Perinatal mental disorders (PMDs) impact more than 20% of women during pregnancy and postpartum (Howard et al., 2014), including depression, anxiety, post-traumatic stress disorder, and postpartum psychosis (Awini et al., 2023).
These conditions stem from various stressors, such as childbirth experiences, neonatal loss, and complications during labour (Biaggi et al., 2016; Milgrom et al., 2019; Ogbo et al., 2018). If undetected or unmanaged, PMDs can lead to maternal morbidity, increased suicide risk, and potential negative consequences for a newborns’ development (Leddy et al., 2011).
Resilience is a concept that describes the ability to adapt to psychological, physical, and social changes. Factors such as optimism, social support, financial stability, and mindfulness interventions contribute to overall resilience. However, research lacks consistency on the mechanisms of resilience in perinatal mental health. The authors of this review aimed to assess current evidence on resilience and its role in mitigating perinatal mental disorders (Mohammedamin et al, 2024).
Could resilience be a useful tool in the armoury for new parents facing mental ill health?
Methods
The present study is a systematic review, preregistered on PROSPERO and reported as per the appropriate guidelines. Three authors carried out the search across five databases and grey literature sources of eligible articles written in English, from anywhere in the world, that included words pertaining to ‘resilience’ or ‘coping’ and the perinatal period. Editorials, corrigendum, case studies, reviews, commentaries, conference abstracts, reports, and non-English articles were excluded.
Two authors then conducted the article screen and data extraction, with a third author advising on disagreement to reach consensus. The quality of included studies was assessed using the Joanna Briggs Institute (JBI) and the Mixed-Methods Appraisal Tool (MMAT); again, discrepancies were resolved between three study authors. A meta-analysis was not performed as part of this study.
Results
The authors identified 2,840 articles from their initial search. Following the omission of duplicates and ineligible abstracts, 56 studies were brought to full-text review. Of these, 28 were eligible for inclusion.
Most included studies were carried out in developed nations, with nine US-based studies and seven from China. Most studies were quantitative and observational; the remaining five were mixed methods. Eleven studies focused on the pregnancy period and the rest covered the perinatal period, i.e., pregnancy and postpartum. Depression and anxiety, followed by perceived stress, were the primary outcomes of interest in most studies.
Most quantitative studies scored low risk of bias using the JBI criteria, with no studies scoring high risk. The mixed-methods studies were assessed using the MMAT and all scored above 60%, indicating high quality.
Findings from most included studies suggested that higher resilience scores were associated with lower incidence of mental health disorders (MHDs) (19/28 studies). One study quantified this as resilience decreasing depression and post-traumatic stress disorder in the perinatal period between 34–56% (Xiong et al., 2010). Conversely, one included study from the US showed that resilience was neither associated with anxiety nor substance misuse and did not mediate the association between lifetime trauma and postpartum depression (Johnson et al., 2018).
The mechanisms by which resilience may be associated with MHDs are complex. One included study identified social patterning in coping strategies, where higher educational attainment was associated with high coping profiles (Werchan et al., 2022). Social support is a key influencing factor observed by several studies, where resilience alone is not sufficient to negate the potential onset or worsening of MHDs. One study highlighted individuals with a history of depression had lower resilience scores (Kornfield et al., 2021).
Overall, higher resilience scores were associated with lower incidence of mental health disorders in the perinatal period. However, the relationship is complex.
Conclusions
The authors of the review concluded that psychological resilience may enable individuals to build strong coping mechanisms, promote assistance seeking, and encourage overcoming mental health-related obstacles during the perinatal period.
However, resilience is a complex latent concept that encapsulates many different facets of someone’s personality, history, and social setting, which makes interpreting the direction of effect and incidence of resilience distinct from mental health challenging.
Promoting resilience and its component parts, like positive cognitive appraisal and adequate social support, is clearly beneficial in the context of perinatal mental health.
