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The impact of traumatic exposure among Faroese women during pregnancy and after childbirth2Art, Aesthetics & Health - Department of Communication & Psychology, Aalborg University, Aalborg, Denmark
Sanne Storm1,2, Signe Fauerholdt Sørensen3 & Ask Elklit4*
1Psykiatrisk Depilin, Landssjúkrahúsið, Faroe Islands
3Municipality of Langeland, Rudkøbing, Denmark
4Danish Center of Psychotraumatology, University of Southern Denmark, Odense, Denmark
*Correspondance: aelklit@health.sdu.dk
Abstract
Background
Previous research findings show a strong association between traumatic exposure and perinatal mental health, with a high comorbidity of depression, anxiety, and PTSD. Objectives: To examine maternal mental health among Faroese pregnant women, in relation to the risk of developing depression during pregnancy or after childbirth. Furthermore, to investigate associations between music and singing activity and mental health outcomes. Method: Data were collected from 424 Faroese women during pregnancy (20–35 weeks of gestation) and 8–10 weeks after childbirth. Data included the Edinburgh Postnatal Depression Scale (EPDS) and the Perceived Stress Scale (PSS-10). A questionnaire was developed to obtain information about demographics, previous pregnancy and birth experiences, sleep quality, previous traumatic exposures, expectations about parenthood, and music and singing activity in everyday life. Results: Previous traumatic exposures had an impact on the risk of developing depression, anxiety, and high levels of stress. A total of 18% were at risk of developing depression during pregnancy and 11% were at risk postnatally. Additionally, 23% had anxiety during pregnancy and 14% postnatal. Risk factors related to age, living situation, social relations, worries, and fear of childbirth (FOC), mental illness, previous traumatic exposure, experiences of abuse, and stress level were identified. Participants who did not grow up with music and/or singing, were found to be significantly more at risk of stress. Conclusions: A considerable minority was screened positively for depression and anxiety. Therefore, obligatory screening is important; this should include previous trauma exposure. A team specialized within the perinatal period with psychological, psychotraumatological, and psychiatric knowledge is recommended, as well as trauma informed care among midwives and health visitors.
Keywords:
Perinatal mental health
Edinburgh Postnatal Depression Scale (EPDS)
Perceived Stress Scale (PSS)
maternal postpartum depression
Faroese women
music therapy
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1 Introduction
Depression and anxiety are the most common maternal mental health problems. During pregnancy or in the first year after childbirth (WHO, 2022) will one in every five women experience a mental health condition. However, there is a lack of studies on how much of this burden can be attributed to depression during pregnancy or in the first year after birth (Woody et al., 2017). When severe, undetected, and untreated, these disorders can have a great impact on 1) the mother, 2) the mother-infant attachment 3) child behavior disturbances and development, and 4) the family’s mental health (Netsi et al., 2018).
The extant literature emphasizes a strong association between traumatic exposure and perinatal mental health, and the comorbidity of depression, anxiety and posttraumatic stress symptoms (PTSS) is high (Dikmen Yildiz et al., 2017a). According to a systematic review and meta-analysis (Dikmen Yildiz, 2017b), four percent of women who have experienced a traumatic birth will develop Post Traumatic Stress Disorder (PTSD). Key risk factors for PTSD in relation to birth such as prenatal depression, fear of childbirth (FOC), poor health or complications in pregnancy and a history of PTSD were identified in a meta-analysis of 50 studies. The strongest risk factors during birth were a negative subjective birth experience, having an operative birth (i.e. assisted vaginal or caesarean section), lack of support during birth, and dissociation. After birth, PTSD was associated with poor coping and stress, and it was highly comorbid with depression (Ayers et al., 2016). Women with previous experience of complications during pregnancy or while giving birth, or with previous experience of mental health problems was according to the review considered at high risk. The prevalence of PTSD was found to be almost 19% both during pregnancy and postpartum, and up to 39% postpartum if the child died (Dikmen Yildiz et al., 2017b, Ayers et al., 2018). The review, additionally, found that the prevalence of PTSD appears to increase between one and six months postpartum (Dikmen Yildiz et al., 2017b).
