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Abstract
Background Poor mental health in the perinatal period is associated with a number of adverse outcomes for the individual and the wider family. The unique circumstances in which military spouses/partners live may leave them particularly vulnerable to developing perinatal mental health (PMH) problems.
Methods A scoping review was carried out to review the literature pertaining to PMH in military spouses/partners using the methodology outlined by Arksey and O’Malley (2005). Databases searched included EBSCO, Gale Cengage Academic OneFile, ProQuest and SAGE.
Results Thirteen papers fulfilled the inclusion criteria, all from the USA, which looked a PMH or well-being in military spouses. There was a strong focus on spousal deployment as a risk factor for depressive symptoms and psychological stress during the perinatal period. Other risk factors included a lack of social/emotional support and increased family-related stressors. Interventions for pregnant military spouses included those that help them develop internal coping strategies and external social support.
Conclusions US literature suggests that military spouses are particularly at risk of PMH problems during deployment of their serving partner and highlights the protective nature of social support during this time. Further consideration needs to be made to apply the findings to UK military spouses/partners due to differences in the structure and nature of the UK and US military and healthcare models. Further UK research is needed, which would provide military and healthcare providers with an understanding of the needs of this population allowing effective planning and strategies to be commissioned and implemented.
- military
- armed forces
- perinatal
- mental health
- spouses
- partners
- midwifery
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Key messages
All papers that fulfilled the inclusion criteria for this review originated from the USA.
Deployment of the serving partner during the perinatal period is a significant risk factor for depression and psychological stress in US military spouses.
The protective nature of military-specific social and emotional support against perinatal mental health problems in US military spouses was highlighted in the literature.
More UK research is needed for a better understanding of the perinatal needs of the military population in the UK context.
Introduction
The Maternal Mental Health Alliance reports that 10%–20% of women will develop mental illness during the perinatal period (conception to 1 year post partum).1 2 Women are more at risk of developing poor mental health in the early postpartum period than any other time of their life.3 It is widely accepted that mental health in pregnancy can be exacerbated by a number of biological, psychological, sociological and biopsychosocial factors (see Box 1).
Risk Factors for developing poor mental health in the perinatal period (adapted from O’Hara and Swain44)
Powerful predictors
History of psychopathology.
Antenatal psychological disturbances—anxiety, depression or dysphoric mood.
Poor marital relationships/marital discord.
Low levels of social support.
Stressful life events.
Socioeconomic disadvantages/poverty.
Lone parenting.
Teenage parenthood.
Early emotional trauma/childhood abuse.
Unwanted pregnancy.
Lack of affective emotional support.
Less powerful but significant predictors
Low social status.
Educational attainment.
Personality type and attributional style.
Employment status.
Familial history of mental illness.
Pre-existing mental health disorders may return or be exacerbated by pregnancy and childbirth due to the personal, physical, emotional and social demands of pregnancy and caring for a newborn.4 ,5 The 2017 ‘Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries Across the UK’ (MBRRACE)6 report showed that between 2013 and 2015, 14% of maternal deaths up to 1 year were attributed to poor maternal mental health (the leading cause). Poor perinatal mental health (PMH) is associated with a number of adverse outcomes for the individual and the wider family.7 Indeed, postnatal depression is linked with paternal depression and risk of poor birth and childhood outcomes.8–13
The relatively unique circumstances in which military families live may leave them particularly vulnerable to developing PMH problems. Frequent moves to new areas are common across the UK Armed Forces, with little geographical choice of posting, resulting in moves away from friends and family.14 Military spouses/partners are likely to experience low social support, stressful life events and lone parenting.15 The sense of associated isolation is further exacerbated by overseas postings with additional cultural and language barriers.16 In addition to isolation from support networks, military spouses/partners must renegotiate and redefine their roles and routines during partner absence, changing and potentially destabilising the family dynamic.17 18 Furthermore, military spouses/partners often experience fear and anxiety about the safety of their serving partner during deployment, which is linked to increased depression.15 19
Considering the stressors associated with being a military family, it might be expected that military spouses/partners would be more vulnerable to mental health problems than their civilian counterparts. However, this comparison is lacking in the literature. Research has shown that military spouses have lower overall well-being than matched civilian controls,20 and these findings are supported by recent research on military spousal employment.21 Deployment is associated with increased risk of a mental health problems in military spouses, including depression, anxiety, sleep disorders and adjustment disorders, and this risk of diagnosis increases with length of deployment.22 23
The impact of the military lifestyle on marriages, families and children is well described in US literature17 24 25; however, research in the UK is lacking.26 Furthermore, there is limited research on the experience and psychological well-being of military spouses/partners during the perinatal period. Considering the vulnerability to mental health problems for women in the perinatal period and military spouses during deployment, the following question arises: Are UK military spouses/partners particularly at risk of developing PMH problems? In an attempt to answer this question, the aim of this paper is to review the international literature pertaining to PMH in military spouses/partners, using a scoping framework.27
Methodology
A scoping review of the literature around PMH in military spouses/partners was conducted as outlined by Arksey and O’Malley.27 A scoping review was chosen as this technique is designed to ‘map’ the available literature in a broad or emerging field of interest. The methodology provided by Arksey and O’Malley provides a comprehensive five-stage framework detailed below.