Strengths and limitations
The review included a wide range of articles, not limited by time period or geographical origin. Risk of bias was assessed using tools specific to the type of approach employed by the individual study.
However, the present study has some limitations. The authors note that studies may not have been included in the review because they were written in another language, which may have in turn limited the conclusions drawn by the review. They also highlight that no quantitative analysis was performed, such as an assessment of publication bias or study variability, which should be factored into the interpretation of the review findings.
Limitations of individual studies were not discussed in this review. A key unanswered question is whether individual studies are confident that resilience truly occurs first in the relationship with mental health disorders (MHDs). We need to explore whether resilience causally influences MHDs, i.e. they occur before MHDs. Poor resilience may instead be a symptom of a MHD that is likely associated with poorer MHDs in the future. In this scenario, poor resilience is not a cause of MHDs, but rather is a proxy for a past measure of a MHD. The authors included a paper that acknowledged an association between history of depression and resilience (Kishore et al., 2018), giving weight to this concern. This concept is called confounding by indication, whereby depression, for example, is causing both poor resilience and future depression in the perinatal period.
The review found that other types of confounding variables were also relevant to this research question. The authors highlight that various characteristics, like age and lower educational attainment, are associated with poorer resilience. If the included quantitative studies did not account for these characteristics in their analyses, then doubt is cast over the isolated mechanism of resilience on MHDs. The authors used a risk of bias tool that did not focus on confounding factors as an assessment criteria, as highlighted by the authors of the tool (Hong et al., 2018). Had another risk of bias tool been used, the ROBINS-I tool for example, that focuses on confounder adjustment as a key assessment criteria for the quality of included studies in a review, confounders may have been discussed in more detail in the present review to critically appraise the findings.
Chicken and egg: does resilience prevent mental health disorders, or does experience of mental health disorders itself foster resilience?
Implications for practice
Per the findings of the current review, in the absence of a pre-existing mental health disorder (MHD), promotion of resilience mechanisms may help to protect against the development of MHDs in the perinatal period when delivered pre-emptively. Given that certain groups, such as older women and those with an adolescent partner, may have lower scores on resilience scales, these may represent key individuals who would benefit more from these types of interventions. Involving partners, where appropriate, to enhance support at each stage of the perinatal journey will also be crucial to success.
However, it is important to note that resilience mechanisms are difficult to enact when suffering from a MHD. Those who are already struggling with depression and/or anxiety may have poor resilience because of these conditions. Promotion of resilience boosting mechanisms is likely of use in these individuals, but it is important that other mental health interventions are delivered alongside, shifting the focus from tasks that might be too difficult to engage with, like self-esteem, gratitude, and forgiveness, when actively mentally unwell.
Resilience interventions will likely be helpful for women in the perinatal period, though consideration should be given to what is safe and effective for those with and those without pre-existing mental health disorders.
Statement of interests
I am a consultant epidemiologist in the Methods and Evidence Generation team at IQVIA, with a PhD in epidemiology from the University of Bristol investigating maternal antidepressant use during pregnancy.
