The place where children are born: migrants’ experiences and risk factors.

Abstract. During pregnancy and after childbirth women develop specific representations, expectations and fantasies about themselves and their children. Pregnancy involves both physical changes and relational and affective ones. The mother’s role is a culturally transmitted element that conveys values, myths and rules; birth can be considered as a cultural event with unique characteristics. A multi-factorial model is useful for  tackling motherhood and depressive symptoms in migrant women, before and after delivery. The aim of this study is to analyse the motherhood experience in migrant women; data were collected during pregnancy and after delivery in order to evaluate maternal representation (IRMAG, IRMAN), family relationship representation (DSSVF) and levels of depression (EPDS). The results of this study show that migration processes could increase vulnerability in first-time mothers,  who might feel exhausted, upset and experience feelings of loneliness due to a lack of support from significant figures.

Key Words: pregnancy, maternal representations, birth, migrant women, native country.

Introduction
We consider pregnancy as an event that should be inscribed in a evolutive perspective; women need to elaborate the critical event of pregnancy in relation to personal identity, family  relationships and relationships between couples. Motherhood offers a new way of seeing oneself because women start questioning their female models, they try out  new social roles and  new relationships with their partners, in order to create space for the newborn child all  relationships in the nuclear family need to be re-arranged and the distance from the family of origin needs to be remodified (Malagoli Togliatti & Lubrano Lavadera, 2002; Scabini, 1995).  
The most important change in parenthood regards nurturing, the task of taking care is perceived as the most significant change within the family life cycle (Nyström & Öhrling, 2004); the birth of a child, with all these new tasks, might sometimes provoke negative feelings. Pregnancy, delivery and puerperium are related to physical change, pain, health concerns for the child, and also with the personal experience of losing one’s independence  and create new priorities  in everyday life (Rutter & Rutter, 1992).
This deep transformation during pregnancy regards the inner and external world because motherhood is a mental state; during pregnancy and soon after child birth, women may  express different typologies  of affective disease (Born, Zinga, & Steiner, 2004). Bydlowsky’s  concept of mental transparency (Bydlowsky, 1997) might help us to understand the greater vulnerability that women face  during and after pregnancy; psychic functioning becomes more explicit, unconscious representations become more clear and one’s emotional life seems to have a more direct expression.
Postpartum depression is a clinical condition that might occur after childbirth; women with PPD have multiple symptoms such as depressed mood, markedly diminished interest in pleasure in everyday activities, significant weight loss or weight gain, sleeping disorders, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive or inappropriate guilt, diminished ability to think or concentrate, or indecisiveness, not having any interest in the baby or being overly worried about the baby or afraid of hurting the baby, recurrent thoughts of death and recurrent suicidal ideation (APA, 2000). With regard to  PPD it is important to distinguish between maternity blues and postpartum psychosis because maternity blues has minor symptoms that tend to regress in a short time; on the contrary,   postpartum psychosis  can last for up to 90 days after childbirth.  It is a serious disease that can affect new mothers soon after childbirth with symptoms of depression, losing touch with reality, hallucinations, agitation, bizarre feelings and behavioural problems (O’Hara, 1999).
Searching for risk factors for postpartum depression is a hard task because we have to consider multiple variables in different dimensions: biological function (hormonal change), environmental characteristics (socioeconomic status, social isolation, social expectations of motherhood), obstetric and gynaecological condition (obstetric complication, lack of support during delivery), psychosocial variables (life-stressing events, unsatisfactory couple relationships, lack of social support, social stigma of postpartum depression) and psychological factors (previous depression symptoms, a difficult mother/daughter relationship, child temperament, negative beliefs about oneself and one’s children) (Caretti & Crisafi, 2009).
Empirical research and clinical experience tend to stress that migration is a familial experience, and for this  reason it is important to understand what  migration means to mothers and pregnant women (Cattaneo & Dal Verme, 2005; Chinosi, 2002; Moro, 2002, 2005; Scabini & Rossi, 2008).  Becoming a mother abroad  might represent a risk factor caused by difficulties with regard to migration processes; migrant women have left their relatives and cut off their links with  their places of attachment, in their search for a better place to live, but without clear plans for their future. Refugee women have left their native countries in order to survive, thus enduring an obligatory  exile and a rupture in their personal and familial history (Moro, 2008); adjustment to a new context is always associated with  perceived social support and maternal representations during pregnancy and puerperium (Camilleri & Cohen Emerique, 1989; O’Hara, 1986; Romito, 1992). Various researchers suggest that the psychic condition of motherhood is supported by tradition and a shared role with regard to motherhood, which  convey knowledge and the practice of caring (Balsamo, 1997; Balsamo, 2003; Author, 2004; Author, 2005; Taliani & Vacchiano, 2006).
Migration may increase vulnerability in women who feel a sense of  inadequacy with regard to newborn children and their  role as mothers, whereas parenting self-efficacy is a mediating factor in a model of maternal postpartum depression (Elder, 1995); parental self-confidence boosts positive responses in children, which in turn enhance the parent-child relationship (Bornstein, 1995; Gondoli & Silverberg, 1997; MacPhee et al., 1996; Teti & Gelfand, 1991). As Moro (2005) points out, lack of social support could lead to a sense of void that diminishes the capacity to understand and elaborate difficulties with motherhood and caring; without good adjustment, western methods of treatment (gynaecological visits, echography, amniocentesis, epidural anaesthesia, caesarean delivery) are seen by migrant women as incomprehensible and invasive experiences (Campagnola et al., 2007; Dusi, 2007; Gozzoli, 2008).

