Psychological conditions in pregnancy and the puerperium and their relevance to postpartum sterilization: a review.

L ,1 nalses l Bulletin ofthe WorldHealth Organization, 61 (3): 533-544 (1983) @ World Health Organization 1983 Psychological conditions in pregnancy and the puerperium and their relevance to postpartum sterilization: a review* K. D. BLEDIN1 & B. BRICE2 In many parts of the world, elective sterilization has become the preferred method of contraception for large numbers of women who have completed their families. Some concern has been expressed in the medical literature about the adverse psychological sequelae of the procedure. However, although many sterilizations are performed post- partum, there have been no attempts to separate the effects that may indeed be attributable to sterilization from those often associated with pregnancy and the puerperium. The present paper reviews major research findings in the perinatal field and relates them to results ofselected studies offemale sterilization. The review concentrates on psychological disturbances in the postpartum period, but changes during pregnancy, as well as disturbances in postnatal sexuality and menstruation, are also discussed. Well designed studies are called for in order to overcome the methodological difficulties often encountered in the existing literature. BACKGROUND Increasing numbers of women in many parts of the world are choosing sterilization as a means of fertility regulation when the desired family size has been reached (1-3). This phenomenon has turned the attention of many researchers to the psychological, psychosocial, and psychosomatic correlates and con- sequences of the procedure (4-6). There is also grow- ing concern about the number of women who are reported to be dissatisfied or regretful following sterilization or who request reversal of the operation (7-10). However, there is little clear evidence con- cerning the true incidence of dissatisfaction or regret following elective sterilization. Schwyhart & Kutner (11) described the weaknesses in design and method- ology that were to be found in many of the studies * From the Department of Psychiatry, Queens Medical Centre, University of Nottingham, Nottingham NG7 2UH, England. 1 Research Psychologist. 2 Research Assistant. they reviewed. These included combining women sterilized for medical reasons with those undergoing sterilization for purely contraceptive reasons, and the failure to differentiate between women who were sterilized at the time of or shortly after a delivery (with or without caesarean section) or termination, or at a longer interval after their most recent pregnancy. In addition, findings from cultures as diverse as Hong Kong (12), India (13), and Puerto Rico (14) have been compared in the literature with those from the United Kingdom (5) or the United States of America (15), although there is little evidence to support the validity of such crosscultural comparisons. Several studies have indicated that the incidence of an adverse psychological outcome may be reduced if an interval is allowed between any obstetric event and sterilization (5, 16). Nevertheless, in England and Wales, postpartum sterilizations comprise a large (though decreasing) proportion of all sterilizing operations performed in National Health Service hospitals (1), and in India, most reported psycho- logical studies of tubal ligation contained only a 4311 533- 534 K. D. BLEDIN & B. BRICE "sprinkling" of non-puerperal cases.' It may be in- structive to consider studies of postpartum steriliz- ation in particular, for example those of Lu & Chun (12), Sacks & LaCroix (17), or Kaij & Malmquist (18), and more recent studies of sterilization that in- cluded postpartum cases, such as those of Whitelaw (6), Campanella & Wolff (15), or Enoch & Jones (19), in the light of what is known about the puerperal period generally. If pregnancy and the puerperium are periods of great emotional lability, major de- cisions taken during these periods may well be charac- terized by subsequent doubts or ambivalence. In this context, it is worth mentioning a report that 20 patients who chose not to be sterilized postnatally did not have significantly different symptoms during pregnancy than the sterilized sample in that study (20). The present paper provides a broad overview of the literature concerning emotional and psychological aspects of pregnancy and the puerperium, with par- ticular reference, where applicable, to the types of problems and dissatisfactions reported by sterilized women. INTRODUCTION The subjective experience of pregnancy is said to be determined by the woman's capacity to maintain an equilibrium between and within her biological, social, and psychological systems and subsystems (21, 22). Persistent or severe inadequacies in any of these areas or in their interaction may lead to spiralling adverse effects (23). Identification of the inadequacies or pre- disposing factors involved in this process may be useful in identifying the women most at risk of puer- peral disturbance of varying levels of severity. It is possible that such women are among those at highest risk of an adverse outcome following postpartum sterilization. Their early identification would allow appropriate counselling to take place, which might help to reduce subsequent regret and dissatisfaction, and their consequent effects on the lives