Reproductive Health Psychology

Reproductive Health Psychology

Olga B.A. van den Akker BSc PhD C.Psychol AFBPsS

Professor of Health PsychologySchool of Health & Social Sciences

Middlesex UniversityLondon, UK

A John Wiley & Sons, Ltd., Publication

This edition first published 2012© 2012 Olga B. A. van den Akker

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Library of Congress Cataloging-in-Publication DataVan den Akker, Olga B.A. Reproductive health psychology/Olga B.A. van den Akker. p. cm. Includes bibliographical references and index. ISBN 978-0-470-68338-5 (cloth) – ISBN 978-0-470-68337-8 (pbk.) 1. Reproductive health–Psychological aspects. I. Title. RG133.V36 2012 618.1–dc23 2011035198

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Set in 9.5/11.5 pt Minion by Toppan Best-set Premedia Limited

1 2012

Contents

Preface xiii

Facts xvi

Acknowledgements xvii

Part1 PsychologyofReproductiveHealth 1

1 IntroductiontothePsychologyofReproductiveHealth 31.1 MaternalMorbidityandMortality 41.2 AgeShiftsandReproductiveConsequences 41.3 InteractionsbetweenSocioeconomic,Behavioural,BiologicalandGenetic

FactorsandReproductiveHealth 61.4 Summary 131.5 References 13

2 PsychologicalTheoriesofHealthandIllness 172.1 Twentieth-centuryPsychologicalModelsAppliedtoHealthandIllness 172.2 HealthPsychologicalModels 182.3 ChangingHealthStatus 252.4 ConceptsUsedinHealthPsychology 252.5 Stress,CopingandAppraisal 262.6 Cross-culturalDifferences 272.7 EthicalIssues 282.8 Counselling,AdviceandSupport 292.9 Methodologies 302.10 Summary 302.11 References 31

Part2 PsychologicalProcessesofEarlyGrowthandDevelopment 33

3 GrowthandDevelopment 353.1 FoetalGrowthandDevelopment 353.2 InfantandChildGrowthandDevelopment 363.3 CausesofSignificantVariationsinGrowthandDevelopment 373.4 ManipulationsofGrowthandDevelopment 373.5 Disability 38

viii Contents

3.6 GenderDevelopment 393.7 CausesofSignificantVariationsinSexandGender 403.8 Epidemiology 413.9 Screening/Assessment 413.10 Theories/Models 433.11 Treatment/Management 453.12 Guidelines 463.13 Summary 463.14 References 47

4 AdolescentDevelopment 504.1 BehaviouralFactorsInfluencingReproductiveHealthOutcome 504.2 Epidemiology 504.3 SexualDevelopment 524.4 EffectsofAdolescentSexualandReproductiveBehaviours 524.5 Treatments/Interventions 534.6 Theories/Models 544.7 DiseaseandTreatmentEffectsonAdolescent’sReproductive

HealthOutcomes 564.8 Individual,HouseholdandFamily 564.9 Guidelines 574.10 Interventions 584.11 Summary 584.12 References 59

Part3 PsychologicalFactorsofMenarche,SexualandReproductiveDevelopment 63

5 TheMenstrualCycle 655.1 Menarche 655.2 Menstruation 665.3 TheEffectsofEatingDisordersontheMenstrualCycle 675.4 TheEffectsofExerciseontheMenstrualCycle 685.5 TheEffectsofNutritionontheMenstrualCycle 695.6 MenstrualCycleDisorders 715.7 Treatment/Management 735.8 Summary 755.9 Reference 75

6 PremenstrualDysphoricDisorder 796.1 Epidemiology 796.2 Definition 796.3 Assessment/Measurement 816.4 Theories/Models 826.5 CharacteristicsofWomenwithPMDD/PMS 826.6 EffectsofPMDD/PMS 836.7 AttributionsofSymptomstotheMenstrualCycle 856.8 TreatmentforPMDD/PMS 856.9 Summary 866.10 References 86

7 SexandContraception 907.1 SexualBehaviour 907.2 SexualDysfunction/Disease 91

Contents ix

7.3 Epidemiology 927.4 Interventions/Treatments 927.5 Contraception 937.6 Definition 937.7 ContraceptiveUse 947.8 SafeSex/ContraceptivesBehaviours 947.9 EffectsofRiskySexualBehaviours 967.10 ProcessesandFactorsAffectingtheProblem 967.11 Theories/Models 977.12 Treatment/Management 997.13 Guidelines 997.14 Summary 1007.15 References 100

8 ReproductionandFertility 1048.1 Definition 1058.2 LifestyleFactorsAffectingReproduction 1068.3 Treatment/Management 1138.4 ReproductiveHealthPromotion 1148.5 Policy/Guidelines 1158.6 Summary 1158.7 References 115