This finding is supported by a recent retrospective chart review by Padin et al. (2022) including data from 1402 pregnant women who completed a prenatal screening for PTSD and depression during a routine prenatal care visit. The research study revealed that about 5% screened positive for both depression and PTSD, 11% of the participants screened positive for PTSD alone, and close to 4% for depression alone. This emphasizes the risk of overlooking PTSD, and not providing the necessary mental health support accordingly, and highlights a healthcare gap in missing the opportunity in current obstetric care practice in having a routine system for identifying PTSD during prenatal care (Padin et al., 2022). Furthermore, FOC is a common problem affecting women’s health and wellbeing, and a common reason for requesting caesarean section (Nilsson et al., 2018). FOC can be experienced on a continuum varying from almost no fear to phobic fear. The association between a previous subjectively negative birth experience and fear of childbirth is high and higher than the association between previous obstetric complications and fear of childbirth (Størksen et al., 2013). FOC during pregnancy also increases the risk of experiencing the childbirth as traumatic and stressful (Ayers, 2014).
A Swedish study (Grundström et al., 2022) with 76 women who had undergone a complicated childbirth, examined the prevalence of FOC postpartum and the correlations with Post Traumatic Stress Syndrome (PTSS) and Quality of Life (QoL). The results indicated that almost one-third of the women with complicated childbirth reported severe FOC postpartum, and almost every fifth woman reported PTSS, indicating PTSD, and deteriorated QoL. The study highlights the importance of supporting women with FOC already during pregnancy and to raise awareness of the risk of mental health problems after complicated childbirth.
Women affected by PTSD during pregnancy and postpartum are rarely identified and treated (Ayers et al., 2018). In addition, women with PTSD during pregnancy are at higher risk for pregnancy complications and adverse birth outcomes (e.g., pre-eclampsia, low birthweight, preterm birth), which may have negative impact on infant development (Padin et al., 2022). Therefore, prenatal PTSD can impart long-lasting consequences on families.
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The WHO guidelines (2022) recommend that midwives, general practitioners, and health visitors conduct perinatal mental health assessments (WHO, 2022). The Edinburgh Postnatal Depression Scale (EPDS) is an internationally recognized and widely used screening tool for the early detection of women who are at risk of developing depression both during pregnancy and after childbirth. The EPDS has been validated in many countries including Denmark (Smith-Nielsen et al., 2018) and the Faroe Islands in 2019 (Fjallheim, 2019). In the Faroe Islands, mental health assessments with EPDS have been performed nationally postnatally since 2012. In contrast to national recommendations, there is a large variation in when and where the perinatal mental health assessments are conducted in Denmark (Rambøll Management Consulting, 2021). A
The national guidelines only highlight that it is possible for the general practitioner, midwife, or health visitor to perform a systematic perinatal assessment (Danish Health Authority, 2021).1.1 Objectives
The general objectives of the research study were to examine 1) maternal mental health among Faroese pregnant women during pregnancy and after childbirth. Furthermore, the objectives were to 2) identify relevant risk factors for perinatal mental health issues. This included demographic factors, previous pregnancies and birth experiences, and previous traumatic exposures and their role in relation to anxiety, stress, and depression during pregnancy and childbirth. Finally the objectives were to 3) carry out an examination of associations between music and singing activity and mental health outcomes among pregnant women.
2 Procedure
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The research study was based on a total population of pregnant Faroese women during a period of 14 months. All cross-sectoral parties: the general practitioner, healthcare providers, the midwifery service, and the obstetric ward had an opportunity to contact an advisory, investigating, and treating perinatal team directly during the research period. The study utilizes two data sets. One is founded within the midwifery and the other is based on the archives of the health visitors’ center. Preventive interventions were defined according to cut-off rates of the EPDS.A
The first study: During the 14 months (November 2019 until February 2021) 737 folders were handed out offering an extra midwife consultation focusing on: How are you? A total of 121 women were excluded for various reasons, and 190 women (31%) declined to participate in the research study, leaving 424 (69%) participants. Data were collected during pregnancy, between 20 and 35 weeks of gestation, by two midwives using 1) EPDS and 2) PSS. In addition to the scales, the midwives collected demographic data, as well as information about previous pregnancies, birth experiences, previous traumatic exposures, music, and singing activity.The second study
EPDS screening was carried out by the health visitors 8–10 weeks after childbirth. This included 382 women (90%) of the total pregnant women. The EPDS screening results were compared with data collected from the health visitors’ archive.