of the women and on the resources of the health service. Sterilizations that are medically indicated, or that are performed concurrently with caesarean section, will not be considered further here (see 5, 16, 24). Similarly, the woman's experience of labour and delivery will not be discussed, although this is not to deny its possible relevance to later psychological problems (21, 25). The literature relating to various psychological out- comes following pregnancy may be considered in a WIG, N. N. Mental health and population growth. First Dr D. L. N. Murti Rao oration, 31st Annual Conference of Indian Psychiatric Society, Pune, 5 January 1979. terms of several interrelated aspects of the psycho- logical experience of pregnancy. These aspects and their relationships will be considered in turn. CHANGES DURING PREGNANCY Physiological changes Pregnant women experience obvious changes in body shape, but changes also occur in the endocrine system, in the autonomic nervous system, in the cir- culating fluid, and in cardiac output (26). The weight gained and carried during pregnancy often results in increasing problems in mobility, and may also be associated with a variety of physical complaints of varying severity. Consequently, a formerly active woman may find herself limited in her ability to func- tion fully in all of her roles, and her body image may be radically altered (27). A sense of frustration may result, which may be exacerbated by, and may re- bound on, other members of her family who maintain high expectations of her performance (22). A decision at this time to be sterilized, as a way of avoiding a repetition of her present situation, may later be re- gretted, as it would not necessarily be based only on the wish to end her fertility, an important criterion for successful outcome (28). Other physical symptoms may be more psychologi- cally or psychosocially based than those described above. In one study of primiparae, for example, patients who complained of a large number of physi- cal symptoms during pregnancy were found to have a less favourable reaction to their pregnancy than those without symptoms (29). Moreover, they more commonly had a history of isolation, anxiety, in- adequacy, social disorganization, and sexual and interpersonal difficulties. It is clear that the social and psychosocial environ- ment may be of considerable importance to the sub-jective evaluation by the pregnant woman of her own health (27). Accordingly it should be taken into account in any investigation of general physical health following postpartum sterilization, for example that carried out by Enoch & Jones (19). Social changes The interaction of internal and external events in the life of a pregnant woman produces a set of circum- stances that she may find stressful. Most significant may be the role changes and consequent change of status that she is expected or forced to undergo in relation to her husband and children (22, 30, 31). These may result in increasing tension within the family unit, particularly if there are difficulties in the prospective father's attitude to the pregnancy (32). PSYCHOLOGICAL CONDITIONS IN PREGNANCY AND THE PUERPERIUM Changes in sexuality Marital conflicts may be aggravated by a decline in coital activity during pregnancy (33). However, sexual adjustment during the pregnancy appears to be related to the importance of sex in the relationship before the pregnancy (34, 35), although information concerning pre-pregnancy sexual activity is perforce retrospective. Some pregnant women report increased sexual activity and enjoyment (22, 33), but the majority are unable to adjust successfully or completely to their changed circumstances because of fatigue, loss of libido, fear of injuring the baby, physical discomfort, problems in positioning, or because they are follow- ing the recommendations of a medical practitioner (33-35). These problems may well be of relevance to reported changes in sexual activity and satisfaction following postpartum sterilization. The question of postpartum sexuality will be discussed further in a later section. Psychological changes The psychological state of the pregnant woman determines to a large extent the way she reacts to the variety of physiological, social, and sexual changes that the pregnancy brings about. Marked mood changes have long characterized medical and psychological profiles of pregnancy (22, 36). However, recent research (37) has indicated that the incidence of mood change or of depression may be no greater among pregnant women than among non-pregnant controls. The present discussion will focus on the small proportion of women who ex- perience more extreme psychological changes, or even psychiatric symptoms (38), during pregnancy. Pre- diction and identification of such cases should enable early or preventive intervention to take place (30). In the developed world, and in certain areas of the developing world, pregnant women are in a favour- able position to receive such intervention since they are already in contact with the medical profession whilst their counterparts in the general community may well go unnoticed and untreated. In other cul- tures, traditional preventive measures or remedies may be employed (39-41). In a study by Namboze and others (cited by German (42)) of pregnant rural Ugandan women with a variety of psychiatric disorders, depressive symp- toms