Part4 ThePsychologicalContextofInfertility 119

9 Infertility 1219.1 Epidemiology 1229.2 CausesofInfertility 1229.3 BehaviouralandLifestyleFactors 1229.4 InfertilityinChildrenandYoungAdultsTreatedforSeriousIllness 1239.5 BehaviouralProcessesandFactorsAffectingInfertility 1269.6 AgeEffectsonReproduction 1279.7 Theories/Models 1289.8 GenderandCulturalDifferences 1339.9 CopingwiththePsychologicalEffectsofInfertility 1349.10 SocialSupport 1369.11 Summary 1379.12 References 137

10 OvercomingInvoluntaryChildlessnessandAssistedConception 14410.1 Epidemiology 14510.2 EffectsofLifestyleFactorsonTreatment 14610.3 Treatment/Management 14810.4 DefinitionsandConsequencesofTreatments 14910.5 Adoption 16510.6 TreatmentAbroad 16610.7 EthicalIssues 16810.8 GivingUpTreatment 16810.9 Counselling 16910.10 Guidelines/Policy 16910.11 Summary 17010.12 References 170

x Contents

Part5 PsychologicalProcessesofFertilityandPregnancy 181

11 Pregnancy 18311.1 BehaviouralFactors 18411.2 LifestyleFactors 18511.3 PsychologicalFactors 19111.4 SocialandCulturalFactors 19211.5 DifficultPregnancies 19411.6 EffectsofMaternalMoodontheFoetus 19611.7 PartnersofPregnantWomen 19611.8 Theories/Models 19711.9 Guidelines 19711.10 Summary 19811.11 References 198

12 Screening 20712.1 ScreeningforFoetalHealth 20812.2 ScreeningTests 20812.3 ReasonsforUptakeofTests 21012.4 TheConsequencesofTakingtheTests 21112.5 Theories/Models 21212.6 TheSocialImpact 21512.7 Policy/Guidelines 21512.8 SexSelection 21612.9 FoetalReduction 21712.10 Foeticide 21812.11 Summary 21812.12 References 218

13 Miscarriage 22213.1 Definition 22213.2 Epidemiology 22313.3 Causes/RiskFactors 22313.4 Theories/Models 22513.5 EffectsofMiscarriage 22713.6 Monitoring/Assessment 23213.7 Treatment/Interventions 23313.8 Summary 23413.9 References 235

14 Abortion 24114.1 AbortionProcedures 24114.2 Epidemiology 24214.3 Legalization 24214.4 AttitudestoAbortion 24314.5 AbortionforSexSelection 24414.6 AbortionforSocialReasons 24414.7 AbortionforMedicalReasons 24514.8 CharacteristicsofWomenHavingAbortions 24614.9 PsychologicalEffects 24714.10 PartnersofWomenHavinganAbortion 24814.11 Theories/Models 249

Contents xi

14.12 Treatment/Interventions 25014.13 Guidelines 25114.14 Summary 25214.15 References 252

Part6 ThePsychologyofthePuerperiumandParenting 259

15 LabourandDelivery 26115.1 Childbirth 26115.2 Interventions 26315.3 TheExperienceofChildbirthasaTraumaticEvent 26415.4 PretermLabour/DeliveryComplications 26615.5 PerinatalDeath 26815.6 Summary 26815.7 References 268

16 PerinatalAnxietyDisorders 27216.1 Definitions 27216.2 Epidemiology 27416.3 CausesofPerinatalAnxietyDisorders 27416.4 Theories/Models 27516.5 Treatment/Management 27516.6 Summary 27616.7 References 276

17 PerinatalDepressiveDisorders 27917.1 TheBabyBlues 27917.2 MaternalPostnatalDepression 28017.3 PaternalPostnatalDepression 28817.4 PuerperalPsychosis 28817.5 Summary 28917.6 References 289

18 ParentingandthePostnatalPeriod 29518.1 EffectsofParenting 29518.2 ParentingPractices 29618.3 AdjustmenttoParenthood 29718.4 Theories/Models 29818.5 GenderRoles 29918.6 DecisiontoBecomeParents 30018.7 TransitiontoParenthood 30218.8 Summary 30718.9 References 308

Part7 PsychologicalFactorsofMenopause,SexandReproductioninLaterLife 315

19 Menopause 31719.1 TheMenopauseandHealth 31719.2 Definition 31819.3 CausesofMenopausalDistress/Discomfort 31919.4 Epidemiology 32119.5 Screening/Assessment 321

xii Contents

19.6 Theories/Models 32219.7 ProcessesandFactorsAffectingtheProblem 32319.8 Treatment/Management 32419.9 Guidelines 32719.10 Summary 32719.11 References 328

