Optimism and other psychosocial influences on antenatal

depression: A systematic review

Authors
Emily C. Evans MSN, RN,
1.

Linda F. C. Bullock PhD, RN, FAAN

1.
First published: 5 July 2012Full publication history
DOI: 10.1111/j.1442-2018.2012.00700.xView/save citation
Cited by: 3 articles
Citation tools

Emily C. Evans, University of Virginia School of Nursing, P.O. Box 800826, Charlottesville, VA 22908-0826, USA.
Email: emilyccevans@gmail.com

Abstract
Antenatal depression is a debilitating experience for many women with significant personal and
familial sequelae. Low-income pregnant women living in rural settings are especially vulnerable
because of isolation, decreased resources, and stressful living environments. This systematic
review summarizes what is known about antenatal depression and synthesizes the evidence
regarding the role psychosocial variables could play in the development of safe, effective, and
culturally-acceptable non-pharmacological interventions. Searches of the CINAHL, MEDLINE,
PSYCHINFO, and ERIC databases, as well as the Cochrane Library, were conducted in
September 2010 to identify articles relevant to our topic of study. Psychosocial variables have a
significant association with antenatal depression. Optimism has been shown to be inversely
correlated with depression, and directly correlated with improved birth outcomes. Optimism is a
potentially modifiable variable that could be used to design antenatal prevention and treatment
programs. As depression continues to increase in prevalence, and treatment options for pregnant
women remain limited, effective interventions must be developed that address the psychosocial
variables examined in this review.