were found to be most common. Kumar & Robson (43) and others have found the incidence of depression to be at its highest in the first trimester, although unresolved intrapsychic conflicts have been said to arise often during the second trimester, when the individual's defence mechanisms and resources for coping appear to weaken (44). Other writers, such as Caplan (22), have recorded that, in later stages of pregnancy, women become increasingly introverted, passive, dependent, depressed, lacking in confidence, and overwhelmed by fears connected with the role of motherhood. Such fears sometimes developed into clinical symptoms, often of anxiety (22, 45). Some of these anxieties- for example, fearful forebodings concerning the baby's health -can be seen to be asso- ciated with the fears and regret sometimes experi- enced postpartum by women who have been sterilized and who would thus be unable to replace a lost child (28). However, in trying to identify variables predictive of psychological disturbance in pregnancy, evidence has, until recently, consistently been descriptive rather than explanatory. It is important to establish whether mental disturbance in the perinatal period is precipitated by or simply coincides with the preg- nancy; indeed, the pregnancy may simply be used as a channel to express emotions relating to preceding or continuing social, cultural, or environmental stresses such as poor housing, socioeconomic disadvantage, or unplanned pregnancy (46-48), or being separated or unmarried in certain African cultures (39, 41). In a few cases, it may represent a reactivation of pre- viously suppressed mourning concerning an earlier induced abortion (43). Dalton (49), on the other hand, postulated that in- creases and sudden drops in placental progesterone levels during and after pregnancy may lead to the commonly experienced rapid mood swings of preg- nancy and the puerperium. The symptoms would be particularly marked in women who have difficulty in adjusting to these changing levels (49, 50). In conclusion, it would appear that the medical profession prefers to allow psychological and mood changes during pregnancy to run their course (40). However, this does not account for the deficit of psy- chiatric admissions (in relation to their expected incidence) during pregnancy or for the excess of admissions postnatally (51); there is firm epidemio- logical evidence that childbirth itself is associated with mental illness (52). For the women whose psychological problems during pregnancy continue after delivery, the lack of early attention may be regarded as an unjust aggravation of their difficulties. However, the alternatives are often not straight- forward. Even if hormonal changes are indeed at the root of the problem, as suggested by Dalton (49, 50) (and it should be noted that the samples on which her conclusions were based were small and suffered from high drop-out rates, and the technical grounds on which her conclusions were based are difficult to establish), the safety of hormonal or other drug thera- pies during pregnancy could not be ensured (53-56). If environmental factors are found to be reliable pre- dictive indicators, as suggested, for example, by Nilsson and his colleagues (46, 47, 57), little could be 535 536 K. D. BLEDIN & B. BRICE done to improve inadequate income or housing. Con- sequently, low levels of attention to psychological problems in pregnancy may be due, at least in part, to the absence of any practical solutions to these problems. POSTNATAL DISTURBANCE Psychological and emotional disturbances con- tinue or begin to manifest themselves in a substantial proportion of women postnatally. In most cases, these disturbances occur as mild depression ("the blues") of rapid onset (3-10 days postpartum) and short duration (36, 58). In others, the depression may be atypically severe (59, 60). In such cases, onset usually occurs within three months of delivery (61). A very small minority of patients suffer from major psychiatric disorders in the puerperium (60, 62, 63). Each of these categories of disorder warrants further consideration. Mild postpartum disturbance: the blues Probably the most common form of postpartum psychological disturbance is the "baby blues", with reported incidence ranging from 507o to 80%o (36). Pitt (58) reported that 50%o of a sample of new mothers experienced the blues some time during the first ten days following delivery. This condition is character- ized by fatigue, insomnia, tearfulness, anxiety, irri- tability, restlessness, and/or mild confusion (36, 58), symptoms which have also been observed, with an incidence similar to that found in developed coun- tries, in East African and West Indian mothers (48, 64). The blues have been associated with the vomiting, crying, and sleeping behaviour of the new- born infant (49), with high parity (48, 65) -possibly related to social and socioeconomic factors within a particular sociocultural environment (48) -and with psychosocial ("delayed stress reaction") and endo- crinological factors (imbalances between the proges- terone and estrogen levels following delivery) (36). These explanations account for the transient nature of the syndrome and the frequent absence of causal personality or stress factors (36). However, the as- sociation of hormones and puerperal mood has yet to be shown conclusively (66, 67). Postpartum blues appear to