Clinical evaluation of motherhood 

There has been an increasing interest in studying how a mother’s caring might influence child development, focusing on risk factors such as postpartum depression, which might reduce emotional, cognitive and relational development (Ammaniti, Sergi, Speranza, Tambelli, & Vismara, 2002; Bradley et al., 2001) or life conditions, which  in a family system could increase vulnerability to trauma, neglect, abuse and  developmental delays (Grussu & Quartaro, 2006; 2007). One of the major aims of psychosocial intervention is to evaluate, during pregnancy and the first year of life, the quality of parenting and to recognize indicators for health risk factors in the mother-child dyad. 
On these bases we conducted research with 87 primiparous migrant women1, aged between 19 and 34 years old, benefitting from the special migrant gynaecological services of the University Hospital of Palermo and Messina; none of these women reported pregnancy risk factors. We identified two aims for the research: a) to explore maternal representation during pregnancy and at three months after childbirth, b) to evaluate family reorganization during pregnancy and after childbirth.
To evaluate maternal representation two different measures were used:
-	an adapted version of Interview for maternal representation during pregnancy - IRMAG (Intervista per le Rappresentazioni Materne in Gravidanza; Ammaniti, Candelori, Pola, & Tambelli, 1995);
-	an adapted version of Interview for maternal representation at childbirth - IRMAN (Intervista per le Rappresentazioni Materne alla Nascita; Author, 2002).
The IRMAG interview consists of 41 questions and analyses various issues: mother’s and father’s desire for parenthood; emotional reaction of mothers, fathers and families to revelation of pregnancy; emotions and changes during pregnancy in the woman, in the couple and in the woman’s relationship with her own mother; fantasies about childbirth; feelings, emotions and fantasies about the baby inside; future expectations about maternal role, parental style and mother-child relationship; temporal inner perspective about subject’s role as daughter and as mother.
The post-delivery IRMAN interview evaluates changes in the narrative model after childbirth. In particular it examines: the mother’s perceptions, emotions and fantasies about the baby; caring practices and emotional involvement; changes in the relationship in the couple and that of the subject and her own mother. 
Both the interviews analyze women’s representations during pregnancy and after delivery, as regards two issues: self-representation as mother and representations of the baby. These two issues were analyzed via seven dimensions (richness of perceptions, openness to change, range of involvement, coherent narrative structure, differentiation between representations of one’s self and the baby, social dependence, fantasies); each of these was evaluated in relation to specific items in the interview.
The interview coding system by Ammaniti and colleagues (1995) was used to also evaluate the post-delivery interview, IRMAN (Di Vita & Giannone, 2002); the coding system consists of three representational categories and further subcategories: 
1) “integrated/equilibrated” representations: this category indicates that women present a rich and coherent narration of their pregnancy as an element of their femininity; 
2) “restricted/disengaged” representations: this category indicates that women feel pregnancy as a necessary phase in their life; women try to control themselves and their narration is poor, lacking information about both psychological and physical changes;
3) “not integrated /ambivalent” representations: this category indicates that narration is contradictory and women show ambivalent tendencies with respect to pregnancy, motherhood and the baby. Narrations are poorly integrated and sometimes confused. 
In order to evaluate how changes in the family system might influence the representations of family relationships, we administrated, both before and after childbirth, symbolic drawings of family-life space DSSVF (Disegno Simbolico dello Spazio di Vita Familiare; Gilli, Greco, Regalia, & Banzatti, 1990). By evaluating the use of space this projective test is able to represent the psychic reality. The DSSVF consists of a circle, drawn on a sheet of paper, which represents the family system; the space outside the circle represents the social system. During DSSVF administration the subjects are asked to draw themselves symbolically as well as other significant persons in their lives; they then add important events and various organizations (for instance, associations, services, institutions, etc.). Finally the subjects are asked to distinguish the relationships between themselves and others (good, conflicting, so-so, poor)2 and to indicate boundaries and communications between what is inside and outside the circle. 
