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Abstract

Background:

Coping strategies like self-distraction and self-blame predict later maternal mental health problems; however, little is known about changes in coping strategies that occur within pregnant individuals.

Objectives:

This study analyzed intrapersonal changes in individual coping strategies between the prenatal and postnatal periods.

Design:

A prospective longitudinal pilot study

Methods:

We recruited 59 women from a perinatal medical center in Tokyo. Participants answered the Brief COPE at late pregnancy and 4 weeks postnatally. We performed paired-samples t-tests to identify the differences in coping strategies between two timepoints.

Results:

Fifty-four women completed questionnaires at both timepoints. The scores for self-distraction, denial, and self-blame significantly decreased after childbirth.

Conclusion:

This study demonstrated that women may change their individual coping strategies throughout their perinatal experiences. This finding could help further research explore women who cannot change high-risk coping strategies, as well as consider ways to empower women in selecting coping strategies during the perinatal period.

Keywords

pregnancy postpartum mental health COPE intra-personal change longitudinal study

Introduction

A significant proportion of women experience high stress levels during pregnancy.¹ Stress management during the perinatal period is crucial because high stress during pregnancy has been associated with the deterioration of maternal mental health, such as perinatal depression.² Maternal mental health is a major issue in Japan, where 14% of women develop depression at 1 month after childbirth.³

Similar stressors appear to affect individuals differently. One reason may be coping,⁴ which has been defined as the constantly changing cognitive and behavioral efforts aimed at dealing with the demands of specific situations that are appraised as stressful.⁵ Some previous studies found that pregnant women who relied more on avoidant or passive coping strategies were at a higher risk of later depressive symptoms^6–8; however, a systematic review indicated that variations in the timing of assessments (from early pregnancy to postpartum) make it difficult to conclude the associations between coping and psychological states during the perinatal period.¹

Moreover, since pregnancy and childbirth trigger fears such as childbirth and well-being of the child and mother,⁹ individual coping strategies may be modified. Previous studies have focused on between-person differences in coping; however, little is known about the dynamic nature of coping in individuals over time. One previous study examined within-person changes and found that most coping strategies declined at 2 months postpartum compared to before giving birth¹⁰; however, a high dropout rate and selection bias (overrepresentation of primiparous pregnancies without major complications) in the study draw difficult conclusions.

This study examined within-person differences in individual coping strategies among women during the perinatal period by assessing them at two points (prenatal and postnatal), using a high follow-up rate sample in Japan.

Materials and methods

Settings and participants

This prospective longitudinal study was a pilot study for further examination of perinatal mental health in Japan. This study was conducted at a single regional perinatal medical center in Tokyo. Outpatients who were Japanese, aged 18 years or above, pregnant with one baby, in late pregnancy, had no difficulty in reading Japanese, and were planning to deliver at this hospital were eligible for this study. The exclusion criteria included women whose fetuses were diagnosed with congenital abnormalities because this may induce unique stress due to concerns for the baby. Eligible participants were consecutively recruited both orally and in writing during the office visit by the first author in March 2021 (response rate: 100%). They were informed that participation was voluntary and that they could return the questionnaires either directly or by mail. Participants answered questionnaires at two timepoints: late pregnancy (28–36 weeks pregnant on recruitment: T1) and 4 weeks postnatally (at 1-month postpartum: T2) (Supplemental Material). Mothers whose babies could not leave the hospital until T2 were considered as dropouts because of unique parenting stress. Participants received a 500-yen gift certificate (roughly equivalent to U.S. $5 when this study was conducted) in return for each questionnaire. This study was approved by the institutional review board of the University of Tokyo (approval code: 2020154NI). All participants provided written informed consent for participation before administering the questionnaires.

Sample size

We calculated the sample size in pilot studies for identifying unforeseen problems for a potential larger study.¹¹ We chose to identify 5% probability of problems in a potential study; therefore, we need to include 58.4, or rather 59 participants in this study, so that we can detect the problem with 95% confidence. Unlike the primary object, the current report is a post hoc analysis conducted to find patterns of variation in coping strategies during the perinatal period.