be of little concern, either to the women themselves or to the medical pro- fession. Pregnant women are usually forewarned about the probable advent of these symptoms. Their relatively brief duration and mild nature prevent them from becoming a medical problem. No published study of postpartum sterilization has investigated the psychological effects of the pro- cedure in the very early puerperium. It is thus unlikely that postpartum blues have been erroneously de- scribed as regret or dissatisfaction following steril- ization. In this regard, it is of interest that four post- partum ligation patients in Davidson's study in Jamaica all experienced "severe" levels of the blues, although only in one case could the ligation itself have been held as a possible cause (48). It is easy to under- stand that women sterilized postpartum may attribute their "normal" experience of the blues to the steriliz- ation. Scapegoating of this kind has also been described in relation to oral contraceptive use (68). Any complication surrounding the delivery or steril- ization procedure, or doubts or ambivalence concern- ing them, may then compound the mild depression, and regret or dissatisfaction with the sterilization may ensue. Atypical postnatal depression More severe problems persist in a smaller propor- tion of women. Chronic fatigue, appetite distur- bances, loss of sexual interest, irritability, anxiety, depression, and physical symptoms such as headache, backache, mastitis, or feelings of bloatedness have been reported in such cases (27, 59), which Pitt (59) described as atypical depression. This depression worsens toward evening and is characterized by the prominence of neurotic symptoms, notably unjusti- fied anxiety over the baby (21, 60). The reported incidence of such symptoms has ranged from under 3% (61, 69) to 19-25%7o (25, 47)," but is most often cited as around 10%, a proportion found in a number of diverse cultures (40, 59). Some studies have indicated that women suffering from atypical depression were comparable with non- puerperal cases of psychological disturbance in terms of history of previous mental illness (70). One impli- cation to be drawn from these findings is that preg- nancy or parturition, like many other stressful events (71), may trigger a negative reaction, which culmin- ates in psychological disturbance in vulnerable indivi- duals (72). Ryle's data supported this view, empha- sizing the provocative, rather than causative, role of childbirth in the generation of "attacks of depression with endogenous features" (61). From this stand- point, Ryle pointed out the dangers of recommending sterilization in such cases. Yet early identification of high-risk patients is by no means straightforward. Prediction ofpostnatal depression The identification of variables predictive of post- natal depression has been hampered by method- ological problems in research in this area. There is a b The 25%o reported by Jacobson et al. (25) was made up of sub-jects who had experienced seven or more "fairly serious symptoms" of anxiety and depression. PSYCHOLOGICAL CONDITIONS IN PREGNANCY AND THE PUERPERIUM 537 lack of adequate brief rating scales of mood validated for pregnant women (40) and studies such as those of Nilsson and his colleagues (57, 73) have been uncontrolled and retrospective. Standardization across different studies of depression has seldom been attempted,c and criteria for case definition have varied considerably (74). In addition, published reports have often been based on data from small numbers of postnatally depressed cases (e.g., 49, 50, 69, 75). For all these reasons, it is difficult to draw firm conclusions from the available literature. Investigators have been variously concerned with postpartum blues (36, 76, 77), postnatal depression (61, 69), postpartum psychosis (78-80), or the whole spectrum of severe postpartum mental illness (62, 63, 81, 82). Nevertheless, few studies have been suffi- ciently complete to allow comment on the full range of relevant variables. Furthermore, there has been little systematic research on psychiatric disorder as a late sequel to childbirth (74) and Gelder's review (67) emphasized that the course and symptomatology of postpartum depressive disorders have not been ad- equately described. All these factors have contributed to the difficulties involved in identifying clearly unique or definitive features of postpartum depression. Full psychosocial and endocrinological profiles, assembled in method- ologically sound studies, are needed in order to iden- tify the variables and (subsequently) their interactions that may be indicative of future psychological disturbance (67). The psychological/psychosocial findings available to date, subject to the above qualifications, are summarized below.d Various studies have found that women at high risk of postnatal depression may be younger than low-risk women (70, 74), or over the age of 30 years (37), or there may be no difference in age (25, 59, 86). Parity has been discounted as a related variable (25, 74), with qualifications (87), although a recent study (63) suggested that primiparous women may be at in- creased risk of psychiatric admission in the puer- perium. Previous psychiatric history is not necessarily a risk factor (59, 86), but often is one (53, 57, 70), and may include previous episodes of postpartum depression (88). Experience