhan AD et al. (2001) The physical. Mitchell ES (2002) Patterns experiences of Thai women. Kaprio J. everything. Mariella A. of gender differences in depression during adolescence: national panel results from three McKinlay SM. 41: 190-198. DC: 34-37. Women and Health. Woods NF. Brambilla DJ. 289: 2673-2684. 26: 1-13. Research in Nursing and Health. postmenopausal women. 46: 1381- 1396. 22 (2): 155-161. Glazer G (1992) Attitudes of low a review of cross cultural findings. Maturitas. Palacios S et al. a mother and granny. 139: between hormone replacement therapy use and 64-76. (1995) Changes in sex behaviour Journal of Epidemiology and Community Health. hormone replacement therapy. Mazza D et al. Dennerstein L (1997) Menopausal Woods NF. Initiative Memory Study: A randomized In: 2006 World Development Indicators. transition: approaches to studying patterns in Rapp SR et al. Health Care for Women International. New York. Posner GJ (1992) The countries. (2003) Effect McMaster J. Part 2: The of depressed mood across the menopausal cultural context. The Women’s Health World Bank (2006) Women in development.

injuries and consequent infertility (Adamson. to women (Germain. In addition. but are not using contra- marriage and first pregnancy. which is narrowly defined as the ed to females in many societies. increase the availability of good quality repro- 1999). 2000). 2001). experience other. such services are of poor quality. who are respectful of local beliefs obstetric morbidity. the needs of women with respect to the timing of clinics and the availability of female doctors (Jaswal. 1998). have received little attention. for example. tions may be adversely affected by local social proximately 30 others incur injury. Other structural factors also inhibit The International Conference on Population women’s use of health services. 1996. ductive health services in developing countries. despite Too often. Monitoring of progress ashamed of their reproductive functions and should include indicators that are of importance being blamed for gynaecological infections. The main focus in this area has. Appropriate provider–patient interac- who dies from pregnancy-related causes. 6 Chapter Gynaecological conditions Non-infectious gynaecological conditions – Heather Rowe Infectious gynaecological conditions – Lenore Manderson & Narelle Warren Malignant conditions – Lenore Manderson & Narelle Warren O ne of the most important aspects of wom- en’s health care is the prevention of ma- ternal mortality and the after-effects of injury sexual and reproductive health and rights as fundamental to human rights and develop- ment. with the fact that maternal injury affects substantial inadequately trained staff and no counselling numbers of women globally. reported disrespectful and abusive treatment treated (Adamson. and the mental Decisions about seeking treatment. The ICPD Programme of Action aimed to sustained in pregnancy and childbirth (Wall. infection or hierarchies (Mayhew. Wall. standably. Many more women by health care providers (Petchesky. Services The causes of much obstetric and gynaecologi- should respond to the needs of a wider clientele cal morbidity stem from the neglect and abuse than is represented in the “unmet need for fam- associated with the low social position accord- ily planning”. health implications even less. Barriers to attendance at reproductive health The physical dimensions of these conditions services are commonly linked to cultural factors. remains un. for the most part. been on maternal mortality. Mark & Straton. Services are often designed with scant regard for naecological health problems. 1998). which. 1996). under. For every woman services. Miller & Rosenfield. Malnutrition 100–150 million married women who wish to in childhood and early adulthood. an emphasis on fam- Non-infectious gynaecological ily planning. and lack of ac- ceptives. The low level and Development (ICPD) in 1994 recognized of literacy and formal education of women in 89 . 1998. Myths associated with sex and practices (Toussaint. non-pregnancy-related gy. early age at space or limit births. are often in the hands of husbands and moth- ers-in-law. 1996. ap. and reproduction result in many women feeling Hunt & Geia. 2000). and women have disability. 2002). may discourage women from attending. Women value services staffed by trust- cess to obstetric services result in high rates of ed providers. and particularly discrimination conditions and coercion in various population programmes.

communities and clinical settings have used a pregnancy before 2001). so too are the social sufficient and that. in community settings often underestimate health many of those who survive. grinding down the skull of an already asphyxi- eralizable than those from clinic-based studies. agree to clinical examination or blood collection. although there the typical patient is small and short (less than is no clear evidence-based explanation of the 44 kg in weight and under 150 cm tall) and mar- differences (WHO. vaginal wetness. The fetal death rate in obstructed labour is over very few research studies have addressed the 90% (Wall. adequate obstet- While the physical ices have often been based on the assumption ric care (Muleta. It is a devastating morbidity of pregnancy. causes growth worsening poverty. 2000). ated baby onto the soft tissues of a pelvis that as women frequently do not seek treatment for is just too small” (Adamson. who have a high probability of remaining child- less thereafter. However. The 90 . mental nation of malnu- consequences: stigmatization. 1996). including pelvic growth is interviews to obtain self-reports of symptoms. Finally. 1999). data collected in obstetric services results in maternal death or. amenorrhoea. Data derived from representa. tula also develop neurological injuries. 2002). malnutrition logical health problems in developing countries retardation). both.5 years) porting equipment and samples. 1999). obstetric health problems. Erpalding & Pathak. 2002). 2001a). and the poor development of other which is prevalent in resource-poor countries. vaginal scarring and stenosis. Studies continue to report high rates of gynaeco. Amenorrhoea following fistula Obstetric fistula is common. and the vagina. and the cost (Wall et al. trition in child- isolation and loss of social hood (which support. “obstructed labour problems. Long-term health consequences include skeletal which further undermines the feasibility of com. a condition known as “foot drop” which makes terview (Bhatia & Cleland. medically diagnosed morbidities. further limit the evidence base (Bonetti. or the rectum and the vagina. ear- and suffering. Frequently. their limited opportunities for which causes urinary or faecal incontinence or employment and therefore lack of economic in. Women are often reluctant to tions. dependence. Mental health aspects of women’s reproductive health many countries. variety of methods of measurement. Difficulties in trans. and many of these women face stigma. divorce or separation. Erpalding & Pathak. health will follow (Gulcur. 2004). such as transport and communication. which causes genital ulcera- lect information. labour – “days of futile contractions repeatedly tive community-based samples are more gen. 1999). and laboratory analysis in cephalopelvic disproportion and obstructed of specimens. Women’s own reports. complete results clinical examinations. 15. the loss of both a child An obstetric fistula is a tract between the bladder and the role of motherhood is especially harsh. A combi- disabling. In a society where childbearing is central to women’s status. in par. Approximately 20% of women who are in ob- There is little consistency in the results of the structed labour for long enough to develop fis- different studies. Prevalence studies in ly marriage. primarily affects young. who do not a negative effect on women’s reproductive health have access to (Aoyama. including ticular. and premature death (UNFPA. and a combination of cervical injury. In addition. ried early (average age at marriage. leading to secondary infertility (Wall. Most such la- self-reported symptoms do not correspond to bours in developing countries end in stillbirth. It sectors. consequences of fistula are that addressing barriers to physical health is 2004). 2000). Most cases of obstructed la- mental health implications of gynaecological or bour occur in women having their first baby. 2001). injuries. of the studies. frequent infections and terrible odour. Prolonged these conditions because of financial and cul. policies and serv. obstructed labour in the absence of emergency tural constraints. poor women with little all inhibit women’s access to services and have education and limited social roles.. once this is attained. the conditions and because of the lack of reli- able and qualified personnel willing to travel A woman with fistula suffers from constant to remote places in adverse conditions to col. munity-based epidemiological studies (Bonetti. walking difficult (Wall. 2000). both because women under-report injury complex” – obstetric fistula. and ultimately (Bhatia & Cleland. are influenced by the context of the in.

it is often hidden. Timely access to skilled antenatal and intrapar- tum services is the key to preventing injury in childbirth (Donnay & Weil. with as- sistance from personnel from the Addis Ababa Fistula Hospital in Ethiopia. some women with fistula can continue to live a dignified. 2000). and the average age at first of disability. 1999). However. Social age pregnancy. It is thought that. Unlike in developing countries. after the age at which pregnancy can tematic investigations. UNFPA. but between 500 000 and tein deficiencies in girls and young women com- two million women are estimated to be living promise this growth and development (Messer. Chapter 6. productive life. Gumodoka & Berege. there have been no sys. 1996. 2004). gical repair are above 90% among trained sur- Gumodoka & Berege. Because of the shame associated ties where females are accorded low social status. i. two social changes are also needed: girls’ nutrition must be improved. such as pelvic fullness. It causes tries. maternal and child health Weil. Pelvic organ prolapse is a significant descent of the uterus and vagina. women overcame enormous obstacles to attend in large numbers (Bangser. jury. 2002). which may protrude Fistula is almost unknown in developed coun. Social changes that promote the value of girls lates women’s internationally recognized human and delay marriage and first birth are potentially right to reproductive health care (Cook. Sadiq & Daniel. care (Ibrahim. between 50 000 and 100 000 wom. humiliation. 2004. pain. 1999). 1998). 91 . Dickens powerful agents for reducing the incidence of fis- & Syed. school curriculum. There are anecdotal reports that tula and other obstetric injuries. education is being introduced into the Koranic every year. with the condition (Adamson. household food allocation is common in socie- mature death. in order to reduce the incidence of obstructed la- bour. in the United Kingdom over 70% of fistulae A study of women with fistula attending a clin. and malnutrition. 1996). There are no reliable occur (Moerman. always curable. 1997). follow pelvic surgery (Hilton. birth must increase. with the aim of helping to en develop fistula. Most of these go untreated. However. 1995. often ending in pre. with the condition. to ensure adequate Women with untreated fistula face a lifetime growth of the pelvis. geons (Bazeed et al. abandonment.e.. Obstetric ic in the United Republic of Tanzania revealed fistula is almost entirely preventable and nearly that half of them were not living with their hus. isolation confirms the woman’s belief that she is where 90% of fistulae result from obstetric in- to blame and has brought shame on her family. Prual & Ould el Joud. The pelvis continues to grow of the physical and social burdens endured by after menarche and full adult height have been women with fistula. when the Bugando Medical Centre Project on fistula opened in the United Republic of Tanzania in 1997. Lack of services for safe childbirth and timely repair of fistula vio. Donnay & 1997). Despite and is associated with poor access to health care the undoubted psychological consequences (Messer. 2004). partly or completely beyond the vulva. In Nigeria. Micronutrient and pro- data on prevalence. 2001). UNFPA. 2001). three-quarters of these said that the rea. 2001). but quality obstetric services and lower rates of teen- thought to be notable (Adamson. Gynaecological conditions rate of suicide in such women is unknown. Success rates of sur- son for the separation was the fistula (Bangser. In sub-Saharan Africa the ensure that young women are better able to have number of new cases annually is around 33 000 a safe pregnancy and obtain appropriate health (Vangeenderhuysen. Gender discrimination in poverty. 2001). Most affected women and girls in developing coun- tries are unable to afford the cost of fistula repair (UNFPA. and require repeat surgery. but the determinants Pelvic organ prolapse of apparent individual differences remain unin- vestigated (Hilton & Ward. although repairs can break down band. reached. where there is both universal access to high disturbing symptoms. 1982).

by the vary widely. 2001). 1997) to as high as 56% in Egypt (Younis that many women with incontinence do not seek et al. such as mary predisposing factor. cific instruments to assess the quality of life of tribute to the condition. poor general health status and poor personal hygiene can lead to higher rates of reproductive 92 . most women with prolapse had only one child (Bonetti. fects and quality of life measures among women nal pressure. Recently validated condition-spe- chronic coughing and poor nutrition. symptoms. It is estimated that in the is estimated to be between 2% and 20% among USA more than 10% of women will undergo a women under 45 years (Bonetti. pelvic organ Strategies to prevent urinary incontinence.or post-surgery (Barber et al. elicited. Luber. tions on distress caused by symptoms and their such as water and wood for cooking. 57% had not sought treatment. but in developing countries it occurs in a antenatal and postnatal education programmes younger population. may con. but not all. sive. incontinence. 1993). first birth at a young age.. data medical help (Walters. Boero & Choe. 2002). Multiparity is considered to be the pri. 2002).. including urinary incontinence. constipation. 1998. The difficult first delivery. Erpalding & surgical procedure for symptoms of pelvic organ Pathak. In turn. 1993). vaginal discharge. Women reported Infectious gynaecological conditions shyness. Walia & Singh. 2000). 2004). surgery is the principal bleeding (Aoyama. because of hormonally mediated increases in tis- sue laxity. 2002). infections of the genital tract in both men and ing a doctor. such as obesity. from 3. women with pelvic organ prolapse include ques- including lifting and carrying of heavy objects. cluding pelvic floor exercises. and In developed countries. lack of cooperation of the husband. long-term pelvic floor dysfunction remains women with pelvic organ prolapse are reported underinvestigated. and miscarriage. 1995). At 6 weeks. not a doctor. 2002). the women were asked about symptoms of other conditions. Little attention has been paid to psychosocial ef- Chronic health problems that increase abdomi. but only by 12 weeks of 227 women with self-reported prolapse in a had their goals relating to social interaction and household survey conducted in north India. In developed countries. However. There have been on pelvic organ prolapse are inadequate. Symptoms re. health and ap- in underdiagnosis of the condition. Of those who were offered surgery. some of these. and few evaluations of the success of surgical treat- there is little agreement on prevalence (Bump & ment. The majority of those who did seek care consulted a traditional birth attendant. in developed country settings (Mason. Erpalding & Pathak. are included in 2001). although in one study heavy manual labour. and women and clinicians may disagree Norton. impact on women’s mental health of progres- gynaecological surgery. 2001). However.. Estimates in developing countries prolapse. are sexu- few took it up (Kumari.. prior to ing and foul-smelling discharge. in- prolapse is associated with mature age (Luber. Erpalding & Pathak. 2001). Heavy manual labour. despite the fact al. organ prolapse. self-image been achieved (Hullfish et al. may in fact be the physician visit. Mental health aspects of women’s reproductive health back pain. is also a general impact... assessment of psychological functioning for use Women themselves explain prolapse in terms of pre. but there has been no validated risk factor (Bonetti.. their perceptions of the outcome of surgery. 2001). the risk factors for pelvic organ prolapse. the pre-surgery goals of a infections (Younis et al. women agreed that most of their goals Poor medical history-taking appears to result in relation to activity. In a prospective study con- to be at a much greater risk of reproductive tract ducted in the USA. Even in developed countries. At 6 and 12 weeks post-surgery. group of 33 predominantly white women were ported by women with prolapse. and Reproductive tract infections (RTIs) include all lack of time or money as reasons for not consult. they do not address factorial. 2002). such as itch. ally transmitted. women.4% in South India (Bhatia et age of 80 years (Olsen. in Nepal. treatment and over 390 000 repairs are per- formed annually in the United States of America The global prevalence of pelvic organ prolapse (Norton et al. The on whether surgery has been successful (Hullfish prevalence is higher in postmenopausal women et al. These strategies may also help prevent pelvic The causes of prolapse are believed to be multi. pearance had been met. 1997). with prolapse. Environmental conditions.

anxiety and somatization disorders. Koenig et al. redness and/or swelling of the vagina comparison of microbiological laboratory testing and vulva. of the most common causes of vaginal discharge ample. and may in themselves is. diabetes. deep cultural meanings (Dekker et al. candidiasis can cause considerable distress. leading to an Netherlands found that. growth are antibiotic treatment. 1994. when urine is passed. in both developing of chronic. Bhatia & Cleland. 1990. causing vulval and vaginal itching. There Trollope-Kumar. Karaca et al. such as demonstrated that presence of a symptom for cancer. undervalued – has not inal symptoms is difficult to determine. and dicate or will lead to serious disease. Wang & Yan. pregnancy. Cleaning the anus by symptoms have a profound effect on their life.. In Nepal. Distress is related both to the of infection in symptomatic women. clumped dis- senting with vaginal symptoms.. cilities were limited. in 25% of women pre. The symptoms can have estimates tend to be based on clinical presenta. laboratory diagnosis indicates low rates and discomfort. there is a widespread belief ted (Whittaker 2002). infection characterized by a thick.. they may. 1999). depletes vital an impact on women’s mental health. and a stinging or burning sensation and clinical examination of pregnant women. The prevalence of unexplained vag. body. no microbial in. wiping towards the vagina can also spread yeast 93 . Gynaecological conditions tract infections that are not sexually transmit. to the reproductive tract are extremely common 1999). 1993). Whittaker. 2002). 1999. 1995.. fatigue and aches in India highlighted the association between and pains (Chaturvedi et al. Candidiasis arises when. but diagnosis is frequently difficult (Younis associated with psychological distress. over the past year were risk factors for the devel. for ex. 1995. particu- et al. Women may fear that the symptoms in- cal distress (Prasad. depression. Bhatia & Cleland. In other cases. charge. reproductive tract infections and psychologi. Patel & Oomman. 2002. Erpalding & Pathak. and causes weakness. 1995.. 1999). the yeast multiplies. a survey in general practice in the conditions. The pain. women report that the orders and general illness. These infections may have that vaginal discharge is abnormal. – and by implication. The most common causes of candidal over- Epidemiological data may indicate that repro. Chapter 6. however. and Candidiasis rates of self-reported symptoms are not accurate estimates of the prevalence of gynaecological Candidiasis (vaginal thrush or monilia) is one morbidity (Koenig et al. Strong cultural taboos and shame may prevent opment of common mental disorders. The infection can be very debilitating. which have and developed countries (Jaswal. since been fully examined. distressing symptoms. Research energy. 1998). “inevitable” part of womanhood. supporting symptoms and to misunderstanding of their a cautious approach to symptomatic treatment cause.. immune system dis- health concern.. Zurayk et al. Symptoms related nosed (Stewart et al. Patel & Oomman. Dekker no medical explanation and remain unresolved et al. In Asian societies. Unexplained vaginal discharge Boonmongkon. and abnormal but non-bloody vaginal discharge can be distress. The impact on women’s mental health among low-income women.. In many Some reproductive tract infections in women are cultures. fection could be diagnosed (Dekker et al. under certain Similarly. (Wathne et al. in a systematic irritation.. Itching. 1993). (2005). 2003). 2000). 2002). 1993. oral contracep- ductive tract infections are not a cause for public tives. The experience of gynaecological symptoms is ing.. instead. 2001. a low correlation between vaginal be somatic expression of depression and psycho- discharge and laboratory evidence of infection social distress (Patel & Oomman. itchiness and found that reproductive tract infections were general discomfort associated with recurrent underdiagnosed in settings where laboratory fa.. 1993. Guo. tion and laboratory analysis of specimens. Abraham et al. 2002). women endure vaginal symptoms as an caused by overgrowth of organisms that are nor. discomfort or However. 1993. irritation. including women from seeking professional treatment. 2001. mally present. However. 1998). Zurayk et larly when no genital tract pathology is diag- al. Whittaker. 2001. try to treat themselves. women may be reluc- more than one month – most commonly vaginal tant to seek medical advice because they believe discharge – and a history of similar symptoms that these conditions are sexually transmitted. Candida yeast is always present in the for RTIs (Bonetti. which in turn may endanger their health (Jaswal. Nichter & Pylypa.

