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PERSONALITY, FAMILY CONFLICT AND AGE IN MARRIAGE AS PREDICTORS OF POSTPARTUM DISTRESS

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CHAPTER ONE

INTRODUCTION

The birth of a child in several cultures is heralded with happiness; and feasts are held to celebrate it. The period that follows child birth is termed postpartum period. It is however a period that is known to be associated with events that can cause both physiological and psychological changes in the life of the woman. It could be regarded as a significant life event. Prominent risks to life have been associated with pregnancy, child birth and postpartum. Life threatening events in pregnancy include hemorrhage, infections, unsafe abortion, pre-eclampsia, gestational diabetes, and minor symptoms ranging from vomiting, nausea and marked hypertension (MacArthur, 1991; MacArthur, Lewis & Knox, 1991; Thorpe, Greenwood & Goodenough, 1995). Other changes occur in biological secretions, immune systems and responses. Psychological symptoms include anxiety, insomnia, and loss of socio-economic status, depression, eating disorders and pains (Fisher, CabraldeMello & Izutsu, 2003). These may be a source of distress to the mother during postpartum. A collection of symptoms that affects psychological or mental health of women after child birth is termed postpartum distress including postpartum blues, postpartum depression and postpartum psychosis. The term postpartum and postnatal can be used interchangeably.

In most parts of the world, attention is being given to the processes of alleviating or treatment of physical or biological factors towards preventing maternal and infant mortality and/or morbidity. As pregnancy, child birth and postpartum stages get safer, with subsequent reduction in infant and maternal death from septic and infectious procedures made possible by advanced methods in medicine. Much less attention has been given to mental health as a contributing factor to maternal and infant wellbeing (Affonsso & Mayberry, 1990). Violence is seen as contributing factor in maternal mortality (Frausetchi, Ceralli, & Maine, 1994). Considering an integration of psychological or mental health status of women during pregnancy, child birth and postpartum are necessary. This is because during this period women often relinquish their autonomy, personal liberty, occupation, identity, capacity to generate income and social relation for caring and nurturing of the infant (Thorpe & Elliott, 1998). The rate and determinants of suicide either in pregnancy or after child birth have proved difficult to determine because of the extent to which the problem is under- estimated or obscured in recording of the causes of death or due to unavailable systematic data.

Brockington (1998) opined that child birth should be seen as a general stressor that can cause illness across the whole spectrum of psychiatric disorders.  Postpartum or postnatal period is a period of increased risk for development of mood/affective disorders. There are three forms of postpartum affective illnesses: The blues (baby blues) and maternal blues, postpartum depression and postpartum psychosis. These differ in their clinical presentation and management (Robertson, Calasum & Stewarts, 2008).

Maternal stress and mental illness seen to have a profound impact in less developed parts of the world. A mother experiencing mental disorder in a low income setting is at risk of providing sub-optimal care for her offspring, which have grave consequences on the health of the woman. Poverty, overcrowding, poor sanitation, malnutrition, tropical diseases, lack of appropriate medical and psychological services may have impact on development of postpartum distress (Patel, DeSouza & Rodrigues, 2003; Rahman, Lovel, Bunn, Iqbal & Harrington, 2004).

The most common postpartum distress is the postpartum depression. It is a clinical and research construct used to describe an episode of major or minor depression arising from child birth (Cox, 1994; Epperson, 1999; Paykel, 2002). Postpartum depression usually begins within the first month to twelve months after child birth. The term is used to describe a non-psychotic depressive episode that begins in postpartum period (Cox, Murray & Chapman, 1993). The period that starts from the moment the placenta is expelled to six weeks is termed as early postpartum. After this period is considered late postpartum period.

Maternal blues is a mild symptom occurring within the first ten days of child birth (Pitt, 1973; Kenerly & Gath, 1986; Austrialia National Infancy Network, 2011). It is characterized by a range of symptoms such as anxiety, crying, disturbance of sleep (Wilkie & Shapiro, 1992) irritability, liability of mood between euphoria and misery, heighten sensitivities, tearfulness without associated sadness, restless and poor concentration (Yalom, 1968; Stein, 1982). Those symptoms may persist for hours up to several days. However, the symptoms may remit in few days or weeks even without experts’ interventions (O’Hara, Neunaber & Zekoski, 1984). In some women, postpartum blues simply continues and becomes severe that expert attention is needed. In some cases, there is a period of wellness after child birth which is followed by gradual onset of depression. The pattern of symptoms in women with postpartum depression is similar to those with clinical depression that are not related to child birth (Wisner, Parry & Piontek, 2002). The clinical presentation of postpartum depression is characterized by tearfulness, despondency, emotional liability, feelings of guilt, loss of appetite and sleep disturbances; other symptoms are feeling of inadequacy, unable to cope with infant care, poor concentration and memory loss, fatigue and irritability (Robinson & Stewart, 2001). The authors further state that women may worry excessively about baby’s health, feeding habit and perceive themselves as “bad” inadequate or unloving mother.