of postpartum blues may also be an indicator (59), although perhaps only in a "small hormonal group" (70). Symptoms of anxiety during the current pregnancy have been found by some (69, 89), but not by others (53, 60), to be strong indicators of later depression. Personality predisposition has been offered as an important factor in atypical de- pression (59, 69) although Gordon et al. (30) found c See, for example, Jacobson et al. (25). d For further details concerning psychoendocrinological studies, see Nott et al. (66), Stein et al. (83), Handley et al. (84), and Ballinger et al. (85). their "personal insecurity factor" to be of less signi- ficance than their "maternal role conflict factor". There is indeed relatively widespread agreement that high-risk women are more likely to have (a) had problems in their relationship with their mother (30, 90); (b) rejected or had ambivalent feelings toward the female or mothering role (90, 91); (c) held nega- tive attitudes toward the current pregnancy (92); and (d) if married, had marital problems or non- supportive husbands (32, 70, 74, 88). However, un- married status itself may be a risk factor (74, 88), although this does not appear to be invariably the case (25). A history of gynaecological difficulties, most notably dysmenorrhoea, has been implicated in pre- dicting atypical depression (25, 59, 86). Similarly, obstetric problems, either previously (32, 69) or cur- rently (57), have been associated with mental disorder following parturition. So too have unplanned and undesired pregnancies (73, 88). In this regard, find- ings in sterilization studies such as that of Barglow & Eisner (20)- "marked psychopathology" in 6% of their sample, retrospectively assembled- require further, closer scrutiny; a high proportion of the women surveyed had not expected or desired the preg- nancy that preceded the sterilization. "Social circumstances" (23, 69), such as belonging to a lower social class (74), and significant life events (70) or "life stresses" (32), within the context of the prevailing culture (32, 41, 48), also appear to be of significance in understanding postnatal morbidity. The breadth of this final category of risk factors highlights the sweep of the variables listed above. While the presence of the variables listed may indeed serve as a predictor of later illness, their "absence tells us nothing" (31). Subtler factors, that are even more difficult to evaluate, may be at work. In this cloud of confusion and contradictions, it is not surprising that research to date has failed to estab- lish a definitive profile of the women at risk of post- natal depression. It should be clear that adding post- partum sterilization to the list of variables is likely to render attempts at prediction of outcome even more tentative. Further, it may be surmised that, to some extent at least, reports of adverse sequelae of female sterilization reflect "normal" levels of atypical post- partum disturbance. In these cases, the sterilization may be identified as the significant causative factor by the women themselves or by researchers investigating its outcome, although in fact it may be related only in- directly, if at all, to the reported symptoms. This difficulty could be overcome by appropriate method- ology, and a well designed study is certainly called for. The literature concerning the prediction of more severe postnatal mental illness is also not straight- forward. Indeed, recent retrospective studies of puer- 538 K. D. BLEDIN & B. BRICE peral psychoses have been complicated by the recom- mendations contained in the Eighth Revision of the International Classification of Diseases, concerning "puerperal psychosis" (93). Yet disturbances of greater severity may be regarded as even more of a problem since they may persist or recur for up to four years (or more) after delivery (81, 82). Indeed, data from a recent study (82) suggested that poor prog- nosis may be positively related to the severity of the morbid episode. The question of severe mental illness and psychosis in the puerperium has received much attention in the medical literature of many countries (62, 63, 78, 79, 94-104), and is considered further in the following section. Postpartum psychosis and severe mental illness The incidence of functional psychosis and severe depressive illness in pregnant and puerperal women increases sharply in the first three months following delivery (51, 62, 63). However, the pattern of psy- chiatric admissions in the puerperium appears to be bimodal, with a second peak 9-24 months later (62, 105). One small American study (106) has distin- guished patients admitted early in the postpartum period (within 5 weeks) from those admitted late (10 weeks to 15 months postpartum) on a number of items on a "specially constructed rating scale". Al- though the value of these findings is open to question, the relevance of outcome to timing of onset is not to be denied (96, 107, 108). The incidence of postpartum psychosis, most commonly manifested in affective symptoms (63, 93, 109), has usually been reported as 1-2 per 1000 de- liveries (63, 93, 110), although rates in excess of 2 per 1000 have also been reported (62, 111). Ebie (109) commented on the high proportion (24%/) of patients diagnosed as in a "confusional state" in his Nigerian sample, which reflected not only their poor physical status (109) but also the "massive contributions" of organic or toxic conditions to "any mental state" in sub-Saharan Africa (42). Clinically and constitutionally, women suffering from severe puerperal illness seem to resemble other comparably ill patients more closely than they do puerperal women free of psychosis or severe disturb- ance (60, 72). Although one study (112) has identi- fied two types of psychotic process during the puer- peral period-a "recurrent type" and an "attack- like progressive type" -there appears to be general agreement that puerperal psychosis is no different from other functional psychoses in terms of genetic predisposition, symptoms, or outcome (94, 110). However, more recently, Dean & Kendell (93) con- cluded that the possibility that some cases may be spe- cific to the puerperium had not been excluded; the few differences that have been found between women with puerperal and non-puerperal psychoses may be largely accounted for by small subgroups of cases with "organic" symptoms (93). Banzhaf et al. (113) have advised, in this regard, that comprehensive neurological testing may be needed to exclude the possibility of confusion with cases of organic cerebral disorders. Complications of pregnancy have been implicated in the etiology of postpartum psychosis (111). Febrile illness in the puerperium, preceding or coinciding with the onset of psychiatric symptoms, has been noted in a high proportion of patients in Nigeria (109), and Cox (114) suggested that "amakiro", a traditional puerperal illness among the Baganda women of Uganda, may have its origins in a physical illness. The relevance of infection has also been dis- cussed outside the African context (15) while the role of immunoallergic processes has been affirmed in another Russian study (116). Paffenbarger et al. (78) distinguished postpartum psychotics from non-psychotics in terms of a number of obstetric features and length of interpartum inter- vals and concluded that these psychoses are primarily of somatic rather than psychic origin. However, con- clusive evidence concerning the role of somatic factors in severe postpartum illness is lacking, although women having caesarean section may be more at risk (63, 93). Psychological and social factors, in particular stress and intrapsychic conflict, have also been postulated as key factors in the etiology of postnatal illness (60). Psychodynamic models have been prof- fered, which revolve around the patient's relationship with her husband and/or mother (91, 97). A stress- summation theory has been proposed by way of ex- planation (117), and a number of authors (30, 95, 98) have argued that mental disturbance results from the interaction of life stresses (complicated pregnancy or delivery, new roles and responsibilities in the absence of adequate models, etc.) and an existing predispo- sition to mental illness (118), which may be related to a family history of psychiatric illness (72, 111). Kadrmas et al. (80), by contrast, found no evidence that postpartum psychosis followed familial patterns. Age may also be a factor, older women being more at risk (78, 98), although Kendell et al. (63) found no such association for disturbance within three months of the birth, and most patients in Ebie's Nigerian sample (109) were primiparae aged under 30 years.e Primiparity itself has recently been identified as a high risk factor (63). Grundy & Roberts (110) suggested that cyclical variations may interact with life stresses to be the ' Ebie (109) pointed out, however, that young primiparous women were likely to be over-represented in the population from which his sample was drawn. PSYCHOLOGICAL CONDITIONS IN PREGNANCY AND THE PUERPERIUM 539 major etiological factor in all psychoses, including those in the puerperium, but analyses performed by Kendell et al. (62) failed to support this view. In summary, it is clear that the etiology of severe postnatal mental illness is not well understood and, that problems concerning its nosological status remain unresolved (93, 95, 96)! Whatever the causes of puerperal psychiatric ill- ness, good prognoses have been reported (80, 120). The reported risk of recurrence has ranged from under 10%o (121) to 35%o (78) in published studies, although some groups of high-risk women may avoid further pregnancies (121). A variety of treatment methods has been assessed (122-124), and it has been suggested that, in traditional societies, treatment may be more effective when there is collaboration between orthodox and traditional healers (114). It is relevant that, with few exceptions (e.g., Enoch & Jones's study (19)), psychoses following post- partum sterilization have been reported only rarely (less than 1% in Lu & Chun's sample (13), for in- stance). Morbidity in the study by Enoch & Jones (19) was strongly associated with a previous psychiatric history. The timing of this morbidity (onset within three months of surgery in most cases and 18-24 months postoperatively in the remainder) and its symptomatology ("of the affective type") are sug- gestive of postpartum psychosis (cf., 60, 62, 93, 105), but it is not clear from the published report what pro- portion of Enoch & Jones's patients who developed "frank psychiatric illness" were in fact sterilized post- partum. Disturbances in postnatal sexuality Even if women do not suffer from psychological problems in the postpartum period, they may well experience adverse