20 AgeingandSexualBehavioursandSexualHealth 33320.1 FactorsAffectingtheSexualHealthofOlderPeople 33320.2 AttitudestoSexinOlderPeople 33420.3 SexualHealthEducation 33520.4 EffectsofIgnorance/ProblemswithSex 33520.5 HealthRisks 33720.6 Theories/Models 33820.7 Treatment/Management 33920.8 Policy/Guidelines 34020.9 Summary 34120.10 References 341

21 AgeingandReproduction 34421.1 Epidemiology 34521.2 CharacteristicsofOlderPeopleSeekingAssistedConception 34521.3 ReproductiveChoiceandReproductiveRights 34621.4 ReproductiveHealthofOlderPeople 34721.5 ReproductiveOutcomes 34821.6 Screening/Assessment 34921.7 Treatment/Management 34921.8 Theories/Models 35021.9 Policy/Guidelines 35021.10 Summary 35021.11 References 351

Index 353

Preface

Health is described as a state of physical, mental and social wellbeing, and not just the absence of disease or infirmity. Specifically, the application of this definition to reproductive health addresses the reproductive processes, reproductive systems and reproductive functions at all stages of the life span. Included here are lifestyle-related factors, human rights to choice, information and access to acceptable methods of sexual health and freedom, fertility control and reproductive health regulation and health-care services designed to assist all people with safe and effective health care for pregnancy, delivery and a healthy future for their infants.

A focus on sexual and reproductive health is not a privilege, it is a necessity. In 2000 the World Health Organization (WHO, 2004) reported estimates of maternal mortality in the region of over half a million each year as a result of pregnancy and delivery complications. The WHO has noted that health indicators are hugely difficult to quantify and that measures of access to reproductive health may provide more reliable information worldwide on maternal mortality. Thus, a shift away from health towards health-care access is indicated. The latter is easier split into basic and comprehensive essential obstetric care. Any focus on health-care access will include a focus on poverty, inequality, educational, economic status, age and urban versus rural access. These are important considerations, often forgotten, in interpreting national aver-ages. Similarly, the relationship between mental health and reproductive health is substantial and relates to morbidity and mortality (Lok and Neugebauer, 2007), and psychological factors too contribute to a population’s reproductive health.

This book aims to provide psychologists, such as social, applied, developmental and health psychologists, with a comprehensive handbook covering numerous specialist areas within reproductive health and their disorders from foetal development through childhood, adoles-cence into adulthood and older age. It will also serve medical professionals, including psychia-trists, obstetricians and gynaecologists, nurses, midwives, health visitors and other allied health-care professionals, with a sound theoretical and empirical background from a multidis-ciplinary perspective to the major topics relating to the psychology of reproductive health. Psychological factors in maternal and infant health, the health of the foetus, gender development and reproductive growth and development, (in)fertility, pregnancy, miscarriages and abortions, the psychology of screening in pregnancy, diagnosis, labour and delivery, the postnatal period and parenting are covered in detail. The main reproductive lifespan events of menarche, the menstrual cycle and some prominent conditions associated with the menstrual cycle such as premenstrual syndromes and dysmenorrhoea, the menopause and sexual and reproductive events in older age are also addressed.

xiv Preface

Each topic is accompanied by ample evidence drawn from numerous sources to provide epidemiological, social, cultural, psychological, behavioural and biological information. Theo-retical models are included in some chapters so that theory, research and practice are thoroughly interlinked. Each topic will draw on up to date quantitative and qualitative research demonstrat-ing how research-based evidence drives theoretical model building in some areas and enhances progress in the management of the psychology of reproductive health care. Included in each chapter are comprehensive though not exhaustive reviews of the current literature. The key to much research into reproductive health psychology is the utility of the findings to clinical practice. Theorizing and modelling of behaviours related to the conditions discussed contribute to the general fight to improve reproductive health. Where possible, the application of research to policy and practice is covered, since empowered individuals and local communities are needed to overcome health inequalities, as described in The Marmot Review (2010), focusing on effective local delivery systems and decision-making.

This book therefore sets out to address important issues of the individual’s reproductive health experience, and acknowledges its reciprocal impact on the wider sociocultural, economic and policy context. Societies or the political, economic and cultural environments of different countries are subject to, and usually benefit from, the implementation of contemporary scien-tific, medical and technological developments. Health technology assessment is the study of the effectiveness or impact of the implementation of new technologies directly into health care such as screening, diagnosis or the treatment of disease or to improve or increase the quality of life of populations. Social and behavioural scientists tackle the indirect effects of health technologies on the individual and on societies.