After a focus group regarding mothers’ psychological problems a few months after delivery, thirteen migrant women participated in the second stage of the research. The women were aged between 18 and 28 and their native countries were: Morocco (3), Sri Lanka (3) and Romania (5). 11 women completed all the tests before and after delivery. The aim of this second stage was to support the mother-child dyad, with special attention to migrant women and their needs. Various dimensions were evaluated both before and after delivery: maternal representations, family relation representations and depressive risk.
Risk factors for depression were measured, during pregnancy and three months after childbirth, using the Edinburgh Postnatal Depression Scale - EPDS (Cox, Holden, & Sagovsky, 1987; adapted by Benvenuti, Ferrara, Niccolai, Valoriani, & Cox, 1999), a 10-item self-assessment rated on a 4-point Likert-type scale. With regard to the EPDS, various studies showed the validity of the questionnaire; it manages to distinguish between different levels of depressive symptomatology (Cox, Holden, & Sagovsky, 1987; Cox, Holden, 2003) and is useful for assessing postpartum depression (Agostini, Monti, & Martini, 2004; Murray & Carothers, 1990).
Our results suggested a prevalence of “restricted/disengaged” maternal representations (58% in the first group and 50% in the second one) associated with a diffused representation of relationships between the subjects and significant other persons: mothers drew themselves in the centre, but at a distance from others. “Integrated/equilibrated” maternal representations (26% in the first group and 35% in the second one) were associated with a graphic representation of very positive relationships with relatives and the community.
Furthermore “not integrated /ambivalent” representations (16% in the first group and 15% in the second one) were associated with a peripheral representation of themselves, in which significant other persons are drawn quite far away.
From a prevention perspective, data analysis focused, on the one hand, on the correlation between “restricted/disengaged” maternal representations, evaluated from 5° to 7° month of pregnancy, and, on the other hand, on depressive risk both during pregnancy and after childbirth. Six of the eleven participants reported non-pathological scores at the first administration, while the other women had a score higher than the cut-off score of 10. After childbirth, in some cases the scores tend to increase and in others they decrease (table 1). We can interpret this data by looking at the differences between the mother’s child representation before and after childbirth. We might suppose that for some women the baby could represent a protective factor, associated with a lower score at the EPDS, whereas for other participants parental transition could increase vulnerability to depression.

                                        TABLE 1: Edinburgh Postnatal Depression Scale Scores

Becoming parents is a complex task that affects the family system, within the couple, the families of origin, and significant relationships. The symbolic drawings of family life space - DSSVF (Gilli, Greco, Regalia, & Banzatti, 1990) explore how close relationships change from pregnancy to the first months after childbirth. Relationships are seen from the subject’s perspective so that we have an image of what they think and feel about their motherness within their relationships. 
Participants tend to create DSSVF with one similar characteristic. All the drawings are quite poor; the women put themselves in a peripheric position compared with others figure in the family life space; husbands are often put in the middle, and during pregnancy they  include neither the baby nor community organizations (public or private, formal or informal); the pregnancy seems to be the most important thing in their lives and there aren’t any other events that they take into account. 
The DSSVF of a Moroccan women (23 years) could be an interesting example of  a family relationship for migrant women during pregnancy; this drawing is characterized by restricted relationships, both during pregnancy and after childbirth, and all significant others are placed  outside an empty circle representing the family. The couple is closed within a rectangle under the circle and members of the families of origin are quite  distant, and they too are closed in two different rectangles. The subject and her husband are isolated, without any relationships, and alsono significant person or event is inserted. It seems that this couple cannot have contact with others; their two families are tied together and their communication has a positive evaluation, but we have a clear sign that the couple experiences feelings of loneliness. The baby is not included in the first DSSVF and in the second one the subject put herself, her husband and their daughter closed in a small circle near the big one; the only person in the circle is the subject’s mother, the only one that is involved in a close and positive relationship.
Interviews were analysed looking at several central issues of research. 
During pregnancy anxiety and depression factors emerged from interviews and women talk a lot about how they feel: 