Mental health aspects of women’s reproductive health

from the digestive tract. Contemporary prod- Bacterial vaginosis
ucts, such as some soaps, antiseptic douches,
perfumed sprays, and tight-fitting and synthetic Bacterial vaginosis is caused by overgrowth of
underwear, can also change the local environ- anaerobic bacteria, and is characterized by vagi-
ment in the vagina and may result in overgrowth nal inflammation and discharge. It has serious
of yeast. Candidiasis is rarely sexually transmit- adverse consequences, in particular an increased
ted. All women are exposed at some time to at risk of premature birth, pelvic inflammatory
least some of the biological factors associated disease and sexually transmitted infection, in-
with thrush, and 75% of all women will experi- cluding HIV and herpes simplex 2 (Harville,
ence the infection during their life (CDC 2005). Hatch & Zhang, 2005; Uma et al., 2005). It is
Candidiasis is treated as a minor infection and thought to be more common in women who
its impact is rarely studied. Because it is often as- have reduced immunity as a result of chronic
sociated with menstruation, pregnancy and the stress. Ehrstrom et al. (2005) found higher lev-
use of oral contraceptives, it is frequently con- els of stress hormones in women with recurrent
sidered trivial by women and their health care bacterial vaginosis than in age-matched healthy
providers. However, urination and intercourse controls. However, Harville, Hatch & Zhang
during infection can be extremely painful, and (2005) found that rates of bacterial vaginosis in-
lesions may occur as a result of friction with fection were no higher in a sample of 411 African
swollen tissue, increasing the woman’s risk of American women with high self-reported life
acquiring other infections, including human im- stress than in those without.
munodeficiency virus (HIV).
Bacterial vaginosis may be more likely to occur
Treatment is usually with an antifungal cream or in women living in chronic adversity, whose
suppositories, such as miconazole or clotrima- general health status is low. Poor women attend-
zole, although such treatments are rarely avail- ing an outpatient clinic in Hyderabad, India,
able and affordable for women in poor coun- who were seriously undernourished, were more
tries. Women may also experiment with natural likely to have bacterial vaginosis than those who
therapies (e.g. by including yoghurt in their diet) were adequately fed (Yasodhara et al., 2006).
and by applying various herbs topically, but few Sex workers are at increased risk of concurrent
studies have reported on women’s perceptions infection with bacterial vaginosis and sexually
and self-management of this condition, or on transmitted infections (STIs), and it is thought
its effects on their mental and emotional health that bacterial vaginosis may increase vulnerabil-
(Bechart 1996). ity to STI (Kim et al., 2005; Uma et al., 2005).

In a small cross-sectional study of women with
Sexually transmitted infections of the
chronic vaginal candidiasis, the women reported
that recurrent infection seriously interfered with reproductive tract
their sexual and emotional relationships (Irving,
Miller et al. 1998). The women were signifi- Sexually transmitted infections are a major cause
cantly more likely than controls to suffer from of morbidity, disability, psychological suffering
clinical depression, to be dissatisfied with life, to and death worldwide. In addition to their direct
have low self-esteem, and to perceive their lives effects, they can make people more vulnerable
as stressful. Similarly, in a small study in the to infection with the human immunodeficiency
United Kingdom, women reported that thrush virus and cause infertility.
had a major adverse impact on their life, mak-
ing them feel miserable, unable to work, embar- In both industrialized and poor countries, the
rassed, and even stigmatized (Chapple, Hassell prevalence and incidence of sexually transmit-
et al. 2000). Women of south Asian descent drew ted bacterial and viral infections have increased
attention to the physical discomfort, personal since 1995 (WHO 2001b). In 1999, an estimat-
distress and embarrassment, and the impact that ed 340 million new cases of sexually transmit-
infection had on their personal and professional ted bacterial infections (syphilis, gonorrhoea,
lives; they reported feeling “dirty”, embarrassed, chlamydial infections and trichomoniasis) oc-
depressed and stigmatized (Chapple 2001). curred in men and women aged 15–49 years;
this number has continued to rise (WHO 2001;
2006). Precise global surveillance data on the

94

Chapter 6. Gynaecological conditions

prevalence and incidence of sexually transmit- veloped or developing country settings. In rela-
ted viral infections (other than HIV) are dif- tive terms, more evidence is available on spe-
ficult to find, but indicators suggest that 630 cific infections for North America and Western
million, or two-thirds of people who have ever Europe.
been sexually active, are infected with a human
papillomavirus (Baseman and Koutsky 2005; Diagnosis is universally described as stressful.
Pagliusi and Vaccine Research and Development Being diagnosed with an STI is stigmatizing
[2001] 2003). The prevalence of genital herpes (1997; Duncan, Hart et al. 2001; Donovan 2004),
(herpes simplex virus type 2 (HSV2) and, to a and carries an implication of one’s own or the
lesser extent, type 1 (HSV1)) varies widely, from partner’s infidelity. In addition, infection may
4% in the United Kingdom to up to 80% in sub- have implications for reproductive health in the
Saharan Africa (Paz-Bailey, Ramaswamy et al. long term; establishing or maintaining a sexual
2007). In addition to the primary symptoms, relationship may become problematic; and there
HSV infection increases the likelihood of de- may be concerns
veloping other sexually transmitted infections, about prevent-
such as genital ulcer disease (GUD) and HIV in- ing recurrence Lack of information on
fection (Paz-Bailey, Ramaswamy et al. 2007). of disease. These reproductive health problems
psychosocial re- means that women are often
Poverty, low income, urbanization, unemploy- sponses may be unaware that conditions are
ment and migration are all associated with the exacerbated or treatable, and that without
incidence and continued transmission of STIs compounded if treatment many conditions
(Holtgrave and Crosby 2003), in particular clinic staff have have serious long-term
when condoms are unaffordable or unavailable negative atti- implications.
(Duncan, Tibaux et al. 1997). STI epidemics tudes (Connell,
have been reported from the emerging states of McKevitt et al. 2004). Universally, the research
Eastern Europe and other countries experienc- literature draws attention to the short- and long-
ing rapid structural, political and social change term psychological responses of individuals
(Purevdawa, Moon et al. 1997; Axmann 1998; to STI diagnoses and recurrent infections, the
Aral, Lawrence et al. 2003). Marginalized com- particular emotional, social and mental health
munities are also highly vulnerable. In Australia, costs of these for women, and the lack of system-
for example, indigenous communities have ex- atic responses to meet the mental health needs
tremely high rates of sexually transmitted infec- (Prasad, Abraham et al. 2003).
tions of all kinds, as well as high rates of sexual
violence, and non-sexual physical and mental Infertility in women, as a result of untreated sex-
health problems. In one descriptive study among ually transmitted reproductive tract infections,
indigenous Australians, over a quarter of women causes particular distress and hardship, with so-
aged 20–43 years were infertile. Nearly 50% of cial and emotional consequences for both men
women in rural northern Australia had been and women, and social stigmatization, particu-
infected with genital chlamydia and there were larly of women (Papreen, Sharma et al. 2000).
high rates of previous pelvic inflammatory dis-
ease (PID), gonorrhoea and syphilis (Kildea and Various factors impede diagnosis and treatment
Bowden 2000). Effective public health interven- and contribute to a substantial global underesti-
tions are hindered by a history of dispossession, mate of reproductive tract infections of all kinds.
violence and racism, as much as by structural, Most women in developing countries have poor
social and economic barriers to service (Kirk et access to appropriate, acceptable, gender-sensi-
al., 1998). tive health services. Rural women, in particular,
are unfamiliar with reproductive tract infections,
Sexually transmitted infections can result in confuse sexually and non-sexually transmitted
pelvic inflammatory disease, tubal occlusion infections, and perceive and experience consid-
and consequent infertility, ectopic pregnancy, erable social stigma on diagnosis (Guo 1999; Go,
adverse pregnancy outcomes, genital neoplasia, Quan et al. 2002; 2002). Reproductive tract and
and neurological complications. Although these sexually transmitted infections are typically as-
infections cause pain, disability and reduced sociated with sexual freedom, and in much of
functioning, little research has been conducted the world, women’s sexuality is tightly control-
into their psychological sequelae, in either de- led. Any symptom of infection may be taken as

95

Mental health aspects of women’s reproductive health

cological problems, regardless of the diagnosis.
evidence of infidelity, and this may have serious
This influences the extent to which women treat
consequences for women and their children in
themselves, and their concerns about the seri-
terms of personal safety and security.
ousness of recurrent ailments (Boonmongkon,
Nichter et al. 2001; Boonmongkon, Nichter
For women whose quality of life is tied to their
et al. 2002). Women typically minimize their
fertility, reproductive tract and sexually trans-
concerns about their gynaecological problems
mitted infections cause short- and long-term
and employ self-management strategies rather
problems that affect their economic and domes-
than seek medical advice. As the gynaecologi-
tic life (Walraven, Scherf et al. 2001). Women
cal problem therefore remains unresolved, these
who are vulnerable and who fear informing their
factors result in substantial suffering. Elsewhere
partner about an infection may not accept that
in south-east and south Asia, women find re-
they have been infected, because of profound
productive tract symptoms stressful, leading a
feelings of shame and stigma, as well as fears
number of authors to suggest that women over-
of intimate partner violence. In Morocco, for
report vaginal discharge for reasons that are un-
example, STIs are viewed as women’s illnesses
clear but may be culturally constructed (Bang
(Manhart, Dialmy et al. 2000); a diagnosis of
and Bang 1994; Ramasubban and Rishyasringa
STI can lead to victimization and stigmatization,
2001; Ross, Laston et al. 2002). Such research
by both the male partner and family members.
highlights how discharge is commonly cultural-
As a result of gender discrimination in sexual
ly constructed and therefore perceived by wom-
health services, women may remain untreated
en as being unrelated to sexual contact (Bhatti
and vulnerable to sequelae of the infection. In
and Fikree 2002), regardless of its cause. These
Zimbabwe, women’s psychological reactions to
findings suggest that, while not all discharge is
repeated multiple STIs highlight their lack of
indicative of reproductive tract infection, women
power to negotiate safe sex within marriage,
may over-report some symptoms and under-re-
their lack of choice in terms of conditions of
port others, because of confusion about their
marriage, and the lack of social support net-
origin. In particular, women who fear the social
works for infected women (Pitts, Bowman et al.
repercussions of sexually transmitted infections
1995). Women reported fear or worry about the
may report somatic symptoms, such as dizziness,
risk of HIV/AIDS, yet highlighted their feelings
backache and weakness, rather than discharge
of shame, social isolation and stigma; they also
(Trollope-Kumar 2001). As a further complica-
related their infections to being unable to trust
tion, women seeking treatment for reproductive
their husband’s sexual behaviours. This finding
tract symptoms may receive unnecessary treat-
was supported by data collected from men, most
ment, especially in areas of high STI prevalence,
of whom indicated they were unlikely to change
and may experience fungal infections (candi-
their sexual practices (multiple partners, not us-
diasis) as a side-effect of the overprescription of
ing condoms) despite the infection. Research in
antibiotics (Hawkes, Morison et al.), which com-
Uganda has also illustrated that psychosocial
pounds rather than reduces their distress.
factors, including gender relations and types of
sexual partner, as well as poor quality of health
Sexually transmitted infections are prevalent
care, discourage women from referring their
among women who have experienced sexual
sexual partner for treatment (Nuwaha, Faxelid et
violence, compounding effects on their mental
al. 2000). Limited financial resources and a per-
health, sexual functioning and social relation-
ception that symptoms are not severe discourage
ships (Holmes 1999; Jewkes 2000; Firestein
women from seeking care. A study in Nairobi,
2001; Brokaw, Fullerton-Gleason et al. 2002;
Kenya, demonstrated that women waited longer
Upchurch and Kusunoki. 2004). Gender-based
than men before seeking reproductive and sexu-
violence is associated with STI infection; both
al health care (Voeten, O’Hara et al. 2004).
are associated with other physical and mental
health problems, including mood changes, sleep
Few studies have documented the social and cul-
disturbances, self-harm, and psychosomatic
tural aspects that lie behind recognition, diag-
symptoms (Suris, Resnick et al. 1996; Kawsar,
nosis and treatment of reproductive health prob-
Anfield et al. 2004; Plazaola-Castano and Perez
lems in women. Ethnographic research in north-
2004).
eastern Thailand highlighted how family life and
sexual relations are disrupted by fears of gynae-

96

Chapter 6. Gynaecological conditions

Young people are at high risk for STIs, because with a general increase in STIs. Specific targeted
of various social, economic, environmental, programmes aimed at high-risk populations in
psychosocial and behavioural factors (Bishop some parts of southern Africa have been suc-
Townsend 1996). In addition, young women are cessful in reducing incidence rates (for exam-
physiologically at greater risk of lesions during ple, in Botswana: Creek, Thuku et al. 2005), as
sexual activity, whether intercourse is forced or have programmes in the Caribbean (Jamaica:
not. Adolescents may be asymptomatic or una- Figueroa 2004) and South America (Argentina:
ware of the significance of their symptoms, and Pajaro, Barberis et al. 2001). These declines,
not attend for investigation; as a result, STIs may largely in developing countries, have contribut-
remain undetected and untreated. Risk is higher ed to an overall decrease in the global incidence
among young women with multiple partners, of syphilis (De Schryver and Meheus 1990; Piot
or whose partners have multiple partners, who and Islam 1994; Gerbase, Rowley et al. 1998;
use condoms inconsistently. In many countries, WHO 2001b). Nevertheless, focal epidemics con-
access to condoms and relevant information is tinue to occur in most parts of the world (Finelli,
limited and they may be completely unavailable Levine et al. 2001), particularly in rapidly de-
to those who are unmarried. Young women typi- veloping and developed countries. Data from
cally lack the skills to negotiate with partners South Africa demonstrate that the prevalence of
regarding the occurrence of sex and the use of syphilis has increased since 2003 (Department
condoms. of Health (South Africa) Directorate 2006); simi-
lar trends have been observed elsewhere, in-
In various settings other factors may compli- cluding central America (Nicaragua: Hoekstra,
cate the effect of gender-related variables (Boyer, Riedijk et al. 2006) and Asia (Thirumoorthy
Shafer et al. 2000). In a study among young 1990; Reynolds, Risbud et al. 2006; Chen,
people in Lima, Peru, 18% had a history of STI Zhang et al. 2007). Syphilis prevalence has in-
symptoms or diagnosis, but only 11% of those creased to critical levels in some populations
who were heterosexually active reported con- across Western Europe (Cowan, 2004; Cronin et
sistent use of condoms. Those with a history al., 2004; Marcus, Bremer & Hamouda, 2004;
of STI were more likely than others to associ- Righarts et al., 2004; Sasse, Defraye & Ducoffre,
ate condom use with casual sex, and to report 2004; Defraye & Sasse, 2005; Lautenschlager,
a history of sexual coercion or of having paid 2005; Oliver & Christensen, 2005; Payne et
or been paid for sex. For women, sex at a young al., 2005; Simms et al., 2005; Wallace, Winter
age was a risk factor for STI and unplanned & Goldberg, 2005; Del Giudice et al., 2006),
pregnancy (Caceres, Marin et al. 1997). Mental Eastern Europe (Tichonova, Borisenko et al.
health problems, including depression and low 1997; Uuskula, Silm et al. 1997; Ciment 1999;
self-esteem, appear to be significantly associ- Dencheva, Spirov et al. 2000; Grgic-Vitek, Klavs
ated with risky sexual behaviour among young et al. 2002; Karapetyan, Sokolovsky et al. 2002;
people. In the United States, depressive symp- Zakoucka, Polanecky et al. 2004; Resl and
toms are associated with an increased probabil- Kumpova 2005; Yakubovsky, Sokolovsky et al.
ity of not having used a condom during the last 2006), the United States (CDC 2006; Kerani,
sexual intercourse; for girls, they are associated Handsfield et al. 2006) and the Pacific region
with a history of STI (Shrier, Harris et al. 2001). (Thirumoorthy 1990; Mak, Johnson et al. 2004;
Rosenthal & Biro (Rosenthal and Biro 1991) Azariah 2005; Johnston, Fernando et al. 2005).
draw attention also to the presence of intrusive Prevalence rates are different in men and wom-
or avoidant thoughts in young women following en; surveillance data from Serbia suggest that the
infection, and argue for the need to explore the incidence of syphilis has remained fairly stable
coping mechanisms of young people with sexu- in women since the mid-1980s, despite signifi-
ally transmitted infections. cant fluctuations – with a recent surge – in men
(Bjekic, Vlajinac et al. 2001). Recent increases,
Syphilis globally, have been attributed to substantial in-
creases in incidence among men who have sex
Syphilis is highly infectious and was epidemic with men (Cowan 2004; Fairley, Hocking et al.
until the early twentieth century (De Schryver 2005; Fenton and Imrie 2005; Wade, Kane et al.
and Meheus 1990; WHO 2001b). Efforts to con- 2005; Kerani, Handsfield et al. 2006) and female
trol it had some success in the 1960s, but preva- sex workers (Hernandez-Giron, Cruz-Valdez et
lence increased in the mid-1980s coincident al. 1998; Smacchia, Parolin et al. 1998; Uribe-

97

2005. An untreated infected indi. one Australian study (Giles and Garland 2006). 2006). Nigro. Philips. Fetuses of infected women may tomatic. or irregular most women were unaware of any association menstrual bleeding. if left untreated. In women. arthralgia and depression. Briolat et al. Petry et al. it can thus have a major impact on wom. Secondary et al. 2000. from 6–8 has been found in 16% of women in China (Li. Avis & Whynes. Genital HPV infection may be asymp- transplacentally. on the labia and in the vagina (due to two spe- cific strains of HPV: Handsfield 1997). or genital suffer from extreme developmental disorders or cervical intraepithelial neoplasia (often diag- and often die in utero or at birth (Brockmeyer nosed by cervical smear tests Tinkle 1990. Women’s knowledge on passing urine and a yellow discharge from about the association between HPV. often diagnosed by cervical smear tests vidual can infect others through sexual contact Wiley and Masongsong 2006). mucocutaneous and long bone disorders. 51% of women in the United States (Kahn. and anxiety (Linnehan and Groce 2000. Mental health aspects of women’s reproductive health Salas. Leggatt and Frazer 2007). can be treated effectively. enous Australians is 78 times greater than in the McMullin et al. Cox. Kahn et al. (Wiley and Masongsong 2006). of cervical intraepithelial neoplasia and cervical riod of 2–10 years followed. Gonorrhoea is relatively (Andersson-Ellstrom & Milsom. 2002. Boyle et al.. Larocca et Human papillomavirus (HPV) infection al. 2006). 2005) and 58% in Brazil (Oliveira. cervical the penis. Diagnosis of HPV infection has a significant causing pelvic inflammatory disease and infer. often isolated tion is common in women. in all but although some women may have a yellow vagi. Genital There has been virtually no consideration of the warts can provoke a sense of shame. Posner. 2006). In Australia. (Frazer and Cox 2006. fever. 2005. yet little research has been conduct- en’s quality of life. al. its prevalence among indig. generally appear women. in about one-third cancer with HPV has led to increasing interest of untreated individuals. (HPV). Faxelid et al. groups. 2001). Secondary infection group and country of residence: HPV infection can occur in any part of the body. nal discharge. both sexually and al. a flat red body rash. by the development of in testing for HPV during screening for cervical skin. 2005. 2006. Philips. Dalstein. 2003. Wiley In men. Stoler and Reimann 1998). particularly young ulcer at the site of inoculation. manifestation of HPV is cauliflower-like warts Brizendine et al. Epidemiological Gonorrhoea data indicate that genital warts and cervical in- traepithelial neoplasia are caused by different Gonorrhoea is a bacterial infection. weeks after infection. involved in the development of cervical cancer sis. or may cause genital warts. Pitts rare in industrialized countries. infection can cause a burning sensation and Masongsong 2006). It is not indicate that a smear test will be abnormal usually diagnosed through laboratory testing. Prevalence rates vary by population 10–90 days after infection. Thus. For a to gonorrhoea has focused on issues relevant to small proportion of women (~3% in an Indian disease control. 1995). study: Singh. various Gardner et al. rest of the population (Roche 2001).. Symptoms may include Dai et al. 2003. (Ault 2006. There are a number of human papillomaviruses The disease is caused by a bacterium (spirocha. It has also stimulated the devel- In some cases. 2005. Slap myalgia. 2004. 98 . Sexually transmitted HPV infec- first symptoms. Rosa et syphilis is highly contagious. 2006). Gonorrhoea 2005 ). hair loss. the gonococcus. or outcomes of either of these conditions. low abdominal pain. The association for up to two years. abnormalities. Klug. depres- mental health factors associated with diagnosis sion. 2002). The sexual contact. 2006. There is then a latency pe. it is mostly asymptomatic. Hetzer & Blettner. the infection can spread to the reproductive organs.. Hughes et tility. Psychosocial research related ed on the mental health effects of HPV. cutaneous eruptions on the genitals and anus. the presence of warts does Neisseria gonorrhoeae. the physical ferral (Nuwaha. screening and cancer remains limited. 1996. Gudmundsdottir et al. psychological impact (Conaglen. Fortenberry. severe complications of the brain opment of vaccines against two types of HPV and spinal cord may result in progressive paraly. 11–38% in Australia (O’Keefe. including barriers to partner re. and can be diagnosed by a blood test. Sehgal et al. usually a painless. except in poor & Clarke. Conde-Glez et al. Avis et al. caused by HPV types. some of which are transmitted through ete). 2002.