Science, technology and medicine are constantly developing and are increasingly impacting on society and the individual within it. Previous ‘universal’ truths about origins and certainty are changing, and even the buying in or out of these changing truths impact upon the individual in society. Bioethical issues, the principles of autonomy, integrity, beneficence and justice are subject to differential individual attributions. These attributions are influenced by powerful legal or religious constraints, alliances and tensions in interpretation and implementation. Deontological and utilitarian theories, for example, provide opposing tensions. Deontological reasoning concerns what is right according to a moral principle or rule, and utilitarian reasoning focuses on the effects or consequences of an action upon the wellbeing of those involved. An act is therefore right when it maximizes wellbeing compared with the alternative acts. The former moral question suffers from the subjectivity of what the rights and duties are, whereas the latter moral question of the consequences, allows for verification through empirical means. Reproductive health forms a significant area of health affected by rapid advances which need rapid adaptation from government legislation and professionals with unique socio-cultural values implementing these to the populations they are responsible for. Within these populations, each individual interprets health technology advances and takes responsibility for contributing to the health profile and health values of future generations and the society they live in. The immediate and long-term impact of this responsibility in reproductive health and the reasoning behind these is not always assessed.

It was not until 2007 that the UK Equality and Human Rights Commission replaced a number of previous bodies including the Equal Opportunities (gender) Commission the Race Relations Board and the Disability Rights Commission. Contradicting the aims of this commission, of removing discrimination of any sort and equality of opportunity for all, is the focus on the apparent social desirability of routine screening in and out of impairments and disabilities, pre-conception and prenatally, and of, for example, a preferred gender. Women in many Western countries now have a right to choose to have or not have a baby, but men and disabled people do not have an equal right to become parents. Globally, women’s low social status particularly in low-resource areas, limits their sexual and reproductive negotiating power and selective access

Preface xv

to education and health care, and leaves them vulnerable in reproductive terms. The effects of inequalities, social, cultural beliefs and values and of individual differences in the ability to cope and adapt to reproductive events are highlighted wherever possible in this handbook.

References

Lok, I.H. and Neugebauer, R. (2007) Psychological morbidity following miscarriage. Best Practice andResearch.ClinicalObstetricsandGynaecology, 21, 229–247.

The Marmot Review (2010) http://www.marmotreview.org/World Health Organization (2004) Maternal mortality in 2000: Estimates developed by WHO, UNICEF

and UNFPA. World Health Organization, Geneva.www.equalityandhumanrights.com (2007)

This book is dedicated to my children Maximilian, Sebastian and Olivia.

Facts

• Genderdeterminationstartsatconception• Genderdevelopmentcanbedisruptedatanytimeduringearlyfoetalgrowth• Femalesarebiologicallystrongerthanmen• Atbirthgirlsarebornwithapproximately700,000folliclesintheirovaries• Numbersoffolliclesreducedramaticallyinthedecadebeforemenopause• Atthelastmenses,womenhavenearlyrunoutoffollicles• Overawoman’slifespan,folliclestimulatinghormone(FSH)increasesandseruminhibin

concentrationsdwindleovertheyears• Decreasing ovarian secretion of inhibin (B) may affect increasing FSH and decreases in

oestradiolinmiddleagedwomen• After the menopause oestrogen production continues; ovaries continue to produce small

quantities of androgens which are converted to oestrogens, oestrone is produced by theadrenalcortexandindirectlybythefatcellsconvertingandrostenedionetooestrone

• Thereisaneffectofbodymassindex(BMI)onhormonelevels;oestradiolandFSHdecreaseandtestosteroneincreaseswithincreasingBMI

• Sexualandreproductivediseaseanddisordershaveasubstantialimpactuponthoseaffected• Stressandlifestylebehaviourscandirectlyinfluenceandmediateendocrinefunctioning• Unhealthylifestylescanimpactnegativelyuponsexualandreproductivehealth• Individualhealth-careuseisdeterminedbynationalandregionalaccessibilityandprovision,

sociodemographicsandindividualdifferences• Individualattitudestohealthcareareinfluencedbysocialandculturalnormsanddemo-

graphicfactors• Inequalitiesinsexualandreproductivehealthareprevalentworldwide• Prospectiveparentshealthbehavioursaffectthehealthoftheirchildren• Sex and reproduction in the young and old may need pharmacological therapeutic or

medicaltechnologicalinterventions.

Acknowledgements

I would like to thank my research associates Farhanah Khan, Subarna Roy and especially Dr Satvinder Purewal for their help with much of my research whilst writing this book. I would also like to acknowledge the enthusiasm my Post Graduate students Marzieh Abassi, Vilte Dau-girdaite and Abi Jones have shown for their work on our current reproductive health research studies.

