Premature Birth & Postpartum Depression in Kosovo
Early Childhood Development
Master-Thesis Peace & Development Work
Author: Adina Björk
Supervisor: Christopher High Examiner: Heiko Fritz Term: Spring 2020
Subject: Peace & Development Work Level: Masterprogramme
Course code: 4FU42E
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Table of Content
Abbreviations
List of Figures & Appendices Acknowledgement
Dedication Abstract
1. Introduction ………... 7
1.1 Research problem, objective, relevance & questions………..7
1.2 Structure of Thesis ………. 8
1.3 Limitations/Delimitations ……….. 8
2. Background/Justification ……… 10
2.1 Kosovo as a case ……….. . 11
3. Literature Review ………. 14
3.1 Research objective, aim and outcomes ……….. 18
4. Methodology ……….... 19
4.1 Type of Study ……… 19
4.2 Data collection ………. 20
4.3 Reliability, Validity & Biases ………. 21
4.4 Selection Procedure ……… 22
4.5 Thematic & Content Analysis ……… 23
4.6 Ethical arguments ……….. 23
5. Conceptual Framework ……….. 25
5.1 Family Systems Theory ………. . 25
5.2 How the model was developed ………. 26
5.3 The Approach ……… 27
5.4 How the Model works in clinical practice ……… 27
5.5 Model developments over time ………. 28
5.6 Bowen`s Model – Critique ………. 29
5.7 Attachment Theory ………. 30
5.8 Four attachment styles ……….. 30
6. Findings ……… 32
6.1 Key informants interviews ………. 32
6.2 Healthwork professionals ……….. 34
6.2.1 Factors that influences mother`s psychological well-being after a premature birth … 34 6.2.2 Risk factors for mother`s to develop PPD ………. 34
6.2.3 The effect of physical separation on the mother`s mental health ……… 35
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6.2.4 Healthcare relationship ………36
6.3 Workshop Discussion ………. 36
6.4 Focus Group Discussion ……….37
7. Analysis ……….39
8. Conclusion ………49
9. Recommendations ………52
Bibliography ……….. 54
Disclaimer
The opinions expressed in this report are those of the authors and do not necessarily reflect the opinions of Linnaeus University in Växjö, or the organisations UNICEF & AMC in Kosovo.
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List of Abbreviations
Acronyms Meaning
AMC Action for Mother`s and Children
AT Attachment Theory
FST Family Systems Theory
MoH Ministry of Health
PTB Preterm Birth
PPD Postpartum Depression
SDG Sustainable Development Goals
UNICEF United Nations Children`s Fund
UNDP United Nations Development Programme
WHO World Health Organisation
List of Figures:
Figure 1. Conceptual framework module of family systems theory.
Figure 2. Attachment styles linked to treatment motivation and client clinical progress Figure 3. The effects of internal & external factors on mother`s mental health
Figure 4. Factors that increases the risk of PPD
Figure 5. The effect of physical separation on mother`s mental health Figure 6. Importance of healthcare relations
List of Appendices:
Appendix 1. Interview guide
Appendix 2. Questions for quantitative online survey
Appendix 3. Consent written forms
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Acknowledgement
I am grateful to everyone that have helped and supported me during this Master-Thesis. Without you, nothing of this would have been possible.
Special thanks to all of the staff within the main organisations, UNICEF & AMC Kosovo, especially Dafina and Vlorian for your constantly support and advice throughout this whole research process.
Moreover, my gratitude goes to all participants within different relevant professions, which contributed towards this study by setting aside their own time.
Another special thanks goes to all my wonderful classmates which have contributed throughout the year with their immense support and positivity. Special appreciation goes to my friends Pranvera Mucaj and Carina Bach for their endless encouragement.
Further, my gratitude is channeled towards my supervisor Christopher High, for his support.
Finally, a massive thanks to all professors within Peace & Development studies for these instructive four years. You are all important parts of the puzzle, which now enables me to achieve my dream.
For that, I will always be grateful!
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Dedication
I have dedicated this thesis to my dear friend Lillian Dover who past away the summer of 2019. She always encouraged me to follow my heart and aim for my dream. Lillian and I met 2016 in Zambia, a country which forever holds a special place in my heart.
By our shared passion for Africa, Lillian supported me to believe in my ability to achieve my goal. I knew from the start that the peace & development programme was the right path forward, and I know that Lillian would have been proud over my strength and determination to reach my African dream.
Lillian Dover “Always loved, Never forgotten, Forever missed” – Unknown.
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Abstract
Scholars around the world emphazise the value of more research within newborn health and maternal care until 2025, while some even express the need for more research whitin these topics in the specific case of Kosovo. Research about women`s postpartum depression (PPD) in Kosovo linked to the type of delivery was conducted by Obertinca & Dangellia, (2016), which demonstrate a research gap by asserting that current topic information within the country is scarce.
This research objective was to focus on different expert perspectives in Kosovo, around linkages between a premature birth (PTB) and the mother`s PPD. Kosovo as a case presents an example of how low and middle income countries address their health policies within their national health-care system. The aim of the study was to understand what it is about PTB that seems to raise PPD amongst women in Kosovo. One important indication of further research value, is that research presented by Vigod et al, (2010) indicates strong linkages between prematurity and the mother`s PPD, while research according to Halbreich, (2005) claims that it is need for more conceptually integrated research and interdisciplinary approaches before one can establish possible linkages.
An abductive logic of enquiry was used together with mixed methods within a multistage methodological approach, conducted remotely with representatives of United Nations Children`s Fund (UNICEF) and Action for Mother`s and Children (AMC) health-care staff, specialized on maternal and child health. It was found that different experts in Kosovo working with maternal and child health, shared the general perception around linkages between prematurity and the increased risk for the mother to develop PPD. Increased understanding about this topic is of highest
importance since it can be linked to the country`s high numbers of infant mortality rate and performed caesarean sections, which directly affects maternal health and child development.
The study used family systems theory and attachment theory in combination to develop a conceptual framework, which was useful during the thematic and content analysation process of the presented data. This study has contributed with new scientific knowledge to the on-going debate about prematurity and women`s postpartum depression, by triangulation of data from different key informants in Kosovo. This paper has provided conclusions with the basis for further research to be conducted.