McCaffery et al. Melville et al. emotional and psychosocial responses to a diag. ity.. Dalkvist et al. it appears to be more severe which had significant implications in terms of in women than in men (Mindel 1996. distress. but not transient changes in mood. and support from a partner appear to help with 2003. con- fusion. Chapter 6. Ongoing responses include tention should be given to psychosocial issues fear of telling future partners. Friedman and telling sexual partners. 2003). a sense of despair and low Genital herpes quality of life. with HSV2 increases the risk of infection with Psychosocial considerations are important in the HIV. It is incurable and can cause recurrent painful Despite its global prevalence. including her sexual practices and fection. Halioua type 2 (HSV2) is one of the most common sexu. Mischel et al. et al. Dibble and their sexual relationships (McCaffery. lowered self-esteem. Antoni et al. women viewed HPV current outbreaks of herpes. may result in recurrence of symptoms and. and hostility adults with genital herpes have therefore been towards the person believed to be the source of advocated (Lewis. “dirty”. nosis – which often occurred in the context of Pereira. Continuing psy- McCaffery et al. Distress may be associated with and Swanson 2000). (Cohen. including denial. with genital herpes.. 1999. Mindel 1996. and therefore be especially likely to experience re- cancer risk. of genital herpes. fertility. 2004). 1999. symptoms. Melville. 1999) found that persistent stress and anxi- exploring women’s responses to a diagnosis ety were particularly predictive of recurrence of of HPV infection. herpes infection results in significant the person. In addition. life change events. Leplege et al. in Specifically. Wahlin this may have consequences subsequently for et al. 2003). Kemeny et her physical health. 1995) and Cohen et al. 2006). men. Kamali et al. 2003). Women with herpes tend to have a more negative self-view and more Diagnosis of HSV2 infection is associated with a confusion and stress symptoms than infected range of psychological responses. (Dalkvist. little work has been outbreaks. Dibble the infection. In one of the few studies al. which need to be addressed. and feeling sexually unde- diagnosis (Miller. anger. Taboulet. affecting the woman’s health ner. relief. Rosenthal et al. management of recurrent genital herpes (Longo ing transmission of HIV in settings where HIV and Koehn 1993). Waller. conducted on the mental health impact of her- ing birth. the adjustment to the in- fection. Yeung-Yue et al. Depression is common among people diagnosed they felt guilty and responsible for the infection. anger at the source part- Shepeard 2007). Brentjens. 2006) argued that it is the diagnosis short-term stressors. including an. Infection pes outside North America and Western Europe. the diagnosis itself. or “infectious”. (McCaffery. Cognitive coping strategies is widespread (del Mar Pujades Rodriguez et al. 1995. which left them feeling “unclean”. Gynaecological conditions McCaffery. chological problems include interference with sexual relationships. 2003) reported strong of life (Wild. ture offspring. Sniffen et al. Infants may become infected dur. Patrick et al. of the menstrual cycle. and concern about transmitting it to fu- attendance for cervical screening (Ault 2006). and has a marked negative impact on quality (Melville. Gender-specific interventions for young guish. 1996. Such findings suggest that greater at. Chronic elevated stress social responses. Sniffen et al. 2006. anxious or upset following diag. Waller et al. fear of 99 . further worsen mental health distressed. disappointment. and the need to decide whether to psychological stress and psychosexual morbid- tell other people (Fraley 2002). 2003). as a highly stigmatizing condition. the type of social supports available to Overall. or phase itself that prompts a range of negative psycho. Women experienc- limited knowledge about HPV – and expressed ing chronic social and economic adversity may concerns about their future health. ally transmitted viral infections in the world. Waller et al. they noted that women often felt a cyclical fashion. Waller et Swanson 2000) and in those with a first episode al. People with genital herpes have also been found to use health services more often Genital infection with herpes simplex virus (Spencer. continued concern associated with cervical screening and HPV about transmission. guilt about acquiring or transmitting the in- behaviour. nosis of herpes infection. Control of HSV2 is a key factor in reduc. sirable and socially stigmatized. adjustment (Mindel 1996). 1999. and quality of life (Rein 2000. Judlin 2002. and develop serious illness.

the burden of disease from tion to others and about the possible effects on cervical cancer is higher than that from breast their future reproductive health (Duncan. factors such as non-use of condoms. (Williams. Hart cancer. In produced anxiety about disclosing their infec. of the disease (WHO. east Asia and the western Pacific (Parkin. agnosed with conditions such as chlamydia sub- ratory testing of swabs collected from the cervix sequently felt less comfortable during sex. Wingood et al. 1999). this neg. Pisani Connell. worldwide. ographical location. 1999). According to one small 2005). Anfield et al. are highest among women aged over 50 years. approximately 80% of women who die et al. Chlamydial infection is very common. Risk factors. lack of recognition of lems appear to be at high risk of infection in all premalignant cervical changes. symptoms may include vaginal discharge. developing countries. ap- suffering. 2002). women who have experienced sexual violence 2004). negative feelings about themselves. and eastern and deprivation and multiple simultaneous sexual southern Africa (WHO. 2000. and tries (Parkin 1994. al. 2004). Thomas et al. This spread through the uterus to the fallopian tubes. 2003. Sriskandabalan et al. Cervical cancer Most people with chlamydia do not have Cervical cancer is associated with infection with symptoms and remain unaware of infection. Gotuzzo et al. tors have yet to be linked to chlamydia (Claman. 2005). 2004). Malignant conditions causing conjunctivitis or pneumonia. 100 000 women per year – occur in Melanesia. 2004). lower abdominal pain. and individuals with social prob. points to the emotional costs of such diagnoses causing salpingitis. social Central and South America. 2005). Bray et al. There Chlamydial infection is caused by the bacterium is evidence from the USA that young people di- Chlamydia trachomatis. but it is often diagnosed in tive age to attend gynaecological services (WHO. WHO. It can be treat. McKevitt et al. are unclear Pisani et al. or its long-term effects (France. The highest incidence rates – over 30 per pears to be a complex interaction between ge. the cer are diagnosed and some 270 000 women die disease itself. around the testes. most infected women had not in developing than in developed countries. accounting for ap- ing on urination. a sexually transmit- Symptoms in men may include urethritis. 2004(Parkin. Winter. Zimmerman-Rogers et cidences are found in Europe. and felt an- ed with antibiotics. (Parkin. which and the need for readily available mental health may result in pelvic inflammatory disease. It is the second most common cancer women. 2004). in. infection often starts in the cervix. had in women or the urethra in men.. and in women after breast cancer (Lambley. and limited treatment services (WHO. street youth. The prevalence of chlamydia associated with sexual violence in The difference in incidence and mortality rates young people points to the need for services to between developing and developed countries re- 100 . human papillomavirus. ing programmes. a painful condition. North America. Bray et al. (Martin. Rein et al. Rohan et al. often occurring in young adults. or pain proximately 15% of all cancers in women. 2003). 2004). Matza et al. who may be less likely than women of reproduc- Toye et al. 1999). and there ap. Mental health aspects of women’s reproductive health Chlamydia appropriately assess and respond to their mental health needs (Kawsar. The lowest in- partnerships (Potterat. 1999). 1995). In men. Parkin. Death rates from cervical cancer Other psychological. It is diagnosed by labo. Bray et al. Cervical cancer rates are higher population-based data are needed. causing considerable cidence is increasing: each year. awareness of the disease. burn. In ted virus. 1999. particularly young people or women can result in infertility through inflammation who have experienced sexual violence. age. The incidence of cervical cancer is higher study in Glasgow. Its in- during sexual intercourse. 78% of all new cases occur in developing coun- atively affected their reactions to diagnosis. 2001). and considered that they were at risk of STI. 1993. lack of screen- settings (Paris. and can be passed from mother to child during birth. ethnic group. Untreated chlamydia may gry after sex (Whitten. behavioural and social fac. other than behavioural from the disease are in these countries (Parkin. chlamydia subgroups. While better et al. services and interventions targeted to specific fertility or ectopic pregnancy. 2001). Little work has been conducted on proximately 500 000 new cases of cervical can- the mental health effects of the diagnosis. in countries in which there is a general lack of sex workers.

1995. The only treatments for cervical In Canada.. may also derive from a lack of knowledge about volves an intimate vaginal examination. Intimate screening examinations are in- outside the United States on the mental health vasive. (WHO. 2004)... with the ultimate aim & Adab. Kirk Scandlin & Roth. Relatively little research has been conducted 2001). The situation is more compli- women are more likely to be diagnosed with late cated in developing countries. The immigrants have higher rates of cervical cancer Papanicolaou cytological test (Pap smear). mortality rates in Latin American immigrants 2003.. 2001). education about the importance of early detec- and economic factors associated with partici. MacQuarrie & Herbert. Manderson. may be physically uncomfortable and aspects of cervical cancer and knowledge of the can arouse anxiety. how. Women in one stage cervical cancer than other women born Thai province understood the Pap smear as a 101 . social. and Asian nosis and availability of effective treatment. 2004). marginal- spection of the cervix is often the only method ized and immigrant women in the USA have a available to detect cervical dysplasia (WHO. across the African continent) ((Parkin. 2004). Twinn ers to accessing screening. Women may be bility of diagnosing an abnormality. colpos- cially if they have inadequate knowledge about copy or visual examination. Even when women present wider psychological and social factors associated for cervical screening. 2002). whether screening involves a Pap smear. abuse are also less likely to attend for screening. These authors interpret not common in poor countries. 1998. 1997a. low knowledge about risk factors. tions and more likely to be identified when pre- oping countries. 2003). Screening rates are low in Hong Kong.. in particular to learn about barri. which are are less compliant with screening recommenda- costly and often unavailable to women in devel. and therefore do cervical cancer typically occurs at an advanced not attend existing services (Perez-Stable et al. they may doubt that there with it is limited. ly screened. Prevention therefore offers the cancerous tissue is already present (Gupta et al. Suarez et al. but there of developing cervical cancer (Coker et al.. (ranging from 41% in Eastern Europe to 49% 1999). stage. 2004). practical. Pisani et al. 2003). 2004). poor understanding of cervical cancer etiology.. Gynaecological conditions flects differences in both stage of disease at diag. 2004). In developing countries. many women see screening as a way of detecting cancer (Howson. are still groups of women who are not adequate. diagnosis of prevention. Effective screening. Golding & Minkoff. Ambivalence is to present for screening than other women and generated by the tension between the reassurance subsequently experience higher cervical cancer potentially offered by screening and the possi- incidence and mortality rates. logistic. Women with a history of sexual of encouraging women to attend these services. Screening programmes in developed countries and these women appear also to be at higher risk have led to improved survival rates. and cervical cancer incidence and at least 80% (Van Til. and the 5-year survival rate is around 48% 1992. 2000. cultural values related to modesty. 1994. the findings as indicating that poor.. American- can detect premalignant changes in cervical born and immigrant Vietnamese women are five cells. Consequently the incidence of cer- investigated.. most effective strategy for controlling the disease 2003). Phipps et al. Studies in the USA have found is an effective treatment for any abnormalities that: women with disabilities have low utilization detected (Gregg & Curry. moted as a preventive measure. espe. places high demands on resources. Chapter 6. is recommended by WHO for population times more likely to be diagnosed with the dis- screening. Farley. Although it is pro- the causes and development of cervical cancer. and em- pation in cervical screening services have been barrassment. et al. cultural. Members of minority Many women experience anxiety and uncertain- ethnic groups and immigrants are less likely ty when attending for screening.. tion. WHO. vical cancer is relatively high (Holyroyd. which has been found to be related to cost. 1997b. African-American & Hoban. 2004). and is (Scarinci et al. Kirk et al. 2004). women of low socioeconomic status cancer are radiotherapy and surgery. Early intervention among those found ease than white women born in the USA (Taylor positive can reduce cervical cancer mortality by et al. Uncertainty reluctant to attend for screening because it in. 1999). in the USA (Schwartz et al. and are diagnosed when disease is advanced (IARC. Temple-Smith rates of cervical screening services (Havercamp. where visual in. are more than double those of white women ever. which mortality (Singh & Miller. China. lack of Individual. and symptoms.

(2004) surveyed 428 health once cervical cancer has been diagnosed. While there were no differences in len legs and backache. those who were Broom. Lack of knowledge six months after the test. Diagnoses of cancer commonly arouse are alarming indicators of possible cervical can. In Thailand. ies has been suggested as an additional or alter. abnormal smear result. While this may be re- cancer with promiscuity. advanced stage. postcoital discomfort sults. women with normal or abnormal Pap smear re. who had or had not been tested for HPV or bleeding. Signs of cer- 2003). excessive fatigue. because the disease is detected at a more and disease (Wood. In those who tested negative. Indigenous Australian and found to be more pessimistic about their prog- South African women also associate cervical nosis than other women. vical abnormality (Karasz. 2001). Studies have tended to focus on women’s need ing in London. Burk & France. fertility control and karma (the negative itching or odours. it is also a result of misinforma- Manderson. perceived themselves to be at high risk Limited knowledge about the natural history of of cancer. Jewkes & Abrahams. 1998) and Karasz. with recurrent symptoms of abdomi- its occurrence also to poor vaginal and perineal nal or lower back pain. anxiety following a positive result (Kavanagh & positive women in this study. and who had difficulty understanding cervical cancer may also contribute to women’s the test results were most distressed (Maissi et confusion regarding medical responses to a cer- al. fear and in the group not tested for HPV. Misunderstandings about risk gener- Boonmongkon et al. and are of- 102 . Maissi et al. It et al. Thai women are fa. to psychological symptoms.. (2005) compared groups of vical cancer include irregular vaginal bleeding. al. hygiene.. insomnia. England. including anxiety. 1997. adult women following routine cervical screen. caused their condition. dirt alistic. Karasz. 2001. tion and poor education about the progression and implications of the condition (Rodney et al. For some women. cer. 1997. the association of HPV infection and follow an abnormal screening result are some- cervical cell abnormalities can discourage wom. 2002). The detailed physical investigations that However. McCaffrey et al. times unexpected and can be emotionally dis- en from attending for screening.. these signs may mood or quality of life between the four groups also indicate other conditions. Nichter & develop into cervical cancer (Boonmongkon et Pylypa. Jirojwong & Manderson. However. 2003).. rather than a way of screening for precancer McKee & Roybal (2003) found that women be- (Boonmongkon et al. Among the HPV. Kirk & Hoban. symptoms and generally feel well. specific anxiety about about the implications of an abnormal smear test abnormal test results remained and was highest often exacerbates women’s confusion. 2001) and as having an ad- abnormal Pap smear result rejected the explana. lieved that vaginal itching and discharge could miliar with some risk factors for cervical cancer. and indicated that they were afraid that their personal morality would Relatively little is known about women’s mental be judged. 2001. pelvic pain. 2002). women of low socioeconomic status and pecially concerned about the impact on future members of minority ethnic groups have been sexual relationships. McKee & Roybal. they have been described as intense and Broom (1998) found that women who had an traumatic (Howson. 2003). with less attention being paid to who were HPV-positive were more anxious than other aspects of psychological functioning. Kavanagh & ruptive.. but attributed Thailand. the women were es. unusual vaginal discharge. 2002). and found that those for support. linking sexuality. younger. McKee & Roybal. be indicators of cervical cancer and lead to an such as a history of sexually transmitted infec. women’s fear and worry about their cervical cancer risk led Testing blood for the presence of HPV antibod. would reduce demands on resources and is like. any gynaecological symptoms 2002). also believed that these could effects of past action) (Boonmongkon. is less invasive than other screening methods. and increased stress (Boonmongkon native screening technique to the Pap smear. swol- infection. infirmity and death. general. Kavanagh & Broom (1997... 2004). 2002). fears of illness. and vaginal discharge. Women who have dysplasia (abnormal cervi- ly to improve access for older women and hard. 2004).. Women in north-east tions or multiple sexual partners. Mental health aspects of women’s reproductive health way of diagnosing all gynaecological problems. cal cell changes) or cervical cancer may have no to-reach populations (Rohan. ate high levels of fear. verse impact on day-to-day psychological func- tion that their own sexual behaviour could have tioning (Forss et al.