The first stage of a scoping review is to identify a research question broad enough to capture relevant literature, and includes the population, topic and outcomes of interest. For this review, we chose to ask: Are UK military spouses/partners particularly at risk of developing PMH problems? In stage 2, appropriate search terms and databases were identified. Search terms included “Army/Navy/Marines/Royal Air Force/Military wife” OR “Army/Navy/Marines/Royal Air Force/Military spouse”, OR “Army/Navy/Marines/Royal Air Force/Military partner” “Mental Health” OR “Postnatal Depression” OR “Post-partum depression”, “perinatal/antenatal/postnatal/post-partum” OR “Pregnan’”. Initial searches using a number of databases (EBSCO, Gale Cengage Academic OneFile, ProQuest and SAGE) yielded 856 papers.
Study selection involved a number of stages which are shown in Figure 1. Following duplicate removal and exclusion of all papers other than peer-reviewed journals, 611 papers remained. The titles and abstracts of the remaining papers were then reviewed for relevance using the inclusion criteria shown in Box 2, with 31 papers identified for full-text review. A narrative search and backwards/forwards citation searches were carried out independently by two of the authors and identified 11 additional papers which were relevant to the topic. Two of the authors then independently reviewed the remaining full texts for inclusion. Thirteen papers were included in the final literature review that met the inclusion criteria, all originating from the USA.
Methodological process for literature search.
Inclusion criteria for the literature search
Study investigating the mental health or psychological well-being of military spouses/partners during the perinatal period.
Paper written in English.
Paper published in the past 15 years between 2002 and 2018.
Qualitative, quantitative or mixed-methods studies.
Published in peer-reviewed journals.
Stage 4 of the scoping review involves charting the relevant data from the identified papers to enable extraction and synthesis of findings. The following information was extracted and charted: full journal reference, location of research participants, study aim or objective, methodology type, outcome measures and results/main findings. Finally, a thematic analysis of the charted data was conducted to identify the main themes and gaps in the available literature. This was based on assessing the main risk and protective factors and mental health outcomes investigated in the available research. We present the charted data (see Table 1) and thematic analysis of the research papers in the results section below.
Extracted data from the 13 papers included in the scoping review
Results
Thirteen articles were identified that fulfilled the inclusion criteria. All papers focused on military spouses (although the inclusion criteria allowed for unmarried partners) and originated from the USA. Four papers included spouses from all US military service branches (Marine Corps, Navy, Coast Guard, Army and Air Force), two focused on US Army spouses, four on US Navy and Marine spouses, and three on US Air Force spouses only. Four broad themes were identified from the literature: deployment-related increases in perinatal depression, deployment-related increases in perinatal stress, other risk or protective factors from PMH problems, and support interventions for military spouses. All papers used quantitative research methodologies.
Deployment-related increases in perinatal depression (PND)
Four of the identified papers used the Edinburgh Post Natal Depression Scale (EPDS) to investigate the relationship between spousal deployment and PND incidence. Robrecht et al 28 found that positive screening for PND (which they defined as EPDS 12 or above)29 was three times higher in US military spouses whose partners were deployed versus not deployed. Furthermore, deployment was an independent predictor of raised EPDS score, even when accounting for feelings of isolation, history of depression and history of deployment.
The remaining three papers reporting EPDS scores used a cut-off of 14 or above as a positive screen, and as such reported lower overall percentages of PND. Tarney et al 30 reported that US Army spouses whose partners were deployed during their entire pregnancy were at a higher risk of developing PND compared with women whose partners were not deployed (16.4% vs 6.1%). Furthermore, they were more likely to report pre-term delivery (21.4 vs 8.9%), for which anxiety and stress can be a risk factor.31 Smith et al 32 recorded EPDS at the initial obstetric visit, 28–32 weeks of gestation and 6–8 weeks post partum. The women were then compared by deployment status (‘currently deployed’ and ‘returning from deployment’ were compared with ‘no deployment planned’). At the initial obstetric visit, only spouses whose partners were returning from deployment were significantly more likely to positively screen for PND (14% vs 6%). Both deployment groups had significantly more positive screens at 28–32 weeks, and the currently deployed group had significantly more positive screens in the postpartum period (16.2% vs 8.2%). Using the same methodology, Spooner et al 33 found a significantly higher proportion of positive EPDS screens at the initial obstetric visit and 6 weeks postpartum in women whose spouses (US Navy and Marine Corps) were currently deployed compared with non-deployed. Additionally, women whose partners were planning to deploy were also at a significantly higher risk of positively screening for PND at 6 weeks postpartum (6.9% vs 3.5%).