Screening for postpartum mood disturbances can be difficult due to the fact that numbers of somatic symptoms typically associated with having a new baby are also symptoms of major depression (Nonacs & Cohen, 1998). Differentiating between depressive episode and the supposed “normal” sequelae of child birth such as changes in weight, sleep, libido and energy challenges complicate clinical diagnosis (Hostetter & Stowe, 2002). International Classification of Diseases tenth edition ICD-10 (World Health Organization, 1992) does not have a specific diagnostic category for postpartum depression, it classifies postpartum depression as a depressive episode of mild (four symptom) moderate (five symptoms) and severe (at least five symptoms with agitations, feeling of worthlessness or guilt, suicidal thought or act). The Diagnostic and Statistical Manual of Mental Disorders fourth edition text revised (DSM-IV-TR) (American Psychiatry Association, 2000) recognizes an onset within one month after giving birth as postpartum depressive episode. However, Cramer (1993), Paykel (2002) argued that the nosology did not differentiate postpartum depression from other depressive episode. Postpartum depression differs from general depression in the perspective of time scale (Evans, Heron, Francomb, Oke & Golding, 2001) and in the context of role transition, the loss of familiarity, loss of control and the need to feel normal (Scandis, 2005).

Postpartum psychosis develops as an acute psychotic presentation within the first month of postpartum. Postpartum psychoses have been associated with prim parity, personal or family history of affective psychosis, unmarried status and prenatal death or still birth. This is the most severe psychiatric illness associated with child birth (Kumar, 1994). Brockington (1996) described the symptoms of postpartum psychosis as odd affect withdrawn, distracted by auditory hallucinations, incompetent, confused, catatonic or alternatively elated labile, rambling in speech, agitated or excessively active. Clinical characteristics of postpartum psychosis include acute onset and extreme affective variation with manic and elation as well as sadness, thought disorders, delusion, hallucination, disturbed behavior and confusion (Mark, 1992; Pfuhlmann, Stoeber & Beckmann, 2002). Wisner, Peindl and Hanusa (1994) reported that women with child bearing related onset of psychosis frequently experience cognitive disorganization and unusual psychotic symptoms, most of which are often mood incongruent delusions of reference, persecution, jealousy and grandiosity, along with visual, tactile or olfactory hallucination that suggests chronic organic syndrome. Postpartum psychosis are mostly described as cycloid affective illness since the rate of schizophrenic psychotic episodes are not elevated post-natally (Brockington, Winokur & Dean, 1982; Brockington, 1992; Kendell, Chalmers & Platz, 1987; Kumar,1994; Pfuhlmann, Stoeber & Beckmann, 2002).

The DSM-IV-TR (American Psychiatry Association, 2000) allowed classification of postpartum psychosis as a severe form of major depression as the onset/recurrent of a primary psychotic disorder such as schizophrenia as preponderance of data suggest that postpartum psychosis is an overt presentation of bipolar disorder following delivery of a child (Yonkers, Wesner & Stowe, 2004). Among child bearing women who develop postpartum psychosis 72-88% has bipolar illness or schizoaffective disorder, whereas only 12% have schizophrenia psychopathology as factor that only predispose individual to postpartum distress (Brockington, 1996; Wisner, Peindlf & Hanusa, 1995). However it is not confirmed that premorbid psychopathology is a factor that only predispose individual to postpartum distress. The way and manner people react to stress differ as Mefoh (2007) rightly puts it that what one count as stressful may be an excitement to others. This individual differences attribute of people occur as a result of personality, which explains why people do not react to similar stimuli in the same way, including reaction to distress of child birth.