Every effort was made in the writing of this book to ensure permissions where asked in reproducing material from other sources. Correct acknowledgements have been used as appro-priate. Lastly, the publishers would welcome communications from copyright holders who were not contactable during the production of this book.

Part 1

Psychology of Reproductive Health

Part I of this book introduces the concept of the psychology of reproductive health. The aim of Chapter 1 is to demonstrate that any biological developments, whether predictable according to normal natural changes or unpredictable or subject to disruption, distortion, disease, dis-comfort or disability, are influenced by or have an effect on psychological, behavioural, social, cultural and environmental variables. Chapter 2 outlines the conceptual processes and theories of health psychology, providing a suitable background to the reproductive health issues that are discussed in many of the following chapters.

The study The topic The context

Health psychological

concepts

Cultural Economic

Environmental

Reproductive health

Health psychological

theory

Disruption Distortion Discomfort Disability Disease

Psychological Behavioural

Social

Reproductive Health Psychology, First Edition. Olga B.A. van den Akker.© 2012 Olga B.A. van den Akker. Published 2012 by John Wiley & Sons, Ltd.

Chapter 1

Introduction to the Psychology of Reproductive Health

Physiological and genetic factors have long been known to influence reproductive outcome (Galton, 1869). For example, children born to teenage parents or parents of advanced age are at risk of numerous adverse birth and health outcomes (Liu, Zhi and Li, 2011) including well-described disadvantages such as low birth weight and Down syndrome, prevalent in younger and older parents, respectively. However, advanced parental age has also been associated with positive characteristics, such as higher intelligence, in the children. Figure 1.1 (adapted from Ellis, 1926) shows the ages of the parents of 299 ‘eminent’ men to demonstrate that there was a clear majority of elderly fathers among them. More recent research has continued to explore the fascinating early findings of positive effects of parental age on the intellectual abilities of the offspring and alternative explanations have been sought. Influence of parental age on intel-ligence of the offspring does not seem to be mediated by confounding demographic or other socioeconomic factors (Cohen et al., 1980). Instead, higher maternal age may be more impor-tant to superior intelligence test scores in offspring than paternal age (Saha et al., 2009). These inconsistent findings may be due to difficulties defining intelligence, or because testing for intelligence is not sufficiently broad (as it does not include accomplishments, creativity, per-sonality variables and so on). In health or birth outcome terms, the optimum age to have children is 25 to 35 years (Thurstone and Jenkins, 1931), with increasing paternal age resulting in poor outcomes, such as more spontaneous abortions (Kleinhaus et al., 2006) and older maternal age increasing the risks for miscarriage, stillbirth and ectopic pregnancy (Andersen et al., 2000). Both also affect longevity in the offspring (Lansing, 1947), a variable not yet con-quered by researchers.

Reproductive Health Psychology, First Edition. Olga B.A. van den Akker.© 2012 Olga B.A. van den Akker. Published 2012 by John Wiley & Sons, Ltd.

Figure 1.1 Maternal and paternal ages of ‘eminent’ men studied by Ellis (1926).

0

5

10

15

20

25

30

<20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60>

Mothers

Fathers

4 Psychology of Reproductive Health

Unlike the early observations of Galton and others in the nineteenth century, research and developments across the twentieth and twenty-first centuries has shown that our survival is increasingly less subject to natural selection. Changes in our behaviours have also brought about changes in our reproductive health. We now use many forms of medicine, both traditional and Western, therapeutic interventions such as organ transplantation and screening in and out of targeted chromosomal characteristics. There are regional, demographic and socioeconomic and behavioural differences in interventions in natural selection, as well as in many other aspects of reproductive functioning.

1.1 Maternal Morbidity and Mortality

Although women live longer than men (Population Reference Bureau, 2000), they are at a disadvantage because of their reproductive capacity; they can die as a result of pregnancy, labour and delivery, or post partum. It is well known that across the world, maternal mortality and ‘near miss morbidities’ occur disparately between rich and poor countries (Ronsmans and Graham, 2006). Near miss morbidity refers to events that would have resulted in maternal mortality during pregnancy, childbirth or within the 42 post partum days, if medical or other intervention had not occurred (Say, Pattison and Gulmezoglu, 2004). Even within countries, ethnicity confers an increased risk for maternal mortality (CDC, 1999) and for differences between men and women in general (Anderson et al., 1996). Brown et al. (2011) reported sig-nificantly higher near miss mortality among Hispanic women than African-American or White women in the USA, see Figure 1.2.

Figure 1.2 Near miss mortality in 12,774 Hispanic, African-American and White women who delivered between 1994 and 2005 in the USA (adapted from Brown et al., 2010).