Keywords: Premature birth, Postpartum depression, Multistage methodology, Child development
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1. Introduction
The responsibility for a new born can in general be overwhelming, however, the unexpected motherhood to a premature infant often causes mother`s to feel additional emotional distress. The high mortality rate across the globe for premature infants is being one reason. Approximately fifteen million infants were born pre-term a decade ago, and around twelve percent died as a result of that (Gerri et al, 2013: Lilliecreutz et al, 2016). Other reasons for mother`s to experience emotional distress are due to the infants developmental challenges or that the delivery was experienced as a traumatic event, which influence the attachment ability and therefore also child development (Green, 1990: Lonio et al, 2016).
1.1 Research problem, objective, relevance & questions
According to the World Health Organisation (WHO) and other institutions, there is global
importance of future research priorities within the development agenda, such as improved maternal care and newborn health by 2025. These aspects are important for positive child development, which therefore link this research to development studies. The importance of reducing numbers of mothers who suffers from complications during and after pregnancy, is strongly related to positive early childhood development (Journal of Global Health, 2016: Ibishi et al, 2018).
This study was conducted based on the above research that emphazise a global value of further knowledge around this topic (Journal of Global Health, 2016). Moreover, the relevance of this case study being conducted in Kosovo is linked to the worldwide demand amongst several scholars which emphazise the importance of more research around maternal and newborn health within the country.
While researchers emphasize the value of increased understanding about this topic, Kosovo`s perinatal annual report presents a high perinatal mortality rate, up to twelve percent. A clear research gap is identified by research conducted of Obertinca & Dangellia, (2016), focusing on women`s PPD in Kosovo where linkages towards type of delivery was identified. These findings indicates the importance of the topic being researched further within this specific country. The need for further research is also demonstrated by the presented data of this study, which indicates a national lack of data (Ibishi et al, 2018: Lotfalipour et al, 2019: Taaffe McLearn et al, 2006: Vigod et al, 2010).
Based on the above indications, this study objective was to focus on different expert perspectives in Kosovo, around linkages between prematurity and mother`s postpartum depression.
To be able to conduct the study, the following four research questions were developed.
What different factors influence the mothers mental health after a premature child-birth?
How is a mother emotionally affected by being separated from her premature infant?
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How does a premature birth affect the mother/infant attachment and the early childhood development?
What role do health-care relationships play, in terms of the mothers mental state after giving birth prematurely?
1.2 Structure of Thesis
This study comprises nine chapters, starting with an introduction of the thesis, followed by background and literature review, which discuss research problem, relevance and objective.
A multistage methodology approach has been conducted in three steps, including online interviews, an online survey and an online workshop discussion. In doing so, the study draws on a conceptual frame of family systems theory (FST) and attachment theory (AT), used as analytical tools to critically analyse the data. Increased knowledge about the linkages between PTB and the mother`s PPD will promote the value of women`s mental health, and therefore have a positive impact on the countries child development process (Bettmann, 2006: Cho, 2019: Beavin Bavelas & Segal, 1982;
Cummings et al, 2002).
Finally, the last chapters summerize the study conducted by presenting conclusions and recommendations.
1.3 Limitations/Delimitations Limitations:
This study was feasible to achieve during the current circumstances and during the time limit at my disposal. Limitations during this remote study, in other words interactive fieldwork conducted at distance, was to explore the efficency of the countries postpartum depression programme which was beyond the scope of this research project. Moreover, the language barrier was another limitation,
Concept Meaning
Premature Birth A child born earlier than week thirty seven of gestation (Definition WHO)
Postpartum Depression Refers to the initial time after birth, especially the first six weeks.
Early Childhood Development
Usually refers to under the age of three and should include
“nurturing care, good health, optimal nutrition and a stimulating and safe environment for all-round development
and learning” (Definition UNICEF)
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since many people do not speak English in Kosovo. To be able to conduct, send out and collect the quantitative online survey, the host organisations AMC and UNICEF supported with translation of the survey, as well as the participants response. Moreover, due to the current Covid-19 pandemic, the previous plans to conduct a field study were cancelled. Therefore, new practical constraints arose, since face to face interviews were not possible to conduct at all. Further, since the original plan to interview participants changed, the research structure changed during a late stage (Bryman, 2012).
Delimitations:
The research topic was developed in line with the presented research gap in the literature rieview, combined with personal values and interests. An active choice was made to not only focus on one data collection method within this study, with the purpose to increase the research validity when presenting a generalisation of data. The main organisations chosen for collaboration during this research are UNICEF and AMC Kosovo, due to their expertise in child health and development. The targeted organisations have also developed educational programmes around maternal care and developed specific projects for mother`s that experience PPD. The research includes different perspectives expressed by experts within similar professional fields, but different positions across the country. UNICEF and AMC staff expressed their perception around this highly relevant topic through online interviews. By including different methods, data from different working positions could be included. Additionally methods within this remote study, included a online survey and a online workshop. This strategy was chosen to include as many participant perspectives as possible, as all individuals could not take part in all three research methods, but at least in one (Bryman, 2012).