INTRODUCTION
Depression is a growing problem, with estimates placing it as
the second-most common disability in the world by 2020
(Dennis et al., 2007). During pregnancy, suffering from
depression causes biopsychosocial distress in the mother that
affects her well-being and that of her unborn baby. Maternal
psychological distress, including antenatal depression
(AND), has been correlated with significant public health
concerns such as low birth weight (LBW) and preterm birth
(PTB) (Mulder et al., 2002; Talge et al., 2007). Although risk
factors for postpartum depression (PPD) are commonly
recognized, screened for, and treated in obstetric settings,
risk factors for depression during pregnancy are less well
known and addressed (Jomeen, 2004; Jomeen & Martin,
2005; Boyd et al., 2006; Dimidjian & Goodman,
2009; Reid et al., 2009). This relative inattention to AND is
concerning, because women are at the highest risk for
depression during their childbearing years, and rates of AND
have been suggested to be equal to, if not greater than, rates
for PPD (Cardemil et al., 2005; Dimidjian & Goodman,
2009; Luke et al., 2009; Price & Proctor, 2009; Reid et al.,
2009).
Systematic reviews of AND have focused on prevalence
rates, treatment recommendations, and risk factors
(Bennett et al., 2004; Dennis et al., 2007; Dennis & Allen,
2008; Dimidjian & Goodman, 2009; Muziket al.,
2009; Lancaster et al., 2010). Many of the risk factors for
AND relate to psychosocial factors in a woman's life, such as
stress and social support (Lobel et al., 2000; Blaney et al.,
2004; Glazier et al., 2004; Jesse et al., 2005; Records & Rice,
2007; Reid et al., 2009; Dunkel Schetter, 2011). Other
psychosocial variables, such as optimism, might prevent or
decrease the severity of AND, but continued research is
needed to inform the development of interventions utilizing
such variables (Scheier & Carver, 1985; Lobel et al.,
2000; Seligman et al., 2005; Moyer et al., 2009).
Optimism is typically measured with the Life Orientation
Test, and is not necessarily the opposite of pessimism
(Glaesmer et al., 2011). According to Scheier and Carver's
(1985) seminal work, optimism is a measurable construct
with application in psychology, as well as other health fields.
It is generally described as a disposition, wherein people
expect better things from life than that things will work
out. Positive psychology theory holds that optimism, among
other personality traits, significantly contributes to a person's
positive psychological experience and has the potential to
decrease and prevent mental illness (Seligman &
Csikszentmihalyi, 2000; Seligman et al., 2005).
More recently optimism has been investigated in disciplines
as diverse as biology and behavioral economics. The
optimism bias, or overestimation that positive things will
happen, is present and adaptive in humans, as well as
animals, with notable exception in depressed individuals
(Sharot, 2011). In their meta-analysis, Rasmussen et al.
(2009) synthesized the examination of optimism and physical
measures of health, such as mortality, cardiovascular disease,
immune function, cancer, pain, and pregnancy outcomes.
They found statistically significant correlations between
optimism and physical health in all areas examined.
Although the relationship between optimism and health has
been under investigation for more than three decades,
optimism during pregnancy and the postpartum period has
not been examined in great depth (Scheier & Carver,
1987; Scheier et al., 1994).
BACKGROUND
Prevalence
Prevalence rates for major depressive disorder (MDD) during
pregnancy vary, ranging from 10% to 16%, with rates of
pregnant women who experience depressive symptoms as
high as 38% (Cardemil et al., 2005; Price & Proctor, 2009).
Women living in poverty or underserved areas, who are
already at risk for poor health, have been shown to
experience depression at higher rates (Jomeen, 2004). In a
screening of low-income, African American pregnant
women, Luke et al. (2009) found that 25% had depressive
symptoms equivalent to those necessary for a diagnosis of
MDD. Although studies have been criticized for not
verifying diagnoses of depression with psychiatric
evaluations, subclinical depression levels remain prevalent
and potentially dangerous for pregnant women (Jomeen,
2004; Furber et al., 2009).
Treatment
Routine screening for depression in a prenatal setting has
been strongly advocated and is now recommended by the
American College of Obstetrics and Gynecologists for all
pregnant patients (Blaneyet al., 2004; Jomeen,
2004; Boyd et al., 2006; Lancaster et al., 2010). In a study of
depression screening and provider intervention for pregnant
women, Flynn et al. (2006) found that women diagnosed with
MDD were not being treated before, during, or after
pregnancy. Treatment rates for depression are even lower in
underserved populations (Bennett et al., 2010). Rural women
are more likely to refer themselves for help in non-traditional
settings, where costs were low and seeking help is more
culturally acceptable (Price & Proctor, 2009).
Examples of ways in which women self-treat for depression
include seeking information from books or the Internet;
talking with friends, family, or religious leaders; engaging in
spiritual or religious activities; exercising; crying; or
negative behaviors, such as smoking or substance abuse
(Flynn et al., 2006; Poudevigne & O'Connor,
2006; Mann et al., 2008; Furber et al., 2009). Although
traditional psychological therapies have been shown
effective in decreasing PPD, less attention has been paid to
their effectiveness during pregnancy (Dimidjian &
Goodman, 2009). In a Cochrane review of non-
pharmacological, psychiatric, or psychosocial interventions
for depression during pregnancy, only one study was found
rigorous enough to be included (Dennis & Allen, 2008).
Continued research in this area is needed.
Sequelae
Depressed mothers are more likely to commit suicide,
receive inadequate health care, have poor health practices,
abuse drugs and alcohol, have poor pregnancy and birth
outcomes, and suffer from PPD or psychological distress
long after pregnancy ends (Spinelli & Endicott,
2003; Jomeen, 2004; Grote & Bledsoe, 2007; Dimidjian &
Goodman, 2009; Muzik et al., 2009). Reviews regarding
negative consequences of psychological distress have
centered on behavioral effects, such as poor maternal health
practices and fetal effects, due to changes in maternal
immune and neurohormonal systems (Knackstedtet al.,
2005; Dunkel Schetter, 2011). Furber et al. (2009) found that
mild-to-moderate psychological distress was debilitating in
the 24 pregnant women who were a part of their qualitative
study; the distress keeping them homebound and
exacerbating obsessive thoughts, as well as compulsive
behavior.
Research on fetal programming, or the process by which the
maternal environment permanently imprints changes on fetal
bioneurohormonal pathways, is emerging as a promising area
of investigation to help explain negative sequelae of maternal
psychological distress through adulthood (Dunkel Schetter,
2011). Infants of mothers with higher levels of stress,
anxiety, and depression during pregnancy are more likely to
have PTB, LBW, decreased newborn neurobehavioral
performance, and impaired maternalinfant attachment
(Talge et al., 2007). The effects of AND continue into
childhood, as evidenced by its correlation with language
delay, temperament and behavior problems, psychiatric
disorders, attention deficit hyperactivity disorder, and
cognitive delay (Talge et al., 2007).
Rationale and aims
This review provides an overview of what is known about
AND and synthesizes findings relating to the psychosocial
factors, particularly optimism, that influence pregnant
women's experiences of AND. We also give special
consideration to research related to low-income, rural
populations because of their higher risk for depression, poor
birth outcomes, and lack of access to resources.
Understanding these risk factors, and optimism in particular,
helps to identify potential areas for development of non-
pharmacological interventions to reduce depressive
symptoms during pregnancy.
Methodology
In September 2010, the CINAHL, MEDLINE, PSYCHINFO
and ERIC databases, as well as the Cochrane Library, were
searched using the following terms: United States, non-
pharmacologic, antenatal, depression, pregnancy, and
optimism. In all cases, search terms were expanded to
include MeSH headings. Inclusion criteria for the search
were peer-reviewed articles, with references, published in
English between January 2000 and September 2010. These
searches yielded 163 articles for examination. The criterion
for the search regarding optimism was modified to include
all types of research published at any time. This increased
our yield to 174 articles. The title and abstract of each paper
was examined for relevance to our topic. Articles were
excluded if they were duplicates; if they were narrative,
comment, opinion, or dissertation research; and if they did
not pertain to pregnant women or did not address
psychosocial correlates of AND. Exceptions were made for
articles examining optimism and PPD because of the limited
research on this topic. This further reduced our number of
articles to 20. References were hand-checked for additional
relevant research, and another 10 articles were located in this
way. The total number of articles evaluated was 30. Details
of the search process are given in Figure 1.
 Figure 1.
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Search strategy and selection criteria for reviewed studies.