Hispanic

African-American

White

1.2 Age Shifts and Reproductive Consequences

In Europe and the USA, demographic studies have shown age-related shifts in pregnancy timing and numbers since the 1980s (Maheshawari, et al., 2009). Women over the age of 35 are now more likely to present as first-time mothers, and they tend to have fewer children. Accompany-ing the female age shift in reproduction is a male shift, with women still having children with men of equivalent or older ages. Women’s (and men’s) empowerment, defined as a dynamic process that takes place over time (Lee-Rife, 2010) and that includes resources (e.g. education) and agency (e.g. the ability to act upon goals), affects a person’s interaction with the economic, legal, political, cultural, social and psychological domains. These domains affect health, wellbe-ing and quality of life. This book will address many of the biological, psychological and behav-

Introduction to the Psychology of Reproductive Health 5

Figure 1.3 Complexities and interactions between individual differences, behavioural, biological and socioeconomic factors affecting reproductive health.

Individual differences

Behavioural factors

Socioeconomic factors

Biological factors

ioural, social and societal, cultural, regional and economic factors impacting upon reproductive health and illness, and their complexities as shown in Figure 1.3.

The complex interactions between individual differences, behavioural, socioeconomic and biological factors are due to numerous components within each of these domains (Table 1.1). Some of these are not easy to pin down, and many are not considered in research and theory investigating aetiological, causal or contributory factors to the development or maintenance of disease or discomfort associated with reproductive events.

Table 1.1 Components within the socioeconomic, individual differ-ences, behavioural and biological domains

Socioeconomic factors • Social inequalities• Cultural and religious differences• Educational opportunities• Economic diversity• Occupational costs and benefits• Environmental toxicants / pollutants

Behavioural and lifestyle factors

• Smoking• Drinking alcohol• Drug use• Exercising• Hygiene and health care

Psychological and interpersonal factors

• Personality factors• Stress• Vulnerabilities• Partner, family, friends• Social support• Quality of life

Biological / genetic factors • Racial differences• Genetics• Infection• Disease• Disability

6 Psychology of Reproductive Health

1.3 Interactions between Socioeconomic, Behavioural, Biological and Genetic Factors and Reproductive Health

A number of factors such as the shifts in age at first pregnancy, overall fewer pregnancies and shorter periods of lactation, due to the introduction and use of formula milk, have resulted in a longer lifetime occurrence of menstruation, as described in Chapter 11. Age at menarche declined from 17 to 13 years in Europe between 1850 and 1960 (The Plowden report 1967), with averages across the world differing according to geographic, regional, ethnicity and genetic factors (Tanner and Davies, 1985) – varying from 12.5 in the USA (Anderson, Dallal and Must, 2003) to 16.6 in Iceland (Magnússon, 1978). Timing of menarche is influenced by biological, genetic and environmental factors, including nutrition (see Chapter 5). Similarly, age at meno-pause (last period) shows variations from 40 to 61 in the Western world, (Minkin et al., 1997) averaging at 51 (Kato et al., 1998), although in the Philippines it is 44 years (Ringa, 2000) (see Chapter 19). The introduction and widespread use of contraceptives, particularly non-barrier contraceptives such as the oral contraceptive pill, has led to an increase in sexual freedom (see Chapter 7), decrease in unplanned pregnancies, altered spacing of children within families, and increased incidences of sexually transmitted and reproductive tract infections. In the developed world, the impact of changes in lifestyle, such as people having sex at an earlier age, delayed conception (Jensen et al., 2004; Waters et al., 2006) and interventions in pre-conception and pregnancy care have all had an effect on reproductive health and fecundability. Although efforts are made to reduce teenage pregnancy, little effort has been spent on the problems associated with delayed or postponed childbearing (Soules, 2003).

1.3.1 Religious factors

In the developing world, sexual activity and reproduction are less likely to be influenced by liberal Western social conventions about sex and reproduction, but tend to be ruled by religious doctrines and strong cultural influences (as demonstrated in Chapters 7 and 20). Rural Palestin-ian couples, for example, adhere to Muslim traditions, such as no sex before marriage (Khwaja, 2003), and Muslim couples usually want to start a family immediately after marriage (Rashad et al., 2005). Nevertheless, fecundability within 1 year of marriage is no better than that reported in Western populations (Issa et al., 2010) (see Figure 1.4).

1.3.2 Social factors

Social factors not directly associated with health, such as the impact of having a child on an individual’s financial status, as well as the ability to care for a child in a manner demanded by society as optimal, requires financial stability, which is not always achieved. The United Nations Human Development Index shows that the more a country is developed, the more the oppor-tunity costs for a child (Sorrentino, 1990). A comparison of number of children per woman across different countries shows that industrial countries have a lower birth rate than developing countries. In a study of men and women’s desires to have children, men were less likely to express a desire to become a parent than women (Stöbel-Richter et al., 2005). These authors reported that many women in developed countries who were initially intentionally childless, years later

Introduction to the Psychology of Reproductive Health 7

became unintentionally childless (Klipstein et al., 2005) when they reconsidered their life goals and achievements.