Before I had a job, now I’ve stopped...now I can’t go out...I can’t eat a lot and I can’t do a lot of other things...I stay in bed, I don’t get up in the morning to clean for example. I just know that I am frightened and nothing more...my mother told me  not to be worried, but she is my mother, what else could she tell me? The baby doesn’t move about a lot, twice a day, especially if I don’t eat or if I am angry or when I get out of bed. I dreamed about  a baby s crying and I wasn’t able to see the baby (18 years, Romania).

I was very worried...when I went to my mother, she took care of me, she arranged a lot of things...I felt like a child and I felt powerless (18 years, Romania).

I felt bad inside...I couldn’t get up in the morning, I was sad, I felt alone and I wished to be close to my family (23 years , Sri Lanka).

I am a little bit worried...but I don’t tell  anyone...I am frightened...I don’t know what to do...even if I hid at the beginning I felt anxious...I would like to be less anxious (28 years, Sri Lanka).

During pregnancy women seem to be more anxious if they reflect on elements of planning; at the question: What do you think will be necessary for  your baby during the first months? participants  tend to become anxious when they think of parenting skills and most of them think that they will need to receive medical help. After childbirth, as well as preoccupation and anxiety, women tend to feel more and more insecure about their capacity to be able to take care of the baby:

I  always feel very tired, I don’t have time and I have a lot of things  to do and I always have to look after the baby (27 years old i, Sri Lanka).

It is possible that mothers feel exhausted and upset when considering their children’s total dependence on themselves and sometimes, during the post-delivery interview, the women report fantasies about death or illness:  

 She depends on me...she can’t live without me (23 yearsi, Sri Lanka).

This kind of preoccupation and feeling of depression could became an obstacle to mother-child relationships as some participants state during the post-delivery interview:
It is an arduous task, in the night you don’t have any energy...there are moments when he is crying and you don’t know why, so you feel desperate and you don’t know what to do...when he keeps on  crying. My husband supports me when I am  sad, sometimes I think about my unborn children (referring to previous abortions). I am frightened that something bad could happen to him (28 years, Romania).
I was frightened because I was alone...I felt discouraged, I cried. I didn’t imagine that it would be  so hard. I am frightened and I am scared...I lost my mother when I was a child and I remember that I was crying and how I felt alone, I don’t want my child to feel alone...when we were children we suffered (referring to her husband), we lacked  just about everything... I feel melancholy because I am alone...I feel alone...I don’t know what to do on my own with the baby...I’m about to cry... at least if I was in my native country , but here I don’t know who can help me...it is bad when I am alone with the baby and he cries or I have something to do but I can’t leave him alone (27 years, Romania).
I was scared to death and I was frightened that the baby would die...in Romania one of my girlfriends had a baby and he died in the cradle because she wasn’t looking after him. I am worried that something could hurt him and that something bad could happen, an illness that I could prevent by being more careful. When he cries and I don’t know  why then I get scared (27 years, Romania).

I have been worried about  my baby and I would like someone to take care of me or of her for  a little bit, so that I could take care of myself. Sometimes I feel so tired that I would like to fall asleep, without knowing anything, and wake up in a couple of years (23 years, Morocco). 