Based on the inclusion and exclusion criteria, a total of 12
review and 18 original research articles were selected and
reviewed as most relevant and insightful to our topic.
In Table 1, we give the methodology, inclusion criteria, and
level of evidence used by the review articles (Polit & Beck,
2008). These articles were primarily used to summarize what
is known about AND prevalence, treatment issues, and
sequelae, and provided the background for our study. Their
findings help to establish the breadth of research that has
informed this subject and the important variables identified
with AND. The original research articles included focused on
the psychosocial variables related to AND and provided the
primary evidence for our findings and discussion section.
Two qualitative and 16 quantitative studies were included in
our study. Table 2 provides more detail regarding the
methodology and findings of these articles. Further
evaluation of their quality follows in the Results section.
Table 1. Description of review articles applicable to antenatal depression

Characteristics of articles included in r

Type of Level of
Author Focus
review evidence
No.
Inclusion criteria D
articles

1. Level I, systematic review of randomized, controlled trials; systematic review of non-randomized trials; Level II, single randomized, con
single non-randomized trial; Level III, systematic review of correlational/observational studies; Level IV, single correlational/observational study; L
systematic review of descriptive/qualitative/physiological study; Level VI, single descriptive/qualitative/physiological study; Level VII, opinions o
authorities, expert committees (Polit & Beck, 2008).

Beddoe and Lee Review Level III Mindbody stress 12 Investigated mind 19
 Characteristics of articles included in r
Type of Level of
Author Focus
review evidence
No.
Inclusion criteria D
articles

(2008) reduction body intervention

interventions

Sample adult pregnant

women

Prospective design

Original research

Contained quantitative
data

Published in English

Peer-reviewed journals

Measurable variable of
psychological stress

Dennis and Allen Meta- Level I Psychosocial and 1 Preventive 19

(2008) analysis psychological psychosocial or
interventions psychological
interventions

Published,
unpublished, and
ongoing randomized,
controlled trial

Primary or secondary
aim to treat antenatal
depression

Randomized,
controlled trial of non-
pharmacological
treatment
 Characteristics of articles included in r
Type of Level of
Author Focus
review evidence
No.
Inclusion criteria D
articles

Dimidjian and Review Level I Non- 29 Treatment for N

Goodman (2009) pharmacological antenatal and sp
treatments for postpartum depression
antenatal depression
and postpartum
depression Randomized,
controlled trials

Dunkel Schetter Review Level V Stress processes in > 100 None specified N
(2011) pregnancy and sp
preterm birth, low
birth weight

Jomeen (2004) Review Level V Psychological status > 100 None specified N
as a sp
multidimensional
construct

Knackstedtet al. Review Level V Mediators in stress- > 50 None specified N

(2005) triggered changes sp

Lancasteret al. Systematic Level III Risk factors for 57 Developed countries 19
(2010) review depressive symptoms

Greater than 20
participants

Sample pregnant
women with
depressive symptoms

Association between
risk factors and
depression

Excluded studies of
women with known
depression
 Characteristics of articles included in r
Type of Level of
Author Focus
review evidence
No.
Inclusion criteria D
articles

Latendresse (2009) Review Level V Stress and preterm > 50 None specified N
birth sp

Mulder et al. Review Level V Effects of stress on 50 None specified 19

(2002) fetus

Muzik et al. (2009) Review Level V Antenatal depression > 100 None specified N
screening and sp
treatment

Poudevigne and Review Level III Physical activity and > 100 None specified N
O'Connor (2006) psychological health sp