including problems cal screening and women using one or other of with arousal. of factors. The psychological impact of this Women’s reactions to the diagnosis. 1995.. genital pain and altered sexual these approaches were compared prospectively self-concept (Lagana et al. psychologically informed did not have adverse psychological sequelae. (2005). communication regarding familial risk and deci- sion-making about prophylactic oophorectomy. Suarez et al. Among American women. In a twelve-month scribed in general terms and include: difficulty post-investigation comparison of tested women adjusting to side-effects of treatment. However. most distressed. Zulu toms. 2000. with ovarian cancer.. counselling Globally. 2001. many cases occur in women and smoking (Stewart et al.. Klee. Purdie & information and economic status (Perez-Stable Green. diabetes and hyper. including who were and were not found to carry the muta- nausea. Although the cause is as make sense of their illness by seeking a cause.. through DNA testing. it is the fifth most common In common with all those diagnosed as having cancer and the leading cause of death from all cancer.. 2001. Dyck.. 103 . specific to tions affect confidence. 1997a. 2000). 2005. ronmental pollution. eral reduction in distress after screening (Tiffen. cervical cancer has a more severe a systematic review. 2001). hormones. endometrial and other individual reactions are influenced by personal- gynaecological cancers ity factors. Ovarian. by Madalinska et al. Jensen et al. A recent study with poor Latin American surgery had fewer cancer-specific anxieties and immigrants in the United States identified high a more optimistic view of the future. Phipps et al. 2001). In Canada. Chapter 6.. 2005). and fear of undergone prophylactic oophorectomy were the recurrence of cancer after treatment. Li. Unfortunately. treatment testing is complex and has been examined in and prognosis of cervical cancer have been de. 2001. 2003). older.. 1999. The authors concluded that these risks women patients in South Africa also had high need to be weighed against the benefits of sur- levels of psychiatric morbidity (Nair. in particular whether the person has an active or avoidant coping style. access to & Berek. loss of weight. et al. Mental health research has focused on effective DiGiacomo. sexual practices tension.. 2000). survey and interview studies.. 1999. While professional support is beneficial for all those who screen positive (Hopwood. Loman et al. envi- as well as infertility.. those carrying mutations and who had not about the impact on relationships.. but cancer support services are needed by all (Lalos that counselling and expert advice were needed & Eisemann. (2005) found adverse effect than other chronic conditions on that cancer risk assessment and genetic testing women’s quality of life. of the BRCA1 and BRCA2 genes. quality of life. 2005). The alternative to pro- higher levels of sexual dysfunction than among phylactic oophorectomy is regular gynaecologi- survivors of other cancers. but worse levels of self-reported depression related to sexual functioning and more menopausal symp- having cancer (Meyerowitz et al. 2004). to help women interpret the risk assessment. Awareness without any known risk factors (Holschneider of cancer is generally related to age. Some studies have indicated that 2005). late age of menopause and nulliparity. socioeconomically advantaged women Hopkins et al. Thranov & Machin. Samsioe & Iosif. and hair loss. but there was a gen- er have children (Basen-Engquist et al. These reac. was apparent in all carriers (Claes et al. Women who had 2004). ease were persistent in carriers of genetic muta- ence anger and frustration that they can no long. Endometrial women with ovarian cancer believed they had cancer appears to be associated with early age at developed the disease because of a wide variety menarche. including stress. 1992. 2000). Runnebaum & Stickeler. 1999).. yet unknown. concern tion. Nelson et al. no direct cer is increased in women who carry mutations cause can usually be identified. 2005). women with ovarian cancer often try to gynaecological cancers. which is available in most rich countries. Others have found reduced sexual interest and Sharp & O’Toole. In gery in the clinical care of individual women. the risk of developing ovarian can. In the long term. tions (Watson et al. self-esteem and general cancer. Non-clinical distress. genetic factors. Gynaecological conditions ten associated in the short term with elevated Mutations in BRCA genes can now be identified rates of anxiety and depression. ovarian cancer is most common among needs to take this into account (Aziz et al. Anxieties related to development of dis- women who survive cervical cancer may experi. obesity. 1999. in highly industrialized countries.

nausea. support and disease and its treatment. which need to be considered siderable frustration regarding their experiences during routine health care. tion for gynaecological conditions should be tain prognosis and the prospect of premature systematically ascertained. reproductive tract morbidity and can- rates. Social support assists adjustment follow- logical morbidity can be reduced by: encour- ing chemotherapy for ovarian cancer (Hipkins et aging social changes that promote the value al. that women do not return to hard manual labour shortly after childbirth. women who develop these diseases often feel isolated and distressed. 2004). and have a personal history nied by efforts to improve women’s social of cancer or a family history of breast or ovar. logical functioning. Its impact on mood and interpersonal rela- tionships has not yet been systematically investi- gated (Andersen & Vanderdoes. 2005. including vulval and vaginal cancers and teratomas. Manderson et al. cers in women need to be considered and in- vival and mental health status. a pervasive diminution in quality of life. which should 1. Geirdal et al. Delays in diagnosis. 3. The physi- evaluated. as doctors dismiss complaints such as back pain and discomfort (Markovic. poor gynaecological health has direct specific abdominal symptoms. and gradual social withdrawal (Ferrell strategies to reduce obstetric injury and gy- et al. Andersen. Other gynaecological cancers. counselling during treatment and rehabilita- gical pain. 1999a. position. these 1.. As a result. the high mortality Policy rate and lack of curative treatments have an ad- verse impact on mental health. Accurate diag.. cluded in all research into these conditions. and women report con. Obstetric injuries and consequent gynaeco- 2005). 1999b. weight loss. Mental health aspects of women’s reproductive health Ovarian cancer commonly presents with non. as a result. because of Future research delays in seeking treatment. in seeking help. Delays in diagnosis influence both sur. cological morbidity need to be designed and cancer stage and the type of tumour. cal effects of surgery and adjuvant treatment affect quality of life and emotional well-being. In women who are Summary members of minority groups. with 2. ian cancer (Halbert et al. 104 . both prevention and treatment of obstetric Many women with ovarian cancer experience injury and gynaecological morbidity. linked to an inade- quate general understanding of their disease and inaccurate beliefs about their causes. death. The psychosocial consequences of obstetric women have higher mortality and morbidity injury. disease is usually detected at a more advanced stage. 2. 2006). including to post-sur. morbidity during treatment and more than one- ensuring rapid access to trained personnel third of patients have clinically significant de- during labour and childbirth. social confidence and sexual life. hair loss. 2005). and ensuring pression and anxiety. 3. Barton. self-esteem. Where women’s access to health services is preoccupation about risk of recurrence and life constrained by social and cultural factors. Distress is worse in those who are naecological morbidity should be accompa- younger and poor. effects on women’s mental health and psycho- nosis may be delayed. Primary prevention programmes for gynae- Length of survival depends on age at diagnosis. The specific needs of women in cultur- Depression can occur in response to both the ally diverse settings for advice. purpose. but there is significant psychological of girls and delay marriage and first birth. 1994.. Overall. uncer. 2003). Treatment may involve surgical excision of the vulva. Policy and service delivery need to address always be taken into account in routine care. which is deeply traumatic and adversely affects body image.. are rare.

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2000. lack of decision. proportionate domestic responsibilities. however. 7 Chapter Women’s mental health in the context of HIV/AIDS Mridula Bandyopadhyay T he epidemic of human immunodeficiency virus (HIV) infection and acquired im- munodeficiency syndrome (AIDS) is a major Gender and the risk of contracting HIV/AIDS international public health problem. ular vulnerability to various infections. 2006b). Clinical research has shown care (Patel & Oomman. the populations affected are poor. There is. HIV/AIDS has spread particularly rapidly among acts with vulnerability. and in the im. Worldwide. Poverty is a major factor in risk of infection. Most research that women who contract HIV/AIDS have short- on HIV/AIDS and its effects on mental health er survival times than men do because they tend has been conducted in the United States. and globally 39. sub-Saharan region. Since the HIV epidemic began. and 2. reproductive and mental women visiting clinics for antenatal checkups health problems for women (Gulcur. if at all (Bury. 2006a). 1992). and contribute to. reaches almost 60% in sub-Saharan Africa. the increase in the extent were living with HIV. this rate making power. the number of women living with ing with HIV and 72% of all deaths from AIDS HIV is the highest it has been in the history of occurred in sub-Saharan Africa. economic dependence. from HIV/AIDS. million adult women (aged 15 years and over) At the same time.7 pact of infection on a person’s general health. conflicting gender roles. 2002). women because of entrenched and pervasive response to diagnosis. 2000). One-third of pregnant to. are HIV-positive (UNAIDS. and subsequent health gender inequality. there were 4. at the end of December 2006. Morrison is some from other rich countries. while the psy- 113 . making it the fourth leading tionately. more than 60 ly in contexts where access to health services million people have been infected with the virus. In 2006. there to seek treatment later.5 million people are currently The patterns of transmission of HIV and de. 2006b). with especially high prevalence in the tries (Dodds et al.3 million in 2005 (UNAIDS. 63% of people liv- Worldwide. all HIV-infected adults were women. 1999). Studies of women’s partic- tle from developing countries. an increase from 16. living with HIV/AIDS.5 mil- and severity of poverty that occurs with AIDS lion in 2004 and 17. have until recently concentrated on clinical and physiological aspects. worldwide. 2006a.. but very lit. especial. includ- ing HIV. risk of HIV infection.9 million deaths context of infection and disease: dispropor. ethnic minorities. cause of death in the world (UNAIDS. 48% of tions. Rights viola. 2006b). marginalized. 17. dis. Africa. & McLachlan. is difficult and social inequalities are marked. In 2006. In 2006. a marked lack of evidence on women’s mental health and how it inter. and people The AIDS epidemic is highly concentrated in living in resource-poor settings and coun.3 velopment of AIDS reflect the socioeconomic million new infections. Tiamson. is felt most acutely by women. the epidemic (UNAIDS. and Three-quarters of all HIV-positive women live gender-based violence are also closely linked in sub-Saharan Africa.

low condom use. Young women are particularly vulnerable refuse sex. in northern ease progression. or to end received less research attention. AIDS on the streets – you have to accept when the incidcence of HIV among female adolescents your husband says. and route of infection. Cayemittes & Gringle (1996) reported that between 80% and 90% of HIV-infected Haitian women attending antenatal clinics had “no possible source of in- fection other than their own husbands” (WHO. ethnicity. In particular. Wyatt et al. two mil- “Women tend to agree that refusing sex amounts lion of them in sub-Saharan Africa (UNAIDS. In 2005. tions were in young people between the ages of you should like the seed. on the emotional impact of HIV/AIDS. Clark (1998). in reality their partners might not recognize this right. Girls and women are often women (Jones et al. a greater sense of isolation. which sought to explain the higher rates of HIV infection in young mar- ried women than in single women. 12 years of age were infected with HIV. Ulin. 1996). poverty. particularly in resource-poor tion for social and economic reasons. A history of trauma has also a higher risk of epithelial lesions through which been found to be a general risk factor for HIV in infection can occur. alternatively. or as a way of escaping qualitative differences between women and from unhappy or abusive relationships. in a review of the literature many young women in the face of family debt. 1996). 2002). 1996). half of all new adult HIV infec- selves.. 2006b). high frequency of intercourse. because their vaginal wall is support or domestic violence: (Ulin. found that their husbands were three times more likely to be HIV-positive than the boyfriends of the sin- gle women (Clarke. ment. such as the withdrawal of financial to HIV infection. they may turn to sex workers. ‘Let’s make love’” (Ulin. In cultures where early marriage is common. Recent research in urban settings in Kenya and Zambia. young married women often have a higher risk of HIV infection. and and alcohol to deal with the circumstances of oppression related to gender. information. poor access to education. described landlessness and poverty. Women may also be subject to reprisals if they 2002). 2001. women experienced gender-specific condom use. 2002b. UNIFEM. because of its association with early sexual debut. Cayemittes thinner than that of older women. where they risk contracting the Worldwide in 2006. Mental health aspects of women’s reproductive health chological and mental health ramifications have (even from their partner or husband). young women may risk assault if they insist on In addition.” “People say that when you like the skin. is increasing steadily. affecting their life circum- Cayemittes & Gringle. and health care. 2004). there appears to be an intri. 2001). quality of life and disease out. dependent on men for financial security. economic and educational bar- makes it difficult for them to insist on safe sex riers impede effective communication between 114 . 2001). 2. These men in terms of grief. HIV infection and its interaction with mental Young women are also more at risk of HIV infec- health in women. Thailand. to refuse sex. However. shame. to little less than a death warrant for them- 2006a). There have been relationships that increase their risk of infec- few investigations of the social epidemiology of tion (UNAIDS. For example. and may be dependent on drugs social stigma. and they have & Gringle. In these times – with 15 and 24 years (UNAIDS. their work (Bond. While women have the right. 2002a. including settings.. commercial sex work is the “choice” of come. stigma. and women’s limited right to refuse sex. Celentano & Yaddhanaphuti.. and depression. employ- cate relationship between mental health and dis. in theory. stances and potential by predisposing them to poor physical and mental health (Brady et al. and the combination of dependence and subordination Sociocultural.3 million children under virus and bringing it back to infect their wife.

port that their first sexual encounter was forced Sexual violence and abuse are now recognized (Astbury. miscuous (UNIFEM. 1998. significant ral causes (BBC. the community (Vetten & Bhana. found 115 . in their investigation of HIV-related risk factors in a community sample in the United States. 2002. Pizzi. Armistead & Forehand (1999) found investigated the death of a woman with that HIV-positive women were more likely to re- HIV/AIDS in Andhra Pradesh. (Catalan et al.. . Women’s mental health in the context of HIV/AIDS partners (Gupta.. including Brazil. the National AIDS Control more likely to have experienced traumatic life Authority said that she had died of natu. 1996. HIV-positive women experience high rates of sexual and physical violence (Gielen et al. for example. was 1996). previ. found that more than one in four women re- tor to. for women are limited material resources. 1999). 1997.. depres- being turned out of her family home. including HIV. press concerns about stigma. (Sadik. Quinn. McMahon. Various studies have reported that women and gestions that she had been burned alive. against women. 1992. 1997). (2002). Jamaica and South Africa. placing volving 48 countries. HIV infection. sexual exploitation increase women’s and girls’ perienced by women: one review revealed that exposure to. Linn et al. In December 1998. and substance abuse (Brady et al. 1996. and distress regarding physical National Commission for Women said symptoms (see also Linn et al. and ex- munity after disclosing her HIV status. they had not been able to determine the exact cause of death. contribute to a significant level subject to discriminatory treatment. Women who are HIV-positive. Fikree & Bhatti. a young South Vlahov et al. 2002). stigmatization and discrimination Goodwin & Stringer. Reproductive tract infections. in a study in- as a significant public health concern. did not like us. 1998.. sexual assault. and a range of ner (WHO. Emlet & Gusz. an Indian women’s rights group Kimerling. physical abuse. 2002). Gugu Dlamini. including or who are perceived to be HIV-positive. post-traumatic stress disorders. and port a violent victimization experience. A study by Recently. 2000. 1997). Several Gender-based violence and HIV/AIDS studies from South Africa. 2003). with adverse effects on physical and mental health (Carballo. WHO found that 10–69% women at high risk of sexually transmitted in. Sowell et al... and had concluded that she had been stoned after higher levels of psychological distress. Witbeck & Mayer. 2001). for women’s ability to protect themselves from ing condoms because they feared the condom HIV infection (Institute of Development Studies. Lack Sexual violence by men against women and girls of information about reproductive anatomy of all ages is found in all societies. and risk of.. Violence and may also contribute to fears and pressures ex. The best predictors of HIV risk and even killed if their husband or partner dies. Weiss & Mane. Chapter 7. 1996). 2001). assaulted. violence. such as incest. 1996). able in coercive situations. and have serious implications India. where they have little power to insist on condom use or otherwise con- trol the terms on which sex takes place. 1993. often have inadequate social support beaten to death by members of her com. India. may be STIs and HIV. The sive symptoms. 1996). Moser. The HIV pandemic has reinforced gender-based Grocutt & Hadzihasanovic. and a consequence of. events.. 2001).. Zierler. Women are more likely than men to be blamed ous exposure to violence. of women had been abused by an intimate part- fections (STIs). dismissed from employment. and and shunned by their families and communi- continue to pose a threat beyond the menopause ties. but there were sug. including HIV. 2000. girls living with HIV/AIDS are significantly However. 2002). 1996). women from several countries. discrimination and because she was seen to be a disgrace to hopelessness (Gielen et al. Weiss & Mane.Furthermore. Sowell & Phillips. have Gender-based violence can be both a contribu. and high-risk sexual for spreading the disease and stigmatized as pro- behaviour (Wyatt et al. Wyatt et al. abandoned of ill-health in women of reproductive age. might fall off inside the vagina and harm them 2002). multiple infections. African woman. Women and girls are extremely vulner- (Gupta.

more severe trauma. They reported cause of breakdown of law and order. 1993. security or money are at an especially conclusions were drawn by Gielen et al. many women have no 1998. large-scale greater anxiety. and post-exposure prophy.. partners and more sexually transmitted infec. adult sexual abuse and to report a more severe history of trauma than other women. Armistead Women who have sex in exchange for goods. overall health. be. rape of young girls and women by likely to have unprotected intercourse and to opposing forces. creased HIV-related risks (Kimerling. (2001). Research by Wyatt et al. the context of most sex work and sexual ing HIV-positive is associated with significantly transactions is poverty-driven. Women In addition. 1997b). Kalichman et al. Some employers may although they also found that a supportive so- also try to exact sexual services in exchange for cial network was associated with better mental job security (Gordon & Crehan. and symptoms of population movements. sexual risk-taking. 2000). Wyatt. PEP is the adminis. So far. industrialized countries). ally assaulted since the age of 15. and little is known about status. Arnow et al. 2002). Parillo & Forehand. are available regarding the type of exposures for cial or ethnic group affiliation. Similar services. Even when PEP is available (e.. in a study in the USA. UNIFEM. Currently. as have traded sex than HIV-negative subjects. HIV infection (Amaro. Heise. 1999. in the (Newcomb et al. Women who report knowledge or information about it and no means early and chronic sexual abuse have a sevenfold of accessing it. These factors all have an immense impact depression. particularly of women borderline personality disorder.. and were more and children. 1999. 2001. Thompson et al. for many women is to make money to keep them. Simoni & Ng. Several other cupational exposure to HIV. incidents women. in many countries. Institute health and overall quality of life. Regardless of ethnicity. in most countries. Mental health aspects of women’s reproductive health that HIV-positive women had had more sexual establishment of infection (Anderson. 1997a.. of Development Studies. & Forehand. found that 68% of women and 35% of men liv- In war and conflict situations. women try to survive the loss of income. et al. increased risk of infection. and are more at risk of been well documented (Allers et al. PEP may prevent 116 .. employed. home Women with HIV/AIDS who had been sexually and family (Institute of Development Studies. 2002. depression. 2000. 1997. Recommendations have and physical abuse in childhood and adulthood recently been developed for PEP after non-oc- increase the risk of HIV infection. and the population most likely to seek PEP (Kwong et prevalence of sexually transmitted infections al. Wyatt et al. 1999. on women’s psychological well-being and coping opportunistic infections and AIDS-defining con- mechanisms. are less able to ne- abuse and HIV-related risks in adulthood have gotiate sexual decisions. (2002). rather than avoid. (2002) showed that be- tings. Theoretically. were un- access to treatment. 1999).. ally assaulted or raped. 2002). and increased “survival sex”. risk exposure in order to reduce the likelihood of HIV infection.. 1995. and is not available to HIV-negative women. 2002b. 1998. higher prevalence of HIV-related risk behaviour and markers of risk than women with no history Domestic violence is also associated with in- of abuse (Allers et al. and had suffered more severe abuse than to health care professionals. The associations between child sexual tend to have more partners.. 2000). ditions than HIV-infected women who had not been sexually assaulted (Kimerling. emotional distress. socioeconomic which PEP is prescribed. 1995. including ra. Armistead Bensley. In resource-poor set. children and men who have been sexu- of rape and attempted rape since the age of 18. assaulted reported more symptoms of trauma. Zierler et al.. Van Eenwyk & Simmons. Sexual abuse. the risk and in. women who are serop- selves and their families alive. 1991). HIV symptoms. 1999.. Wyatt et al. had a history of laxis (PEP) is not available. ositive are more likely to report being victims of ing becoming infected. had had more STIs. Moore & Toubia. 1999). 2002a. and the priority lower income for women of all ethnic groups. women have little who had had more sexual partners. ing with HIV/AIDS reported having been sexu- cidence of violence against women escalate.g. also more likely to be HIV-positive. 2001). 1993. UNAIDS. Women in violent relationships 1991).. PEP is available only tions. Wingood & DiClemente. limited data factors are also linked to HIV risk. or were less educated were tration of antiretroviral medication after a high. Zierler et al. Forge & Guthrie.