Links
Primary paper
Mohammedamin H, Seyife AS, Zakir A, Mulatu TG, Alemayehu WY, Aman D, Mustefa AH, Fikadu WL, Wubishet G. (2024) Resilience and mental health among perinatal women: a systematic review. Frontiers in Psychiatry: 15. 2024. https://doi.org/10.3389/fpsyt.2024.1373083
Other references
Awini, E., Agyepong, I. A., Owiredu, D., Gyimah, L., Ashinyo, M. E., Yevoo, L. L., Aye, S., Abbas, S., Cronin de Chavez, A., Kane, S., Mirzoev, T., & Danso-Appiah, A. (2023). Burden of mental health problems among pregnant and postpartum women in sub-Saharan Africa: systematic review and meta-analysis protocol. BMJ Open, 13(6), e069545. https://doi.org/10.1136/bmjopen-2022-069545
Biaggi, A., Conroy, S., Pawlby, S., & Pariante, C. M. (2016). Identifying the women at risk of antenatal anxiety and depression: A systematic review. J Affect Disord, 191, 62-77. https://doi.org/10.1016/j.jad.2015.11.014
Hong, Q. N., Gonzalez-Reyes, A., & Pluye, P. (2018). Improving the usefulness of a tool for appraising the quality of qualitative, quantitative and mixed methods studies, the Mixed Methods Appraisal Tool (MMAT). J Eval Clin Pract, 24(3), 459-467. https://doi.org/10.1111/jep.12884
Howard, L. M., Molyneaux, E., Dennis, C. L., Rochat, T., Stein, A., & Milgrom, J. (2014). Non-psychotic mental disorders in the perinatal period. Lancet, 384(9956), 1775-1788. https://doi.org/10.1016/S0140-6736(14)61276-9
Johnson, K. M., Paley, F. M., Modest, A. M., Hacker, M. R., Shaughnessy, S., Ricciotti, H. A., & Scott, J. (2018). An assessment of depression, psychosocial factors, and resilience among women seeking prenatal care at an urban community health center. International Journal of Gynecology & Obstetrics, 140(2), 153-158. https://doi.org/https://doi.org/10.1002/ijgo.12358
Kishore, M. T., Satyanarayana, V., Ananthanpillai, S. T., Desai, G., Bhaskarapillai, B., Thippeswamy, H., & Chandra, P. S. (2018). Life events and depressive symptoms among pregnant women in India: Moderating role of resilience and social support. Int J Soc Psychiatry, 64(6), 570-577. https://doi.org/10.1177/0020764018789193
Kornfield, S. L., White, L. K., Waller, R., Njoroge, W., Barzilay, R., Chaiyachati, B. H., Himes, M. M., Rodriguez, Y., Riis, V., Simonette, K., Elovitz, M. A., & Gur, R. E. (2021). Risk And Resilience Factors Influencing Postpartum Depression And Mother-Infant Bonding During COVID-19. Health Affairs, 40(10), 1566-1574. https://doi.org/10.1377/hlthaff.2021.00803
Leddy, M., David, H., James, G., & and Schulkin, J. (2011). Postpartum mental health screening and diagnosis by obstetrician–gynecologists. Journal of Psychosomatic Obstetrics & Gynecology, 32(1), 27-34. https://doi.org/10.3109/0167482X.2010.547639
Milgrom, J., Hirshler, Y., Reece, J., Holt, C., & Gemmill, A. W. (2019). Social Support-A Protective Factor for Depressed Perinatal Women? Int J Environ Res Public Health, 16(8). https://doi.org/10.3390/ijerph16081426
Ogbo, F. A., Eastwood, J., Hendry, A., Jalaludin, B., Agho, K. E., Barnett, B., & Page, A. (2018). Determinants of antenatal depression and postnatal depression in Australia. BMC Psychiatry, 18(1), 49. https://doi.org/10.1186/s12888-018-1598-x
Werchan, D. M., Hendrix, C. L., Ablow, J. C., Amstadter, A. B., Austin, A. C., Babineau, V., Anne Bogat, G., Cioffredi, L.-A., Conradt, E., Crowell, S. E., Dumitriu, D., Fifer, W., Firestein, M. R., Gao, W., Gotlib, I. H., Graham, A. M., Gregory, K. D., Gustafsson, H. C., Havens, K. L., . . . Brito, N. H. (2022). Behavioral coping phenotypes and associated psychosocial outcomes of pregnant and postpartum women during the COVID-19 pandemic. Scientific Reports, 12(1), 1209. https://doi.org/10.1038/s41598-022-05299-4
Xiong, X., Harville, E. W., Mattison, D. R., Elkind-Hirsch, K., Pridjian, G., & Buekens, P. (2010). Hurricane Katrina experience and the risk of post-traumatic stress disorder and depression among pregnant women. Am J Disaster Med, 5(3), 181-187. https://doi.org/10.5055/ajdm.2010.0020