Discussion 

A considerable amount of literature has been published on motherhood and depression (Aceti, Aveni, Giacchetti, Motta, & Straniero Sergio, 2010; Guarino, Ammaniti, & Papaccio, 2010), we know that postpartum depression could occur in various cultural contexts but there is one  element that may influence the expression of depressive symptoms, attribution of meaning to depression during pregnancy and after childbirth. Migration seems to be an important factor in explaining postpartum depression because migration processes could lead to a condition of privation, exclusion and powerlessness (Gozzoli & Regalia, 2005); these variables are included in a multifactor model of depressive symptoms in pregnant women and mothers during the first months after delivery. In this perspective postpartum depression is not a women’s problem but concerns the family as a system and is influenced, in particular, by the interpretation of symptoms and family organization (Downey & Coyne, 1990).
Becoming a mother for the first time always leads to a new definition of identity and increases vulnerability with regard to self-esteem, self agency and ego resiliency; in an intergenerational perspective, during pregnancy and after delivery, women tend to elaborate new relationships with their mothers and others significant figures from the  family  of origin. After leaving their native country, adjustment to a new context takes some time and pregnancy represents an event that could intensify feelings of incertitude and insecurity. 
The results of this study show that migration processes could increase vulnerability in new mothers,  who feel exhausted, upset and experience feelings of loneliness due to a lack of support from significant figures.
Most of the subjects reveal “restricted/disengaged” maternal representations, their accounts about motherhood tend to be incoherent, rigid, poor with  in emotional content and focused on rational processes rather than inclined to freely imagining their life with the baby. Findings from DSSVF are consistent with those from interviews and children are probably not represented in the drawings because women have  still not constructed a clear image of their babies; moreover, subjects tend to put themselves in a peripheric position, which shows an image of themselves as isolated beings. 
We might  consider childbirth as a factor that could increase psychological problems; anxiety, fear and insecurity, already present during pregnancy, tend to increase after delivery and this is especially  true, three months after birth, in maternal representations. People in all cultures have values, beliefs and myths that regulate pregnancy, delivery and caring, so that without symbolic references, without using good traditional practices women feel confused and occidental practices seem to intensify the sense of strangeness and inadequacy. 
Difficulties with regard to caring, fear for baby’s health,  responsibility and fatigue, threaten auto-efficacy and increase feelings of guilt and anguish; moreover, being in a new country, without support, tends to lead to a negative self image (an incompetent mother, an inept wife, an imperfect woman) and facilitates depressive symptoms. 
Anxiety and depression tend to decrease after the first months, since insecurity is associated with the task of caring; the less insecure the mother is the  more capable she is  of being satisfied with her new role and her relationship with the baby. Severe depressive symptoms, or a not complete remission, also represent an obstacle to child development (Murray et al., 1996) and children of (previously) depressed mothers – evaluated with EPDS - tend to represent their mothers as less joyous (Edhborg, Lundh, & Seimyr, 2001).
These results need to be interpreted with caution because of the small sample size, which does not allow us to generalize regarding our results; a second limitation of this study is the use of EPDS, which  evaluate risk for depression, but do not permit an accurate diagnosis of postpartum depression and do not distinguish between either severe and light symptoms or chronic and transitory symptoms. Furthermore, it should be noted that migration leads to  social withdrawal, which  could increase insecurity, anxiety and depression.

Conclusions.

With regard to practical implications we would like to emphasize that researchers need to take into account cultural differences regarding parental roles and caring tasks (Sponchiado, 2004); research into  parenting and mother-child relationships is  necessary to establish social intervention, to promote mother-child health and to evaluate risk factors for depressive symptoms. 
Hospital treatment should be planned by taking into account cultural differences and the migrant women’s traditions with regard to motherhood (Moro, 2002) to make it easier for  new mothers to construct a positive relationship with their children.
A multi-factorial model is useful for  tackling motherhood and depressive symptoms in migrant women, before and after delivery; Moro (2008) has examined how cultural factors influence both the mother’s role and mother-child relationships and she has suggested that a trans-cultural perspective,  permitting the sharing of beliefs and interpretations about motherhood, might enable migrant mothers to have a positive outcome and to avoid negative consequences.

¹ Their native countries were Bangladesh or Sri Lanka (21%), Romania and Poland (20%), Mauritius (15%), Guinea, Ivory Coast, Ghana, Nigeria (14%), China (12%), Arab Maghreb Union (5%), Balkan area (5%), Ecuador, Dominican Republic, Peru (4%) or other countries (4%). 

2 For a detailed description of measures with different administration procedures (joint, individual, concerning the present and/or the future etc.): Gilli et al. (1990); Gozzoli & Tamanza (1998).