and Sri Lanka. and risky sexual behaviour increase vul. nerability to infection (Wyatt et al. 2002). comprising almost 50% of all inter- non-compliance with recommended health care national migrants (UNFPA.. be worried about be. which leads to a history of multiple STIs. nearly 95 million women sion or anxiety. help their people to migrate (Fernandez. clinical depres. Weingourt et economic factors play a major role in migration al. Indirectly. 1996. Women who reported sexual abuse in adulthood had increased rates of anxiety. substance abuse. no control in their relationships. Most migrant workers travel without their sexu- al partners.. racial and ethnic minorities are sexual abuse are more likely to have a high level marginalized and underprivileged. engage in high-risk be. partic- ularly in industrialized countries (Moser. therefore. Globally. substance abuse is classified infected women in Zambia found three major as a psychiatric disorder. 2006). 1998b) found that women in Australia sections of the society. live in poorer al. 2006). and identi- ties. The governments of a number of develop- ing countries. and have unaddressed psychosocial prob. (Institute of Development Studies. Other studies on violence and its relationship to lence. 2006). 2001). in which exposure to violence in childhood ual and physical abuse were more likely to have leads to risky sexual behaviour. A growing number of also had a significantly higher risk of harmful al- women are being diagnosed as having both HIV cohol consumption and drug dependence. important than income in increasing risk of HIV Doubly abused women (as a child and as an adult) infection (Schifrin. higher rates.. 1993. mental health have come to similar conclusions. because female migration has increased as a sur- vival strategy for families (Wolffers & Fernandez. Roberts et have fewer economic resources. each year.. Social and and treatment (Brady et al. (Hall et al. DiClemente & Raj fied the potential for a cyclical pattern to material- (2000) found that women experiencing both sex. 1998). Sexual and physical abuse are frequently associ. infection and substance abuse problems. 2001). phobias. Mullen et al. ize. and experience more episodes of physical abuse. harmful alcohol pecially employment and education. abused women. who experienced abuse as adults had elevated haviour or engage in transactional sex for sur.. dys- Inability to access socioeconomic resources. increased risk of HIV infection. For example. 2002. 2001). In many cases. women dominate migration flows. 1988). and alcohol abuse (Murray et al. use marijuana and alcohol to the initial risk of violence related to HIV status to cope. The authors highlighted the important overlap ated with physical and psychological co-morbidi. women who had experienced lems. and possible migrate. depression. information and knowledge. Being a migrant 117 . thymia. 1998). domestic violence. which leads back ing infected with HIV. They often have to deal with the dis- ruption of social support. 1999). Indonesia.. problems. as women and as migrants (Long & Ankrah. may be more consumption and psychoactive drug dependence. Bangladesh. In particularly that women exposed to physical and most societies. rates of mental disorders compared with non- vival. Lukalo. symptoms of de- pression.. the Philippines. attempt suicide. Migrant women face dou- ble problems. Fernandez. exposure to vio. es. UNAIDS. between violence and HIV infection. 1998). (1998a. of depressive symptoms and psychiatric disorders cess to education. 1998. Sowell A recent study investigating violence among HIV- & Phillips. Chapter 7. poor living conditions and poor provision of care for their health needs (Bandyopadhyay & Thomas. 2002. have less ac. e. HIV/AIDS risk is a abuse both in childhood and as adults had still function of race and ethnicity. 2002). Such traumatic life experiences are often associated with high Migration and HIV/AIDS rates of psychiatric co-morbidity. Wingood.g. Women’s mental health in the context of HIV/AIDS Low socioeconomic resources. feel as though they had (Murray et al.

(Kalichman. in a migrant’s life: stress. regularly confronted with sexual harassment. as domestic servants. 1998). 2000). Their low sta. migrants are particularly up for African-American or European women) vulnerable to STIs and HIV infection. identified four major sets of issues: (1) the emotional and sexual impact on the relationship. (3) the future of children and the non-in- fected partner. but independent contribution to mental health cial support networks make them vulnerable to status. 2002. to friends and family. shifting child care responsibilities. contributes to the greater vulnerability of mi- cumstances can lead to increased personal risk. primarily related to being HIV-infected. Thailand. and family migration. and increase their depend. 2002. VanDevanter et al.5 and low levels of social support. and tle or no bargaining power. disclosure and the men- ment. (2000) entertainment industry. In stigmatized groups.. particularly for women working in the tal health status of women. but also to their children’s and partner’s health. levels of depression. and have multiple causes (Tostes. Mental health aspects of women’s reproductive health is not in itself a risk factor for infections. that poor mental health might predict lower lev- discrimination and exploitation. studied the relationship between disclosure of or in the sex industry. The ence on others for survival.. An estimated one in four women newly infected with HIV is between 35 and 44 years of age. Institute of Development Studies. in a study on the impact of a diagnosis of HIV on serodis- cordant heterosexual couples. and sexual abuse and exploitation. Unwelcome The mental health problems experienced by sexual attention and sexual abuse by employers women who have HIV infection are considerable are often reported (Bandyopadhyay & Thomas. 2004. They found that disclosure made a small tus. mented the profound negative impact of HIV infection on women who had given birth and their families (Manopaiboon et al. Other adverse family impacts that women faced were reduced income. Specific links have been knowledged features of the working environ. low pay. docu- Singhanetra-Renard. Heckman & Kochman. Murray. (2) reproductive de- cisions. The women experienced depressive symptoms and anxiety. (1999). They are often els of disclosure. 1997). 2000). A study in Bangkok. poor working and housing conditions and lack of autonomy. as well as to emo- Two quite different sources of risk may be present tional and mental health problems. They looked at one particular trapped in situations where they cannot refuse study of Hispanic women in the United States. However. Women are particularly infection and mental health among an ethnically vulnerable in work situations involving isolation diverse group of 176 women with mean age 36. found between stigma. Migrant (Comer et al. part- 118 . workers are generally concerned first with their livelihood and survival. disclosure was abuse and infection. grants to STIs and HIV/AIDS. where greater disclosure was related to higher They may have few negotiation skills and lit. 2002). Comer et al. separation from or death of partner. stress is associ- Mental health and HIV/AIDS ated with low wages. 1998). In these situations. Migrant women are researchers also explored an alternative model. to provide sexual services (Fernandez. During the initial reported pain (although this finding did not hold period of adaptation. psychological distress. 2004). but cir. years. women may face a variety (Bandyopadhyay & Thomas. and isolation from family and so. and (4) disclosure of the infection Sexual abuse and exploitation are under-ac. rather than HIV risk Throughout their lives. Little is known about the impact of HIV/AIDS on these women and their partners and families. predictive of poorer mental health status. Stress often of challenges: fear of unwanted pregnancy.

home cannot ask me to use condoms. anger. 1987). isolation and grief may trigger feelings of titution to feed. 1989. and is associated with a variety of other dom as a preventive measure. as well as by mental cantly higher among those with HIV infection distress (Abrams. A study in the United States A emerging trend has been the increase in HIV found that half of HIV-positive adults had symp- infection among people aged over 50 years. A large number of these patients tor for older women is heterosexual sex. 1996. Sambamoorthi et al. 2000). and are forced to turn to pros. This young are more likely to develop depression at two spe- girl can ask you. family rejection. generalized anxiety disorder and 2005 (UNAIDS. In HIV-infected patients also experience varying addition to the physical effects of the infection. Jacobsberg & Fishman. and educate their chil. including major depres- reaching approximately 2. toms of mental disorder. HIV infection. substance abuse. Older visited mental health specialists. of age identified five risk factors for contract- ing HIV: poor mental health. including lowered immune response. they may be seen problems. and other HIV-related problems.. Parket-Martin & Unger. with manifesta- suicide (Heckman et al. further in. 1996). dysthymia. can chondria. acute anxiety attacks. discrimi. Cayemittes & Gringle. 2006a). In many societies. often related to childhood or domestic ample. 2001). 1985. insomnia. re- Kalichman. multiple partner non-infected mothers and their children. if they contract HIV. including loss of patient may develop chronic generalized anxiety physical and financial independence. hypo- nation. and lack of information on HIV 2000). often lead to significant distress and a risk of Dementia may be prominent. 2000.. untreated depression have higher medical costs than those treated with antidepressants. 2005). A from an ethnic minority attended mental health study of HIV-positive women over 45 years outpatient services (Bing. the relationship. and rural areas. and a lower quality of they face being accused of causing it. not only in ignorance of the earlier HIV risk behaviour of those with HIV infection (Kalichman. Inability to cope. because she doesn’t want to get cific times: when they are diagnosed and when pregnant and have problems with her parents” the first symptoms appear. found more symptoms of depression in abuse. patients times you sleep with a young girl. them from receiving important care services.. image. particularly in small towns creasing women’s vulnerability to STIs. Heckman sexual partners.. Perry. Leserman et al. such as thinning those with low income. variety of organic disorders. as promiscuous or unfaithful (Long & Ankrah. Generally. sulting in anxiety and depression (Heckman et 119 . People relationships are condoned for men. 1990. ranging from mild unease to women often lose their jobs and the support of full-blown panic. but also in people close to them (Sikkema prevention (Neundorfer. the dren. The multiple difficulties. of social condemnation and sanctions persist. 2000). both be. Biggar & Firehand (1998). Women’s mental health in the context of HIV/AIDS ner infidelity. for ex- issues. includ. discrimination and religious and other forms Married women often face considerable diffi. few of that occur during menopause. altered body their husbands. Heckman & Kochman. Suicide is one of tions ranging from mild forgetfulness to severe the ten leading causes of death for women aged disorientation. As a result. HIV/AIDS still carries a stigma. group treatment. Symptoms of depression are common. despair and frustration. major depression or brief psychosis. 2000). If they request their partner to use a con. 2002. were found to contribute to an increased HIV-infected mothers and their children than in risk of HIV. disorder. and the risk of suicide is signifi. Delirium too can be caused by a 35–44 years. and loss of economic support and domestic violence. Women’s disclosure of their HIV infection of- ten triggers a downward spiral to destitution.8 million cases in sion. with HIV infection. fected. (Kalichman. 2000. risk-taking in order to preserve & Kochman.. Kalichman. disease progression to AIDS. participated in women are particularly vulnerable. On the other hand. with little education. However. HIV patients with (Ulin. used psychotherapeutic medi- cause of the sexual behaviour of their husband cation and discussed their emotional problems or partner. or of the vaginal wall and reduced lubrication. and because of physiological changes with their medical practitioners. but some. time. Heckman & Kochman. shorter survival 1996). Globally.. increased disability. The dominant risk fac. “My wife at life (Chesney et al. Nichols. 1999). Chapter 7. 2000). Mental health et al. WHO. levels of anxiety. culty in attempting to assert their reproductive Depression is common among those who are in- rights. panic attacks. Rompa & Cage. may face barriers that prevent ing HIV (Institute of Development Studies. clothe.

1998). Thailand. many women infected with HIV dentiality. the male-controlled sexual decision-making. Connors & Simmons. this & Compton. Seropositive women (Ciambrone. a study in the USA found that depression planned nature of the pregnancy. women whose babies were Recent studies have tended to concentrate on HIV-infected had greater worries. 2001. Despite this. AIDS dementia complex (ADC). the women reported infections. the psychosocial and spiritual dimensions of the Bennetts et al. 1996. 2003). has been found in 25– et al. and mental was associated with reduced quality of life and health issues related to HIV infection. festation of AIDS (Adams. tial disruption. Mental health aspects of women’s reproductive health al. low energy. al. Wingood. 2004). quite common among women with HIV infection. fection has focused on homosexual white males atric problems. Chibnall (2002) moderate levels of perceived stigma and high found “death distress” (death-related depression levels of depressive symptoms. such as health status. Chuang neurological dysfunction. in some cases. For ex- that barriers included the unexpected and un. a (Chesney. These psychosocial ramifications are sive symptoms and HIV-related worry among especially relevant to patients living with AIDS. 2000. 2002. substance dependence. Demi et al.. 1993). Folkman et al. 2001). of sexual autonomy. HIV (Brady et al. 1993). 2000). on functioning and well-being... 2000. Raj & dictive of psychiatric disorder (Bing. Rabkin et al. al. women in one study and lack of social support.. They found infant. observations were made by Comer et al. 120 . Folkman & Chambers. 1996. Gillespie and those who reported suicidal thoughts had & Holditch-Davis. 1996. depressive mood. diffi. 2001) did not consider HIV to be the perceived the health care system as threatening. 1995. (1998) studied a number of variables in women with HIV In a study of the physical and mental health of infection. drug use. African-American mothers with a seropositive family cohesion and perceived stigma. ers and who reported that their family would Moser. which increase the risk of 1995. a direct reflection of their low status and lack rounding HIV infection (Armistead & Forehand. Napravnik et be ashamed about their HIV infection. and gynaecological problems (Miles.. Depression has tenatal care by HIV-infected women reported a serious impact on the course of disease. Sambamoorthi et fected patients. Moreover. Sowell & Phillips. 1987). As the Most research on psychosocial stress in HIV in- disease progresses. Farmer. 1989. et al. Women who were HIV/AIDS and depression no longer with their partner were at greater risk of depression. 1991). tive elements in their lives. Demas et al.. 1997. 1997). and sexual assault (Amaro. psychosocial stress found that the probability of screening positive for may be greater in patients with AIDS than in anxiety and depression was related to the number those with other chronic diseases (WHO. Williams et al. Dodds et al. it is the only mani. most devastating event in their lives. poor adherence to HIV treatment regimens (Tate periodic homelessness. Women reported more HIV-related symptoms. 2000. as did those the overall health and well-being of people with who had not disclosed their HIV status to oth. A study of 2864 HIV-positive adults WHO.. 2001). 2001. of HIV symptoms present (Tsao. sexual health problems and make it difficult for them to obtain appropriate treatment and sup- HIV symptoms are likely to have a negative impact port. 2001. Women’s sexual health is led to greater stress because of the stigma sur.. and anxiety) among younger patients with spe- relations between depressive symptoms and cific. or separation their mental health and well-being (Napravnik from their children as more significantly disrup- et al. Leserman et 90% of AIDS patients and in 30–40% of HIV-in.. Women’s health is frequently linked to in- who found that one of the main concerns of se. (1999) found evidence of depres. Additonally. the physical health status were found. thereby increasing in which women’s vulnerability is increased by psychological distress and anxiety. there may be further psychi. (2000). This is evident in the HIV/AIDS epidemic. 2000). et al. Semple et al. Significant cor. Bing Reed.. HIV-infected mothers in Bangkok. at 18–24 months postpartum. diagnosable life-threatening conditions. Women were mostly concerned with regarded family violence. In particular. that suicidal thoughts and suicide attempts were culty thinking and remembering. patient’s life. equality and generalized oppression (Travis ropositive men and women was disclosure. DiClemente & Raj. A study on access to and use of an.. part- presence of multiple HIV-related symptoms is pre. poverty. 2000. ample. ner violence. 2001). Similar al.. suggesting a experience of death distress was associated with clear link between mental and physical health. Despite ini- and feared discrimination and breach of confi....

. and its interaction with reproduc- loss of friends. those who used mental health services were less Evans et al. 1991). 1989. more likely to be diagnosed with depression 2. including dementia. Ferrando et al. There are significant gaps in the literature patients with HIV infection and AIDS include on the mental health of migrant and refugee lack of family support. 2006). The prevalence of depression in HIV-infected lar results: those with chronic depression were clinic populations in the United States has been 1.. dren are extremely rare. likely to be victims of violence.. For example. mental illness will be orphans. A study in 2006 examined the re- lationship between treated or untreated depres. The and transmitting the disease (Sadvosky.. There have been few reports on the psycho- HIV-positive women (Cook et al. the predicted increase in their number indicates an urgent need for such Conclusion research.. occur in 40–70% of AIDS patients dur- A number of studies have investigated the impact ing the later stages of the disease (Abrams. women are more parenting (Perry. Further research is required to therapy than those not receiving any treatment complement the strong biomedical efforts to for depression. 1991). 1992. In fact. in various HIV-positive groups. 1987. in the general community (Brown et al.. These women continue to the illness. 2006). both within and outside their home. in either developed or developing apy were more likely to adhere to antiretroviral countries. Patel et al. Women’s mental health in the context of HIV/AIDS there has been little research on the psychoso. was positively associated with increased use of health care services and adherence to antiretro. Factors associated with psychosocial stress among 4. mental health problems of these highly vul- Depression is the most common mental health nerable groups are either sidelined or disre- 121 . 2004). among female injecting drug users found simi. women. In a study of 5073 HIV-positive pects of being HIV positive and breastfeed- injecting drug users. receiving quality care. 1989.. including HIV. 1998. 2004). Those logical problems of new mothers with HIV given antidepressants in addition to psychother. Similar findings have been found reduce mother-to-child transmission of HIV. phaned as a result of AIDS has barely been studied. and were during the antenatal and postnatal periods. 3. An estimated 14 such as substance abuse and affective disorders million children have lost one or both par- (including depression). Studies of distress and anxiety in HIV-posi- (Turner et al. access- mental health services was associated with low. fear of discrimination. 1997. that AIDS-related deaths were more common and they are more likely to have difficulties ac- among those with depression. Future research sion and adherence to antiretroviral therapy in 1. Summary Starace 2002). Williams et al. Again. women were less adherent ing and of decisions about HIV treatment to antiretroviral therapy than men. Some studies have found depression to be one of the primary reasons for poor adher- ence to antiretroviral treatment (Bogart. However. Sadvosky. 1991). delirium and de- pression.. 1990)..7 times more likely to die from AIDS-related found to range from 22% to 32%. This needs to consider the psychosocial as- ing drug users. treatment. ing information. Rabkin et likely to die than those who did not use such al. stressful life events associated with being female tion and the related issues of childbearing and (Patel et al. uncertainty about the course of tive functioning.. Parket- of depressive symptoms on adherence to HIV Martin & Unger. and is closely linked to the cial problems faced by women with HIV infec. 2–3 times that causes than those without (James. and satisfying their nutritional er mortality rates (Cook et al. The impact on the mental health of girls or- viral therapy (Mijch et al. including inject. Jacobsberg & Fishman.. were not associated with ents to AIDS. 2003). 1998. 1999). and that use of cessing health care. and it is predicted that by 2010 decreased adherence to antiretroviral therapy one-third of all children in southern Africa or with reduced survival. and concerns about sexual activity be vulnerable to STIs. a study published tive women regarding the fate of their chil- in 2006 found that mental health disorders. they are more likely to be de- A 2004 study of 1716 HIV positive women found nied educational and employment opportunities. syndromes. Neuropsychiatric services. 2000. A study needs (Das Gupta. problem in women. 1999). Chapter 7. infection.

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Larsen (2000) in terms of whether the condition is identified used linked population census data. Kols & Nguyen (1997) sum- in defining both the population with compro. ary infertility following the birth of at least one child was more common (6%) (Sundby. In 128 . Primary infertility was physician diagnosis. and have limited ac- ing child but are unable to conceive again). whose most recent birth was more than five years ago. The comparison (Fathalla. populations have sometimes included those who A population survey in Gambia. e. using randomly have never tried to conceive and large groups selected census areas. least seven years without having a child. in the developing world. 2002). 1989). marized the available estimates of infertility in mised fertility and the appropriate comparison developing countries. that 8–12% of wide range in secondary infertility (5–23%). Buss. but second- conceive. 1994). or based on a life calendar of re. on the basis of investiga. infertility or involuntary childlessness is hampered by variations in the definitions of women in North America are unable to conceive spontaneously (Beral et al. 1998). 1994). The tries. and found wide varia- population.. 1997). a physician consultation or a in 28 African countries. often. which in- by self-report. alence of fertility difficulties in developing coun- ing medical assistance in order to conceive. and cess to diagnostic tests or treatment and. Infertility can be regarded assumed in those who had been married for at as a heterogeneous group of health problems. 1995. Rowe & Griffin. The central difficulty is of Statistics. in. Primary infertility was low (less than It has been estimated. 3% in the countries surveyed). Vayena. Some concerns about overpopulation and the costs of studies have included people with primary in. There have been relatively to conceive after a specified period of regular few population-based investigations of the prev- unprotected sexual intercourse or those seek. 8 Chapter Infertility and assisted reproduction Jane Fisher E stimating the prevalence of fertility difficul- ties. 2004). second.. Half of those affected had not impact on clinical outcomes. While this reflects local research capacity. and fluenced by a range of risk factors (Marchbanks secondary infertility in those aged 20–44 years et al. The former may be conceptualized tions. found that primary infer- of young women who may not yet have tried to tility was relatively uncommon (3%). cluded childbirth history. equivalent figure there is 15% (Australian Bureau Kols & Nguyen. Definitions vary ing and treatment were limited. to examine infertility productive events. sub-fecundity (the capacity to conceive but not no access to assisted reproductive technologies to sustain a pregnancy to term). including those sought treatment and both investigative test- reported in research studies. unrestrained fertility in these areas (Inhorn & fertility (the inability to conceive at all). 1992. Mboge The definition of infertility has a significant & Sonko. Most women with infertility live ary infertility (those who have at least one liv.g. 11–20% in sub-Saharan Africa and as either individuals or couples who are unable 14–32% in Namibia. Postal surveys of a national sample in Australia suggest that the these conditions (Schmidt & Munster. but there was a tions in several clinical services. specified time of trying to conceive has varied it is also argued that it reflects predominant from 12 months to more than 24 months.