Talge et al. (2007) Review Level III Stress and child 23 Independent, N
neurodevelopment prospective studies sp

Table 2. Studies of psychosocial influences on antenatal depression and optimism: methodology

and findings

Sample
Psychosocial Depression
Author Findings
variables tool
Recruitment Size Population

1. BDI-II, Beck Depression Inventory, Second Edition; CES-D, Center for Epidemiological Studies Depression Scale; DISC, Diagnostic Int
Schedule for Children; EPDS, Edinburgh Postnatal Depression Scale; PDPI-R, Predictors of Postpartum Depression Inventory Revised; SF-12, S
12; SLC-90-R, Symptom Check List. Level I, systematic review of randomized, controlled trials; systematic review of non-randomized trials; Leve
randomized, controlled trial, single non-randomized trial; Level III, systematic review of correlational/observational studies; Level IV, single
correlational/observational study; Level V, systematic review of descriptive/qualitative/physiological study; Level VI, single
descriptive/qualitative/physiological study; Level VII, opinions of authorities, expert committees (Polit & Beck, 2008).

Blaneyet al. (2004) Convenience 307 Pregnant, Stressors, social CES-D Perceived
HIV, low support, coping stress, social
income, isolation, and
minority behavioral
disengagement
coping
associated
with higher
depression
 Sample
Psychosocial Depression
Author Findings
variables tool
Recruitment Size Population

Positive
partner support
associated
with lower
depression

Boydet al. (2006) Random 89 Pregnant, Negative & BDI-II Enhanced

minority positive life psychosocial
events intervention
showed no
reduction in
depressive
symptoms
over health
centers' usual
psychosocial
care

Churchill and Convenience 181 Pregnant, Optimism, CES-D New measure

Davis (2010) first child, pessimism, of realistic
not depressed realistic orientation.
orientation Higher
optimism
scores predict
lower
depression.
Realistic and
positive
oriented
women show
same
depression
scores

Dornet al. (1993) Convenience 40 Pregnant, Depression, DISC Optimism and

Caucasian, anxiety, self-worth
adolescents optimism, self- were
worth significant
predictors of
anxiety and
depression in
pregnant
adolescents

Fontaine and Convenience 45 Postpartum, Optimism, self- EPDS Self-esteem

Jones (2007) British esteem inversely
correlated with
 Sample
Psychosocial Depression
Author Findings
variables tool
Recruitment Size Population

depression
during late
pregnancy and
early
postpartum.
Optimism not
correlated with
depression
after
controlling for
self-esteem

Glazieret al.(2004) Convenience 2052 Pregnant and Stress, social CES-D High social
postpartum, support support
high income, correlated with
Canadian lower anxiety
and depression

Stress related
to low social
support and
anxiety and
depression

Grote and Bledsoe Convenience 179 Pregnant and Optimism, SCL-90R Stress
(2007) postpartum, stress significantly
married, correlated with
white depression
severity during
pregnancy and
postpartum.
Optimism
during
pregnancy
negatively
correlated with
stress.
Optimism
during
pregnancy
associated
with lower
depression
scores at 6 and
12 months'
postpartum
 Sample
Psychosocial Depression
Author Findings
variables tool
Recruitment Size Population

Jesseet al. (2005) Convenience 126 Pregnant, low Stress social BDI-II Stress, self-
income, support, self- esteem,
African esteem, religiosity,
American spiritual social support,
perspective, use of
religiosity Medicaid, and
abuse
significantly
contributed to
variance in
depression
scores.

Jomeen and Convenience 129 Pregnant Self-esteem EPDS Personal self-

Martin (2005) esteem
significantly
predicted
depression
status, but not
general self-
esteem or
social self-
esteem.

Lobelet al. (2000) Convenience 129 Pregnant, Stress, None Optimism was
high risk, optimism inversely
Caucasian, related to birth
married weight and
stress in high-
risk
pregnancies

Mannet al. (2008) Convenience 344 Pregnant, Religiosity, EPDS Increased

highly spirituality, spirituality and
educated, social support religiosity
married reduced
likelihood of
anxiety

Moyeret al.(2009) Convenience 101 Pregnant, Optimism SF-12 Optimism

Ghanaian negatively
correlated with
knowledge of
HIV, positively
correlated with
no prior
testing for
 Sample
Psychosocial Depression
Author Findings
variables tool
Recruitment Size Population

HIV

Moyeret al.(2009) Convenience 168 Pregnant Optimism, SF-12 Optimism

women from quality of life associated
China, with country,
Ghana, and education,
USA work status,
and previous
deliveries,
despite
matching for
age, previous
pregnancy, and
gestational age
of mother