References
Aceti, F., Aveni, F., Giacchetti, N., Motta, P., & Straniero Sergio, B. (2010). La depressione post-partum: inquadramento del problema. Terapia Familiare, 94, 189-202.
American Psychiatric Association. (2000). DSM IV-TR: Diagnostic and statistical manual of mental disorders--Text revision (Fourth ed.). Washington, D.C.: American Psychiatric Association.
Agostini, F., Monti, F., & Martini, A. (2004). L’Edinburgh Postnatal Depression Scale (EPDS) a 3, 9, 18 mesi dopo il parto. Psycofenia, 8, 12, 63-67.
Ammaniti, M., Sergi, G., Speranza, A.M., Tambelli, R., & Vismara, L. (2002). Maternità a rischio, interazioni precoci ed attaccamento infantile. Età Evolutiva, 72, 61-67.
Ammaniti, M., Candelori, C., Pola, M., & Tambelli, R. (1995). Maternità e gravidanza. Studio delle rappresentazioni materne. Milano: Cortina.
Balsamo, F. (1997) (Eds.). Da una sponda all’altra del Mediterraneo. Donne immigrate e maternità. Torino: L’Harmattan. 
Balsamo, F. (2003). Famiglie di migranti. Trasformazioni dei ruoli e mediazione culturale. Roma: Carocci. 
Benvenuti, P., Ferrara, F., Niccolai, C., Valoriani, V., & Cox, J.L. (1999). The Edinbugh Postnatal Depression Scale: Validation for an Italian sample, Journal of Afective Disorders, 53, 137-141
Born, L., Zinga, D., & Steiner, M. (2004). Challanges in Identifying and Diagnosing Postpartum Disorders. Primary Psychiatry, 11, 29-36
Bornstein, M. H. (1995). Handbook of Parenting. Lawrence Erlbaum Associates. Inc., Hove.
Bradley, R. H., Corwyn, R. F., McAdoo, H. P., & Coll, C. G. (2001). The home environments of children in the United States: Part 1. Variations by age, ethnicity, and poverty status. Child Development, 72 (6), 1844−1867.
Bydlowski, M. (1997). Il debito di vita. I segreti della filiazione. Tr. it. Urbino (2000): Edizioni Quattro Venti. 
Camilleri C. & Cohen Emerique M. (1989) (a cura di). Chocs de cultures. Paris: L’Harmattan.
Campagnola N., Gugliotti M.E., Boaretto M., & Cremonese, C. (2007). Immigrant pregnant women: preliminary data on attitudes towards Pubblic Health Services. II European Community Psychology Association Seminary, Siviglia 19-20-21 settembre. 
Caretti, V. & Crisafi, C. (2009). Fattori di rischio della depressione postpartum. Psichiatria e Psicoterapia, 28, 1, 1-16
Cattaneo, M.L. & Dal Verme, S. (2005). Donne e madri  nella migrazione. Prospettive transculturali e di genere. Milano: Unicopli. 
Chinosi, L. (2002). Sguardi di mamme. Modalità di crescita dell’infanzia straniera. Milano: FrancoAngeli.
Cox, J.L., Holden, J.M., & Sagovsky, R. (1987). Detection of Postnatal Depression – Development of the 10-item Edimburg Postnatal Depression Scale. British Journal of Psychiatry, 150, 782-786.
Cox, J.L. & Holden, J.M. (2003). Maternità e psicopatologia. Guida all’uso dell’Edinburgh Postnatal Depression Scale. Tr. it. Trento (2008): Erickson.
Dusi P. (2007). Riconoscere l’altro per averne cura. Brescia: La scuola.
Author (2002) 

Author (2004) 

Author (2005) 

