Continuing the Science & Sensibility occasional series: Welcoming All Families, Certified Nurse Midwife Emalee Danforth examines the research on perinatal and postpartum mental health on the family who arrives in your classroom or office with a history of infertility. As the childbirth educator, you (and the rest of the class) most likely will not be aware of the families with this specific history, unless the family chooses to share privately or in the class group. The educator needs to understand and recognize the increased risk of perinatal and postpartum mood disorders these families face. Childbirth educators should evaluate their language and stories to be sure that they are providing sensitive and appropriate language and examples that welcome and apply to those whose path to parenthood might not be the same as other families in your class. - Sharon Muza, Community Manager, Science & Sensibility.

By Emalee Danforth, CNM

© Wikipedia

Infertility, defined as the inability to conceive after 12 months of timed intercourse or donor insemination (Practice Committee for the American Society of Reproductive Medicine, 2013), is a common experience. While estimates range, approximately 6-15% of the United States population will experience infertility (Chandra, Copen & Stephen, 2013) with higher rates possible when viewed from the global perspective (Mascarenhas, Flaxman, Boerma, Vanderpoel & Stevens, 2012).

The majority of research on the experience of pregnancy and parenting following infertility examines only those who have conceived using IVF (in vitro fertilization, also referred to as ART, assisted reproductive technology). This group of patients is easy to identify and therefore study, but represents only a portion of those who have experienced infertility. Additionally, study designs have often excluded those with multiple gestations, those with same sex partners, and those who have utilized donor gametes. In everyday life, all of these types of clients will cross the path of a care provider or childbirth educator and each has a unique experience. The available research can outline some of the known characteristics of persons who have conceived via IVF after infertility but caution should be applied to generalizations.

The Psychology of Pregnancy after Infertility

There is a particular psychology of infertility that can transfer to pregnancy, childbirth and postpartum. The emotional hallmark of infertility is anxiety (Bell, 2013). Once pregnant, this worry does tend to persist through the pregnancy and heighten as the due date approaches. The level of general anxiety appears similar to those who have conceived spontaneously, but pregnancy-focused anxieties are heightened in previously infertile women, especially those who experienced prolonged treatment failure and high infertility-related distress (Hammarberg, Fisher & Wynter, 2008). McMahon et al. (2011) points out that 'the relatively low correlation between pregnancy-focused anxiety and state anxiety' confirms that pregnancy-focused anxiety needs to be considered as a separate construct from more generalized anxiety' (p. 1394) and that this phenomena may be due to a particular reproductive history rather than individual personality factors.

Infertility is also known to be associated with elevated rates of depression (Cousineau & Domar, 2007). However, evidence is consistent that once pregnant, ART women and men experience lower levels of depressive symptoms than those that have spontaneously conceived (Hammarberg et al., 2008). This may be related to higher rates of psychosocial factors that are protective for perinatal mood disturbance in ART expecting women and men including higher socioeconomic status, higher education, higher quality and longer lasting intimate relationships, being older than average and having a planned conception (Fisher, Hammarberg & Baker, 2008). This same study posits that 'it is possible that this low rate of distress is reflecting an almost elated mood, in which the pregnant state and family formation achieved after a long period of anticipation and via intrusive and disruptive interventions are somewhat idealized'(p.1110). Indeed, Hjelmstedt, Widstrom, Wramsby & Collins (2003) found that ART women experienced pregnancy in a less negative way and were also less worried about possible 'loss of freedom' in their future lives as parent compared to the spontaneous conception control group.

It is therefore surprising that after birth, ART women experience postpartum depression at similar rates to the rest of the childbearing population (Hammarberg et al., 2008). Fisher et al. (2008) found significantly higher rates of admission for ART women in Australia for postpartum mood disturbances despite their more elevated mental state antepartum. This may be because after a long struggle with infertility and undergoing invasive and costly procedures, ART women feel 'a low sense of entitlement to complain or to express any doubts, uncertainty, or mixed feelings about the realities of motherhood (Fisher et al., 2008, p. 1111).' However, once the baby or babies are born, ART women must adjust to motherhood and cope with the demands of a newborn just as any other mother. The combination of idealization of motherhood and lack of preparation for the experience of ambivalence can cause mental distress postpartum. In addition, the higher frequency of birth complications among ART women including preterm birth, cesarean section, low birth weight and multiple gestation (Hammarberg et al., 2008) all can have an additive effect on the stresses of motherhood.