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2. Background/Justification
The responsibility for a new born can be overwhelming even for mother`s to a healthy full-term infant, therefore the unexpected parenthood to a premature infant often cause the mother to feel different types of emotional distress. One of the most critical reasons for this is due to the high mortality rate across the globe for prematurely infants. Approximately fifteen million infants were born pre-term a decade ago, and around twelve percent of these infants died as a result (Gerri et al, 2013). This perspective is shared by Lilliecreutz et al, (2016), which states that one of the major risk factors for infant mortality is caused by prematurity. Approximately sixty-three percent of all global deaths in children under the age of five is due to PTB. Previous research has indicated that physical factors like smoking, being underweight or a previous experience of preterm delivery, increases the risks for the mother to experience a premature childbirth. However, later research also indicates that even the psychological state of the mother can affect the parturition time, and therefore cause a premature birth. Premature children experience many challenges, which can be divided into two major groups. Medical and neurological health issues as well as social interaction and attachment constraints. Even though relevant professions are aware about these children`s developmental challenges, more research is needed, especially about mother`s emotional state during pregnancy as well as after a PTB. This, to further understand the root causes of these issues and how the infant- mother attachment are affected (Lonio, et al, 2016: Gerri et al, 2013: Lilliecreutz et al, 2016). WHO defines PTB as a child born earlier than week thirty seven of gestation. However, the definition has changed over time. A few decades ago, the guidelines which indicated that a child was born prematurely, were decided depending on the birth weight, compared to the current gestational age definition (Glass et al, 2015; Ibishi et al, 2018; Lonio, et al, 2016). Increased research about mother`s emotional and mental health after they have experienced a PTB, can increase the knowledge around different emotional distress symptoms, like PPD as well. This is of importance since evidence indicates that PPD in the mother have negative affects on child development by affecting long-term cognitive functions, behavioral disturbances, early interaction skills as well as increase the risk of insecure attachment between them both. Evidence also indicates that children`s learning ability becomes affected, and they seems to hold an increased risk of both psychological and physical issues later in life. The cognitive deficits has been linked especially to children within lower socio-economic backgrounds, which is relevant in developing countries since many people find themselves in these living conditions. Depression do not only affect the individual that are ill, it affects the well-being of the whole family. Therefore, the functioning of a whole society may be at risk, due to the issues wide spread occurrence. By this research topic being a societal health and developmental issue affecting both mothers and children, the research is linked to development studies (Murray & Cooper, 2009: Center on the developing child, 2009).
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The general definition of maternal depression can be referred to how the mothers mental state influences the development of the child and the overall family structure according to Wachs et al, (2009), while the specific concept of postpartum depression refers to the initial time after birth, especially the first six weeks. The later concept also includes other health related issues, where around 13 percent of mother`s worldwide suffers from this condition. Since most research around these topics hold a western perspective based on the developed world, a research gap is indicated amongst developing countries (Glass et al, 2015: Stewart et al, 2016: Halbreich, 2005: WHO, 2010:
Josefsson, 2003).
2.1 Kosovo as a case
Firstly, global scholars emphazis the value of more research in general within newborn health and maternal care until 2025 (Journal of Global Health, 2016). The research was conducted as a case study in Kosovo due to the identified research gap where Ibishi et al, (2018): Lotfalipour et al, (2019): Taaffe McLearn et al, (2006): Vigod et al, (2010), claiming the importance of further research around the topics of newborn health and maternal care in the specific case of Kosovo.
Research done by Obertinca & Dangellia, (2016) has focused on distribution patterns of PPD amongst women in Kosovo and their study demonstrate a research gap by asserting that current topic information within the country is scarce. The study indicates the importance of the topic being researched within this specific country, especially since evidence demonstrate linkages between type of delivery, the womans internal stresslevels during pregnancy, family structure, socio-economic circumstances and the woman develop PPD. Since all these factors have the potential to affect the women`s mental health negatively, it is important to increase understanding about what causes PPD and improve preventative measures whitin the countries health care system. This, to increase the well-being and living conditions of these women, which long-term also benefits child development (Obertinca & Dangellia, 2016). Based on the research above, this study has specifically focused on linkages between PTB and PPD of women in Kosovo, since these topics within maternal care and newborn health, both have long-term affects on child development (Ibishi et al, 2018: Johansson, 2019).
Since evidence indicates that more research are needed within developing countries, and that the population in Kosovo would benefit from more research around how mental healthcare services attend the issues of psychological diseases, Kosovo is a relevant case. It is of highest importance to understand and hold knowledge about the root causes of mental issues like PPD, to be able to improve the mental healthcare services and clinical health practices in relation to the specific cultural and contextual factors. Improved intervention strategies and efficient policy practices around mental health issues like depression, would decrease the number of people suffering from a psychological
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disease and therefore alleviate the burden of the national healthcare system long-term (Russo et al, 2020: Obertinca & Dangellia, 2016). Another relevant reason to focus on Kosovo as a case, is that the nation as many other low-middle income countries experiences both socio-economic and health disparities between urban and rural areas and between ethnic groups. This causes many women in Kosovo to experience different opportunities to receive maternal care, which therefore can affect child development (UNICEF, 2017). These factors in combination with specifically high perinatal mortality rate, as well as the high stigmatized culture regarding people`s mental health, supports that not enough is known about the situation in low and middle income countries. Due to the nations different health care services, Kosovo experience low national reporting around how many infants are born prematurely and around psychological issues like PPD. The later since it is not openly discussed, and not always socially accepted. Difficulties finding statistics indicates that these topics are under researched and therefore also supports the chosen research gap (UNICEF, 2017; UNICEF, 2020; Ibishi et al, 2018; Toci et al, 2014: Vuthaj & Maxhuni, 2016).
Research not being able to establish why the nation experiences a perinatal mortality rate as high as over 12 percent, referring to the death of a foetus under 500g or born before week 22 of gestation, is another factor making Kosovo a relevant case. During 2015 Kosovo lost over 8 percent of their new born infants, while the rate for stillbirth were over 5 percent and early neonatal mortality rate just over 3 percent. What also makes Kosovo a relevant case, is that during 2015 statistics indicated that over a third of all mother`s held the relatively young maternal age of 25 – 29 years old (Vuthaj &
Maxhuni, 2016). The maternal age is of importance since younger mother`s that are pregnant indicates to have an increased risk for developing PPD, were some risk factors is lack of social support and earlier experienced depression. Comparatively, amongst older mother`s one of the indicated risk factors for PPD were the mental state during pregnancy. The highly stigmatized culture around mental illness in combination with poor access to health information, makes it difficult to detect and treat mothers suffering from PPD in Kosovo (Vuthaj & Maxhuni, 2016: Nunes
& Phipps, 2013: UNICEF Kosovo, 2017). Since the beginning of the millennium many health sector reforms have improved, however one aspect that have worsened is the rapid increase regarding the nations caesarean sections. During the decade 2005 to 2015 these numbers increased from seven point five to over twenty seven percent, well over WHO recommendations. The country`s healthcare system is divided in three different parts, which in 2015 received approximately ten percent of the total national budget. Within these different levels of health care, specific programmes have been developed to promote both maternal health and child development (Dartmouth Global Health Policy Lab et al, 2018: Kosovo Agency of Statistics et al, 2014: Vuthaj & Maxhuni, 2016). After the war in 1999, the nation was left with severe health challenges within reproductive as well as maternal and child health. Therefore, the country has developed different levels of health care, where specific
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programmes have been developed to promote both maternal health and child development
(Dartmouth Global Health Policy Lab et al, 2018: Kosovo Agency of Statistics et al, 2014: Vuthaj &
Maxhuni, 2016).