Nelsonet al. (2003) Convenience 972 Pregnant, Optimism, CES-D Depressive

African social support symptoms or
American optimism not
related to risk
of spontaneous
abortion.
Depressive
symptoms
highly
correlated with
optimism

Raymond (2009) Convenience 9 Postpartum, Social support Self-report Women who

low income, felt low
British during
pregnancy
reported
emotional
isolation,
loneliness,
lack of partner
support,
pressure
regarding
motherhood,
and
fragmented
health care

Records and Rice Convenience 139 Pregnant, Social support, PDPI-R Third trimester
 Sample
Psychosocial Depression
Author Findings
variables tool
Recruitment Size Population

(2007) Caucasian, stress, self- CES-D depressive

married esteem symptoms
strongly
correlated with
social support
and
moderately
correlated with
stress

Reidet al. (2009) Convenience 302 Pregnant, Social support, EPDS Practical
Scottish stress support from
partner and
emotional
support from
mother
explained
depression in
multiparous
women.
Emotional
support from
partner,
practical
support from
mother, and
emotional
support from
other
explained
depression in
primiparous
women

Tsenget al. (2008) Convenience 12 Pregnant, Social support, EPDS Unbalanced

Taiwanese, body image, commitment to
depressed commitment to motherhood
pregnancy was the
common
theme among
depressed
women.
Subthemes
included body
image
dissatisfaction,
lack of social
support,
multiple
conflicting
 Sample
Psychosocial Depression
Author Findings
variables tool
Recruitment Size Population