2.1 Methods
A general questionnaire was developed to collect demographic data, and data regarding previous pregnancy, birth experiences and breastfeeding, as well as sleep quality and previous traumatic exposures. Additionally, the questionnaire included thoughts, expectations, and ideas about the future, birth, feeding the baby, and parenthood. The questionnaire also included reflections on well-being, and physical well-being during the last pregnancy, and questions examining music and singing activity in everyday life, including singing to the child during pregnancy. The list of previous traumatic or adverse exposures included: 1) losing a close relative, 2) divorce, 3) difficult conditions in childhood, 4) physical violence, 5) physical or psychological harassment, 6) experience of traumatic childbirth, 7) other experiences.
The EPDS was used to obtain information about anxiety and depression. EPDS is a ten-item screening scale for antenatal and postnatal depression. It is not a diagnostic tool, but a valid and reliable tool for identifying a lack of well-being and a risk for developing depression, as well as the need for supportive interventions, closer evaluation, and treatment. The EPDS asks participants to rate how they felt during the previous 7 days. Response categories were scored 0, 1, 2, or 3 for each item according to the increased severity of the symptoms. A cut-off score of 10 was used for categorizing a risk for developing depression, based on a study validating the Faroese version of the EPDS against a diagnosis of depression (Fjallheim, 2019), and international recommendations (Cox et al., 2014; Levis et al., 2020). EPDS also allows the evaluation of anxiety (EPDS-3A). The anxiety factor is based on item 3,4 and 5 (for elaboration, see Kozinszky et al. (2017). A cut-off score of ≥ 5 was used to identify anxiety (Smith-Nielsen et al. 2021).
Perceived stress was measured using the PSS developed by Cohen et al. (1983). PSS-10 is a 10 item instrument that evaluates the stress intensity of the participants. PSS-10 rates statements about how unpredictable, uncontrollable, and overloaded they find their lives on a 5-point Likert scale from “never” to “very often”. Each response is converted to a score of 0 to 4 with the overall PSS score computed as the total score of the 10 items, with four reverse-coded items. The higher the score, the worse the perceived stress, with a maximum score of 40. According to Nelholt and Søndergaard (2019) and the Danish medical handbook, a cut-off score of ≥ 17 points is cause for concern. It is also stated that if this level of stress persists over a longer period, preventive interventions should be considered. At the same time, further development of stress levels should be monitored. A score above 25 are considered to require treatment, where interventions should be initiated and sick leave considered. A cut-off score of ≥ 18 points is used in this study.
2.2 Statistical analysis
A statistical analysis was performed using SPSS, version 28. The first step was to perform a descriptive analysis, calculating the mean, standard deviation (SD), and percentages. This analysis provided a description of the population in focus. The second step was to perform a one-way ANOVA to explore the relationship to the indication of risks for developing perinatal depression (EPDS), anxiety (EPDS-3A), and prenatal perceived stress (PSS). ANOVAs were only carried out if the distribution in any of the groups was ≥ 9% (n = ≥ 40).