2004). women in Botswana (Upton. or because narrowing of the introitus may lead to the anus or urethra being used for intercourse (Ng. Reproductive tract infections. The assessment of male fac- viability and dysfunction of sperm motility are tors is limited because many men refuse to par- most common (Johnson & Everitt. Rowe & Peterson. Normal vaginal intercourse may be impossible if the introitus is narrowed through infibulation (Okonofua et al.. Sundby. 1997. In a comparison of consecutive women present- ing with fertility problems and female hospital In reviewing prevalence surveys. that the patients were significantly more likely to time prevalence of infertility ranged from 3. including genetic conditions. superstitious attribution infection. of Neisseria gonorrhoeae antibodies and of a 2002). 1999). southern mental toxins. is common. history of other sexually transmitted infections ductive tract infections is not widely available. In countries where treatment for repro. In a single matched controls in Ile-Ife. overall. occupational ex- idiopathic infertility – or of shared etiology. and exposure to environ.. may also con- difficulties are obstructed fallopian tubes and tribute to infertility (Inhorn & Buss. in Egypt (Inhorn & Buss. and that about including curettage in Gambia (Sundby. the most common causes of fertility metabolites. the re. 1999) and Mozambique pecially sexually transmitted infections. Male and female factors are each believed to which damages the male genital tract) have been account for 40% of cases of infertility. 1998) and cervical electrocauterization seek medical assistance to conceive. maining 20% are either unexplained – so-called 1997). 1994) may contribute to infertility. 1998). but parasitic infections (including schistosomiasis. 1997). The balance is attributable to ological functioning. It has ticipate in studies.2% and of secondary infertility control study of 60 women with infertility and 53 21. as a result of chronic pelvic infections leading to obstruction of the fallopian tubes. Infertility and assisted reproduction a survey using random sampling in a rural com. pesticides and heat. In posure. Female genital schistosomiasis. anatomical defects. are the (Mariano. 2001. 1991). biological women. which is common in sub-Saharan Africa.7% of al. 2000). It has also been suggested that inap- 24% of the global population experiences either propriate treatment of undiagnosed conditions. leads to granu- lomatous inflammation of the cervix and in- creases the likelihood of other reproductive tract infections (Poggensee et al. tion or childbirth are also implicated (Kols & fertility caused by tubal occlusion resulting from Nguyen. 2001). es. 2001). 5. by constitutional problems. which may mean that cause is been suggested that 5% of infertility is caused misattributed (Aghanwa et al.. 1994. the infertile group had higher rates couples were reported to be infertile (Thwaites. while in men low sperm & Nguyen. leading to the field observations. Kols ovulation dysfunction. Female fertility may be reduced fol- lowing genital mutilation.6%. than the controls. Anthropological investigations of ticularly in obstetrics. 2000). the prevalence of primary lopian tubes (Kols & Nguyen. infection (Vayena. 2002). In developing countries. using in-depth interviews and predominant cause of infertility. formation of scar tissue which obstructs the fal- munity in Nigeria. Mboge 15% of the population of reproductive age will & Sonko. They concluded that. 1997). Nigeria (Koster-Oyekan. Mboge & Sonko. poor access logical or immunological dysfunction (Kols & to services or little general knowledge of physi- Nguyen. implicated in some countries (Kols & Nguyen. In a case- infertility was 9. In groups with limited education. about an abortion. unhygienic health care practices. Infectious causes appear to Causes of infertility be less common in male factor infertility. primary or secondary infertility.. 1997). Chapter 8. for example to heavy metals. Schmidt & workers in Nigeria. Poggensee & Feldmeier. Infections secondary to abor- more than 30% of women develop secondary in. 1997). (1999) found Munster (1995) found that current and life. par.1% (Adetoro & Ebomoyi. and endocrino. Nigeria (Okonofua et survey of one urban region in Viet Nam.6% be married to polygamous men and to have had to 32. concluded that women are usu- 129 . Aghanwa et al. 2002).

are regarded as tion norms. but been tested (Eugster & Vingerhoest. and rates of psychiatric illness. and alcohol and drug use. 1997). erectile dysfunction and vaginismus. Downey & McKinney. This has commonly to misattribution of responsibility and “blam- been defined as fertility difficulties for which no ing” of victims. 130 . The issues proposed as etiologically in. 2001). particularly of unknown etiology. Downey & McKinney. some authors ing. the severe weight loss associated (usually those seeking treatment) to pre-existing with the eating disorder. 1999. or between infertile groups and popula- ral areas. Visser et inated individuals (Inhorn. Women with lescence and investigated pre-existing psycho. cigarette smok- volved have included uncertain gender identity.. a substantial epidemiological study.. can factors. including systematic sampling. ambivalence about hav. sample size and standardized measures. infertility as a defence decreased fertility. supernatural factors. differences between fertile and infertile women In particular. 1991. where men and not representative of the population with in poor rural communities migrate to urban areas fertility difficulties. rather than etiologically involved (Edelmann et matized and socially marginalized in strongly al. 1999). 1997). ing. It has been argued that women who and Mariano (2004) identified a contemporary seek treatment may be psychologically robust paradox in some African countries. There has been a long-standing belief that female infertility. Greil. pair the completion of intercourse (Rosenthal & depression and anxiety. between fertile and infertile groups are more ac- curately regarded as secondary to the infertility. The their wives are still expected to have children and observed differences in mood and self-regard are responsible when this does not occur. but this assertion has not to work and are absent for prolonged periods. adequate gression of sexual taboos or rituals relating to bur. is One of the criticisms of efforts to ascribe infertil- attributable to psychological factors – so-called ity to psychological factors is that they have led “psychogenic infertility”. As understanding of the com- adverse effect on the mental health of couples plex physiology and biology of reproduction has who want to have children. People who cannot have children may be stig. can also lead to external locus of control. chological mechanisms are assumed to be operat. 1999). were more likely to groups. 1994). infertility was attributed to: trans.. lead to suppression of ovulation. These ial of a dead child. anorexia nervosa. have used an intrauterine contraceptive device. and behaviours make individuals more vulner- Almost all have focused on women. ment. Upton. In these son studies have used more adequate method- investigations. 1991. ology. Upton (2001) al. 1994). especially against inner conflicts. or between groups with infertility having been subjected to kabsa. Studies have attempted to find personality or have argued that certain psychiatric illnesses psychiatric factors that would explain infertility. Egyptian fertile groups and those seeking infertility treat- women of low socioeconomic status living in ru. al. The links between behavioural querading as infertility” and sexual dysfunction factors and fertility pathology were examined in (Callan & Hennessey. who cannot conceive. Moller & Fallstrom. tubal obstruction There have been no population-based prospec. including studies have found no significant difference in witchcraft or a curse by ancestors or deities. 1992. 1988b. in particular. this condition had a lower age of sexual debut logical differences between fertile and infertile and more sexual partners. 1992. 1997). a number of cohort compari. other psychopathol- prior abortions or use of orthodox contraceptives ogy or personality factors between presumed (Koster-Oyekan. has investigated this hypothesis in recent years. Infertility exerts a significant Vingerhoest. Mental health aspects of women’s reproductive health ally regarded as responsible for infertility. or the constraint of different origin and duration (Edelmann et of reproductive capacity by exposure to contam. psychiatric symptoms. 1991). However. was associated with a higher incidence of previ- tive studies that have followed women from ado. that. Eugster & pro-natal settings. ous sexually transmitted disease. which found 1991. grown over the past three decades. Sexual difficulties. especially women. while there were few differences between fertile and infertile women. little research organic cause can be identified and in which psy. and most have able to infertility and that these should continue made retrospective attribution of the observed to be investigated (Rosenthal & Goldfarb. While agreeing with this view. the proportion of infertility attributed to unexplained origins has decreased from about 50% of cases to between 5% Psychological causation of infertility? and 15% (Moller & Fallstrom. can im- ing children. Goldfarb. marital problems “mas.

Fertility difficulties uniquely stressful because it can last for many can exert a pervasive negative effect on quality years and for many will not be resolved (Berg & of life. self-blame. the labelling of these conditions continuity. 1992). The Psychiatric illness or normal psychological frustration associated with being unable to control reaction to an abnormal circumstance? conception and physiological functioning com- monly leads to feelings of anger (Becker. fertility. Dunnington & Glazer. would be more accurate (Berg & Wilson. along which individuals are ranged. In addition. and an element psychiatric symptom checklists include somatic of adult and gender identity which will never be symptoms (e. There is debate about whether the psychological This may be directed towards a number of people. compromising planning and commitment Wilson. ness. 1990). infertility can be identified only that earlier sexual experiences. Becker ing diagnosis and during treatment for infertility. disturbance observable in people with infertility including the infertile partner. The effect is observable in tified an infertility strain profile. which may offer to allow their spouse to partner someone have a clear resolution. irritability. 1982. 1982. individuals may it has been argued that a syndrome approach to fear losing significant relationships. because ties and relationships it entails. 1985). Two approaches have been taken to describing ficulties of a delay in the age of marriage and the psychological sequelae of infertility (Greil. lowered energy levels. The losses than 20% of women attending an infertility sup. sociated with polycystic ovarian disease (Beral et al. been found to demonstrate some of these features 1994). a positive sexual relationship (Mahlstedt. 1994). the use of con- when it has lasted at least a year. 1982). being punished for past misdeeds or of intrinsic ized and assessed in different ways. Guilt Psychological impact of infertility is prominent among women. which has been conceptual. & Wizny. 1985). clinically significant symptoms of depression and anxiety have been reported in surveys of cohorts Reaction to infertility is also conceptualized as of women and. or logical profile. Chapter 8. Other less rational beliefs – of (Menning. (Abbey. As psychological state is dynamic follow. 1990). Infertility and assisted reproduction and were less likely to have used condoms than Almost all women presenting for treatment have those with other fertility difficulties (Beral et al. friends and associ- is more accurately conceptualized as a psychiatric ates who have been able to conceive easily. 1991. 1992). However. characterized both men and women. Berg & Wilson (1990) have iden. 1990). a generation and genetic 1999). Nachtigall. 1994). partic- ularly if infertility is of unexplained origin. lar with the partner. and illness or as an intense psychological reaction to people who offer unsolicited advice (Mahlstedt. or delaying procreation while pursu- and eventual diagnostic confirmation of infertil. Andrews & Halman. men seeking grief.. the state of parenthood and the activi- as psychiatric illness has been criticized.g. 1992). In this approach.. to other life activities. tile identity (Menning. dren who will not exist. scribed as a profound life crisis or existential blow and a number of common themes are iden- tified (Menning. ing professional goals has compromised fertility ity can have a profound psychological impact (Mahlstedt. but more so in women by increased anxiety. The study also found that obesity was as. The contribution to fertility dif. The experience traceptives.. 1982). 1985. Becker & Wizny. unworthiness – have also been reported. “Something is wrong with my realized and is substituted with a flawed infer- body…”) that are normal among those with in. together with fears By definition. infertility is de- understood (Rosenthal & Goldfarb. infertility is regarded as else in order to have a child. Some may Unlike other adverse life events. to a lesser extent. 1994). 1997). (Berg & Wilson. abnormal personal circumstances. include: the experiences of pregnancy. including for many intangible or disen- fertility treatment (Beaurepaire et al. Olshansky. social iso- lation and heightened interpersonal sensitivity. but the complex clinical description of the experiential responses social and economic factors involved are not well to infertility. Mahlstedt. The first is qualitative investigation and many industrialized countries. Nachtigall. profound sad. in particu- conceptualization is inaccurate and that a psycho. Quantitative investigations have used psychomet- 131 . the children and grandchil- episodic suicidal ideation (Kerr. 1987. High rates of 1985). Brown & Balen. physical attractiveness. More franchised losses (Menning. childbirth port group reported that they had experienced and breastfeeding. reproduction has been identified as a concern in 1997).

Similarly. differences in distress between the they are highly likely to be blamed for infertility two groups. Upton. Beaurepaire et al. Potts & Mattox. because adult tions. 1999. Infertile women may However. search comparing infertile women and couples with presumed fertile controls or already preg. 2004). social exclusion.. highly stigmatizing. In a single study. 1991) and less life satisfaction and happiness 2004. First.7% of infertile can be matched in these terms and in length of patients in Nigeria were depressed or had an anxi- time to conceive (Hearn et al. Divorced and childless wom- (Callan & Hennessey. 1992. (1999) reported that 29. 1992. Beaurepaire et al. Domar et al. which itself is ported by the findings of significantly more non. Perhaps because of the limitations. to women of infertility in these contexts. However. 1994. 1991. experience significant differences in levels of depression be. Upton (2001) (Beaurepaire et al. 2003). Downey & McKinney. of their failure to bear children. Mariano. Second. (1992) acknowledge that individuals have dif. 1997). Given the very limited access to assisted Thoreson & Penney. in both focus of most research in this field (Inhorn & gynaecological and socioeconomic terms. 1995). 2003. 1997). 1992). psychological impact of infertility in developing standardized measures of psychological dysfunc. people. height. but that the severity of this distress is (Mariano. Koster-Oyekan. 1999. reproductive treatments in these settings. a second wife (Koster-Oyekan. be suspected of having evil po- tween infertile and comparison groups (Connolly tential and be subject to harassment. Mariano. 1988b.. en are highly vulnerable when old. Mental health aspects of women’s reproductive health ric measures. and it Buss. 1988b) in infertile popula. 1994). Hynes sequelae of infertility et al. In settings where women are subordinated. the group of women who has been described as reflecting the eurocentric experience infertility is heterogeneous. Although infertility exerts adverse psychologi- ened guilt and self-blame are common. This is sup..7% of fertile non- these limitations. Dare & is unlikely that any control or comparison group Ogunniyi. nevertheless. Visser et al. compared with 2. but not cal effects on both men and women. and (Connolly et al. Connolly et al. tion and marginalization. societies. especially et al. the inaccurate understanding of its determinants. 1985. infertility is highly stigmatizing Significantly higher levels of depressive symptoms (Inhorn. Thoreson & Penney. 1997). although the differ- ences remain within a normal range (Callan & Gender differences in the psychological Hennessey. have led to the condition being “invisible” to poli- fering degrees of dispositional anxiety and that cy-makers. They may be divorced because not clinically significant (Greil. matched hospital staff controls. regard have been reported. Becker & Wizny. 1985. Hynes from their in-laws (Koster-Oyekan... has argued that the presumption that infertility and others finding no differences from controls is rare in countries with high fertility rates. Potts & Mattox. Nachtigall.. Lower levels of self-esteem and self. 1992. 2001).. et al. 1999. Andrews 132 . there is evi- dence that they react differently (Abbey.. Despite ety disorder. 1994). there has been substantial re. It has been suggested that there are. infer- ing anxiety are similar. 2001). Upton. with some studies finding tility has been described as leading to profound significantly higher levels among infertile groups human suffering (Inhorn. other investigators have reported no have their gender identity questioned. As a result. 1992.. 1994). or their husband may marry specific emotional distress (Moller & Fallstrom. pathological (Bernstein. This situation (Greil. Edelmann et al. Upton. 1992. symptoms or syndromes is different in infertile and presumed fertile populations (Greil. It has been suggested that in highly pro-natalist nant women. and relatively little is known about the tion may not be sufficiently sensitive to capture psychological functioning of women with fertil- the complexities of the infertility experience ity difficulties in these settings. there has been insufficient these may lead to varying anxious responses to consideration of the psychological and social costs infertility. tional choices and motherhood is the only identi- fier of adult status. 1987). 1995). The inability to have children for infertility than in presumed fertile controls damages both cultural and adult identity. Berg & Wilson. There have been few systematic studies of the This approach has two potential limitations. have been found among women seeking treatment 2004. Aghanwa. standardized in general populations. 1994). 2001).. attribution of responsibility leads to social rejec- 1990. The findings regard.. countries. 1992). and the (Bernstein. where women may have few occupa- the findings are inconsistent. More severe depression is associated with children are the usual primary supporters of older increasing age and being childless (Morrow. to examine whether the incidence of particular Morrow.

Individuals with high self-esteem and dispositional optimism In the past 25 years. Women have been found to Draye. 1991). divorce so that he or she can achieve genetic par- Andrews & Halman. 1991. Nachtigall. Denial and avoidance are elements idly. Berg & (Nachtigall. Cook. Similarly. most of the pression of anger and frustration about the pre- investigation and treatments focus on the female dicament may be constrained in order to protect partner.. Eugster & Vingerhoest. systematic psychometric investigations and women are more likely to believe that the have revealed few differences in quality of mari- woman is responsible if unexplained or com. 1994). 1991. seeing other couples with children (Hart. This may be because. Private infertility treatment services are for treatments. 1991. 1992).. fected emotionally by the diagnosis of infertility. 1992. in order of major infectious and chronic disease bur- to find an optimistic assessment. in- oped infertility treatment services. the infertile partner (Hart. Greil. Individuals respond to disturbing life events in dif- Psychological aspects of treatment ferent ways. Thoreson & Penney. Both men However. & Penney. scrutiny to which the relationship is subjected. Rowe & Griffin. Morrow. including those for which there is 133 . 1997). tercourse to be carefully timed and by the clinical tity and the experiences of childbirth and parent. 2002).. 2002). Litt et al. They are at high- dens. scant scientific evidence (Woods. Infertility and assisted reproduction & Halman. Becker & Wizny. treatment on the marital relationship Becker & Wizny. WHO. it is estimat- cluding infertility (Menning. sive symptoms associated with infertility than men. Cook. Becker & Wizny. Beaurepaire. Individuals who use avoidant vision of these highly sophisticated services has coping and deny the emotional impact of infertil- to be weighed against the competing demands ity may seek multiple medical opinions. Women’s lives are more disrupted by in. In industrialized countries with well devel- of a normal response to adverse experiences. Morrow. Greil. 1992. Olshansky & 1992. 1995). 2002. vulnerable to exploitation by extravagant claims 2003). Becker & Wizny. 1982). Olshansky & Draye. technologies to treat both are better protected against severe depression (Litt male and female infertility have developed rap- et al. 2002). 1992). Rather they suggest that marital intimacy Andrews & Halman. hood is more profound for women than for men Both partners may experience emotional pain (Abbey. etiological factor. 1995). Chapter 8. Guilt versely affected only by male factors (Nachtigall. Women who are able to take an active part in seeking information and making decisions of infertility using assisted about treatment have lower levels of depression reproductive technology and attract more social support than those who Psychological sequelae of diagnosis and passively submit to medical recommendations treatment (Woods. Nachtigall. neity can be impaired by the need for sexual in- 1991). Sexual sponta- fertility than men’s (Abbey. 1991. except in cases of male factor infertility Impact of infertility and infertility where the degree of distress is similar (Nachtigall. Even when male factors fects on intimacy. enthood with someone else (Hart. Andrews & Halman. and inexpressible blame can have insidious ef- Becker & Wizny. the public pro- emotional distress. 1992). 1997. women experience more guilt rejection or may feel obliged to offer the other a and self-blame than their male partners (Abbey. 1993). 1991). The infertile partner may fear are implicated. Infertility can exert adverse effects on the emo- there are adverse effects on the gender identity tional and sexual relationship between partners of all women with infertility regardless of the (Andrews. et al. Men are more likely and cohesion can be strengthened and enhanced than women to experience infertility as a sign through confronting the experience of infertility of compromised potency and sexual adequacy together (Dennerstein & Morse. 1994. Hart. The ex- even when male factors are involved. and limited obstetric and perinatal health er risk of becoming depressed and may also be services (Vayena. but male gender identity is ad. Abbey & Halman. Thoreson experience more emotional distress and depres. tal relationship between infertile and comparison bined factors are etiologically involved (Abbey. 2002). Andrews & Halman. Wilson. 1993). Although the need for assisted reproductive tech- but denial is not an effective defence against severe nologies in poor countries is high. It also appears that the loss of sex role iden. 1999. 1992. 1991). 1988. Some indi- ed that more than 60% of couples with fertility viduals may appear to be more persistently unaf- difficulties will seek treatment (Dawson. groups. 1992.