1.3.3 Regional factors

At the same time, reports are continuing to reveal the changing quality of semen, with a decrease in semen quality indicated in some countries more than others. These differences are regional, with Danish men producing the lowest sperm concentrations and lowest total sperm counts followed by French, then Scottish men. Men from Finland produced semen with the highest sperm counts, whereas motility is highest in men from Edinburgh. Seasonal variations have been detected in sperm concentrations, with summer months producing about 70% of those in the winter months (Jorgensen et al., 2001). In addition to regional and seasonal differences, testicular germ cell cancer in adult men has increased, and this varies according to geographical location (Adami et al., 1994).

1.3.4 Behavioural and lifestyle factors

The American National Health and Nutrition Survey III has shown that women who start plan-ning a family at a later age are at a greater risk of cardiovascular disease, diabetes, hypertension and congestive heart failure (Alonzo, 2002). These effects involve not only physiological systems such as neuroendocrine and hormonal functioning, but they have psychological and social effects on large numbers of the population. Psychological factors such as coping with stress and adversity, for example, will impact on a developing foetus. Other daily lifestyle factors, such as individuals leading sedentary lives, obesity, smoking and alcohol consumption, have also con-tributed to reproductive health effects (Kelly-Weeder and Cox, 2006), as shown in Chapters 8

Figure 1.4 Minimum and maximum fecundability estimates in Western populations and recent data from Palestinian non Western, newly married couples (adapted from Issa et al., 2010).

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0.05

0.1

0.15

0.2

0.25

0.3

0.35

Fecundability

Western MinimumWestern MaximumNon Western

8 Psychology of Reproductive Health

and 9. Adverse lifestyle behaviours, for example smoking, increases the risk of premature and low-birthweight infants. Chapters 3 and 4 explain some of the factors affecting gender develop-ment and reproductive growth and development. Low-birthweight offspring are disadvantaged from the start with significant and long-lasting effects, such as increased risks of coronary heart disease, type 2 diabetes and obesity in adulthood (Lumley et al., 2009). Occupational risk factors, such as heavy physical labour, exposure to gases and drugs, metals and solvents (Figa-Talamanca, 2006), and chemicals in the environment and in diet (Foster et al., 2008) all have a role in fertil-ity. This book therefore uncovers and brings together a wealth of literature investigating the interactive effects of reproductive functioning and the psychosocial, behavioural, environmental and biological concomitants of these functions and malfunctions, as shown in Figure 1.5

Figure 1.5 Interactive effects of psychosocial, behavioural, environmental and biological factors on reproductive health.

Psychological

Behavioural

Environmental

Biological

1.3.5 Technological interventions

Some chapters in this book will cover the use of technology that makes sex without reproduc-tion and reproduction without sex possible (Benagiano et al., 2010). The separation of people and interactions previously necessary for reproduction has social, psychological and biological/evolutionary implications. For example, Chapters 9 and 10 demonstrate the effects of the per-sonal relationships of people involved in some assisted reproductive interventions; the social, gestational or genetic parent(s) and the genetically, gestationally or socially connected children. Sex without reproduction has implications for the young (Chapter 4) and the old (Chapter 20), and for people attracted to the same sex (Chapter 18). Advances in reproductive biology have had numerous substantial effects on some populations, with possibilities of eliminating (or choosing to screen out) some of the 370 X-linked recessive disorders that have been identified (McKusick and Amberger, 1993). Cryopreservation of oocytes is now, like semen cryopreserva-tion, a reality, allowing women to postpone childbearing beyond their limited reproductive lifespan for non-medical reasons. A recent survey of Belgian population attitudes of just over 1000 women’s opinions of oocyte preservation for social reasons showed about half the women would not consider it, but about 30% would potentially consider doing this in the future (see Figure 1.6, adapted from Stoop, Nekkebrook and Devroey, 2011). The potential oocyte freezers wanted more children and had more liberal and open views of oocyte donation.

Introduction to the Psychology of Reproductive Health 9

The reproductive health literature is, however, plagued by much research using insufficiently powerful study designs, often because some populations are either relatively small such as sur-rogate mothers, as discussed in Chapter 10, or rare, such as people born intersex, as discussed in Chapter 3. Some research uses small samples because specific populations are unwilling to expose their concerns and feelings to researchers, as has been reported for parents of gamete donor offspring (Chapter 10) or women undergoing abortions (Chapter 14) or miscarriages (Chapter 13). Other research lacks theoretical models, such as older people’s sexual and repro-ductive risk taking behaviours (Chapters 20 and 21) leaving researchers unable to pose predic-tive research questions. This is surprising because in many ways older people’s decision-making, knowledge and understanding of risk factors mirror those of adolescents where health theoreti-cal input has been plentiful. This book attempts to draw together much of the better literature using a multidisciplinary perspective, even when the populations they are drawn from are small or the research lacks theoretical guidance.