n | Range/% | Prenatal EPDS | Prenatal EPDS-3A | Prenatal PSS | Postnatal EPDS | Postnatal EPDS-3A | |
|---|---|---|---|---|---|---|---|
F(1,422) | F(1,420) | F(1,380) | F(1,371) | ||||
Age | 424 | ||||||
(17–24) (25–34) (35–42) | 13% 70% 17% | 15.32** | 19.19** | 5.84* | 13.52** | 13.13** | |
Marital status | 424 | ||||||
Married/cohabiting | 95% | ||||||
Living in the FO | 414 | ||||||
less than 3 years | 16% | 6.77* | 9.45* | ||||
≥ 3 years or more | 84% | ||||||
Living situation | 399 | ||||||
Husband in land | 81% | ||||||
Husband a "sailor" | 19% | ||||||
Cohabitation | 412 | ||||||
Not living with the father of the expected child | 5% | ||||||
Living with the father of the expected child | 95% | ||||||
Social relations | 424 | ||||||
0-2relations | 21% | 6.77* | 9.45* | 15.21** | 11.82** | 8.26* | |
3 relations | 27% | ||||||
4 relations | 29% | ||||||
5 relations | 23% | ||||||
Residence | 424 | ||||||
Living in the same house as parents/parents-in-law | 18% | 8.69* | 5.20* | 6.74* | 8.06* | ||
Education | 424 | ||||||
7–10 grade | 6% | ||||||
Highschool | 31% | ||||||
Medium-cycle higher education 3–4 years | 38% | ||||||
Long-cycle higher education, more than 4 years | 17% | ||||||
Other | 8% | ||||||
Mental illness | 424 | ||||||
No previous mental illness | 66% | ||||||
Mental illness more than 6 months | 18% | 35.22** | 23.62** | 27.04** | 26.22** | 18.24** | |
Mental illness less than 6 months | 16% | 5.31* | 7.94* | ||||
Medication | 389 | ||||||
None | 97% | ||||||
Yes | 3% | ||||||
n | Range/% | Prenatal EPDS | Prenatal EPDS-3A | Prenatal PSS | Postnatal EPDS | Postnatal EPDS-3A | |
|---|---|---|---|---|---|---|---|
F(1,422) | F(1,420) | F(1,380) | F(1,371) | ||||
Parity | 424 | ||||||
First pregnancy | 34% | 5.68* | 7.81* | 20.22** | |||
Second pregnancy or more | 66% | ||||||
Childbirth | 280 | ||||||
Vaginal childbirth | 82% | ||||||
Cesarean section | 18% | ||||||
Children | 280 | ||||||
0 children | 2% | ||||||
1 child | 48% | ||||||
2 children | 35% | ||||||
3 children | 13% | ||||||
4 children or more | 4% | ||||||
Previous obstetric complications during pregnancy | 281 | ||||||
None | 65% | ||||||
Yes | 35% | ||||||
Previous birth complications | 280 | ||||||
None | 60% | ||||||
Yes | 40% | ||||||
Traumatic birth experience | 15% | 7.14* | 8.26* | ||||
Worried and FOC | 424 | ||||||
Looking forward giving birth | 52% | ||||||
Looking forward, but also worried | 39% | ||||||
Worried and FOC | 9% | 33.67** | 10.94** | 42.21** | 11.58** | 4.00* | |
Sleep quality | 422 | ||||||
Most often feeling rested | 53% | ||||||
Feeling rested, but not enough | 33% | ||||||
Never feeling rested | 14% | 30.27** | 18.79** | 32.91** | |||
n | Range/% | Prenatal EPDS | Prenatal EPDS-3A | Prenatal PSS | Postnatal EPDS | Postnatal EPDS-3A | |
|---|---|---|---|---|---|---|---|
F(1,422) | F(1,420) | F(1,380) | F(1,371) | ||||
Previous traumatic exposure | 424 | ||||||
None | 44% | ||||||
Yes | 56% | 13.52** | 6.44* | 14.54** | 5.67* | 5.32* | |
Amount of traumatic exposures | 236 | ||||||
One traumatic exposure | 49% | ||||||
Two traumatic exposures | 27% | ||||||
Three traumatic exposures | 14% | ||||||
Four or five traumatic exposures | 10% | ||||||
The character of previous traumatic exposure | 236 | ||||||
To lose a close relative | 23% | 8.97* | 7.83* | ||||
Divorce | 10% | ||||||
Difficult conditions in childhood | 16% | 21.06** | 15.67** | 34.05** | 16.34** | 10.54** | |
Physical violence | 5% | ||||||
Physical or psychological harassment | 15% | ||||||
Physical violence and physical or psychological harassment | 20% | 11.24** | 6.80* | 12.34** | 11.72** | 6.68* | |
Other | 10% | ||||||
Abuse, suicide, depression or self-harm in close relative | 424 | ||||||
None | 55% | ||||||
Yes | 45% | 30.27** | 18.79** | 32.91** | 11.62** | 12.07** | |
n | Range/% | Prenatal EPDS | Prenatal EPDS-3A | Prenatal PSS | Postnatal EPDS | Postnatal EPDS | |
|---|---|---|---|---|---|---|---|
F(1,422) | F(1,420) | F(1,380) | F(1,371) | ||||
EPDS | 424/382 | Prenatal/Postnatal | |||||
0–9 | 82%/89% | ||||||
≥ 10 | 18%/11% | ||||||
EPDS-3A | 424/373 | ||||||
0–4 | 77%/86% | ||||||
≥ 5 | 23%/14% | ||||||
Change of EPDS score over time | 382 | ||||||
0–9 prenatal and postnatal | 77% | ||||||
0–9 prenatal changing to ≥ 10 postnatal | 5% | ||||||
≥ 10 prenatal changing to 0–9 | 12% | ||||||
≥ 10 prenatal and postnatal | 6% | ||||||
PSS | 422 | Prenatal | |||||
0–17 | 85% | ||||||
≥ 18 | 15% | 266.81** | 95,30** | 46.76** | 29.44** | ||
2.3 Ethical approval
Before collecting data, ethical approval was given by the Faroese Data Protection Authority (Project number: 133 − 16/00253-8).