Personality is described variously as that disposition to act in a particular way; Gordon Allport (1937) proposed a definition that is accepted across board. He viewed personality as dynamic organization within the individual of those psychophysical systems that determine his/her characteristic behaviour and thought. The definition sees personality as changing, structured traits involving the mind and the body, learned from the past and predisposition to see person’s future actions that makes an individual unique in his or her actions in the society. They identified four major categories of personality traits those include sociable, aggressive, fearful and anxious. Allport and Odbert (1936) define personality as general and personalized determinant or tendencies that is consistent with mode of an individual adjustment to his/her environment. This classification is elaborated to include biophysical and social roles that are enduring internal and physical states of an individual. Eysenck (1970) define personality as a more or less stable and enduring organization of a person’s character, temperament, intellect, and physique which determine his unique adjustment to environment. He traced the differences between extraversion and introversion to the level of cortical arousal and differences between emotional stability and neuroticism to the level of visceral brain activities. He stated that introversion and extroversion are related to arousal thresholds in the ascending reticular activating system of the brain and that most emotional stability traits are related to differences in visceral brain activation.  He further postulate three traits important to uniqueness of an individual, those are extraversion, neuroticism and psychotics.

Cattell (1943) used Allport and Odbert’s list as a starting point for his multidimensional model of personality structures. He began with 4,500 traits items, using factor analytic method, those traits were summarized into super structure which brought them into relatively short variable. To make a short variable from Cattell’s 16 pf Coast and McCrae developed the NEO Personality inventory with three broad measures of Neuroticism, Extraversion and Openness to experience. However scales on agreeableness and conscientiousness were later added to demonstrate that their five factor model converge with adjective based measures of the Big Five, although their conceptions of openness seems broader than intellect or imagination factor emerging from the lexical analysis (Saucier & Goldberg, 1996).

The super trait of the big five model were developed by John and Srivastava (1991) Neuroticism, Extraversion, Openness, Agreeableness and Consciousness scales. Neuroticism high scorers exhibits anxiety, anger, hostility, depression, self-consciousness, impulsiveness and vulnerability. However those with low score on neuroticism scale, according to Lynam, Caspi, Moffitt (2005), have the following characteristics: lack of appropriate concern for potential dangers in health or social adjustment; and exhibit emotional blandness. Extraversion traits is exhibited by warmth, gregariousness, assertiveness, activity excitement seeking and positive emotions whereas those with how scores on extroversion exhibit social isolation, interpersonal detachment and lack the support of networks; flattened affect; lack of joy and vest for-life, reluctance to assert self or assume leadership role, even when qualified, social inhibition and shyness are common among them.

Openness denotes individuals with fantasy, aesthetic feelings, of actions, ideas, values, and great understanding. Those who scores low on the domain exhibit difficulty adapting to social or personal change; low tolerance or understanding of different points of view or lifestyle; emotional blandness and inability to understand and verbalize own feelings; alexithymia; constricted range of interests; insensitivity to art and beauty; excessive conformity to authority. Agreeableness denotes trust, straightforwardness, altruism, compliance modesty, and tender-mindedness. Those with low scorers shows cynicism and paranoid thinking; inability to trust even friends or family; quarrelsomeness; ready to pick fights, expletive and manipulative, lying; rude and inconsiderate manner, alienate friends, limits social support; lack of respect for social conventions which can lead to trouble with the law; inflated and grandiose sense of self, and arrogance. Consciousness implies competence, order, dutifulness achievement striving, self-discipline and deliberation, those who score low on the domain are characterized by academic performance relative to ability; disregard of rules and responsibilities can lead to trouble with law; unable to discipline self even when required for medical reasons; personal and occupational aimlessness. Individual differences as shown in this facet display a similar character as they react to all stimulus differently including postpartum distress.

The individual attributes of a person and were she/he lives and socializes need to be conducive, clear of clashes and disagreements. This unit of socialization and custodian of one’s culture can significantly interfere with so many aspects of human behaviour. Most environmentally acquired behaviours are learnt, maintained, and reinforced from the family which is usually the first port of entry into the stress fill world. Family is a unique social system that its membership is based on combinations of biological, legal, affection, geographical and historical ties. Voss and Massatti, (2008) posit that healthy family environment is characterized by members comfortably experiencing their feelings and exhibiting low interpersonal conflict. They also identified a healthy family environment as critical in the development of individual resiliency and a powerful protection for association with emotional and physical health among family members.