Measures

The Brief COPE¹² is a validated 28-items measure of 14 coping strategies or styles developed for the general population and has been reported to have acceptable reliability during pregnancy.¹³ This study used the validated Japanese Brief COPE.¹⁴ Items are rated on a 5-point Likert scale, and scores of each coping strategy are calculated as the sum of the two items, ranging from 2 to 10. A high score reflects the frequent use of that coping strategy. Participants were asked about their coping strategies “from pregnancy to present” at T1 and “from childbirth to present” at T2 by explicitly stating this in the question. T1 data were collected in March 2021, and T2 data were collected from April to July 2021. Spearman–Brown coefficients¹⁵ for each coping strategy ranged between 0.44–0.98 at T1 and 0.48–0.87 at T2 in this study (except “active coping”), which were almost similar to those found in the study on the development of the Japanese Brief COPE and thought to have acceptable reliability.¹⁴ “Active coping” was excluded from further analysis because it showed very low reliability (Spearman–Brown coefficient: 0.23 at T1 and 0.15 at T2).

Regarding demographic characteristics, participants were asked about their academic background and annual household income in the T1 questionnaire. Data on age, marital status, obstetric data (parity, means of conception, gestational age, delivery date, and baby’s birth weight), and history of mental disorders were obtained from medical records.

Statistical analysis

The averages for each coping strategy between T1 and T2 were compared using paired-samples t-tests. Cohen’s d was computed as an effect size using the approach in which corrections were made to account for the correlation between the two samples.¹⁶ A complete case analysis was performed for missing values. In addition, a sensitivity analysis was performed after excluding participants who had a history of mental disorders. The threshold for significance was set at p < 0.05. All statistical analyses were performed using R for Windows (version 4.0.2; R Foundation for Statistical Computing, Vienna, Austria).

Results

Study participants included 59 pregnant women. Table 1 shows the participants’ demographic and obstetric characteristics. Slightly more than half of the women were expecting their first baby. Fifty-four women answered the postnatal questionnaire (T2) with a mean (standard deviation (SD)) of 32.0 (3.5) days after delivery. Five women dropped out: three women’s babies were still in the hospital at T2, one woman did not come to the hospital for a postnatal checkup, and one woman did not receive the questionnaire. The mean follow-up time was 80 days (range: 32–114).

Table 1.

Demographic and obstetric characteristics of participants (N = 59).

Variables	N	%
Age (years), mean (SD)	33.2 (5.2)
GA (weeks) at T1, mean (SD)	32.1 (2.5)
Weeks of delivery, median (IQR)	39 (38–40)
Baby’s weight (g), median (IQR)	2998 (2746–3133)
Previous delivery
No	33	56
Marital status
Non-single	57	97
Education
Junior high/high school	7	12
Technical/junior college	20	34
University or higher	32	54
Income
<4.0 million JPY^a	4	7
4.0–5.9 million JPY	11	19
6.0–7.9 million JPY	11	19
8.0–10 million JPY	15	25
>10 million JPY	16	27
Means of conception
Natural	47	80
Artificial insemination	2	3
In vitro fertilization	9	15
Artificial insemination by donor	1	2
Past mental disorder
Yes	2	3

One U.S. dollar is roughly equivalent to 100 yen during the study period. SD: standard deviation; GA: gestational age; IQR: interquartile range.

Only one missing value was observed in “behavior disengagement,” supporting the adoption of complete case analysis. Table 2 shows the mean (SD) of each coping strategy measured by the Brief COPE at T1 and T2. Scores on self-distraction, denial, and self-blame significantly decreased from prenatal to postpartum. The results of the sensitivity analysis, excluding two participants with a history of mental disorder, showed similar results (data not shown).

Table 2.

Differences of each coping strategy during pregnancy (T1) and postpartum (T2) were measured by the Brief COPE.