roles, as well
as uncertainty
about the
future

RESULTS
Discussion of the quality
Examination of the psychosocial factors that might impact
the experience of AND is varied in the scientific approach.
The framework used to evaluate the methodology of the
articles included in this review is based on Polit and Beck's
(2008) hierarchy of research evidence. This model identifies
seven levels of evidence by which to categorize the design of
scientific research. Level I is comprised of systematic
reviews of randomized, controlled trials or non-randomized
trials, the highest quality of evidence; and level VII includes
opinions of authorities or experts. Tables 1 and 2 specify the
level of evidence for each study included in our review.
Qualitative research has been thorough and insightful, but
has only investigated the experience of a few women,
making findings difficult to generalize to other
socioeconomic and cultural groups. Quantitative research
regarding psychosocial correlates of AND has been
dominated by correlational and observational studies. These
investigations have typically used convenience sampling and
heterogeneous measures of depression, such as the Beck
Depression Inventory and the Edinburg Postnatal Depression
Scale. In some cases, samples larger than 300 women have
been used, but more often, small samples limit the ability of
these studies to find statistically-significant results. An
overview of our findings regarding psychosocial factors that
have been investigated in relation to AND are presented,
followed by a detailed examination of optimism as a
potentially modifiable psychological factor that might help
improve depressive symptoms in pregnant women.
Variables related to depression
The most common risk factors for depressive symptoms
during pregnancy are anxiety, perceived life stress, history of
depression, lack of social support, unwanted pregnancy, low
income, domestic violence, lack of education, smoking, and
single marital status (Lancaster et al., 2010). Of these, stress
and social support are the psychosocial variables that have
been most studied (Blaney et al., 2004; Mann et al.,
2008; Tseng et al., 2008; Furber et al., 2009; Muzik et al.,
2009; Raymond, 2009; Reid et al., 2009; Lancaster et al.,
2010). Other psychosocial variables that have been examined
include quality of life, self-esteem, religiosity, spirituality,
fear of childbirth, locus of control, and coping strategies,
such as disengagement and reframing (Blaney et al.,
2004; Jomeen, 2004; Jesse et al., 2005; Jomeen & Martin,
2005).
Stress
Stress during pregnancy is an important contributor to many
adverse pregnancy outcomes, including PTB, LBW, fetal
malformations, spontaneous abortion (SAB), pre-eclampsia,
unplanned Cesarean sections, increased hospital length of
stays, and poor neonatal neurological scores (Mulder et al.,
2002; Beddoe & Lee, 2008). Through immune,
neuroendocrine, and metabolic pathways, high levels of
maternal stress directly affect the fetus, and have the
potential to program the fetus for negative sequelae
throughout life (Latendresse, 2009). Stress is typically
measured by self-reported scales, such as the Perceived
Stress Scale, Social Stress Indicators, and List of Threatening
Experiences, but can also be measured by examining levels
of cortisol (Dorn et al., 1993; Blaney et al., 2004; Glazier et al.
2004; Reid et al., 2009). The root cause of stress varies
between studies, but is typically related to many factors,
including economic status, major life events, job-place
issues, daily hassles, quality of life, living conditions, and
pregnancy-related changes (Grote & Bledsoe, 2007).
Stress, anxiety, and depression are often comorbid, and have
been investigated simultaneously in numerous studies
(Jomeen, 2004). These three psychological experiences can
be triggered by similar circumstances, and produce similar
physiological and psychological pathways in pregnant
women (Latendresse, 2009). Pregnancy-related anxiety
(PrA) has been identified as one of the most effective
predictors of maternal stress, and centers around the concerns
a woman has about her pregnancy, her ability to cope with
the challenges of motherhood, the health of her fetus, and
whether she will have a successful labor and delivery. PrA
has been associated with negative outcomes such as PTB,
LBW, and infant behavioral and developmental delays
(Mulder et al., 2002; Dunkel Schetter, 2011). Educational
interventions that provide information about the typical
course of pregnancy and self-help measures to decrease
stress might help reduce PrA and the associated negative
biopsychosocial pathways.
Social support
Social support is a critical variable that impacts AND, and
might protect against the negative effects of other
psychosocial variables, such as stress or anxiety. Records
and Rice (2007) found that third trimester depression scores
were significantly correlated with social support in a cross-
sectional examination of 139 pregnant women in the
northwest USA. A lack of social support or emotional
isolation was identified as a dominant theme among women
who reported feeling depressed during pregnancy, and has
been associated with increased psychological distress across
cultures (Tseng et al., 2008; Raymond, 2009). In Raymond's
qualitative study, nine women recalled a lack of both
physical and emotional support and felt uncomfortable
confiding in health-care providers, stating that the providers
rarely saw the same patient and seemed more focused on the
fetus. They reported desires to connect with other pregnant
women via the Internet or face to face to receive and give
support (Raymond, 2009). In a study examining the type of
social support pregnant women found helpful, Reid et al.
(2009) found that primiparous women seek emotional
support from friends or siblings, whereas pregnant women
with children seek emotional support from their mothers and
practical support from their spouses. Although complex in its
demonstration in women's lives, the need for social support
during pregnancy seems to be universal.
Other psychosocial variables
Although research regarding AND and other psychosocial
variables may have lacked scientific rigor, the studies are
useful for illustrating the complex nature of psychological
health during pregnancy. Cultural variables, such as
religiosity, spirituality, preference for a male child, and
physical activity patterns, have been examined, although not
in depth, in pregnant women, with lower rates of
psychological distress found in women who were religious,
spiritual, and/or physically active (Poudevigne &
O'Connor, 2006; Mann et al., 2008). Self-esteem was found
to be directly correlated with early-pregnancy depression and
anxiety scores in Jomeen and Martin's (2005) self-report