Zaberiskie and Freeman (2004) identify healthy families as family were members are able to attentively listen to one another, express thoughts and feelings, show supportiveness and loyalty, share leadership, negotiates and rely on one another.  Entry into family systems is through birth, adoption, fostering or marriage and members can leave only by death (Carr, 2006). It is possible to get a divorce and separation but severing all connections is never possible except among couples that are childless, even at these emotional ties remains forever. Family unites individual through bond of kinship; it is present in all societies. However, with increase spade of single parenthood, divorce and separations and remarriages, a narrow and traditional definition of family is no longer useful (Parke, 2004; Walsh, 2003). Therefore, family could be a network of individual’s immediate psychosocial field. They may include household members and others who; while not members of household, play a significant role in the individual life. It provides companionship, socialization, nurturing, instructs and guide the individual into social and moral values, it is the basic unit of social organization; it protects its members from harm and allow the development of emotional bound between them. (Witt,1987). Family allowed us to participate in a number of different kinds of relationships simultaneously.

Family has been conceptualized as a system, a dynamic whole that is greater than the sum of its parts (Kerig, Ludlow, & Wenar, 2012). Within this great sum there are naturally occurring subsystems that join the family together as one entity. However, those subsystems must be allowed to function independently, the only voluntary subsystem is the marital subsystem which is based on complimentary role of husband and wife. Thus this subsystem needs romantic fulfillment, task of raising children and functions as a leader for other sub systems. Other subsystem includes parent-child and siblings subsystems. However with the spate of separations such as divorce, incarcerations, single parenthoods, and African extended family systems, grandparent systems should be considered.

The subsystems function effectively because there are boundaries that separate them; these differentiate them from other forms of social organization or systems. The boundaries define role of individuals and allow family members the opportunity to meet and achieve their emotional and physical needs. The boundaries also allow permeation and adaptation; that promote emotional contacts and independence (Minuchin, Lee & Simon, 2006). The absence of boundaries leads to enmeshment with the result that family members do not differentiate between one another thereby losing individual freedom. Any attempt by any member to individuate will be perceived as a threat to harmony of the family systems which may arouse resistance or anxiety.

Family conflict is clashes, arguments, verbal disagreement, criticism and act of physical aggression that occur among family members (Davis, 1997). Interpersonal tension or struggle among two or more persons whose opinions, values, needs, or expectations are opposing or incompatible (Kramer, Boelk & Auer, 2006). Davis (1997) also defined family conflict as recurrent, stressful differences and disagreements, or overt interpersonal disagreement and a strong feeling of resentment toward a relative. Strawbridge and Wallhagen (1991) saw family conflict as an interpersonal tension or struggle experienced by families in conflict may be exemplified in overt behaviors, such as arguments, disagreements, name calling or yelling, and/or covert feelings of resentment or anger among family members. Family conflict could lead to failure of a mother to carry out her primary task of nurturing and teachings of moral and social value to her children. Family conflicts are facilitated by cognitive appraisals of the effects of the roles and expectations from member(s) of sub system within the family system. As earlier stated, boundaries in the family signify the roles and obligations of each subsystem within the family system. The moment the family environment does not permit performances of those roles, it breeds confusion and conflict. Family conflict has consequences on the physical and emotional health on entire family system because of permeability of its boundaries (Carr, 2006). Family conflict is different from marital discord or conflict, these occur between husband and wife who are members of the family system.

According to Lazarus and Folkman (1984) cognitive appraisal is the process of deciding whether an experience is positive, stressful, or irrelevant with regard to well-being of each family member and may serve as a source of conflict. A stressful appraisal occurs when individuals perceive that the demands of the environment exceed their resources, thereby endangering their well-being. Thus, family conflict and facilitation derive from assessing the relative demands and resources associated with family roles. This view of conflict and facilitation focuses on perceptions rather than objective characteristics that may operate outside the individual’s awareness because such perceptions generally mediate the effects of more objective characteristics on outcomes (Edwards & Rothbard, 2005). Exposures to high levels of unresolved interpersonal and family conflict mediate the process of pathology. Family conflicts that are so intense are avoided through the hard pill of divorce and other forms of separation due to unmanageable conflict between the husband and wife who are the only voluntary members of the family system. This also affects the physical and psychological wellbeing of other subsystems Many families may survive the period of stress and conflict with a great cost on their physical and/or psychological health, many husbands’ ulcers, wife’s headaches and children’s or child’s nervous tics are traceable to domestic tension and warfare (Blood, 1960).

Nigerian economy makes each family responsible for providing for its members, ranging from the care of the young to the welfare of the old. Such care includes; provision of basic physiological needs, and serving as a reference point for directing and supporting its members towards actualization of potentials and advancing family identity. Most of these provisions come from the marital subsystem which serves as the bread winner of the family systems.