changes in other areas of their lives, most notably in their sexual relationship and their menstrual pattern. Changes in sexual behaviour following delivery may be due to tension, fatigue, or pain from episi- otomy (35). Analyses of sexual patterns and function- ing in the postpartum period should take account of these factors as well as of the woman's sexual atti- tudes before the pregnancy, her husband's role, and her experience in caring for an infant (34). Most women interviewed by Robson et al. (35) had resumed intercourse by three months postpartum, but the frequency of intercourse was lower than before the pregnancy. Twelve months after delivery, more than half of this sample were still having intercourse less often than in the month before conception (35). f It is of interest that the traditional Chinese methods of mental treatment dating from 2000 B.C. and still practised in certain coun- tries of south-east Asia include puerperal insanity in the etio- logically-based classification system (119). Sexual adjustment following an unplanned preg- nancy was investigated by Nilsson et al. (73). More problems of adjustment were revealed among multi- parous women, aged over 30 years and married for ten years or longer. Fear of another unwanted preg- nancy was an important source of these problems (73). Postpartum sterilization could eliminate such fears in this group of women, particularly since it is in this age group that elective sterilization procedures are most common, in both developed (1) and develop- ing countries (125). It should be noted that a high incidence of psycho- sexual problems has also been reported following postpartum sterilization in various parts of the world (13, 18). In considering such cases, patients' previous sexual attitudes and relationships should be taken into account (28); subjective reports of sexuality after postpartum sterilization may reflect sexual attitudes and activity before the sterilization or the pregnancy (35). Nevertheless, the possibility of an interrelationship between problems of postnatal sexuality and more overtly psychological disturbances should not be completely discounted. Further research in this area is greatly needed, particularly since normative levels of various aspects of sexuality cannot be prescribed. Disturbances in postnatal menstruation Return to prepregnancy patterns in the menstrual cycle is also difficult to predict accurately. It is, of course, well established that biosocial factors, most notably reflected in lactation patterns, may influence the duration of postpartum amenorrhoea (126). The possibility that postpartum sterilization contributes to postnatal menstrual changes or severe disturbances as reported, for example, by Muldoon (127) cannot be ruled out. However, other authors have suggested that subjectively-reported post-sterilization men- strual disorders, found most commonly in studies conducted in Hong Kong, India, and the United King- dom,9 may be determined by presterilization. men- strual patterns (6) or affected by previous contracep- tive use (128-130). The natural aging process has also been implicated (17), but contradictory evidence has been reported more recently by Kwak et al. (129). The interaction of biological and social factors in determining menstrual functioning constitutes an area of considerable importance in the study of puer- peral health and illness, as shown in the work of Jain et al. (126), for example. Growing interest in this area (131, 132) reflects the increasing recognition of the 8 BLEDIN, K. D. Psychosomatic sequelae of female sterilization: an international perspective. Unpublished paper delivered to British Psychological Society Conference on the Psychology of Human Reproduction, Leicester, 23-27 September 1980. (Copies available from the author on request.) K. D. BLEDIN & B. BRICE wide range of variables that, alone or in combination, may affect psychological and psychosomatic health and illness in the puerperium. CONCLUSION This paper has reviewed the literature concerning psychological and psychosocial aspects of pregnancy and the puerperal period. Factors affecting adjust- ment to pregnancy and psychological and psycho- sexual outcome following pregnancy and delivery have been discussed and the role of postpartum steril- ization in these processes has been considered. Although a wide variety of variables has been im- plicated in the etiology of psychological disturbance during pregnancy and the puerperium, no single vari- able or group of variables has been identified as an essential causative factor. The prevailing social organization and values, aspirations, beliefs, and customs affect health and health care more at the time of pregnancy and the puerperium than at any other time of the adult's life (133). Thus it is difficult to account for the relationships that have been estab- lished in either purely psychological or somatic terms (63). The etiology of psychological illness in general is also not always well defined. Attempts to predict or explain psychological disturbances in pregnancy and the postpartum period may be expected to be cor- respondingly uncertain. The introduction of yet another variable, sterilization, to the array will inevi- tably add to the uncertainty, not least because the psychological implications of this procedure may be expected to vary with its social acceptability in differ- ent