Erikson’s theory of life stages describes the parent as one who has a firm sense of self both within and separate from the relationship with a partner, and that from this position, parents are able to develop and see their child as a separate individual who is dependent on them and whose needs are placed first. For teenagers, many single parents, and those whose childhoods were emotionally deprived, such developmental tasks have often not been mastered prior to parenthood.

Teenage pregnancies have reduced considerably in some Western countries, by more than two thirds in the last 30 years in Australia, for example. They now constitute 18 per 1,000 pregnancies (3). This compares to the United States at 51.5 per 1,000 and the United Kingdom at 29 per 1,000 (the highest in Europe) and is six times the rate in the Netherlands (4). Differences in the prevalence are likely to relate to different cultural and religious attitudes in these countries, which influence sex education, availability of contraception, and financial supports for teenagers. The experience of pregnancy when it does occur in this setting will affect the transition to motherhood (Table 19.1) and may have unrealistic
expectations attached, such as “My child will be the one person who will love me unconditionally” or “This is the one job I will do well.”

Older mothers—particularly first-time mothers and those who have become mothers as a result of in vitro fertilization (IVF)—present with different psychological conflicts. Delaying the age of first-time motherhood has been a universal trend, with the average age 29 years in Australia up from 25.8 years in 1991 (3). For those mothers who delay longer (1 in 35 wait until 35 or older for their first child), reduced fertility has become an increasing concern, balanced, though not evenly, by improved reproductive technology. If there have been difficulties in conceiving, the woman may have difficulty believing she will have a healthy child and may be anxious about the viability of the infant. This can be heightened by any physical difficulties experienced during pregnancy. Idealization of mothering may produce a flurry of activity in preparing the nursery but often also widens the divide between what motherhood is thought to be about and the reality of the experience in the postpartum period. These expectations may contribute to a negative transition. Improved obstetric care has meant better maternal and child outcomes but also shorter hospital stays and a high dissatisfaction with postnatal supports (5).

Historically, society has viewed motherhood as a natural and sacred role, but the epitome of fulfillment and bliss that radiates from women on the covers of mother and baby magazines is for many women an elusive myth. In order to continue the species, it is in society’s interests to promote such views. Rapid change in technology, however, has meant a marked change in women’s roles. With reliable contraception available in the Western world, motherhood is now viewed as a choice.

For many women, the desire to have an infant is a complex one. The motivations are not always conscious, and the woman’s ability to see her infant as separate depends on her ability to understand, to some degree at least, these motivations. In some cases, the pregnancy will be unplanned or unwanted. Studies have varyingly associated this circumstance with an increased risk of depression, although it appears that the “unwanted” carries a greater risk, given that the definition of unplanned varies from a failure of contraception to participation in an active sexual relationship with a steady partner where neither is taking precautions to prohibit pregnancy. These unwanted pregnancies may also include both first pregnancies, where the risk of depression is highest, and grandmultiparity with short interpregnancy breaks, where the risk has also been noted to be increased (6).

Where a woman elects to terminate a pregnancy, as some 1.5 million women do each year (7), there is debate and controversy regarding potential psychological sequelae. Researchers such as Reardon et al. (8) have concluded that there is an increased risk of psychiatric admission following abortion, and pro-life organizations support this association with testimonies of grief and regret. The research, however, has been significantly hampered by methodologic flaws such as not assessing the woman’s mental state at the time of her decision, no controls, and the impossible scenario of how she would have been had she not had the termination. Major (9) noted Reardon et al.’s (8) conclusions to be misleading; indeed women with a mental illness have been noted to be more likely to have unwanted pregnancies rather than the termination itself necessarily leading to mental illness.

It is not uncommon for women to experience some sadness or guilt from a termination, either at the time or after subsequent children, but this is usually transient and does not warrant a psychiatric diagnosis (7).

The experience of a completed pregnancy may have particular relevance to mental health after birth. In Gross et al.’s (10) study, women who reported their pregnancy as being very hard or one of the worst times of their life were at least 4.6 times more likely than comparison women to be depressed postpartum.

Emotionally deprived and abusive or chaotic backgrounds are more likely to be associated with development of personality styles that pose challenges to parenthood. Factors that influence personality development are summarized in Table 19.2. Personality, in turn, will affect how women respond to pregnancy and motherhood and the circumstances in which they conceive.

Individuals diagnosed with borderline personalities have many unmet emotional needs. The vulnerability in their infant is likely to awaken these needs and put them in competition with their infant, more as a sibling than as a mother. In pregnancy, this may manifest as the inability to consider the needs of the fetus. The use of drugs, smoking, and poor obstetric care are likely results. In the setting of becoming mothers, childhood traumas and their own vulnerability are likely to surface—with potential for negative mental health outcomes for both the woman and her child (11).

Temperament and childhood experiences that have shaped the woman’s personality will influence coping strategies during a considerably heightened level of physical and emotional change. Avoidance strategies have been associated with more negative outcomes of fertility and pregnancy, including depression and failed in vitro fertilizaton. High self-esteem is associated with a smoother transition to motherhood. Huizink et al. (12) looked at coping strategies in normal-risk nulliparous pregnant women and identified two key strategies that were used: emotional-focused and problem-focused coping. The former was associated with more distress and pregnancy complaints.

Women’s relationship to their bodies and the feeling of control—or need for control—are likely to influence attitudes. Women with perfectionistic personality styles are at greater risk of postnatal depression (13); the idealization of motherhood most likely begins in childhood but becomes a focus during pregnancy. Women with eating disorders may have particular difficulties of control with respect to body image disturbance and intake. Although researchers have found that
there is a reduction in anxiety about weight and body image in pregnancy, this nevertheless remains the most significant concern (14).

Lower socioeconomic status and education, poor social supports, and poor marital relationship as well as an increased number of life stresses come up consistently as being linked with an increased risk of perinatal depression (Table 19.1; 10,11,12,13,14,15,16). Teenage pregnancies have a high rate of each of these factors (4). The practicalities of caring for a child (or more than one) physically and emotionally, especially when there are financial difficulties and no child care support, put a burden on a mother who may already be vulnerable to depression and poor coping due to a variety of factors: genetic loading, poor role models, and stress in her childhood (11). Such stresses may also be correlated to difficulties in the pregnancy. Morten et al. (17) found stress increased the risk for preterm delivery at 30 weeks, the risk increasing with the level of psychological distress. Such stresses then add further pressure on the transition to motherhood.

In the setting of pregnancy, the role of the partner becomes crucial. The relationship, whether stressful or abusive, can add its own independent risk (10) to the woman’s mental health. Domestic violence is underreported and underrecorded, with an estimated 1 in 3 to 4 women between 16 and 59 experiencing domestic violence and one woman dying every three days as a result in the United Kingdom and the United States (18,19). In Australia, 23% of women report lifetime partner abuse; 61% of these women had children in their care, and 42% were abused when they were pregnant (20). For 20% to 30% of women, the abuse happened for the first time in the course of pregnancy (18,20). Similarly, 1 in 5 women in the United States report domestic violence, with pregnancy rates estimated at between 8% and 26% of pregnant women (21). In this setting, the frequent direction of the physical attack is toward the abdomen, which not only may result in intrauterine damage and prematurity, but also is likely to increase stress on the woman regarding her unborn infant and its viability as part of the family unit.