Coping behavior	Mean (SD)		t	p-value	Cohen’s d
Coping behavior	T1 (N = 59)	T2 (N = 54)	t	p-value	Cohen’s d
Self-distraction	5.7 (1.3)	4.5 (1.5)	5.98	<0.001*	0.80
Denial	2.9 (1.1)	2.3 (0.75)	3.88	<0.001*	0.54
Substance use	2.5 (1.3)	2.2 (0.82)	1.37	0.18	0.28
Emotional support	5.9 (1.4)	6.0 (1.4)	−0.44	0.66	−0.064
Instrumental support	6.0 (1.5)	5.8 (1.5)	−0.23	0.82	−0.036
Behavioral disengagement	4.0 (1.4)	3.9 (1.3)	0.47	0.64	0.068
Venting	5.5 (1.3)	5.1 (1.4)	1.60	0.12	0.26
Positive reframing	5.5 (1.3)	5.4 (1.4)	0.37	0.71	0.054
Planning	5.9 (1.2)	5.8 (1.4)	0.79	0.43	0.12
Humor	3.9 (1.5)	4.2 (1.7)	−1.79	0.079	−0.26
Acceptance	5.9 (0.97)	6.4 (1.5)	−1.89	0.064	−0.30
Religion	2.8 (1.3)	2.6 (1.1)	1.09	0.28	0.14
Self-blame	4.3 (1.7)	3.7 (1.5)	2.67	0.010*	0.40

SD: standard deviation.

p < 0.05.

Discussion

Consistent with its definition, coping strategies changed during the perinatal period. In this study, postnatal women were less likely to adopt coping strategies of self-distraction, denial, and self-blame than in the prenatal period.

A previous study found that most coping strategies including adaptive coping (e.g., planning and using instrumental support) showed a decrease after childbirth.¹⁰ Despite the small sample size of our study, we were able to better narrow down the types of coping strategies that fluctuate during the perinatal period with large to small effect sizes, by following a population with a high follow-up rate and without biases such as prior delivery experience, which has been a problem in the previous study.¹⁰

Individuals who exhibit experiential avoidance, a tendency to engage in behaviors that alter the frequency, duration, or form of unwanted private events, have been reported to rely on specific coping strategies such as self-distraction, denial, and self-blame.¹⁷ One possible reason for the fluctuation of these coping strategies in this study is that during pregnancy, women are more likely to adopt risky coping strategies to avoid stressors. Pregnancy causes emotional ambivalence due to the desire to be a mother on the one hand and the fact that the fetus threatens her very existence on the other.¹⁸ Magical thinking can also occur among pregnant women in which one’s thoughts and actions lead to serious consequences without regard to normal cause-and-effect relationships.¹⁸ This psychological background may make women more prone to self-blame and denial of situations during pregnancy. Specifically, Japanese women may greatly fear childbirth and easily cope with avoidance, because labor pain is traditionally considered as a natural part of birth processes and is necessary for the transition to motherhood; a previous study found Japanese women’s belief that experiences like enduring pain lead to greater confidence as a mother.¹⁹ Japanese women may also be easy to blame themselves culturally because they perceived their unborn baby to be completely dependent on them.²⁰

A second reason for fluctuation may be that the crisis of pregnancy and childbirth may have grown or developed women’s potential ability through childbirth.¹⁸ Self-distraction, denial, and self-blame, which decreased from pre- to postnatal period in the present study, have been reported to be positively associated with postnatal depression, depressive symptoms, and strong anxiety.^6–8 Our study suggests that women in the postnatal period may reduce their choice of coping strategies that may deteriorate their mental health in the postnatal period. In other words, the perinatal period can be a process through which women can be empowered to gain greater control over actions affecting their mental health. This study was conducted in a regional perinatal center where safe delivery is more likely to occur, and the participants’ relatively high levels of education and income might have facilitated empowerment. As the previous study found that anxious women persistently used denial and self-blame from pre- to postpartum,¹⁰ future studies should investigate how to effectively support women who cannot reduce the selection of high-risk coping strategies in the postnatal period.

As described, a systematic review noted that previous studies assessed coping strategies at various timepoints throughout the perinatal period, resulting in inconsistent results.¹ The present study also suggests that researchers should pay attention to the time of evaluating coping among perinatal women because individual coping strategies may change during the perinatal period.