cultural settings. A surprisingly high level of psychiatric illness in women in the community has been observed by Brown and his colleagues in London (71, 134), while in another British study (135), the peak incidence of depressive disorders was found in married women of childbearing age. The extent to which pregnancy, parturition, and postpartum sterilization magnify the risk and/or the severity of such illness remains to be precisely established. A series of controlled prospec- tive studies, preferably in a variety of cultural settings, using standardized instruments and pro- cedures, may begin to resolve some of these issues. ACKNOWLEDGEMENTS The authors wish gratefully to acknowledge support by the World Health Organization between 1978 and 1981, when they were participating in a WHO-sponsored multicentre collaborative study on the psychosomatic sequelae of female sterilization. We wish also to thank Professor J. E. Cooper and Dr M. Oates of the University of Nottingham Department of Psychiatry for their helpful comments and advice during the preparation of this article, Mrs W. M. Bergenroth for patiently typing and retyping several drafts of the manuscript, and Miss J. Mawby of the University of Nottingham Medical School Library for her assistance in obtaining the foreign language references cited. RESUMt IMPORTANCE DES tTATS PSYCHOLOGIQUES DURANT LA GROSSESSE ET L'ACCOUCHEMENT POUR LA STtRILISATION POST-PARTUM: UNE REVUE Dans bien des regions du monde, la sterilisation volon- taire est devenue la methode contraceptive de choix pour nombre de femmes qui estiment avoir eu assez d'enfants. On s'est inqui&e cependant des taux signales de sequelles psychologiques defavorables, de regrets ou de demandes de retablissement de la fertilite apres strilisation a but contra- ceptif. Selon les rapports, les reactions defavorables seraient plus frequentes apres des sterilisations pratiquees au moment d'un evenement obstetrical, de l'accouchement par exemple; mais les sterilisations post-partum constituent dans beaucoup de pays une proportion importante de l'en- semble des st6rilisations. Si l'on veut etre en mesure de d6finir ou d'evaluer clairement les effets des sterilisations pratiquees post-partum, il faudra les distinguer de ces modifications de l'affect ou de la fonction associees a une grossesse et a une parturition non suivies de sterilisation. Cela facilitera l'identification des femmes particulierement exposees a des reactions defavorables. C'est dans ce but qu'a et entreprise une revue de la litt&e rature concernant les aspects psychologiques de la grossesse et de la puerperalite. Les articles qui ont e passes en revue traitent des modifi- cations physiologiques, sociales, sexuelles et psychologiques ou emotionnelles qui peuvent intervenir au cours de la grossesse, ainsi que des troubles psychologiques, sexuels et menstruels de la periode post-natale. Les troubles psycholo- giques de cette periode peuvent etre classes en <cafard de l'accouch&>> frequemment signale par les jeunes meres, et qui ne preoccupe gravement ni les femmes elles-memes, ni 540 PSYCHOLOGICAL CONDITIONS IN PREGNANCY AND THE PUERPERIUM 541 les m6decins; depression <<atypique>>, plus grave, et qui persiste chez certaines femmes; enfin, psychose puerperale et maladie mentale grave, qui n'est que rarement rap- portee. Du fait de nombreuses faiblesses methodologiques, on ne peut guere tirer de conclusions fermes des etudes passees en revue. Ainsi, les facteurs clairement predictifs de troubles psychologiques moderes ou graves pendant ou apres la grossesse n'ont pas ete identifies, bien que l'on ait parle a ce propos d'influences hormonales, ou encore de circonstances sociales; plus specifiquement, les femmes les plus expos&es a des troubles plus importants apres la naissance sont ou bien jeunes, ou bien de plus de 30 ans, ont eu des difficultes dans leurs relations avec leur m&e et dans leur propre role ma- ternel, ont des maris qui ne les soutiennent pas et/ou des difficultes conjugales. Les recherches sur la contribution, a titre de cause ou d'explication, d'autres variables demogra- phiques et sociales et des antecedents obstetricaux ou gynecologiques n'ont dans l'ensemble pas apporte d'indi- cations concluantes. L'incertitude ne fait que s'accroitre si l'on ajoute la sterilisation post-partum a cette liste de variables independantes postulees. Les plaintes relatives a une deterioration de la sante physique ou mentale, de la sexualite ou du cycle menstruel apres sterilisation post-partum peuvent etre en rapport avec le niveau de sante qui existait sur ces plans avant la grossesse, ou avec des difficultes personnelles ou inter- personnelles pr6existantes. Elles peuvent etre une traduction des experiences onormaleso de cafard des accouch&es, ou de la depression <atypique> post-natale, sans rapport donc avec la sterilisation mais rapportees a celles-ci par les femmes elle-memes ou par les chercheurs qui se penchent sur ce probleme. On ne peut toutefois exclure la possibilite que la sterilisation post-partum ait reellement un effet sur le fonctionnement ulterieur de l'organisme, et en particulier sur la menstruation. II est indispensable de proceder a des etudes prospectives bien concues et controlees pour essayer d'apporter une solution a quelques-uns de ces problemes. REFERENCES 1. BLEDIN, K. D. ET AL. 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