The organisations of study are UNICEF and AMC, due to their specialization and expertise on child development and health as well as their involvement in maternal care and depression. Based on this, the research has contributed to the debate by including data from different expert perspectives within the field. It has involved individuals from the country`s postpartum depression programme, where both UNICEF and AMC are involved to increase the psychological well-being for mothers. This is highly relevant, since increased knowledge about maternal care not only hold a value for the mother`s, it also gives the infants the best possibilities towards a healthy start during the early childhood development years (Journal of Global Health, 2016: Ibishi et al, 2018: AMC, 2014:
UNICEF, 2017). UNICEF is one of the main actors on national level working in Kosovo to protect and improve children rights. At current the organisation focuses on six different areas, whereby one includes early childhood development. UNICEF is working as bridging support to improve the cooperation strategies between the Ministry of Health (MoH) on national level, down to actors on regional and local level. This with the purpose to improve the countries primary healthcare. Through improved national guidelines the maternal and child health are considered to be addressed more efficiently. Improvements are especially needed in many rural areas, where health resources are lacking and the country`s less populated communities are being less prioritized (UNICEF, 2017).
AMC is a humanitarian non-profit foundation and one of UNICEF`s partner organisations in Kosovo, aiming to improve maternal health and decrease the countries child mortality rate. This, since the mortality rate of infants may be the highest in Europe. The organisation works within three different main areas, were two of them focus on maternal health and specific care for prematurely infants. The organisation focuses on maternal and child health through four different programmes, where each has specific projects developed on regional and local level. Within a specific supply programme, AMC is now supporting the countries Neonatology Unit with survanta medication, crucial for prematurely infants survival (AMC, 2014: UNICEF, 2017).
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3. Literature Review
The relevance of mental health in developing countries has increased during the last decades.
According to Russo et al, (2020), low and middle income countries are in need of general healthcare improvements, and these nations would benefit from more investments towards mental health services, since treatment and management are severely affected by the countries socio-economic disparities. Even Patel, (2007) addresses the importance of recognizing people`s mental health in low and middle income countries, since it has been recognized as a public health priority by the landmark Global Burden of Disease. The report contributed with
increased knowledge and expanded the concept of mental health by adding disability, which has influenced more people to become aware about mental health issues as an illness, which has increased the attention of linkages to mortality (Patel, 2007). One linkage is seen in research by Lilliecreutz et al, (2016): Marcus, (2009) which indicates that maternal stress and depression during pregnancy increases the risk for a premature birth. An infant born prematurely, holds an increased risk of both diseases and mortality, and therefore the child development are directly affected. In developing countries where advanced intensive neonatal care is lacking, prematurity has devastating consequences, as it is seen to be the most common factor behind infant
mortality. The fact that low and middle income countries already experience high numbers of infant mortality even at late gestational ages, makes improvements within newborn health and maternal care even more relevant (Ngoc et al, 2006: Gerri et al, 2013: Lilliecreutz et al, 2016).
Both PTB and PPD are concepts linked to child development which UNICEF, (2020) refers to as,
“nurturing care, good health, optimal nutrition and a stimulating and safe environment for all-round development and learning”. Moreover, The Lancet (2017) supports the definition and emphasizes the importance of improved early childhood development (ECD) programmes across the world. The ECD years are usually refered to under the age of three, eventhough statistics often mention children under five. Around fourty three percent of the worlds children under five are struggling to reach their full development potential due to lack of the above mentioned resources, which indicates that children`s long-term cognitive and physical development are becoming severely affected (The Lancet, 2017). Since PTB and PPD are linked to child development, the concepts also relate to the United Nations Development Programme`s (UNDP) annual human development reports across the world. In relation to the human development concept, human security has become highly relevant, refering to people`s perception of freedom and safety. It also promotes possibilities for social science to include the modern concept in development policy and practice (Bajpai, 2003: Murray & Cooper, 2009: Center on the developing child, 2009: Lilliecreutz et al, 2016).
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In relation to child and women`s rights, Wachs et al, (2009) states the importance of addressing maternal depression and general care. Especially in low & middle income countries which host most of the worlds children. Further research about maternal depression during and after pregnancy are important, since depression during pregnancy increases the risk of being affected by PPD as well.
Maternal depression is seen as a global challenge, affecting human rights as well as child
development, health and behaviour. The infant-mother attachment is severely affected by a mother`s depression. It may expose the child for increased risks of developmental issues as well as other long term challenges. Even the depressed mother`s are affected by long-term risk factors such as chronic maternal illness, low social support or economic stress, which therefore can be seen to affect human security (Wachs et al, 2009: Josefsson, 2003: Marcus, 2003: Youtube, 2014). The infant-mother attachment also becomes affected after a PTB. Research indicates that approximately twenty percent of mother`s that had given birth premature, had developed secure attachment after six months. While over fifty percent of mother`s to a full-term infant held secure attachment (Borghini et al, 2006).
Moreover, since the research is linked to child development, it is closely related to the global Sustainable Development Goals (SDG`s) introduced 2015, through the Agenda 2030 which aim to
“leave no one behind,” and create a sustainable environment for everyone (United Nations, 2018).