Limitations

One limitation of this study is the relatively small sample size. Although the post hoc power test indicated that this size had sufficient statistical power to detect the modest to substantial effect size ((1 − β) = 0.99994), the sample may not adequately reflect the heterogeneity of the broader population. Although our sample did not differ from those reported by the Japanese national data on the aspects of age and means of conception, the external validity of the findings may be limited because participants were not randomly selected from the target population. Future research should aim to recruit more representative samples—ideally through random sampling methods—to improve the generalizability of the results. Second, some coping strategies (e.g., active coping) showed low reliability in both the prenatal and postnatal periods. Although the indicator of reliability in this study was not far from the study on the development of the Japanese Brief COPE¹⁴ and a previous study in Greece¹³ that reported acceptable reliability during pregnancy with Cronbach’s alphas ranging from 0.54 to 0.88, our study suggests the need to discuss whether coping strategies among perinatal women can be evaluated using the existing scales developed for the general population. Third, the statistical analyses we employed were simple group comparisons without multivariable adjustment. We did not control potential confounding variables such as demographic characteristics (e.g., age), pregnancy-related factors (e.g., high-risk status), or postpartum issues (e.g., maternal mental health). The lack of controlling these factors may have biased the observed associations between psychological defense mechanisms and childbirth-related experiences. While these methods were appropriate for exploratory purposes in a pilot context, they limit the interpretability and causal inference of the findings. Future large-scale studies should incorporate more rigorous multivariate analyses to account for potential confounders and increase the robustness of the results. Fourth, because we were unable to assess pre-pregnancy coping strategies, it is unclear whether the fluctuating coping was elevated during pregnancy or was originally high. Assessing pre-pregnancy coping is difficult, but there is room for exploration in future studies. Despite these limitations, to the best of our knowledge, this is the first study to reveal relevant intrapersonal changes in perinatal coping strategies.

Conclusion

This study investigated the interpersonal changes in women’s coping strategies during the perinatal period. High-risk coping strategies, such as self-distraction, denial, and self-blame, taken during pregnancy were less likely to be taken after childbirth. To alleviate postpartum maternal mental health problems, professionals should consider ways to empower women to achieve their full potential to cope with postpartum stress.

Supplemental Material

sj-docx-1-whe-10.1177_17455057251407853 – Supplemental material for Changes in maternal coping strategies from pregnancy to postpartum among Japanese women: A prospective longitudinal study

Supplemental material, sj-docx-1-whe-10.1177_17455057251407853 for Changes in maternal coping strategies from pregnancy to postpartum among Japanese women: A prospective longitudinal study by Ritsuko Shirabe, Tsuyoshi Okuhara, Hiroko Okada, Eiko Goto and Takahiro Kiuchi in Women's Health

Supplemental Material

sj-docx-2-whe-10.1177_17455057251407853 – Supplemental material for Changes in maternal coping strategies from pregnancy to postpartum among Japanese women: A prospective longitudinal study

Supplemental material, sj-docx-2-whe-10.1177_17455057251407853 for Changes in maternal coping strategies from pregnancy to postpartum among Japanese women: A prospective longitudinal study by Ritsuko Shirabe, Tsuyoshi Okuhara, Hiroko Okada, Eiko Goto and Takahiro Kiuchi in Women's Health

Footnotes

Acknowledgements

We would like to thank Editage () for English language editing.

ORCID iDs

Ritsuko Shirabe

Tsuyoshi Okuhara

Ethical Considerations

This study was approved by the institutional review board of the University of Tokyo (approval code: 2020154NI) on July 22, 2020. All participants provided written informed consent for participation before administering the questionnaires.

Consent for publication

All participants provided written informed consent for publication of the results of this study before administering the questionnaires.

Author contributions

Conceptualization: RS, HO, and TO; Design of the work: RS, TO, HO, EG, and TK; Data acquisition: RS; Data analysis: RS, and HO; Interpretation of data: RS, TO, and HO; Drafting the work: RS; Reviewing critically for important intellectual content: TO, HO, EG, and TK. All authors approved the final version of the manuscript to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Health Care Science Institute Research Grant in 2020.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request. The data are not publicly available for ethical reasons.

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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