Franco et al. there is evidence on the individual. 2002). The authors ar- there then appears to be a decrease in symptoms gued that this is a response to the violation of once treatment starts (Beaurepaire et al. Using life-table calculations to timism and active coping are protective against review 4225 couples who had undergone 8207 depression following implantation failure. Overall. 1994. cally demanding (Callan & Hennessey. of the treating centre (Eugster & Vingerhoest. 2001). ment (Callan & Hennessey. Martin & Thong. The initiation In many settings. rather than exploring other ward. that. It has been shown medical treatment or an unfortunate life circum. 1991). 1992). 1992).. Beaurepaire Rowe & Peterson. MacLachlan & al. transfer arouses optimism. MacLachlan & en who use avoidant coping are generally more Brehny (2001) reported that half the women distressed (Litt et al. While rates continue to improve. scans. but that the interval ize (Vayena. 1992). Critics assert that women Among other factors. order for couples to persist with repeat cycles nosis. Astbury & Baker. 1995).. in whom the expected successful outcome al. 1988a.. privacy and time that diagnosis and treatment Severity of depression at this stage has been involve. There Repeated unsuccessful treatment cycles can is a theoretical debate about whether infertility erode the increase in confidence and hope that should be considered a disease that requires comes at the start of treatment. Optimism gradually diminishes over of a living child is low. 1990. 1994). Yong. rather than making a free choice by social forces. the all regarded as more psychologically than physi- situation in developing countries varies consid. 2001). 2002). erably. There is trained health professionals and essential labo. in terms of availability of appropriately Hammarberg. Teaching et al. symptoms of acute distress may increase. 2001). the costs of infertility treat- of treatment arouses optimism that the condition ment are not subsidized by the state and fall may be alleviated. One qualitative study suggested that a state of There is now substantial evidence that the na. 2003).. after two years of unsuccessful treatment.. 1992.. on or a negative pregnancy test leads to intense sad- average only 20% of couples conceive at each ness. This can add substantially 134 . history of surgery for investigation or treatment of infertility (Domar et al. ily members and friends (Callan et al. and that once this detachment cannot linked to having a confirmed diagnosis and a be sustained. and it is not possible to general. of assisted reproductive technologies means that MacLachlan & Brehny. 2001). Injections. 1988a. despair and a sense of lost control (Litt et embryo transfer cycle (Kovacs. Hammarberg.. Domar et ual. 1994). Making the deci- both patients and clinicians try to seek a cure sion to stop fertility treatment is not straightfor- for the condition. (Benjamin & Ha’elyon. However. 2000. wom- cycles over six years. including the opinions of fam- (Shattuck & Schwarz. & Nachtigall. dissociation between the physical treatment and ture and intensity of emotional distress vary its psychological consequences is necessary in over the course of infertility treatment. hospitals in some developing countries are start. the decision not to attempt are coerced into participating in and persisting another treatment cycle is strongly influenced with treatment. may outweigh the ben. Others have suggested that the availability than six (Callan & Hennessey. Mental health aspects of women’s reproductive health being established in many poor countries. Bewley (1995) argues that the physical treatment and can develop into chronic and se- and mental health risks of treating an individ. At diag. Rowe & Griffin. individuals cease treatment. 2002). Rowe & Griffin. between transfer and pregnancy testing to con- firm whether implantation and conception have Rates of pregnancy and live births following occurred is highly anxiety arousing (Callan & assisted conception depend on the experience Hennessey. vere depression (Berg & Wilson. 2002). consistent evidence that the moment of embryo ratory services.. as there is no clear terminal point if con- means of establishing a fulfilling life (Becker ception has not yet occurred (Covington. 1988). The onset of menstruation 1999). 2002. 1988a. Kovacs. Kovacs. Dispositional op- Brehny. repeated cycles and few couples persist for more efits. but that women hold unrealistically high expecta- are likely to be accessible and available only to tions at this stage of the likely success of treat- socioeconomically advantaged groups (Vayena. Astbury & Baker. 2002). 1988a. stance on which public resources should not be distress returns to a higher level than before spent. WHO. became pregnant within three cycles and two- thirds became pregnant over six cycles.. Franco et al. blood tests and waiting ing to offer public infertility treatment services to know whether eggs have been fertilized are (Vayena.

. Franco et al. Collins. Having a dures (including ovarian hyperstimulation and peer counsellor who had experienced infertility. 1991.. 1996). support groups. 1992). 1992b) but the group did not include women infertility treatment. and nutritional counselling... it has been argued that support- ive counselling should be available at this time (Yong. reduced psycho- ence with treatment. infertility clinicians need to have both medical and psychological skills (Covington. 1990. Chapter 8. Psychological components of treatment It has been cogently argued that. Gleicher et al. shown to provide emotional support and prac- vided by evidence that. including tal in Oslo. couples have to weigh the logical symptoms in women. tical information and to reduce social isolation. (Domar et a fully informed choice about participation in al. after prolonged infer. Norway with a medical record au- 135 . signifi- There have been a number of attempts to relieve cant proportions have to adjust to life without a the psychological distress of infertility and to biological offspring. Seibel & Benson. Some support for this view has been pro. As irritability. 1992. Halman & Andrews. they can feel prohibited from expressing this ambivalence be- cause they consented to the transfer of multiple embryos (Leiblum. exercise marked effect on decision-making about persist. parison group (Domar. Halman & Andrews. was found to be ben- limited success rates. The promotion of op- timism and personal control during treatment reduces psychological distress (Abbey. 1995. proaches have been tried (Hart. Combining a survey of past patients at a hospi- havioural group treatment approach. 1990). Kemmann & Taska. Domar. and the possible adverse eficial (Domar. Termination of infertility treatment General social support has been found to have a more positive effect on women’s distress than Not all couples with fertility difficulties will on men’s (Abbey. 1994). the experience of infertility treatment. there was no untreated com- cycles against their yearning for a child (Abbey. Although couples may have significant fears about fetal well-being and doubts about their own capacity to care for more than one infant. This psychological improvement It has been asserted that couples cannot make was replicated in a subsequent study.. Gleicher et al. because the risks of proce. the economic costs. Seibel & Benson. Couples may actively seek a mul. the as well as a group leader. Infertility and assisted reproduction to the burden of emotional distress.. tility. tiple birth in order to create an instant family (Leiblum.. Goldfarb et al. Individual. and have a relaxation training. cognitive therapy. (Lentner & Glazer. 1990. given the in- tensity and severity of distress that can be ap- parent during treatment. Fewer health effects on women and their offspring are men than women want to participate in self-help generally understated (Pfeffer. conceive following infertility treatment. Goldfarb et al. with severe psychological dysfunction. 2002). 34% of whom con- financial costs of diagnostic tests and treatment ceived. 1995). Halman & Andrews. 1990. although participation has been 1994). multiple gestations). multiple gestations can be idealized and Men who attended such groups to support their the associated hazards underestimated (Franco wives ultimately found them personally helpful et al. couple and group therapy ap. however. 2002). A be. lections of. Martin & Thong. Kemmann & Taska. anxiety and depressive symptoms are most intense during the period between embryo transfer and preg- nancy-testing. 1991). 1995. and recol- rates. 1996). 2000). Long-term follow-up studies examine whether this can increase conception have examined women’s views about. 1992). 2002).

existing psychiatric illness. Those who had a child were satis. from either group who miscarried the pregnan- cy. In Australia. and parents may cessation of treatment found that it was recalled not think about the possibility of losing one fe- as a traumatic life event. Olsen & Multiple gestations are usually diagnosed very Schei. long-term tus. 2001). 1995. Perhaps reflecting this. it is known that keeping secrets ing. & Sullivan. 98% experienced anxiety. Qualitative investigations have assisted in this way carry higher risks for both reported complicated grief reactions in which mother and infant. 1994). 2002). and and may lead to delayed or disturbed grief reac- counselled that psychological stability will even. satisfactory outcome (Sundby. 1992). Pector & Smith-Levitin. mourning and underlying feelings after assisted conception of shame were apparent in most (McKinney & Leary. for example. fetal reduction or selective abortion of one or ity for empathy and kindness was central to sat. Many pregnancies following assisted treatment in the public sector. Hammarberg et al... (Collopy. A follow-up study six years after early after assisted conception. In a study isfaction (Malin et al. One-third had al. 2003). but was high in those and with their life than those who had a baby. tions or disrupt the mother–infant attachment tually be restored and that adoption is often a (Bryan & Denton. 2002). 2002). Swanson. induction of ovulation.. Dean covery and mistrust (Covington & Burns. Independent of Multiple gestations are more likely following whether a child had been born. 1999). Grief in those who have a single baby after psychological functioning was in the normal having lost another fetus during the pregnancy range. Pregnancies that have been Bryan. seeing different conception are regarded as high risk (Dulude et doctors at each consultation. of bereavement and pregnancy presents a psy- The authors commented that people undergoing chological paradox. 1999. Very little is known about the long-term psycho- Dissatisfaction was higher among older women logical consequences of what is termed planned who had not conceived. 69% sadness and 57% guilt as a result of the pro- childbirth and the postpartum period cedure. Similarly. 2002. 1999). Olsen & Schei (1994) showed that ternal age and multiple gestations (Olivennes et most women had experienced discontinuity of al. fetal reduc- In recent years. Fisher & Stocky. Fisher However. the rates of depression were equal in those less satisfied with the treatment and clinical care who ultimately had a baby. been provided by health staff (Sundby. pre. these risks are predominantly those & Stocky. the number of children born as a tion is rarely widely disclosed and may be kept result of assisted reproduction has been increas. but less than half who did not conceive were satisfied. perplexity and grief for a lost sibling. Psychological aspects of pregnancy. caesarean delivery. However. These include increased risk multiple disenfranchised losses are experienced of antepartum haemorrhage. Mental health aspects of women’s reproductive health dit. Grief. health professionals and friends (Kollantai & Those with a hostile marital relationship. which is not easily resolved infertility treatment should be encouraged. been suggested (Bryan & Denton. or low level of edu. characterized by and the infant requiring oxygen at birth (Tallo et guilt. ity of a “survivor syndrome”. 2002). (2001) a singleton pregnancy after in vitro fertilization found that women who had not conceived were (IVF).. 2.. fewer than half the women in a study in Finalnd were satisfied with their infertility treatment. low or very low birth weight. 1993). The coincidence cation were more vulnerable in the long term. Pearsall-Jones & Hay. multiple gestation. but can be unrecognized by both a child compared with those without a child. but the possibil- premature birth. 2001. secret. Overall. In an Australian comparing 42 women who had undergone fe- study of 116 women. 2006).. 2–3 years after ceasing tal reduction with women who had conceived infertility treatment. 2001. However. 2003). more fetuses in multiple pregnancy. Waters et al. associated with pregnancy at an advanced ma- 136 . has al. with greater well-being among those with is intense. 2001. Fleischer. The potential impact on the liv- pregnancy hypertension. Wang et al. 2006). Pregnancy fied with their treatment. stopped treatment without its being formally documented.5% of live births harms family relationships through fear of dis- now follow assisted conception (Waters. and the doctor’s capac. or after the transfer of satisfied with the emotional support that had multiple embryos (McKinney & Leary. ing infant remains unknown. Sundby. many described fetal reduction as extremely stressful. 1994. 70% were dis.

1994). caesarean surgery can induce post-traumatic tity and the adoption of a fertile and maternal stress reactions (Fisher. but port increased anxiety about intrapartum dam. Concern about fetal development of the interactions between these two proce- is high even in women whose pregnancies are dures. Bernstein. van Balen. Gibson et al. 1999. than those conceived spontaneously. It has been suggested that infant health. Klock & heightened anxiety about pregnancy loss and Greenfield. McMahon. 1999). childbirth was reported as 1999.. 1992. 1995. and greater women may need additional support and sen- difficulty in acknowledging ambivalence. 1994). who had had assisted conception than in those Women who become pregnant following assist. tion (McMahon et al. 1999). Naaktgeboren & Trimbos- the potential risks of childbirth to themselves Kemper. Fisher. Lewis (Boyce & Todd. McMahon. becom. Lewis & Seibel. McMahon. who had conceived spontaneously (Stanton & ed conception have been described as: having Golombok. entails may be unexpected (Covington & Burns. Astbury & Smith. “more exceptional” after assisted conception. using avoidant coping. anxi.. 1999. Intense anxiety about the multiple gestation. There is consistent evidence that both known to be low-risk (Reading. grief and dissatisfaction (Dunnington & Glazer. disappointment. Infertility and assisted reproduction Pregnancies in which a heightened risk to ma. 1992. When babies are kept in neonatal reported maternal–fetal emotional attachment intensive care units. Premature birth typically involves separa- 1993. 1997).. 2003). 1999. 1993. sometimes studies controlled for the particular effects of for prolonged periods. In a single 2001. 1991. McMahon. 2000). crease more as pregnancy progressed in those chologically distressing (Dulude et al. Klock & Greenfield. 2002). Chang & Kerin. less self-confidence. 2003). 1994. Although women are at greatly elevated risk of 1996. about whether the health professional or the par- ed that their infants might have more difficulties ent has authority over the baby (Bryan & Denton. 1999. Although mode of delivery does not ap- challenge of pregnancy is to form a maternal pear to make an independent contribution to identity. Chapter 8. sitized care in pregnancy after assisted concep- ety or sadness. McMahon. McMahon. mothers report uncertainty have been reported. 1999. they have often underestimated interpret (van Balen. Although women re. Naaktgeboren & Trimbos-Kemper. those whose infants are seriously unwell. 2001). 2002).. The relinquishing of an infertile iden. Hjelmstedt et al. 2000). and the anxiety can persist for up to three years (Singer No differences in the intensity or quality of self. and most studies excluded infants’ health and development and about the multiple gestations and women who already had separation is universal. The universal psychological 1997). ing hypervigilant. longitudinal study. feeling unable to complain Hjelmstedt et al. Eugster & caesarean birth after assisted conception (Wang Vingerhoest. the first encounter be complicated and prolonged (Covington & between mother and infant and the initiation of Burns. but may in reality After caesarean childbirth. Astbury & Smith. In one study. 1999). 1991. one have to happen rapidly.. Bernstein. Loo et al. (Connolly et al. and is more severe among a child. had conceived after IVF (Stanton & Golombok. 2003). et al. In contrast. 1999). None of the tion of the mother from her infants. 1996). fertility. breastfeeding are disrupted. 2002).. 2000b) and preparation caesarean surgery are associated with increased of a home environment for the baby is delayed anxiety.. two studies reported no differences in Operative delivery and premature birth are anxiety or depressive symptoms measured with both more common among women with multi- standardized instruments between women who ple gestation. & Seibel. Motherhood fol. which occurs in 20% of pregnan- had conceived spontaneously and those who cies after assisted conception (Barrett & Ritchie. Covington & Burns.. 2001. there has been little investigation et al. instrumental intervention in vaginal birth and 1989. this descriptor was not defined and is difficult to age to the baby. with adverse effects lowing infertility has usually been idealized and on maternal confidence that are still measurable the losses and adverse experiences it inevitably eight months later (Rowe-Murray & Fisher. A cooperative approach 137 . anxiety was reported to de- ternal or fetal health is identified are more psy. or seek support and denying the pregnant state as self-protection against loss (Dunnington & Childbirth Glazer. although women anticipat.. 1999. and this process appears to be more postpartum depression when other risk factors problematic in women who have a history of in. are taken into account (Johnstone et al.

Few have focused on these studies included infants conceived by use maternal mental and physical health in itself. Stocky. after assisted conception. (1995) concluded that there was likely to be overprotective and to recall infertil. Loo et al. compared with 1. neonatal hospitalization had had assistance to conceive anticipated that and multiple birth. 2000a).. Hay et al. have to make than that of mothers of single infants.. Golombok et al. while Garel. their infants would have more problems and ficulties are further magnified if the infants are rated their infants as having more difficult tem- separated. acquaintances and friendships than a compari- 2003).7% of live births) of moth- Salobir & Blondel (1997) found that all report- ers who have experienced fertility difficulties ed significant distress and a quarter were being or assisted conception among those admitted treated for depression one year postpartum.. the established dif. However. (1995) (Bryan & Denton. Two to residential early parenting services because studies of the health and social circumstances of of infant sleep or feeding disorders and mater- women admitted to Australian residential early 138 .3–9% depressed 4 months postpartum. Fear (Barnett et al. (1991) found that 40% were 1999). (1990) found that 29. little evidence of differences in quality of parent- ity as an influential negative life event. 2001. Fisher. very low-birthweight infants. respecting parental rights. which make birth. parents may be less conscious There is consistent evidence that the emotional of the challenges of parenthood and. group were found to confide less and have fewer ate emotional attachment (Klock. 2003). 2002. In reviewing the early studies. 2002). of donor gametes or multiple births (Fisher & Descriptive and exploratory studies claim that. for example by discharge of one infant peraments than a group of controls (McMahon ahead of another or by care in different hospitals et al. the quality of moth- that most mothers were sensitive and responsive er–infant attachment and the developmental to their children (Gibson et al. opera. 2001). about the infants’ health and viability can persist Hammarberg & Baker. and “superior parenting” among children con- ficult and anxiety-arousing with premature and ceived with assisted reproductive technologies. while assisted reproduction playing together and when separated from each other. and may be less able to foster the sion have been reported among mothers of tri- child’s capacity for self-sufficiency (Burns. A group of moth- and lead to hypervigilance in relation to infant ers who were members of an infertility support care. 1992).2–1. Further. and women’s capacity to mother. the available studies had methodological limita- enced as long-term adjustment difficulties in the tions. there is an excess (6. Systematic investigations have used the Strange Situations Test. 1997). 2005). (Munro. Ironside & Smith. 42% had high likely to have difficulties separating from their anxiety (three times higher than among mothers infants and with the developmental process of of single infants). mothers are more McMahon et al. nal exhaustion or mild to moderate depression can be helpful (Carter & Leuthner. ception and others. Robin et al. She also suggested that they are particularly ers of single 3-month-old infants). but conceded that most of continues after conception and may be experi. None of outcomes of the children. prematurity. Fisher et al. which assesses the quality of mother–child attachment through videotaped Parenthood after infertility and observations of the mother and child. although health of mothers of multiple infants is poorer the quality of parenting is high. Burns ing between families formed with assisted con- (1990) concluded that infertility is not transient. and that an extraordinary effort to feel effective. In Australia. Even higher rates of depres- individuation. No studies have examined the interacting son group who had conceived spontaneously emotional effects of assisted conception.. 1990. Burns they are at higher risk of becoming depressed.7% of it difficult for them to adjust to the unique de- mothers of 3-month-old twins reported depres- mands and unavoidable ambivalence of parent- sion (a rate five times higher than among moth- ing. These studies have found no differences Most of the investigations into the long-term in mother–child attachment between children impact of assisted conception have focused on conceived spontaneously or with assistance. Mothers who tive birth. (1990) suggested that parents may have formed anxious and clinically exhausted after child- unrealistic and “utopian fantasies”. plets. Maintaining a supply of found no adverse psychological consequences breastmilk and establishing breastfeeding are dif. Mental health aspects of women’s reproductive health to decision-making. and delayed formation of a secure affection. 1993.. family. In contrast.