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All possible participants were provided with written information about the study, and those who agreed to participate in the study signed a consent form.3 Results
The general demographic characteristics of the 424 pregnant women are presented in Table 1, and the demographic characteristics related to pregnancy and birth are presented in Table 2. Most of the women reported being in a relationship with and living together with the father of the expected child.
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Only a few were single parents. Among the women, the large majority lived for more than 3 most recent years in the Faroe Islands and around 16% had lived there for less than 3 years. In the latter group, most reported that they returned to the Faroe Islands after years of studying or working abroad. For most of the couples living together, both parents were present during the everyday life, while one fifth of the couples, the husband was away from home as a sailor or fisherman. A
Almost one fifth lived in the same house as their parents or parents-in-law. Most of the women (85%) were working, 96% reported having a salary income, and 6% were on sick leave due to pregnancy. The vast majority reported not taking any medication.3.1 Trauma history
Focusing on traumatic exposure, more than half of the women were found to have a history of previous traumatic exposures, and a little less than a half had a history of experiencing abuse in close family, depression, suicide, or self-harm (see Table 3). Almost half had experienced one traumatic exposure, 27% two, 14% three and 10% four or five traumatic exposures. Furthermore, 15% had a previous traumatic childbirth experience, while a minority experienced anxious worries (4%) or FOC (5%) overshadowing the joy of being pregnant (see Table 2).
3.2 Psychological sequelae
Among the participants, 18% were at mild to severe risk of developing depression during pregnancy, and 11% postnatally. Additionally, 23% of the participants had anxiety during pregnancy, and 14% after childbirth. It was found that 9% of participants with anxiety were not detected unless they focused explicitly on the EPDS-3A. This also applied to 5% after birth. According to perceived stress, it was found that 15% of the participants had a high level of stress, with 3% meeting the criteria for treatment recommendations (see Table 4).
The second study found that 12% were at mild to severe risk of developing depression during pregnancy, but recovered postnatally, while a small group who were not at risk during pregnancy became at risk after childbirth. A separate group remained at risk both during and after pregnancy, showing that the same women were not consistently at risk throughout both periods (see Table 4).
3.3 The identification of risk factors
The tables provide an overview of the data, showing a significant difference in the distribution between two groups: prenatal and postnatal. Two risk factors were especially connected to the Faroe Islands: 1) a maximum stay in the Faroe Islands of 3 years before birth (homecoming citizens and immigrants) turned out to have a significant impact on vulnerability and risk for developing depression and anxiety during pregnancy, but not postpartum, and 2) living in the same house as the pregnant woman’s or partner’s parents had a significant impact on vulnerability during pregnancy and postpartum. However, having a husband who is a sailor or a fisherman was not found to be a risk factor.
Risk factors identified as having a significant impact on developing a high level of stress during pregnancy as well as depression and anxiety during both pregnancy and after childbirth were as follows: 1) young women aged 17–24, 2) few social relations, 3) worries and FOC, 4) mental illness during more than the last 6 months, 5) a history of previous traumatic exposures (difficult childhood, physical violence, physical and psychological harassment), and 6) experiences of abuse, suicide, depression, and self-harm in close family members.
Mental illness during the last 6 months was identified only as having an impact on the vulnerability of developing depression and a high level of stress during pregnancy, but not after childbirth. Women pregnant for the first time had a significantly higher level of anxiety during pregnancy, as well as both depression and anxiety postpartum. A previous traumatic exposure of losing a close relative only caused a significant impact on developing depression and anxiety postpartum.