questionnaire of 129 pregnant women. Boydet al. (2006)
found that coping strategies, such as disengagement or
giving up, negatively impact a woman's psychology,
whereas strategies, such as reframing negative life events and
paying attention to positive life events, might prevent or
decrease depression. They further established that
postpartum motherinfant interactions were better in women
who reported more positive life events (Boyd et al., 2006).
These findings support the concept of optimism as a strategy
for improving mental well-being and decreasing depression
among pregnant women.
Optimism
Evidence supports a relationship between optimism and
depression. Dorn et al. (1993) examined the relationships
among levels of cortisol, anxiety, depression, self-esteem,
and optimism in 40 pregnant adolescents. They found that
optimism and self-worth accounted for 41% of the variance
in anxiety and depression during pregnancy and the
postpartum period. Another study of optimism in pregnant
adolescents (n > 900) posed the question: Does optimism or
depression affect the risk of SAB? Although no significant
associations between depression, optimism, and SAB were
found, optimism and depression scores were highly inversely
correlated, providing further evidence of a negative
relationship between optimism and depression during
pregnancy (Nelson et al., 2003).
Maternal optimism not only has the potential to reduce
depressive symptoms, it has also been shown to have a
positive effect on infant outcomes. One of the most
compelling examinations of optimism during pregnancy is a
study regarding its impact on birth outcomes. In a sample of
129 medically high-risk pregnant women, the correlation of
optimism and stress with birth weight and gestational age
was examined. Babies born to women who were least
optimistic during pregnancy weighed less than those born to
more optimistic mothers. The impact of optimism on birth
weight was comparable to the impact of ethnicity on birth
weight. In addition, women with higher optimism reported
less stress (Lobel et al., 2000). Benefits of optimism include
decreased maternal depression and stress, as well as
improved infant outcomes. If optimism is modifiable,
interventions designed to foster optimism hold great promise
for the prevention and treatment of AND.
Research about factors that influence optimism in pregnant
women has been international. Across cultures, support of a
relationship between education level and optimism has been
documented by Moyeret al. (2009). Optimism levels in
women from the USA, Ghana, and China were found to vary
with education levels, countries of origin, numbers of
previous deliveries, and whether or not women had paid
employment. The possibility of life experiences, such as
abuse, trauma, or serious illness, to affect optimism during
pregnancy remains unstudied. An examination of the
association between negative life events and optimism was
completed by Moyer et al. (2008) in their study of Ghanaian
pregnant women and HIV-screening attitudes. In their study,
the most optimistic women had little knowledge of, and had
never been tested for, HIV. This important finding is useful,
as interventions aimed at decreasing depression are designed.
Although optimism might help to prevent depression or
reduce its symptoms, educating women about the range of
possible outcomes can help provide them with a realistic
construct within which to prepare for events, such as the
transition to motherhood.
To more fully represent the work that has been done
regarding optimism and psychological health in women of
childbearing age, we also considered studies of PPD. These
investigations have yielded mixed results. Fontaine and
Jones (1997) examined the associations among optimism,
PPD, and self-esteem in 45 pregnant women at three times
postpartum. Although both optimism and self-esteem were
inversely correlated with depression at weeks one and two,
only women with low self-esteem continued to be depressed
at week six. More recently, Grote and Bledsoe (2007)
examined the associations among optimism, stress, and PPD
in 179 women, hypothesizing that optimism during
pregnancy would be associated with lower rates of PPD.
Optimism was significantly correlated with fewer depressive
symptoms, and protective benefits of optimism were found in
light of spousal, financial, and physical stress for up to 1 year
postpartum. In Churchill and Davis's (2010) treatment of
optimism and adjustment to motherhood, the specifics of
what a woman thinks (positive, negative, and realistic
expectations), and her experience of PPD were examined. In
that sample of non-depressed women, those who reported a
balance of positive and negative thoughts (termed realistic
orientation), using Churchill's self-reporting tool, rather
than only positive thoughts, were more likely to adjust well
to motherhood.
DISCUSSION
This review provides an overview of what is known about
AND, as well as the psychosocial factors, such as optimism,
that impact AND. By more fully understanding these
variables, nurses are better able to design and implement
AND interventions that will be safe, effective, and culturally
acceptable. Research regarding psychosocial factors has been
broad in topic and quality, but has consistently shown that
stress and social support have a large impact on women's
experience of depression during pregnancy. In particular,
low-income women living in rural settings have much to gain
from interventions addressing these psychosocial variables.
Research investigating optimism and depression indicates
that there is a strong relationship between these variables,
and those interventions seeking to increase or maintain
optimism might prevent or decrease the experience of
depression.
Previous reviews of the literature regarding AND have
established that it is a prevalent problem with dangerous
consequences for mothers and babies. Pregnancy is an
important time to identify depression in women and assist
them in their efforts to obtain treatment. Unfortunately, lack
of training and unfamiliarity with depression screening and
treatment among obstetric providers makes it difficult, and
potentially uncomfortable, to address depression in prenatal
settings (Jomeen, 2004). Typical prenatal appointments
involve assessing weight gain, blood pressure, fetal heart
tones, fundal height, and signs or symptoms of
complications, as well as performing any testing required to
detect pregnancy problems. For health-care providers,
addressing the array of psychosocial variables that might
impact AND during routine prenatal appointments is
daunting. Even when a woman enters into care with a history
of depression, many providers and women are reluctant to
treatment using antidepressants, because of concern for fetal