1.3.6 Socioeconomic factors

The socioeconomic gradients in health behaviours are in part determined by the socioeconomic life course concept (Kuh et al., 2004), which links socioeconomic circumstances in childhood, such as parental education or housing, to educational pathways, such as age leaving full-time education and own occupation. These socioeconomic gradients have been useful in explaining the effects of childhood on for example, smoking status (Brunner et al., 1999) and obesity (Power et al., 2005), which are mediated by educational achievement and current occupation. Similarly, early or single motherhood have been reported to compound the effects of childhood disadvantage (Graham, 2007). The influential and much-cited Marmot review (and its later strategic review, published by the Department of Health, 2010) stresses that dealing with health inequalities is not a luxury; it is a matter for social justice, with economic benefits and savings. The review stressed that narrowing the gap of the social gradient of health is necessary, and it is not just the most disadvantaged that need tackling by health-care policy.

1.3.7 Political factors

Economic and political factors are important in reproductive health in developed and develop-ing countries across the world. For example, a study using an ecological framework across data

Figure 1.6 Women potentially, unlikely and definitely not willing to consider freezing their oocytes for future use.

17%

32%

51%

Potential

Doubtful

No

10 Psychology of Reproductive Health

from 16 European countries, Japan and the USA (Tanaka, 2005) has shown that non-paid pregnancy (maternity) leave prior to confinement was significantly related to perinatal mortal-ity and low-birthweight babies (Chapter 16). Similarly, studies of American and Canadian full-time working women found that caesarean deliveries and obstetric complications were reduced in women who received maternity leave 4 weeks or more prior to expected delivery date, compared with women who worked for longer (Guendelman et al., 2009; Xu, Seguin and Goulet, 2002), although this is not always reported (Sysdjo et al., 2006).

1.3.8 Equality factors

Other person in society factors that relate to choice and imposition are known to influence health and health behaviours. The concept of autonomy, particularly in relation to women’s rights and gender inequalities are still powerful factors influencing who will live or die. For example, gender inequalities, which have arisen from social standing within a culture or are gained through gender status or power, allow one gender to choose and act on their own choice, and the other gender deals with the esteem imposed on her, rather than by choice (Mason, 1984). Extending this gender inequality to economic power, in societies where women do not have autonomy, control over resources is in the hands of men. Personal autonomy refers to one’s ability to influence the environment through personal control over resources and information (Dyson and Moore, 1983). Women who are afforded adequate autonomy can improve and maintain their health and use health-care resources equally devoted to their needs (Fikree and Pasha, 2004). In poor resource areas such as rural India, where health care may be rare and pregnancy care in particular may be inaccessible to women with low autonomy, maternal mor-tality is still common (Bhat, 2002).

1.3.9 Cultural factors

Similarly, cultural difference can determine health inequality and control over information needed to make evidence-based health-care decisions. Geneticists, social scientists and counsel-lors now include cross-cultural differences and specific issues within their research and practice (Sue and Sue, 1990). Menstrual cycle functions, dysfunctions and related disorders, such as premenstrual dysphoria, have been acknowledged and studied largely in the developed world, as shown in Chapters 5 and 6, although there is evidence indicating it is recognized in non-Western cultures. Similarly, postnatal depressive disorders are recorded in approximately 13% of women in developed (O’Hara and Swain, 1996) and developing countries (Aderibigbe Gureje and Omigbodun, 1993), despite large differences in industrialization, urbanization, medicaliza-tion and education. Cultural and traditional beliefs differ between developed and developing countries and affect diagnostic applicability of health and illness (Alem et al., 1999). A study of sub-Saharan African men and women ranging in age, educational and regional backgrounds showed a number of themes which in their view were associated with abnormal distress states (such as postnatal depression and anxiety) in the postnatal woman (Hanlon et al., 2009); these themes are explored in Chapters 16 and 17. The themes of disappointed expectation and exclu-sion; exacerbation of pre existing problems; and vulnerability and danger, were based on numer-ous factors shown in Table 1.2.

Disordered states resulting from these broad culturally enforced themes would lead to spirit attacks, showing that religious, supernatural or even cosmological idioms which fall outside of Western biopsychosocial models of health and illness (Kirmayer, 1989) are cultural discourses prevalent in other society’s interpretations of similar ill health states defined by specific criteria