There is evidence that ART women experience the process of emotional attachment to the fetus differently from those with spontaneous conception. Fisher et al. (2008) found that ART women thought about their fetus as much in early pregnancy as the general population of mothers did in advanced pregnancy. In late pregnancy, ART women had significantly more intense and protective emotional attachments to the fetus than women who spontaneously conceived. McMahon et al. (2011) found that with age taken into account, there was a strong association between ART conception and more intense maternal-fetal attachment. This is likely the result of extended anticipation of parenthood, investment in the process of conception and intimate awareness of the biology and timing of conception.

© infertile.com

There remains a dearth of information on the experiences of ART women during childbirth. There exists one recent prospective multicenter study out of Finland on this topic (Poikkeus et al., 2014) which finds that dissatisfaction with childbirth was similar between ART women and controls with singleton pregnancies. The factors that have been previously found to be related to risk for a negative childbirth experience still remained true for both groups: low educational level, inadequate social support, dissatisfaction with her partner or spouse, untreated fear of childbirth and antenatal depression. Also recalled intolerable pain in birth and giving birth by emergency cesarean section increased dissatisfaction with birth. The authors' conclusion was that dissatisfaction with childbirth was not related to mode of conception but rather lay with the underlying individual psychosocial and obstetric factors of each patient.

Recommendations for Care

While the body of research on the experience of women pregnant after infertility remains emergent, we can use what we know to help guide the most optimal and sensitive care for this population. Firstly, it is important to remember that this group is often invisible, particularly in the childbirth education classroom. The question 'how many months did it take you to conceive?' or the unwitting quote from Ina May Gaskin 'What got the baby in is what will get the baby out' will land quite differently on the ears of a woman who has gone through ART. In the clinical setting most if not all patients will share their mode of conception, but in the setting of CBE it may be kept private and language usage should be sensitive to this.

The within-group differences in an ART population can also be significant. A woman who needed help getting pregnant due to a very low sperm count in her male partner and conceived on her first round of IVF will likely have a different experience and outlook than a woman who has gone through multiple rounds of failed IVF for unexplained infertility and a miscarriage before having a term pregnancy with an egg donor. Each woman will be having her own unique experience.

The combination of early and intense attachment to the fetus as well as increased levels of pregnancy specific anxiety for ART women points to the need for frequent reassurance and quite possibly increased frequency of care, particularly in the first trimester and prior to quickening. Sensitive care during pregnancy can help transition a client, if appropriate, from a sense of herself as 'high risk' and under specialty care to generalist obstetric or 'low risk' midwifery care. Bell (2013) suggests that this reassurance will help women 'slowly grow to trust in the process which is pregnancy', and 'gain a sense of accomplishment and fulfillment as they continue to gestate' (p.51).

Promoting physiologic birth is the goal for all women including ART women. ART women are more likely to have protective social factors such as greater age, income, education and more stable relationships that can help increase satisfaction with childbirth but concurrently more likely to have characteristics such as older age, multiple gestation and preterm birth that lead to higher rates of obstetric intervention, which leads to a decreased satisfaction with childbirth. Working with each client's individual strengths and limitations will help best prepare her for birth. For many women, feeling like they are active participants in their childbirth care and decision making is critical to their feeling of satisfaction. Involvement in this process may help a client regain a sense of control that may have been eroded during invasive and intensive infertility treatments.

While baby blues and postpartum depression and anxiety should be discussed with every client, understanding more about the psychology of ART women can help guide a practitioner to have a nuanced and sensitive discussion with these clients. A skilled provider or childbirth educator will be able to recognize and honor the joy and gratefulness that an expecting woman or couple feels after conceiving through ART, but also understand that this is likely layered with pregnancy-specific anxiety, a desire to regain some sense of control over one's body or birth, and a vulnerability to postpartum mood disturbances. Anticipatory counseling including statements such as 'some women who give birth after successful IVF treatments are surprised by the many ups and downs of caring for a newborn and may not have anticipated any negative feelings' or 'no matter how glad you are to become a mother, it is normal to experience fatigue and feelings of ambivalence.' can help new parents allow their full range of feelings to surface. When mothers feel safe to share their feelings, more prompt identification and treatment of depression and anxiety is possible.