Forwarding the battleground models Parker (1985) and Trivers (1974) demonstrates that relatedness can be treated as the probability that two individuals share the same allele at any given locus by common descent. Relatedness can be defined more generally (and rigorously) as the genetic similarity between two individuals, relative to the average genetic difference in randomly chosen member of the population (Grafen, 1985). This can be used to characterize the ecological factors that increase (or decrease) the extent of Parent Offspring’s Conflicts. To determine the conflict battleground, however, it is crucial to distinguish two forms of competition between families. Intra-brood and inter-brood competitions; Intra-brood competition occurs between multiple young that are dependent at the same parental investment on a fixed amount that has to be distributed among siblings. In this case, the extent of conflict is expected to depend on the availability of resources for the number of offspring competing for those resources and equitable distribution of the resources. Relatedness between siblings, that is, siblings of same parents may minimize the level of conflicts. However, multiple paternity due to polygamy, reduce average relatedness up to the point where all of one’s siblings can be expected or refers to half-siblings which maximizes conflict (Schlomer, Guidice & Ellis, 2011). Family conflict is an important variable in depression, the level of family conflict are elevated in families in which one parent is depressed (Downey & Coyne, 1990).

The root of the family system is marriage; marriage is the start off of family in many societies, though it’s difficult to define due to lots of cultural variation and diversity in human society. Marital patterns are variously defined by social and economic events, as well as by changes in cultural attitudes and behaviours. Changes in the marriage pattern also affect the family life and other forms of interactions. However, marriage could be seen as a group approved mating arrangement usually marked by ritual (wedding) of a sort to indicate the couple’s new public status. It is the socially recognized and approved union between individuals who are committed to one another with expectation of stable and lasting intimate relationship. Hence, marriage is legally recognized relationship, established by a civil or religious ceremony between two people who intend to live together as sexual and domestic partners.

The birth of a child may adversely affect spouse’s adaptation and reduce marital satisfaction and psychological wellbeing. McMahon, Boivin, Gibson, Hammarberg, Wynter, Saunders and Fisher (2011) reported the role of psychosocial factors in addition to the impact of biological risk for the older mothers though; this assertion is yet to be empirically validated. However, few studies to have examined association between maturity and maternal age, studies are yet to expose whether psychological maturity influences the relationship between age and pregnancy adjustment.

Statement of the problem

Improvement in safety in pregnancy and child birth has shifted emphasis from factors affecting survival to those concerned with the psychological aspects of the experience. In Nigeria, little attention has been given to the mental health problems experienced by women in reproductive age or prenatal period. Even with the evidence that individual differences have influence on how one reacts to stressful life event like child birth and psychological contributions to wellbeing of women both at child bearing age and menopausal stage. It is therefore the interest of this study to find answer to the following problems:

  1. Will personality significantly related to postpartum distress?
  2. Will family conflict significantly related to postpartum distress?
  3. Will age in marriage significantly related to postpartum distress?

Purpose of the Study

            The millennium development goals of Federal Government on health contains section on maternal and child death reduction, subsequently modality to attain such a goal was set and recruitment of Nurses, Midwives and other categories of health services provider were carried out and posted to various communities in the country with non inclusion of (clinical) psychologists in the attainment of the goals on maternal and child mortality reduction, therefore this study examined:

  1. Whether Personality will significantly related to postpartum distress;
  2. Whether Family conflict will significantly related to postpartum distress; and
  3. Whether Age in marriage will significantly related to postpartum distress.

Operational Definition of Terms

Personality, in this study, refers to unique ways of individuals adaptation in terms of how they reacts to stressful stimulus as will be measured using five dimensions of personality (John et.al, 1992)

Family conflict, in this study, refers the degree of disagreements, fights and loss of temper that occurs within a family as measured by Family conflict sub scale of Family Environment scale (Moss & Moss, 1986).

Age in marriage, in this study, refers to the numbers of years spent in the union of husband and a wife or cohabiting of man and woman. Those who have spent 3 or fewer years would be termed low and those within 4-7 middle and those with 8 years and above are termed high.

Postpartum distress, in this study, refers to psychological distress that follows child birth from the moment the placental is expel to six weeks, as measured by Symptom Distress Checklist (SCL90) (Derogatis, Lipman & Covi, 1977).

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