For women with a previous traumatic childbirth experience, there was a significant risk of developing both depression and a high level of stress during pregnancy. A high level of stress during pregnancy had a significant impact on the risk of developing depression and anxiety both prenatal and postnatal. Struggling with severe sleep difficulties had a significant impact on the vulnerability of developing depression, anxiety and a high level of stress during pregnancy. The participants who stated that they had not had the opportunity to grow up with music and/or singing activities were found in this study to be at significantly higher risk of stress (F1,422=3,88, p < .05). Furthermore, the study found that 26% of first-time mothers sing to the baby during pregnancy. This applied to 98% of the women pregnant for the second time. A co-occurrence result showed that when suffering from anxiety, the child(ren) were not sung to (F1,422=5,27, p < .05).
4. Discussion
In general, the findings regarding Faroese women’s maternal mental health status during pregnancy and after childbirth align with international findings (Woody et al., 2017; WHO, 2022). However, an important result is that it is not the same women who are at risk during pregnancy and after childbirth. Only 6% are at risk of developing postpartum depression during both pregnancy and after birth. This finding is supported by the fact that 12% of the participants received preventive and health-promoting interventions provided by either the midwifery or a specialized assessment and treatment team during pregnancy, which showed improved resilience and maternal mental health recovery. Additionally, 5% of the participants were only at risk after childbirth, which highlights the importance of providing early preventive and health-promoting interventions both during pregnancy and after childbirth.
Another important result that supports early preventive and health-promoting interventions targeting anxiety in the perinatal period is that the EPDS screening might overlook 9% of severe anxiety during pregnancy if not using the EPDS-3A explicitly. This emphasizes the importance of continuing to offer screening for anxiety (EPDS-3A). Additionally, there is a risk that severe worries and FOC may be overlooked or not taken seriously enough. The findings show a significant risk of developing high levels of stress when experiencing signs of depression or/and anxiety. It is evident that both anxiety and stress can be early signs of PTSS, often connected to previous traumatic birth experiences or other past traumatic exposures. By overlooking these signs of depression, anxiety, or a high level of stress - or not fully understanding the underlying reasons for signs of depression and anxiety during pregnancy or after birth - women may be prevented from receiving the right support and help. This underscores the importance of the midwives and health visitors having direct access to specialized knowledge about the perinatal period, holding psychological, psychotraumatological and psychiatric expertise.
4.1 Previous traumatic exposures
There is a slight difference in which risk factors are present during pregnancy and after birth. For women with a previous traumatic childbirth experience, there was a significant risk of developing both depression and stress during pregnancy. This might be explained by excessive worries about the forthcoming birth, emphasizing the importance of trauma-informed care in addressing prior birth experiences. Furthermore, the study found that a traumatizing experience of having lost a loved one significantly increases the risk of developing anxiety and depression after birth. At childbirth, not only is a child born, but also a mother. This can awaken many different emotions and may also be related to having experienced the overwhelming loss of a loved one. A feeling of loneliness may then arise, linked to a feeling of abandonment, or a fear of passing away and leaving the child without a mother.
Previous traumatic exposures in the perinatal period have not been examined before in the perinatal period in the Faroe Islands. In general, traumatic exposures are often overlooked, and the impact previous traumatic exposures can have on well-being is underestimated. However, the extent of previous traumatic exposures on the participants in this study, and the impact on the risk for developing depression, anxiety, and a high level of stress, highlights the importance of trauma awareness. It involves professional skills to screen for PTSD and to provide the right psychological support to prevent the perinatal mental health condition from worsening as well as preventing retraumatization or development into a chronic PTSD. This calls for trauma-informed training and care and the importance of having an interdisciplinary unit that holds specialized knowledge in perinatal psychology, psychotraumatology, psychiatry, and mental health.
4.2 Special conditions in the Faroe Islands
A possible explanation for the high impact of previous traumatic exposures in the Faroe Islands may be cultural. As previously mentioned, the Faroe Islands can be described as a small Atlantic Ocean society. This means that the individual must deal with considerable weather challenges as well as tight social relationships. The prominent occurrence of anxiety during pregnancy in this study can therefore be explained by the general high incidence of traumatic exposures, and because there is a risk of traumas being evoked during pregnancy and/or during the birth itself.