safety or cost, or both (Muzik et al., 2009).
The study of non-pharmacological treatment for depression
is relatively recent, and further investigation of their use
during pregnancy is greatly needed (Cardemil et al.,
2005; Furber et al., 2009). In order to be most effective,
interventions of this nature must address psychosocial
variables, such as stress and social support, and support the
development of resources, such as optimism, positive coping
strategies, or spirituality. In addition to being non-
pharmacological, these interventions might be more
acceptable to pregnant women if they are designed with ease
of access and attention to cultural values. Limited
opportunities to obtain effective non-pharmacological
treatment for depression is a large reason why
undertreatment is so pervasive.
Undertreatment of AND is most concerning with respect to
underserved populations, which face additional health
disparities. Decreased resources lead to increased stress and
subsequent depression, as well as limited access to care.
Even when practical resources are available, traditional
psychological and pharmacological treatments for AND
might be undesirable to some women, due to cultural beliefs
and perceptions (Cardemil et al., 2005; Dimidjian &
Goodman, 2009). Mobile and internet technology might
help this population access effective interventions, among
whom forums for social support, group feedback, mentoring,
and validation rarely exist (Cardemil et al., 2005). In order to
be effective, such interventions must be based on
psychosocial variables that have been associated with AND.
The degree to which these psychosocial variables either
protect from or predispose a woman to depression depends
on their presence, magnitude, and interaction with one
another. For example, a pregnant woman experiencing high
levels of stress might not develop depression because of her
optimistic outlook and active coping mechanisms. The
negative effects of stress mighty be buffered by other
psychosocial variables, such as self-esteem or spirituality and
social support (Jesse & Swanson, 2007; Reidet al., 2009). In
contrast, another woman experiencing the same level of
stress, with a low quality of life, no social support, and poor
self-esteem, might be much more likely to develop
depression during pregnancy, and have few resources to
protect from its development.
Not only can optimism buffer against depression, but it can
impact a woman's overall health, directly and through health
behaviors. Studies in psychology that have shown improved
depression scores after participation in online happiness
exercises support the design and study of such interventions
for pregnant women (Seligman et al., 2005). Variables, such
as education, insurance, and transportation, come into play
here, as health resources that enable women to cope with
difficult psychosocial factors. Any effective intervention
designed to decrease depression must consider the health
resources available to women, and whether or not the
psychosocial factors in her life put her at an increased or
decreased risk for depression.
Research extending beyond risk factors for depression must
characterize its severity and trajectory during pregnancy. It
follows that interventions designed to target women when
they are most vulnerable to depression, both in terms of
prevalence and negative sequelae, should focus on improving
psychosocial variables during pregnancy. Stress and social
support are clear examples of psychosocial variables that can
be modified to affect depressive symptoms. Although less
studied, optimism holds promise as a potent mitigating factor
that might offset negative effects of stress or low social
support, thereby decreasing women's risk for depression.
Ideal interventions for depression, should be based on
psychosocial variables, and provide access to health
resources, education about normal course of pregnancy,
positive psychology exercises, and opportunities to connect
with other women in order to decrease stress and anxiety, and
increase social support. If offered in a mobile or online
setting, these interventions might be easily accessible,
culturally acceptable, and most effective in reaching low-
income women living in rural settings.
This review did not examine research in published textbooks
or unpublished dissertations, nor did it include works that
were not peer reviewed, thus limiting our sample size.
Because of the recent attention to AND as a significant
maternal health issue, this review has been broad in scope,
and considered some studies lacking scientific rigor in order
to characterize the full set of research directions that have
been introduced. Pregnancy is an ideal time to foster
optimism because of the receptive nature of pregnant women
to health improvement, the powerful impact on women and
children (including the unborn) that health improvement
during this period offers, and the protective effects optimism
might have on women and their families, even in the face of
psychological distress and subsequent negative health
outcomes.
CONCLUSION
The experience of depression during pregnancy, whether
diagnosed or subclinical, is a prevalent and dangerous health
concern for women and their families. To alleviate symptoms
and improve pregnancy and birth outcomes, there is a need
for non-pharmacological interventions to help women who
experience depressive symptoms. Health-care providers in
obstetric settings have opportunities to assess psychosocial
factors, such as stress and social support, as well as women's
available resources for coping with depressive symptoms.
Attention to well-established variables that might predispose
women to, or protect them from, experiencing depression is
warranted in all obstetric settings, particularly in cases where
there is an unwanted pregnancy, a history of psychological
distress, a lack of social support, high levels of stress, and an
absence of coping strategies.
Much research remains to be done regarding the complex
interactions of psychosocial factors during pregnancy and
their impact on women's psychological health, as well as
interventions designed to address areas of concern.
Interventions to decrease depression in pregnant women
might be most effective when targeting psychosocial
variables that can be altered through psychoeducation,
support, and the provision of resources. This review is the
first to examine optimism as a potential basis for depression
interventions during pregnancy. Optimism holds promise as a
modifiable variable that could help protect pregnant women
from the development of depression in a culturally-
acceptable, easily-accessible, and effective way.
CONTRIBUTIONS
Study Design: EE, LB.

Data Collection and Analysis: EE, LB.

Manuscript Writing: EE, LB.