The Lancet report Countdown to 2030 focus on improved reproductive, maternal, newborn and child health across the world. It states an urgent need for improved interventions that address women empowerment and the root causes of socio-economic disparities, to be able to reach the SDG`s (Lancet, 2018). The study is interlinked to several goals, specifically the third, good health & well- being, by specific targets focusing on maternal, reproductive, newborn and child-health (SDG Knowledge Platform, 2019). It is important to reduce numbers of mothers who suffers from
complications associated with pregnancy, to promote positive early childhood development (Ibishi et al, 2018). According to Lotfalipour et al, (2019) there is limited research around mothers mental state after giving birth prematurely. Further, Taaffe McLearn et al, (2006) presents similar
arguments around the importance of further research about maternal depression symptoms and it`s effects. Further research gap are presented by Vigod et al, (2010), about how specific factors of giving birth prematurely affects the risk of PPD for the mother. Therefore, research by Vigod et al, (2010) indicating strong linkages. However, current research indicates two different perspectives towards the outcomes since research according to Halbreich, (2005) claims that majority of current research are not conceptually integrated. This supports the need of interdisciplinary approaches, to be able to determine a possible relation. Moreover, Ukpong et al, (2003) argue as well for the difficulties to detect and apply appropriate support for mother`s psychological distress symptoms during the postpartum period. In line with the research of Halbreich (2005), this study emphasizes the need for increased multidisciplinary approaches, to be able to discover psychological distress symptoms as early as possible, and therefore be able to confirm a possible connection (Ukpong et al,
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2003). Since Halbreich (2005) emphazise that further interdisciplinary research are needed, this research topic of prematurity and postpartum depression is of highest importance since the study combines research from different fields of study. The majority of current development research are based on perspectives from psychological scholors like Jean Piaget, Lev Vygotsky, Sigmund Freud and Erik H Erikson. Their concepts around cognitive development and human behaviour is still seen as a foundation for further understanding of human development (Huitt & Hummel, 2003; Itard et al, 1932: Erikson, 1985: Freud, 1923:363,364; Freud, 1920; Freud, 1924; Freud & Bonaparte, 1954).
Moreover, the different developmental challenges a preterm infant experience the first months, is usually causing the parents immense emotional distress, influencing their parenthood. A premature child birth is often experienced as a trauma due to many cases being the result of health issues for mother or the infant. This type of emergency can be defined as a traumatic event, according to Green (1990), since the experienced situation threats two lives. This affects both their physical integrity as well as other psychological mechanisms. After experienced a trauma, the mother`s ability to develop positive attachment pattern may be affected as a result of psychological distress. By the mother struggling with her own mental health, the childs development process are being affected (Lonio, et al, 2016: Johansson, 2019: Green, 1990). A childs development process depends according to Prachi et al, (2011), to a large extent on what type of attachment pattern is developed towards the mother. Therefore, many challenges can arise after a PTB which may cause the mother to struggle mentally or emotionally, while find it difficult to develop secure attachment. A similar approach is presented by Borghini et al, (2014), which emphazise that the mother`s experience of the childbirth influences her emotional and mental state afterwards as well as her ability to develop a healthy attachment to the infant. Therefore, research indicates that mothers who processes the grief of their infant being born prematurely increases the chances of developing secure and positive attachment.
Mother`s which have resolved their grief, manage to be present with their premature infant and they are able to accept both challenges and benefits around the life changing event. Comparatively, mother`s which do not procceses the grief have a tendency to relive the childbirth. By the mother not being able to accept the current circumstances, the mother-infant attachment are becoming
negatively affected, and are more likely to end up as insecure attachment (Prachi et al, 2011:
Borghini et al, 2014: Johansson, 2019).
Moreover, as seen in chapter two, different aspects was presented as relevant factors for
identification of the specific research gap as well as this study relevance of using Kosovo as a case.
By statistics indicating high numbers of the countries perinatal deaths, this study presents a clear national health issue as well as a research gap by scholors not being able to present specific reasons behind the high numbers. Therefore, more research around prenatal and maternal health-care in Kosovo are needed. This research has contributed by increased understanding around the linkages
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between a PTB and PPD in mother`s, as well as how that connection may affect child development (Vuthaj & Maxhuni, 2016: Journal of Global Health, 2016: Ibishi et al, 2018: Lotfalipour et al, 2019: Taaffe McLearn et al, 2006: Vigod et al, 2010: Obertinca & Dangellia, 2016: Russo et al, 2020: UNICEF, 2017). The study has analysed what it is about a premature birth that seems to raise the postpartum depression for mother`s in Kosovo.
According to Josefsson (2003) mother`s who experienced more complications and emotional distress during pregnancy, indicated to have a higher risk of PPD. Additional research also indicates that mother`s which have experienced depression earlier in life or during pregnancy, are at higher risk of developing PPD as well (Marcus, 2003: Youtube, 2014). This is highly relevant to consider during this study, since research indicates that maternal stress and depression during pragnency as a
psychological factor, increases the risk for a premature birth (Lilliecreutz et al, 2016: Marcus, 2009).
A premature birth is directly affecting child health and development through the increased risks of diseases and infant mortality. Further, a premature childbirth is in many cases perceived by the mother as a traumatic event, due to the child`s decreased chances of survival combined with physical and psychological development challenges (Pierrehumbert et al, 2003). This research is supported by Prachi et al, (2011) and Borghini et al, (2014) which emphazise that a premature birth often are experienced as a trauma and therefore lead to emotional distress symptoms like PPD for the mother.
Just as a PTB seems to increase the risk for stress symptoms afterwards, research indicate stress and depression to be risk factors for a PTB to arise (Lilliecreutz et al, 2016). Moreover, research according to Johansson (2019), indicates that mother`s which experience PPD also feel a higher degree of incompentence within their role as a parent. This affects the parent`s relationship with eachother, due to increased stress levels. Increased stress for both parents are indicated to be the largest risk factor for both the mother and the father to develop PPD. Parents which experience a high level of stress, seem to influence the child`s development process even more negative then the risk of parents own destructive attachment being transmitted down to the new generation. The most stressful factors for mother`s seems to be the experience of a traumatic child birth and the feeling of inadequacy afterwards, which increases the risk of PPD and anxiety. The vulnerability to develop PPD is influenced by the mother`s own attachment patterns as a young child. However, the one single factor which increases the risk for the mother to develop PPD is the perception of increased stress levels, both during and after childbirth (Johansson, 2019). Another factor which seems to influence the risk of psychological issues for the mother is the aspect of caesarean births (Elshani et al, 2012). The national numbers of caesarean sections has increased in Kosovo during the last decade, and therefore the numbers are exceeding international recommendations.