Similarly, but using electronic personnel and medical records as opposed to self-report, Levine et al 34 found that US military spouses whose partners had deployed at any time from estimated conception to 6 months post partum were significantly more likely to have postpartum depression than those who were not deployed (17.6 vs 15.7%). They were also significantly more likely to suffer from antepartum depression and/or anxiety (15 vs 13.4%).
Overall, these studies suggest that pregnant US military spouses report more depressive symptoms at all stages of both the deployment cycle and pregnancy.
Deployment-related increases in perinatal stress
Three papers by Haas and colleagues35–37 investigated whether spousal deployment impacted on psychological stress during pregnancy in military spouses (US Naval and Marine Corps). Haas et al 37 found that pregnant women with deployed partners were twice as likely to self-report high or severe levels of stress compared with women with non-deployed partners. Haas and Pazdernik,36 in contrast, reported no significant difference in stress levels in those with deployed partners. However, they did find increased pregnancy weight gain and higher birth weights in those who reported higher stress levels. It should be noted that these studies also included a small number of active-duty women with civilian spouses.
Weis et al 38 investigated the effect of spousal deployment on US military wives’ acceptance of pregnancy measured by the Prenatal Self-Evaluation Questionnaire.39 Acceptance of pregnancy, or lack thereof, is associated with feelings of anxiety, stress and conflict about pregnancy and motherhood. The authors found that deployment of the serving partner during the first trimester significantly decreased acceptance of pregnancy.
Other risk and protective factors for perinatal mental health problems
Schachman and Lindsey40 used the Postpartum Depression Screening scale (PDSS) to investigate positive screening for PND in US military spouses who had given birth in the previous 3 months. Scoring positively on the PDSS was significantly associated with being married for a shorter duration, residing on the military base for a shorter period, increased family changes and strains (ie, emotional problems of a family member, financial debt, family conflict over continued service), lower self-reliance and lower social support. Similarly, Weis et al 38 found that in addition to deployment, increased acceptance of pregnancy in US military spouses was linked to women’s perceived emotional and community support during all trimesters.
Haas and colleagues36 37 found that in addition to deployment, having more than one child at home and being on active duty themselves increased the likelihood of higher stress levels and thus increased risk of poorer PMH. Furthermore, Haas and Pazdernik35 found that having at least one support person at home reduced the levels of stress reported in US military spouses during the perinatal period.
Support interventions for military spouses
Three papers discussed intervention strategies to improve PMH in US military spouses. The first was aimed at improving acceptance of pregnancy and adaptation to parenthood.41 The intervention, referred to as ‘Baby Boot Camp’, focused on the identification, development and use of internal (ie, coping strategies) and external resources (ie, support network). Adaptation to parenthood improved as a result compared with traditional childbirth education. Participants were more aware of and likely to access resources, and had better birth outcomes than the control group. However, acceptance of pregnancy (referred to above in Weis et al 38) did not differ between groups. The final two interventions identified involved the Mentor Offering Maternal Support (MOMS) programme for US military spouses.42 43 These peer mentoring sessions used support from military spouses who had experience of pregnancy in the military environment and aimed to reduce pregnancy-based anxiety. Weis and Ryan42 found no difference in outcomes between women who attended these groups and prenatal care as usual, suggesting that the intervention per se made little/no difference. However, in a larger sample (including both US military spouses and active-duty women), Weis et al 43 found a reduction in prenatal anxiety in those who attended the MOMs groups compared with normal prenatal care.
Discussion
This review set out to scope the literature pertaining to PMH in military spouses/partners. Thirteen papers were identified, all originating from the USA, which specifically focused on the mental health and/or psychological well-being of military spouses during the perinatal period. In particular, no research was identified from the UK, which limits the applicability of these findings to UK military spouses/partners.
There was a particular focus on spousal deployment as a risk factor for depressive symptoms and psychological stress during the perinatal period.28 30 32–38 Other risk factors linked to decreased PMH related to a lack of social and emotional support, and increased stressors such as family strains, having more than one child at home and being on active duty themselves.35–38 40 Additionally, three publications explored interventions for pregnant US military spouses to develop internal coping strategies and external social support.41–43
Low levels of social and/or emotional support were identified as risk factors for PMH problems by three of the identified papers,36 38 40 reflecting predictors of PMH problems reported in the general population.3 44 45 These factors could all be exacerbated by military life, and as such may represent a unique vulnerability of military spouses to PMH problems. However, we are unable to deduce from the identified research whether these unique military risk factors translate into an increased risk of PMH problems, as no civilian comparison groups were included.