Also characteristic for the Faroese society is the long-standing tradition of sailing and fishing, which has deep roots in the islands' economic and social fabric. Surprisingly, the results show that having a husband who is a sailor or fisherman was not found to be a risk factor for maternal mental health issues. This can be explained by the recognition of the mother’s situation, which provides strong social support from the social network, reducing feelings of isolation or shame. Furthermore, it was found that a maximum stay of up to three years in the Faroe Islands for both returning citizens and immigrants was identified as a significant risk factor. This finding emphasizes the challenges associated with relocating to or returning to the Faroe Islands, including difficulties in securing affordable housing and simultaneously establishing a family.
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This might also explain why living in the same house as parents or parents-in-law was found to be a risk factor, since the co-habiting can be seen as a necessity rather than choice and challenge the new family’s feeling of autonomy.4.3 Music and singing activity
A surprising result revealed that only 26% of women pregnant for the first time sing to the baby. This result indicates that knowledge about the human voice and its impact on mother-infant attachment (Malloch et al., 2009) is not widely known. Even in the womb the baby begins to orient itself towards the mother’s voice and can recognize voices and songs after birth. Additionally, there is a co-occurrence result showing that when anxiety is significantly present, the children(ren) are not sung to. When the pregnant woman does not sing for the baby, this may be because nearby coping tools and strategies are forgotten when the anxiety level is too intense. Based on knowledge and understanding that music and singing activities are possible tools for self-regulation of physical, emotional and relational states (Winsler et al., 2011; Haslbeck, F., 2013; Storm, 2017) these results call for further research focusing on singing activity as a possible health promoting and self-regulating activity for first time mothers-to-be.
Moreover, a result showed that women who lacked active involvement in singing and playing music while growing up struggled with a high level of stress. This supports further reflection and research focusing on the health-promoting benefits of singing activity.
5. Conclusion
A considerable minority were at risk of developing depression or had anxiety. A multi-layered and tiered system of preventive interventions, assessment and treatment is recommended. This includes the importance of continuing to offer screening for anxiety (EPDS-3A) and the risk for developing depression (EPDS). Furthermore, the high level of a history of previous traumatic experiences and
their significant impact on the risk of developing anxiety, stress and depression perinatally further emphasize the importance of having an interdisciplinary unit that holds specialized knowledge in psychology, psychotraumatology, psychiatry, and mental health related to the perinatal period.
Based on the knowledge and understanding that music and singing activities are possible tools for self-regulation of physical, emotional, and relational states, further research is recommended to study the relationship between being pregnant for the first time, having anxiety and singing to the baby in the womb and right after birth more thoroughly.
There is a need to find a health-promoting approach, which is comprehensible and manageable, and which awakens inner resources rather than focusing on a pathogenic approach. Knowledge and understanding of early signs of PTSS, stress, worries and FOC during pregnancy and after birth will support resilience and the capacity for self-regulation.
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Data Availability
Data availability: Yes, upon reasonable request. Contact the corresponding author.
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Funding statement:
the project was funded by Sjúkrakassagrunnurin Føroyar (the Faroese Health Insurance Fund)
Conflict of interest disclosure: None
Ethics approval statement: Dátuefterlitiᵭ (Faroese Data Protection Authority)*. (Project number: 133 − 16/00253-8).
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The study adheres to the Declaration of Helsinki.A
Informed patient consent was obtained from all of the participants. This consent also included a consent for publication.A
Author Contribution
Authors' contributions: SS designed the study and collected the data. All authors analyzed the data, wrote the draft, and participated in the final editing
Acknowledgements:
Thanks to the pregnant women, the nurses and midwives who participated
* The Data Protection Authority is an independent public authority set up in accordance with the Data Protection Act (https://www.dat.fo/english).
Electronic Supplementary Material
Below is the link to the electronic supplementary material
References
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Only significant results are included. *p < .05,**p < .001.
Note
Only significant results are included. *p < .05, **p < .001.
Note
Only significant results are included. *p < .05., **p < .001.
Note
Only significant results are included. *p < .05, **p < .001.