During 2016, the Ministry of Health (MoH) started to improve policy interventions, due to the purpose of promoting maternal and childhealth reforms (Dartmouth Global Health Policy Lab et
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al, 2018: Vuthaj & Maxhuni, 2016). Diseases and complications during pregnancy has been some of the most obvious reasons for caesarean sections in the past. However, cultural changes have made mothers themselves to request caesarean sections to a larger extent. Medical
knowledge have made it possible with increased caesarean rates when necassary, due to mother and child safety. Eventhough caesarean sections many times are a solution, it involves
riskfactors. The procedure increases the risk for maternal mortality (Elshani et al, 2012). Last year AMC in Kosovo initiated to a national round-table discussion regarding the countries increased numbers of caesarean rates. The discussions included potential reasons, future solutions as well as what long-term health effects it has for both mother and child. Some discussions focused about the importance of communication between midwifes and the mother, were the role of midwifes and nurses is to guide and advice the mother to give birth naturally when possible (AMC, 2014).
3.1 Research objective, aim and outcomes
This research objective was to focus on different expert perspectives in Kosovo, around linkages between prematurity and mother`s postpartum depression. The purpose of focusing on Kosovo was to present an example of how low and middle income countries address their health policies within the system. The aim was to understand what it is about premature birth that seems to raise
postpartum depression amongst the Kosovo women. The research outcomes has lead to increased understanding about prematurity and its linkages towards postpartum depression, and contribution towards scientific knowledge have been made by identified aspects supporting the need for more academic research as well as improved societal recognition around these national health-care challenges within the country.
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4. Methodology
The rationale of this research draws on health interests for mothers and children, based on their mental health and development process. The idea for this specific topic originated from social science traditions within the healthcare system. An ontological position is presented, whereby the constructionism view is focused on. Through this position, the character of reality is challenged by people`s organisational and cultural perceptions. Due to on-going revised organisational structure and the changes of social order, Strauss et al, (1973) refer to this as negotiated order based on the constant alteration. Similar perceptions are being made about culture. According to this point of departure, culture is seen as an changeable phenomena, which is influenced by people continuously.
The concept of culture can be seen as a reference for people`s social constructed lifestyle. However, according to both Strauss et al, (1973) and Becker, (1982) cultural transformations is constantly reconstructured through multi-generational developments (Bryman, 2012).
4.1 Type of study
This research has been conducted as a remote study, which has used mixed method research strategy and designed as a case study of Kosovo. Therefore, it enables in-depth and detailed analysis during the process of answering the four research questions (Bryman, 2012). This, with the purpose to increase understanding around different experts perception around what it is about a premature birth that seems to raise the postpartum depression condition. Further, the study focused on increased understanding and interpretation around this possible relation instead of explaining. Therefore, this research can be argued to take a hermeneutic approach (Bryman, 2012). Since it would be too much of a generalization and difficult to analyse the impact of UNICEF Kosovo`s postpartum programme, this study focuses specifically on UNICEF and AMC experts, and their perception around what it is about premature birth that seems to raise postpartum depression. This is to contribute with new knowledge to the on-going debate. This is linked to social constructivism, which according to Hirtle, (1996) refers to people`s cognitive ability to increase understanding about their social environment.
Even Bryman, (2012) emphazises that the definition of constructivism includes both social interaction linked to the constant change, due to an individuals own perception towards specific events. An abductive logics of enquiry has been used, which Bryman, (2012) refer to a retroductive form of reasoning, focusing on what is behind observable behaviours within societies. This, to be able to understand and interpret the findings the best way possible (Steinglass, 1984; Kuo et al, 2017; Beavin Bavelas & Segal, 1982; Cummings et al, 2002).
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4.2 Data collection
A multistage methodology approach was conducted in three steps, where semi-structured online interviews were completed, combined with a survey and an online workshop, with all participants anonymous. The methods used were based on the research aim to present different expert
perspectives within the field. By a mixed-method approach the validity of a generalisation of data increased. However, limitations is seen as the author not being able to make sure who has completed the survey, and therefore some results could be misguiding. Semi-structured qualitative online interviews were conducted within stage one with participants working in the organisations UNICEF and AMC Kosovo (Bryman, 2012). Moreover, the second stage was conducted through a
quantitative online survey holding mostly closed questions, combined with a few open ones to add more relevant information. The original plan was for psychologists and midwifes to respond to the survey, due to their close working relationsships with mother`s experience a PTB or PPD. This was discussed beforehand with the contact persons in UNICEF and AMC Kosovo, which believed in the idea. However, these individuals did not respond, and therefore the survey was conducted with 9 participants working within relevant organisations like UNICEF or other type of social work. Their work experience ranged from 3 to 10 years. Based on this, the data gave indications, however not as strong as planned. The data was analysed through the quantitative statistical method of discrete data based on whole numbers, and presented in thematic tables (Youtube, 2019: Bryman, 2012).
Finally, the last stage was conducted through an online workshop, whereby the findings from the online survey were discussed together with two representative each from UNICEF and AMC. To fill remaining gaps and increase the validity of the research, an additional focus group discussion was conducted with representatives from UNICEF and AMC to discuss potential reasons why the targeted experts of psychologists and midwifes did not respond to the survey (Bryman, 2012).
Furthermore, much effort has been put into additional online correspondence to receive more information, especially about national statistics. However, few numbers are available, due to the country`s lacking resources. Information about the countries lack of national data, has been received through a number of different people, through snowball sampling. The online interviews were conducted in English and the questions developed with the purpose to explore the field as well as increase understanding about topic linkages. Arranged interviews were set up by UNICEF and AMC professionals, while snowball sampling was used for the online survey during the second stage. The online survey questions were adjusted for more specific professions to respond, essentially for people that work closely with mother`s that have experienced a premature birth or depression. These individuals are also knowledgeable about how PTB and PPD affect infant-mother attachment and child development. The process of developing survey questions changed during my first stage of online interviews, as more knowledge and understanding was received. These changes made sure
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that each question in the survey filled a specific purpose to give as accurate data as possible. After the suvey was completed, a pilot study was conducted in Kosovo to see how the questions were interpreted and to make sure that they were well adapted to the language culture. Before the summary of the findings from the survey, an Albaninan speaking person within relevant field translated necessary responses back into English, for me to make sure that the presented data is accurate. During the online workshop, everyone spoke English and expressed their opinions and we concluded the findings together. It was natural that the two representatives from UNICEF and AMC were present, since these individuals had followed the overall research process from the beginning.