The majority of papers in this review identified spousal deployment during the perinatal period as a significant risk factor for perinatal depression and increased psychological stress.28 30 32–38 Deployment of the serving spouse is associated with social isolation, increased anxiety and stress, and thus is a risk factor for depression.45 46 This is further exacerbated by the stress of lone parenting for the duration of the deployment, renegotiation of identity on return of deployed partner and the potential for adverse birth outcomes, such as preterm birth.47 Indeed, feeling unsupported by one’s partner and being a single parent is associated with depression during pregnancy in the civilian population.48 Spousal deployment is a risk factor unique to only a handful of occupations including the military and as such may represent a specific vulnerability to PMH problems in military populations.
The support interventions identified in this review also emphasise the importance of military-specific social/emotional support for spouses in the perinatal period, particularly during deployment.41–43 The ‘Baby Boot Camp’ intervention was reported to be successful in decreasing anxiety surrounding pregnancy and increasing the sense of social support.41 The MOMS peer-mentoring intervention43 was also shown to reduce perinatal anxiety in military spouses.
Implications for practice
While a paucity of research was found in this area, particularly in the UK context, there are some practical implications. First, the evidence suggests that social support is an important protective factor for military spouses during the perinatal period. This may be particularly important for reducing anxiety during deployment of the serving spouse.41 42 Second, support tailored to the needs of military spouses rather than generic perinatal support may be advantageous.41–43
Implications for practice in the UK?
As the identified literature was exclusively from the USA, consideration of the UK setting is needed. There are a number of differences in the structure and nature of the US and UK militaries making comparison difficult. Deployment is identified as a significant risk factor for PMH problems; however, longer deployment lengths in the USA may put US military spouses at higher risk.
Additionally, the nature of obstetric health services is significantly different for military families in the USA. The US military offers healthcare to soldiers and their families as part of their contract, under ‘TRICARE’ often at a Military Treatment Facility.49 As such, US military spouses are likely to receive specialist care from service providers who have an understanding of their specific needs.
Unlike the USA, UK military midwives do not exist and women receive their obstetric care through the NHS. In some instances, midwifery care is provided by an NHS Midwife near a military base with a good understanding of military culture. However, this is frequently not the case and there is no military-specific training provided to nurses or midwives in the UK to address this knowledge gap. As a result, while midwives may have a good understanding of PMH problems in general, they may not understand or be vigilant to any military-specific needs.
The Armed Forces Covenant50 is explicit about Armed Forces communities not being disadvantaged in receiving healthcare. This means that pressures, such as frequent moves, should not affect the care that families receive from the NHS, including position on waiting lists, access to dental care and fertility treatment. While the Covenant is well enforced overall, it is lacking in obstetric care. Due to the lack of research in this area in the UK, there are limited guidelines in place to adequately safeguard military spouses and consequently care provision may be inadequate.
Implications for research
In light of the paucity of research identified, investigation is required regarding the nature and extent of PMH problems in UK military spouses. There are a number of differences between the US and UK military structures and healthcare systems that make comparison difficult as suggested.
Mpreover, there was limited discussion in the identified papers of other military-specific factors (for example, frequent relocation) and how these may affect women during pregnancy. Investigating these would be advantageous in understanding the perinatal health needs of military families. Furthermore, none of the papers identified included a civilian control group, as such we were unable to make any conclusive statements regarding whether being a military spouse/partner represents a particular vulnerability to PMH problems relative to a matched civilian population.
Finally, much of the research discussed psychological stress and depression, however failed to acknowledge the wider range of mental health disorders that can be associated with pregnancy. These disorders include anxiety disorders such as obsessive-compulsive disorder, post-traumatic stress disorder, psychosis and adjustment disorders.51 In order to gain a fuller understanding, future research may benefit from widening the investigation to include these disorders.
Conclusion
US literature suggests that military spouses are particularly at risk of PMH problems during deployment and highlights the protective nature of social support during this time. Further consideration needs to be made to apply the findings to UK military spouses due to differences in the structure and nature of the UK and US military and healthcare models. To fully understand the perinatal health needs of UK military spouses, research into their individual stressors, risks and needs is essential. This would provide military and healthcare providers alike with a detailed understanding of the needs of this population, allowing effective planning and strategies to be commissioned and implemented.
References
Footnotes
Contributors LRG-M and LI carried out the literature search and drafted the manuscript. CH and MF provided guidance, comments and revisions to the manuscript. All authors approved the final version of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; internally peer reviewed.