The short... Munro. in which women undergo- ing fertility treatment requiring ovarian stimu- New technologies and their lation and oocyte retrieval can donate half the implications resulting ova anonymously to another couple in exchange for reduced fees and rapid access to Donated fresh sperm has been used to treat male treatment (Ahuja et al. The use of cryop- the psychological implications of donating ova to reservation to store sperm for later donation is a other women has only recently begun. donors may change their and depression found an excess of mothers with minds about remaining anonymous or allowing multiple infants (3. Infertility and assisted reproduction parenting services for treatment of unsettled in. regardless of mode of order to donate ova. voluntarily or in exchange for payment. independent of individuals and to families (Blyth. some European countries. 2002). Rowe & Griffin. 1998). Crawshaw & Daniels. Crawshaw & other explanatory factors. contracep- those who donate genetic material anonymously tion or infertility treatment were surveyed. 1998). 1994). closure. emotional sequelae have not been examined sys- payments to donors for their genetic material. of oocytes for either transfer. Consideration complex considerations of what constitutes a par- is being given to whether cadavers. Investigation of factor infertility for 100 years. legal and psychological com- ers.4%) (Barnett et al. general population rate of 1.. 1994. In order to investigate Relatively little is known about the motives and attitudes to this theoretical possibility. and a complex existential notion of altru- tility difficulties may themselves carry sequelae ism combined with a desire to achieve a personal for mental health. higher parenting stress was associ. Vayena. However. 2004). ongoing debate about the ethics of this option. including attending for pregnancy termination. Crawshaw & Daniels. people 1993. 1994). 1999. 2002). er. women have to undergo conception (Cook. but very little evidence is so life goal (Rapport. Depending on local school. 2003). women psychological functioning of donors. Murray et al. de- tematically by independent investigators (Ahuja bates about the maintenance of secrecy and dis- et al. individual perceptions of the fertilization with donated sperm (Barrero. 2003. the number willing to do so is limited (Cleland. Fisher et al. donated gametes as “tissue” or as a “potential The new technologies now available to treat fer- baby”. ovarian stimulation and surgical aspiration. it has been estab- fant behaviour and maternal exhaustion. three times more likely to be depressed than those with a single child.and long-term psychological and plexities of the use of donated genetic material. 2003.. In examining 158 sets of twins entering pre. In a small compara. limitations on treatment in most settings. 1994). In general. The donation in-depth interviews with small samples in the of embryos and oocytes has become possible United Kingdom have found that the decision more recently. However. 2002). 2002. compared with the their identity to be disclosed to offspring (Blyth. Thorpe et al. newer technological development. Bradley & Golombok. a strategy termed egg sharing is available. 1996. mothers of twins were Daniels. eggs (Murray et al. Blyth. In neously conceived twins. five years after the birth. nor. anxiety lished that. and involves the donor undergo- to participate as a donor in egg sharing schemes ing a stimulated cycle and the surgical removal is influenced by the waiting time for treatment. Gestational productive potential should be treated differently surrogacy and the use of donor gametes lead to from those donated post mortem. (Rosenthal. Blyth. In 139 .7–5%. A shortage of donated eggs places significant tive study. In a longitudinal study conceived from donated genetic material want to of more than 13 000 women who gave birth in know their genetic heritage and the identity of one month in 1970. in particular since the evidence in its favour Issues arising with use of the new technologies has been generated to a large extent by provid- include: the ethical. over time.. In ated with having twins. aborted fe- ent–infant relationship (Kirkman. 2004). and the impact of legislation regarding children’s rights to know their biological herit- There is debate about whether tissues with re- age versus parents’ rights to secrecy. eggs may be donated by someone less psychiatric disturbance among mothers of known to the recipient or by an anonymous do- twins conceived by IVF than mothers of sponta. and believe that secrecy is harmful to that. Chapter 8. tuses or live donors may be the best source of Barrero. (1991) found the donor. There is far available (Kirby. and This effect may lessen as the children grow old. cryopreservation or costs of treatment. 2004). Ironside & Smith (1990) found legislation. 2004).

even to increase the supply of donated ova. Mental health aspects of women’s reproductive health general. There is debate about whether these deci. because of 1. should be investigated. who may quality control to protect against consanguinity. try an accurate understanding is needed of ents who may die before the child reached ma. 1995).. professionals in this field need to integrate psy- ing the allocation of health resources. there was strong support for methods persevere in their efforts to have a child. etiology Older women are generally less likely to conceive. from all to the extent of putting their own health at risk sources. dures. with dis- ability of technologies means that some will aggregation by method of conception. may be directed at health professionals. 140 . 1994). 1994). or whether there should be criteria for inclusion in treatment Summary programmes The debate regarding the rights of the child is sometimes used to withhold treat. nificant difficulties in interpreting social and Neither potential donors nor potential recipients ethical dilemmas in individual cases. and 1995). because of the multiple losses. The complex economics of the cost-ef. turity (Hope. quences for both donors and recipients of tion of tissue to protect fertility in those under. and should be considered in research and clini- cal services. There is also debate about whether treatment should be offered to all who seek it. debate about whether individuals should bear the cost or whether it is a social cost to be born The psychosocial sequelae of infertility and the publicly. and patients rated it as worse There is wide variation internationally regard.g. Future research ment from post-menopausal women. be perceived as lacking sensitivity and ability to legal acknowledgment of the social rather than communicate. 1994. 1994). there is chological with medical care. infertility treatment services in sions. (1995) stated that. nature of. 1996). The long-term psychological consequences by an ethics committee (who may not know the of infertility. Gharib & Weinstein. and experimentation on. but women having abortions did not in (Kirkman. or blamed for the limitations of the genetic parent. fertility treatment as worse than either patients or physicians did. 1995). 6. Health professionals face sig- general support post-mortem donation of ova. The disposal of. and the avail- of offspring of assisted conception. 2. age should be refused treatment. Research is needed into the demand for. gametes. including women in egg-sharing going chemotherapy are yet to be investigated. als who offer fertility treatment to older women are assisting them to act irresponsibly (Jackson. In consider. and high failure rate. However. professional fields in which to practise (Kopitzke 1994). programmes.and long-term psychosocial and medical conse- The psychological implications of the preserva. fertility treatment was one of the most difficult ing the use of donated genetic material (Kirby. 1991).. and in each coun- the complex ethics relating to being born to par. child. complex psychological responses to techno- fectiveness of treatment have to be considered logically assisted conception are central to the (Kirby. 5. than physicians did. all agreed that in- ing record-keeping and access to records follow. including after the birth of a individual patient) or by a single clinician (Craft. Neumann. 3. the prevalence. being a mother is core to the follow-up of the physical and mental health formation of their adult identity. Nurses disapproved of the use of fetal ovarian tissue for rated the emotional distress associated with in- research (Murray et al. e. There is a need for data on the short. should be made 4. In most countries. There is a need for long-term comprehensive For many women. and the rights of the children existing knowledge and techniques. the fertility problems of the population. prolonged treatment. Patients’ irritability and frustration expert debate regarding a number of issues. Covington and not just the adults exposed to these proce. There is a need for considered public and et al. especially whether women over 50 years of developing countries. all remain controversial (Kirby. complexities in defining surplus frozen embryos or other genetic material the end of treatment. and mental health effects of fertility prob- and it has been suggested that health profession- lems have not been established. Causes of infertility differ. health of people facing these life experiences. Lockwood & Lockwood.

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1992. among immigrants and opening (Ng. 1994. 147 . 1996. excision of all external female genital organs and 1993. 1996. These include: pricking. Forms that do not and at least three million girls are at risk or are fit the criteria for these three typologies are clas- subjected to it each year (WHO. Chelala. and high rates of poverty. Saharan African communities in which FGM is cedure that involves irremediable partial or total practised. the use of stitches or other techniques to close the Approximately 130 million women alive today wound. ac- sifies this mutilation into a number of types. UNICEF. 70–98% of women have undergone the procedure (Dorkenoo. Eke. 1995). 2005). or Sunna. 2002. 1994. Rattray & Walder. Abd El-Aty grammes of relocation for refugees. also known as infibulation. The age at which FGM is carried out varies. sue damage and lead to tightening of the vaginal dustrialized countries. of prevalence among immigrants in such coun- Abd El-Aty & Fatel. including in. Type II is removal of years. 2005). 2005) The practice is most common in ing. 2000a. cording to region. Okonofua et al. 1998. 2003. Toubia. 2001).. UNICEF. external female genital organs for non-therapeutic reasons. urine and menstrual blood. WHO. Leonard. this is anatomically equivalent to amputation of the penis (Toubia. some European countries and some 2000a. cutting or distending the clitoris or labia. It may be Type I. groups range from 5% to 99%. 2000. Al-Hussaini. agents into the vagina to cause bleeding or tis- It is also seen in other countries. or Pharaonic. WHO clas. The states in the USA have now developed legisla- rate of female genital mutilation is higher in set. or after the birth of a the clitoris and part or complete removal of the first child (Dorkenoo & Elworthy. or injury to. parts of the burning the external genital organs. policies and clinical practice guidelines tings where there are low levels of adult literacy related to female genital mutilation (Allotey. sified as Type IV. existence of prohibiting legislation. but large numbers of people have migrated from the sub- Female genital mutilation is defined as any pro. cutting or Eastern Mediterranean. prevalence Manderson & Grover. Sayed. Canada. Eritrea. 1995. 1994). 1996. 2005). at the age of 8–10 part or all of the clitoris. 1998. prior to marriage. 2002). In general. 2000. in Egypt. WHO. tion. 9 Chapter Female genital mutilation Jane Fisher F emale genital mutilation (FGM) or female genital cutting – sometimes termed female circumcision – is a common practice in some labia minora. Ethiopia. Oman. 2000a) refugees (Black & Debelle. 2000. and Indonesia and Malaysia. Australia. & Fadel. Type III. is the parts of the world (Ladjali. leaving a narrow opening for the flow of have experienced some form of this procedure. As a result of migration and humanitarian pro- Toubia. including Egypt. removal of. pierc- UNICEF. Somalia and Sudan. 2005). Weir. Accurate estimates is lower among better-educated women (Sayed. UNICEF. tries are not available (Webb. The most extreme forms of genital cutting are Estimates of prevalence in different population the least prevalent (Slanger. is excision of the prepuce and done a few days after birth. Snow & Okonofua. scraping the vagina or placing herbs or corrosive Sudan and Yemen. UNICEF. type of procedure and the according to the severity of structural damage. the countries of sub-Saharan Africa.

Leonard. including razor Dickens & Fathalla. 1994). UNICEF. ers type I and type II were combined. often traditional birth at. genital mutilation have been much more com- 148 . which preceded the founding of both Christianity and Islam. which the procedure was performed was often tionales for FGM are that it is performed for aes. 1998. It is deemed a tradition that is mutilation culturally and ethnically determined and is not The health effects of female genital mutilation. ulations. logical limitations in many of the studies. mandated by religious doctrine (al-Sabbagh. 2005). 1994. while only a few studies compared women intercourse and reduction of potential sexual who had and had not had FGM. which recommend that fe- male genital mutilation should stop. Ogunlola. while in oth- thereby a prerequisite to marriage (Al-Hussaini. 1996. tigations did not include clinical examination of garded as intrinsically unattractive or may grow the perineum. Africa. 1996. of female genital mutilation have been done in sion (Dorkenoo. there is evidence that FGM is not always a deeply em- bedded practice and that. However. This before birth. Akitoye & Oyediran. 2002). 2003. It is usually performed en have few occupational choices. Female genital mutilation is widely regarded as an ancient practice. Most tion of hygiene. They are likely to daughters at risk of remaining unmarried (Cook. Dorkenoo. the age or developmental stage at & Fathalla. Many of the inves- thetic reasons because the female genitals are re. sults were given for all types of FGM combined. 1994. 2000a). In (Odujinrin. UNICEF. re- 2003. Dorkenoo. 2000. 2000. 1994. Dickens In addition. promo. and that the decision is made cal settings (Toubia. Cook. In some articles. Orji & Owalabi (2003) settings (Little. replication of 1925 and 1998. maintenance of chastity through of the publications were case reports or case se- the construction of a physical barrier to sexual ries. Abd El. found that the father of a female child in Nigeria 1997). it has been practised for less than a century (Leonard. UNICEF. scissors or sharp. 2005). 2003. pleasure. The sioned a systematic review of the health conse- custom is rationalized and maintained by cul. broken glass. 1994). 1996. 2000. Young. unlikely to break with tradition if it places their tendants or village barbers. Other ra. to circumcise her. 2002. Mental health aspects of women’s reproductive health 1994. Lightfoot-Klein & blades. Sayed. American Academy of Pediatrics Committee on Bioethics. knives. without anaesthetic in unhygienic Toubia. where the practice is widespread. Often. Brody & Elkins. Ng. not reported (WHO. Aty & Fatel. and as an identifier of chaste status and the type of FGM was not defined. These include culturally defined trieved 504 relevant articles published between rituals of initiation into adulthood. 2005). Shaw. 2005). The adverse physical sequelae of female rity and social inclusion in settings where wom. there has been a trend for FGM has the greatest power in making the decision to be undertaken by medical personnel in medi. Most of the studies examining the complications because its presence may lead to sexual confu. in some settings. are just start- 1996. which re- tural beliefs. WHO (2000a) commis- Dickens & Fathalla. 2005). It is not consistently more common in Health effects of female genital one religious group than another (Little. some African groups there is a belief that remov- al of the clitoris clearly demarcates femininity. ing to be documented. UNICEF. 1994. The review identified methodo- the experience of previous generations. Missailidis & Gebre-Mehdin. ened stones. 2002. Wright. Cook. 1990. but some evidence has been gathered in industrialized countries among immigrant pop- Marriageability is essential for economic secu. 2002. Recently. 1996. Odoi. Ng. WHO. Families are by untrained people. and classification of FGM status to an excessive length if left in a natural state may not be reliable under these circumstances (Dorkenoo. and that it should never be performed by doctors or nurses (Wright. use unsterilized instruments. 2000a). 1989). development has been strongly condemned by the World Health Organization and various professional bodies. quences of female genital mutilation. 1996). UNICEF.

anorgasmia (12%). 1994. 2000). Anecdotal reports de. 2000). Chapter 9. (Okonofua et al. FGM was swelling because menstrual blood is unable to associated with a threefold increase in postcoi- flow out of the vagina.. especially Abscesses. 1994). However. especially among those who had undergone type nal secretions and menstrual blood is commonly III FGM. and healing of the is possible (Lightfoot-Klein. 1994). and qualitative investigations suggest that The most obvious long-term adverse effects of they are high (Lightfoot-Klein. 1994). Effects on sexual and psychosexual stances in which the procedure is conducted. has gasmia. They found that women tended to seek health come grossly disfiguring (Toubia. it has been suggested that genital cutting of women The most common immediate adverse effects of increases the risk of transmission of HIV. Enlarged cysts and scar tissue can be. especially in the presence of et al. sexual and obstetric functioning. Studies of clinic populations have found that up to 25% of infibulated women In the short term. ing Khartoum North Hospital between 1987 and ral stump or infibulation scar (Thabet & Thabet. fections are common because of “gross disregard for asepsis” (Eke. Little. especially fol. narrow introitus (Johansen. it is difficult for women to under-nutrition (Toubia. 1999). Okonofua et bladder. The procedure (13%). care only when they experienced severe pain. The drainage of urine. 1994. gangrene and ting. including persistent painful intercourse age (Ng. Absolute failure of penetration because because of poor technique or if the girl or wom. 1997b. prolonged bleeding can cause require surgery before vaginal intercourse is pos- anaemia. prolonged postcoital bleeding (5%) and renders women vulnerable to chronic reproduc. which can lead to chronic pelvic in- fections. Slow-healing seek health care for these problems.. 1996). coupled with abdominal distension. 2002). may be necessary before sexual penetration tetanus infection can occur. 1989 with complications of genital mutilation. Mawad & vulval abscesses may form (Rushwan. functioning and the use of substances such as ash or crushed herbs to cover the wound (Toubia. Knight and development. sex were common. menstrual dysfunction and menstrual Sexual desire and frequency of intercourse may pain (Fox. Moller Women who have been infibulated may have dif- & Hansen. the unhygienic circum. Johansen. 2000. of FGM. 1997a. de Ruiter & Bingham. The authors compared 76 women who had un- scribe young women developing abdominal dergone FGM with 119 who had not. 1997). lowing infibulation. 2000a).. with anecdo- the psychological effects. FGM are on gynaecological health. has been reported an struggles (Fox. 2002). Urinary retention leads been few comprehensive studies. as a result of a anatomical structures. also be adversely affected. Ng. rates are likely to be obscured by under-report- ing. In a systematic comparison of women 149 . They concluded that fear with female genital mutilation. both the procedure are intense pain and haemorrhage. 2000). Although there have 2000. Female genital mutilation prehensively investigated and described than been misinterpreted as pregnancy. 1997b. 1991. including the urethra. and dissatisfaction with. Systemic septicaemia. 2003. Adjacent ficulty having sexual intercourse. tal reports that it has led to unmarried women being killed in order to preserve the family’s rep- Immediate and short-term health effects utation (Dorkenoo. 2003. 1994). Wright. Toubia. wound contamination and local in. More recently. 2003). Toubia. The lack of menstrual tal bleeding and a twelvefold increase in anor- flow. 2002. wound is often slow (Ng. 2000). 2000). Rushwan. 2002). vagina and rectum. were reported in a consecu- tive tract and pelvic infections. (WHO. de Ruiter & Bingham. de Ruiter & Bingham. of. and that they were generally inhibited in dis- There are substantial long-term risks associated cussing sexual matters. Ng. especially type III. lems. 1994). 2000) and Hassanein (1994) reviewed 934 patients attend- dermoid cysts or keloids may grow on the clito. with associated tive cohort study of women attending hospital abdominal pain and offensive vaginal discharge clinics in northern Ghana (Odoi et al. Johansen. sexual prob- to chronic urinary tract infection and renal dam. 2000.. which has adverse effects on growth sible (Fox. Mortality during intercourse (Rushwan. Defibulation.