Sequential data gathering was used to collect data from two different angles. Therefore, the study presents the specific mixed method of triangulation design. Where the qualitative & quantitative methods complement each other with the purpose to broaden the findings and therefore increase the validity for a generalisation (BetterEvaluation, 2020: Fielding, 2012). Except the presented remote research techniques, the study used secondary materials, all from reliable sources found within the library’s browser system or google schoolar. Other reports used were presented by AMC and UNICEF Kosovo programme, government policy documents as well as general research materials (Bryman, 2012: Vuthaj & Maxhuni, 2016).
4.3 Reliability, Validity & Biases
While conducting social research it is of importance to consider aspects like reliability and validity to not produce research which is biased. Therefore it is important for researchers to be aware of their own feelings and perceptions, to not let personal values influence the outcomes, which would influence the research to become biased. Total objectivity is not possible, since we all hold specific thinking patterns and schemes. However, by being aware of this challenge, the researcher can work on to try to be as neutrual as possible within a new environment or towards a new research topic. In this case the author does not hold any previous experiences about the research topic or the country which could influence the result to become biased. Therefore a strong reflexivity is presented by the author being a suitable individual to conduct this specific study. Moreover, it is important to
understand that our personal values always influence the research already from the start, through the choice of method to analysation strategy of the findings. Another aspect which may influence the research to become biased, are increased sympathy with the participants, where emotional feelings affect the outcome. The main aspect is to understand the importance of being self-reflective in all situations during the process, to minimize the risk of the research becoming biased (Bryman, 2012).
By not having any previous experience or knowledge about Kosovo as a nation, the research reliability as well as validity become stronger, due to little personal expectations or perceptions beforehand. Self-reflections have been made throughout the process regarding my objectivity, due to personal interests and perceptions around the organisational commitments within societies. Another
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aspect which can be useful to reduce the risk of biases, is through increased reliability. High reliability is produced when the result is consistent, regardless of different researchers, environmental surroundings or techniques (Drost, 2011). Like Guest et al, (2012) discuss, the reliability and the challenges, are approached differently depending on the method. Thematic analysis, which holds a great focus on identifing patterns and interpret data, also focus to a large extent on the implementation process of reliability during the analysis. The findings and analysation have been presented as objectively as possible based on the participants response. However,
considerations have been made concerning the influence of personal interpretation of body language during the online interview and workshop process. Interlinked with reliability, the research validity is important, since a strong validity means that the researcher has manage to produce the intended result. To increase the research validity, there are four types which can be considered as useful tools, internal and external validity, construct validity as well as statistical conclusion validity. All these different validity types can be useful, however, depending on the specific research, one specific type may be the most relevant (Drost, 2011). Throughout this research process, the issues of reliability and validity have been addressed through the importance of objectivity, triangulation of sources as well as presenting a generalization of the findings. The choice of sources used is based on well recognised scholars from both development and the psychological field, with the purpose to increase the study reliability as well as the validity. However, some primary sources from within the
psychological field are relatively old and therefore more recent secondary sources from development scholors have been included as well. The conceptual frame consisting of Family Systems Theory (FST) combined with Attachment Theory (AT) worked as a useful analysing tool, which according to the author could be beneficial in similar research based on family relations. Additional analytical framework alternatives could be based within other relational theories. This, since relational perspectives, also founded within the psychological field focus on individuals ability to develop stable emotional relationsships among themselves (Slochower, 2014).
4.4 Selection procedure
The participants of this study were chosen by their professional positions within the field as well as through snowball sampling. The organisations UNICEF and AMC were chosen based on their expertise around maternal and child health as well as child development. Moreover, both
organisations are involved in educational programmes which specifically deal with maternal care and mother`s postpartum depression. Within these programmes, close collaboration strategies have been developed with other professions, like midwifes and psychologists that are medically trained to detect and treat mother`s that show symptoms of physical or psychological distress (UNICEF, 2017:
AMC, 2014). Further, the selection process of online interview participants was arranged by UNICEF and AMC staff, based on individuals different positions and therefore relevance to
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participate. The sampling process of participants for the online survey, was based on snowball sampling. However, the sampling process was based on individuals profession and expertise about the research topic. During the online workshop procedure, the present participants were two representatives from each organisation. These individuals were selected based on their specific organisational insight and central positions as well as their general knowledge about the research topic (Bryman, 2012).
4.5 Thematic & Content Analysis
Thematic analysis is a common method within qualitative research, with the purpose to produce well presented textual data after interviews. An important feature is to identify different themes and codes which are reapeted regularly, where an analysing pattern becomes visible. Since it emphazises the involvement of the researcher by interpreting the data from both an implicit and explicit angle, it was a useful technique during this research to interpret and bring similar data together. This identified analytical approach is based on the concept phenomenology, which originates from the
psychological field. Focus on the participants past experiences and perceptions around specific events, are some of the main features within the hermeneutic phenomenology research process (Guest et al, 2012). Within medical professions, this approach has been used to conduct research which indicated that hospital staff has a tendency to speak using academical terms. By increased awareness of hermeneutic phenomenology, the clinicians increase their chances of an improved mutual understanding, which makes it easier to interpret patients/participants verbal expressions through the ontological point of departure (Ho et al, 2017).
Content analysis is a method which can be used for mixed methods research, based on triangulation.
It includes three different approaches, directed towards qualitative or quantitative data. Those approaches have been included in this study based on the suitable combination with the multi-stage methodology, which were conducted in three major steps. The content analysation approach is often used within the psychological field as well. Therefore, based on previous indications and the specific research topic, both the above methods were included during the analysation process (Green, 2004:
Oleinik, 2010).