Understanding the prevalence of infertility and its psychological effects can help the childbirth educator, nurse, clinician or other birth professional provide sensitive and optimal care to the often invisible population of women or couples who are pregnant following infertility treatment.

Have you had families with a history of infertility in your childbirth classes? As clients? What if anything did you do different to be sure to meet the needs of these families? Can you share how you have handled this in your classroom environment? Did your families choose to let you know? Your thoughts and comments are valued in our discussion section below. - SM

References

Bell, K.M. (2013). Supporting childbearing families through infertility. International Journal of Childbirth Education, 28(3), 48-53.

Cousineau, T.M. & Domar, A.D. (2007). Psychological impact of infertility. Best Practice & Research Clinical Obstetrics and Gynaecology, 21(2), 293-308. doi: 10.1016/j.bpobgyn.2006.12.003

Chandra, A., Copen, E.E. & Stephen, E.H (2013). Infertility and impaired fecundity in the United States, 1982-2010: Data from the National Survey of Family Growth. National Health Statistics Report, 67, 1-18.

Fisher, J., Hammarberg, K. & Baker, G.(2008). Antenatal mood and fetal attachment after assisted conception. Fertility and Sterility, 89(5), 1103-1112. doi: 10.1016/j.fertnstert.2007.05.022

Hammarberg, K., Fisher, J. & Wynter, K. (2008). Psychological and social aspects of pregnancy, childbirth and early parenting after assisted conception: A systematic review. Human Reproduction Update, 14(5), 395-414. doi: 10.1093/humupd/dmn030

Hjelmstedt, A., Widstrom, A-M., Wramsby, H. & Collins, A. (2003). Patterns of emotional responses to pregnancy, experience of pregnancy and attitudes to parenthood among IVF couples: A longitudinal study. J Psychosom Obstet Gynecol, 24, 153-162.

Mascarenhas, M.N., Flaxman, S.R., Boerma, T., Vanderpoel, S. & Stevens, G.A. (2012). National, regional, and global trends in infertility prevalence since 1990: A systematic analysis of 277 health surveys. PLOS Medicine, 9(12), 1-12. doi: 10.1371/journal.pmed.1001356

McMahon, C.A., Boivin, J., Gibson, F.L., Hammarberg, K., Wynter, K., Saunders, D. & Fisher, J. (2011). Age at first birth, mode of conception and psychological wellbeing in pregnancy: Findings from the parental age and transition to parenthood Australia (PAPTA) study. Human Reproduction, 25(6), 1389-1398. doi: 10.1093/humrep/der076

Poikkeus, P., Saisto, T., Punamaki, R., Unkila-Kallio, L., Flykt, M., Vilska, S., Repokari, L. (2014). Birth experience of women conceiving with assisted reproduction: A prospective multicenter study. Acta Obstet Gynecol Scand 2014; doi: 10.1111/aogs.12440
Practice Committee for the American Society of Reproductive Medicine (2013). Definitions of infertility and recurrent pregnancy loss: A committee opinion. Fertility and Sterility, 99(1), 63. doi: 10.1016/j.fertnstert.2012.09.023

Toscano, S.E. & Montgomery R.M. (2009). The lived experience of women pregnant (including preconception) post in vitro fertilization through the lens of virtual communities. Health Care for Women International, 30:11, 1014-1036. doi:10.1080/07399330903159700

About Emalee Danforth

Emalee Danforth is a Certified Nurse-Midwife working in Seattle, WA. She practices at University Reproductive Care, the University of Washington's infertility and reproductive endocrinology clinic. Previously she spent 5 busy years practicing full-scope midwifery in the hospital setting. She holds a BSN from the University of Michigan and an MSN from the University of Washington. She is also a co-facilitator of Maybe Baby, a resource and support group for LGBT persons on the path to parenthood.

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