Author (2006) 
Downey, G. & Coyne, J.C. (1990). Children of depressed parents: An integrative review. Psychological Bullettin, 108, 50-76.
Edhborg, M., Lundh, W., & Seimyr, L. (2001). The long-term impact of postata depressed mood on mother-child interaction: a preliminary study. Journal of Reproductive and Infant Psychology, 19, 61-71.
Elder, G. H. (1995) Life trajectories in changing societies. In: Self-Efficacy in Changing Societies (ed. A. Bandura), pp. 46–68. New York, USA: Cambridge University Press.
Gilli, O., Greco, O., Regalia, C., & Banzatti, G. (1990). Il Disegno Simbolico dello Spazio di Vita Familiare. Milano: Vita e Pensiero.
Gondoli, D. M. & Silverberg, S. B. (1997) Maternal emotional distress and diminished responsiveness: the mediating role of parenting efficacy and parental perspective taking. Developmental Psychology, 33, 861–868.
Gozzoli, C. (2008). Servizi sociali, famiglie e sfida migratoria: quale spazio di incontro tra risorse e vincoli reciproci?. In E. Scabini & G. Rossi (a cura di). La migrazione come evento familiare (pp. 235- 253). Milano: Vita e Pensiero.
Gozzoli, C. & Regalia, C. (2005). Migrazioni e famiglie. Bologna: Il Mulino.
Grussu, P. & Quartaro, R.M. (2007). Depressione postnatale e tutela del bambino:elementi clinici e alcune indicazioni operative. Maltrattamento e abuso all’infanzia, 9, 87-105.
Grussu, P. & Quartaro, R.M. (2006). Depressione materna del dopo parto e salute psicologica del bambino: contributi sperimentali e analisi critica della letteratura. Psicologia clinica dello sviluppo, 10, 187-208.
Guarino S., Ammaniti M., & Papaccio M. (2010), “Attaccamento prenatale e qualità delle rappresentazioni mentali materne: indagine preliminare su un gruppo di donne al terzo trimestre di gravidanza”, Età Evolutiva, 96: 33-41.
MacPhee, D., Fritz, J., & Miller-Heyl, J. (1996) Ethnic variations in personal social networks and parenting. Child Development, 67, 3278–3295.
Malagoli Togliatti, M. & Lubrano Lavadera, A. (2002). Dinamiche relazionali e ciclo di vita della famiglia. Bologna: Il Mulino.
Moro, M. R. (2002). Genitori in esilio. Milano: Cortina.
Moro, M. R. (2005). Bambini di qui venuti da altrove. Saggio di transcultura. Milano: FrancoAngeli.
Moro, M. R. (2008). Far nascere in esilio. Clinica del diverso e della finitudine. In E. Scabini e G. Rossi (a cura di), La migrazione come evento familiare (pp. 107-122). Milano: Vita e Pensiero.
Murray, L. & Carothers, A.D. (1990). The validation of the Edinburgh Post-Natal Depression Scale on a community sample. British Journal of Psychiatry, 182, 420-427.
Murray, L., Stanley, C., Hooper, R., King, F., & Fiori-Cowley, A. (1996). Depressed mothers’ speech to their infants and its relation to infant gender and cognitive development. Journal of child Psychology and Psychiatry, 34, 1083-1101.
Nyström, K. & Öhrling, K. (2004). Parenthood experiences during the child’s first year: literature review. Journal of Advaced Nursing, 46, 319-330 
O’Hara, M.W.  (1999). Postpartum mental disorders. In J.J. Sciarra (a cura di). Ginecology and Obstretics (pp. 1-19). Philadelphia, Lippincott: Williams & Wilkins
O’Hara, M.W. (1986). Social support, life events, and depression during pregnancy and puerperium. Archives of General Psychiatry, 43, 569-573.
Romito, P. (1992). La depressione dopo il parto. Bologna: Il Mulino
Rutter, M. & Rutter, M. (1992). Developing minds. Harmondsworth: Penguin Group (trad. it. L’arco della vita, Firenze: Giunti, 1995)
Scabini, E. (1995). Psicologia sociale della famiglia. Torino: Bollati Boringhieri
Scabini, E. & Rossi, G. (2008) (a cura di). La migrazione come evento familiare. Milano: Vita e Pensiero.
Sponchiado, E. (2004). Strumenti per la valutazione della famiglia e del parenting. In G. Axia & S. Bonichini (a cura di), La valutazione del bambino (pp. 301-325). Roma: Carocci.
Taliani, S. & Vacchiano, F. (2006). Altri corpi. Antropologia ed etnopsicologia della migrazione. Milano: Unicopli.
Teti, D. M. & Gelfand, D. M. (1991). Behavioral competence among mothers of infants in the first year: the mediational role of maternal self-efficacy. Child Development, 62, 918–929.

Subjects	FIRST ADMINISTRATION
5°-7° MONTHS
OF PREGNANCY	SECOND ADMINISTRATION
3 MONTHS
AFTER DELIVERY	DIFFERENCE BETWEEN FIRST AND SECOND ADMINISTRATIONS
	
2	14	17	
+3	
3	11	5	
-6	
4	14	16	
+2	
5	7	6	
-1	
7	8	7	
-1	
8	10	12	
+2	
9	9	11	
+2	
10	9	11	
+2	
11	14	10	
-4	
12	8	13	
+5	
13	8	3	
-5	

                                        TABLE 1: Edinburgh Postnatal Depression Scale Scores