4.6 Ethical arguments
The importance of considering ethical issues are crucial within social research, due to scholors and participants integrity. Some different ethical stances which may be beneficial to be aware of are universalism, situation ethics and ethical transgression. Universalism holds the perception that all ethical rules and regulations are there to be followed, without exeptions. Second stance positions itselves around the importance of not follow all ethical rules, to be able to promote development within this research field. Finally, the ethical transgression. A stance which emphasize that scholors
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often conduct methods which can be questionable from an ethical perspective, with the purpose to influence their participants to a minimal degree (Bryman, 2012: Codex, 2019). Ethical
considerations during this study were made in several different steps. A written information sheet together with a consent form was sent out to all participants in advance, to explain the interview purpose, the voluntarly participation as well as the reason for recording. The reasoning behind this was to avoid misunderstandings and the feeling of being deceived. It is important that the person participating in the interview is comfortable with the location, so there will be no feeling of invasion of privacy. Therefore, a clear verbal consent was made before each interview, to confirm that the participant were comfortable with the present surroundings (Codex, 2019). Furthermore, the aspect of who is participating in interviews is important, since all participants during this study were aware of the purpose of their particular involvement. Individuals responsible for decision-making within UNICEF and AMC, have given their consent to some individuals participating in interviews. This was important to avoid that any participant got harmed in any way, before, during or after the process. Local rules and norms were considered and respected, while sensitive information was addressed carefully (Codex, 2019).
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Medical Home
Patient registry Decision making support
Care protocol Family-centered care
5. Conceptual Framework
A conceptual inspiration of family systems theory and attachment theory has been applied as analysing tool for interpretation of data and to increase understanding about possible topic linkages (Bryman, 2012). Moreover, this specific conceptual frame works for this topic based on the theory`s psychological background and that each theory emphazises important development aspects, such as attachment and awareness of emotions relevant for this research. Therefore, the two theories were chosen as analytical tools. Both theories are based on interaction patterns, and how it is perceived as communication as well as how differentiations will affect child
development (Bettmann, 2006; Beavin Bavelas & Segal, 1982; Cummings et al, 2002). The first model emphasizes the importance of an operational system, defined to be the family structure itself.
The study has combined the two theories, since both promote different concepts to interpret what factors influence the family system. Moreover, this model is useful for the research since it has the possibility to interpret people`s percpetions as well as increase understanding around how a system comprised by individuals, relates to eachother. The perception of the family system is influenced by the different individuals relationship towards one another, which affect how different family members behave (Steinglass, 1984).
5.1 Family Systems Theory
“Effective care delivery for preterm infants in the primary care setting based on chronic care model and practice transformation model of care” (Kuo et al, 2017).
Community Resources and policies Culture of QI Designated care team
(including neonatal/tertiary care)
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Informed activated family
Prepared proactive practice team
Figure 1. Conceptual framework module of family systems theory.
The model emphazises the importance of improved health, growth and development as well as lower costs and preventable utilization (Kuo et al, 2017).
Without parents finding a balance between these aspects, the mental health might be affected. The origins of the model were developed through the psychological field during the 1950`s where the term family therapy started to develop. According to Beavin Bavelas & Segal, (1982) the perception of the word family systems theory, explains the model well by referring to a system in which a family exhibits specific behaviours towards eachother, as a communicative relationship. The core patterns of a family system are based on the interactions between individuals. The theory emphazises the importance of all types of communication and how behaviours are interpreted by different people. Further, the model discusses how different behaviours, can be interpreted as a way of communication. This is relevant for a premature infant and the mother, since the specific situation will affect their interactions and non-verbal communication towards eachother. Therefore, this framework was helpful to increase understanding around what it is about premature birth that seems to raise the postpartum depression condition for mother`s (Beavin Bavelas & Segal, 1982;
Cummings et al, 2002).
5.2 How the model was developed
This model is based on Freuds psychoanalytical approach, and one of the most influential models developed during the mid 1950th by Murray Bowen, therefore later called “Bowen Theory”. As a first step, he included mother`s in his strategies to treat patients with schizophrenic symptoms.
However, while he began to focus more on the whole family`s emotional state, he also started to include other family members in his psychotheraphy sessions. Bowen realized that all family systems have similarities and common emotional states. Due to his own family background and experiences, he began to see the value of intergenerational patterns and how increased understanding can be more beneficial than individual treatment only (Brown,1999).
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5.3 The Approach
Fusion as espoused by Bowen` Theory is defined as follows: “ A sense of intense responsibility for another's reactions” as cited in Brown, (1999).
The basic idea of Bowen`s theory was that every family develops their own specific patterns to deal with negative emotions, such as anxiety. One of the reasons that family members may experience anxiety, is due to decreased contiguity. Another aspect that Bowen emphazises, is the importance of parents being aware of their own emotional state. Otherwise their emotional state is easily
transmitted to the children, through social learning patterns, which will increase the risk for the children developing anxiety themselves later on (Brown,1999: Haefner, 2015). One of the concepts Bowen referred to was emotional fusion, which can be explained as one family member setting aside their own needs, to be able to achieve a generalized harmony within the family system. Triangling is another main concept developed by Bowen, which refers to experienced anxiety between a dyad. To relieve the pressure, a third person is becoming involved, only with the purpose to ease the pain for the two people who experience a high level of emotional distress. According to Bowen, this concept is useful to explain situations which are based on negative emotions, expressed somewhere outside the original atmosphere (Brown,1999). Another important concept used by Bowen is the family projection process, which focuses on children`s involvement and how emotional distress can pass on from generation to generation. It is common that a child changes behaviours within the family dynamic, due to the parents tensions and anxiety. It often leads to that the child is being questioned of causing the initial problem. This destructive family dynamic is what Bowen calls detouring triangle. This situation often causes the spouses to project their attention to the child`s condition, instead of dealing with their own tensions between eachother, due to the feeling of denial (Brown,1999: Haefner, 2015).
5.4 How the Model works in clinical practice
The therapy goal as espoused by Bowen`s Theory is defined as follows:“To assist family members towards greater levels of differentiation, where there is less blaming, decreased reactivity and increased responsibility for self in the emotional system” as cited in Brown, (1999).
The practical idea of Bowen`s theory is to support family members through therapy and increase their own differentiation by focusing more on the self. One of the main strategies focuses on an individuals experience from the own family dynamic. First step is discussions about awareness, and the importance of increased understanding for the client about how the experienced anxiety is linked with specific interaction strategies towards the others family members. Second step focuses on awareness about differentiation, the self, and why it is important to take responibilty for the individual emotional system, instead of focusing on others. Finally, during the last stage, Bowen
