Persevering through postpartum fatigue

OBJECTIVE

To construct a substantive theory of postpartum fatigue.

DESIGN

Grounded theory.

SETTING

Participants were recruited in the hospital after delivery and interviewed in their homes.

PARTICIPANTS

Thirteen primiparae (n=5) and multiparae (n=8) women between 2 and 5 weeks postpartum from diverse ethnic, age, obstetric, and financial contexts were theoretically sampled.

RESULTS

Persevering was the central human process around which the grounded theory emerged. The process of persevering was explained through the relationships of influencing factors, postpartum fatigue, coping techniques, self-transcendence, and caregiving. Participants persevered in caregiving of infants and older children in spite of an overwhelming desire to rest and sleep using self-identified coping techniques in combination with the belief that their children brought purpose and meaning to their lives.

CONCLUSIONS

The theory "Persevering Through Postpartum Fatigue" contributes a more complete understanding of the complex phenomenon of postpartum fatigue as it is expressed in the everyday lives of women during the postpartum period. The results may be used to develop and implement health-promoting nursing interventions to reduce postpartum fatigue and its health-related consequences.

Early postpartum sleep and fatigue for mothers after cesarean delivery compared with vaginal delivery: an exploratory study

OBJECTIVE

The purpose of this study was to describe sleep and fatigue during the first week of postpartum recovery, and compare women after cesarean delivery with women after vaginal delivery while their infants were hospitalized in the intensive care unit (ICU).

METHODS

This cross-sectional descriptive exploratory study involved 21 postpartum Chinese American mothers (6 after cesarean delivery and 15 after vaginal delivery). Three types of data were collected: (1) mothers' demographic data; (2) objective sleep that included total sleep time (TST) and wake after sleep onset (WASO) measured using wrist actigraphy, and (3) subjective sleep quality (General Sleep Disturbance Scale) and fatigue severity (Numerical Rating Scale-Fatigue).

RESULTS

All of the mothers experienced poor sleep while their 3- to 5-day-old infants were in the ICU. After cesarean birth, mothers averaged only about 4 hours TST with 34% WASO while still hospitalized, compared with 6.5 hours TST with 14% WASO for mothers after vaginal birth monitored in their home after hospital discharge.

CONCLUSION

Sleep disturbances and fatigue need to be further investigated to better understand the relationship between type of delivery and maternal health outcomes. Despite infant care provided in ICUs, these new mothers could benefit from interventions to promote their own sleep, particularly when also recovering from cesarean delivery.

Patterns of sleep disruption and depressive symptoms in new mothers

OBJECTIVES

This study describes the patterns of sleep disturbance and depressive symptoms in a sample of childbearing women from the third trimester through the postpartum period. The relationship between sleep and depressive symptoms is also examined. A secondary aim of this study was to examine the relationship between self-report measures of sleep and depressive symptoms between women with depressive symptoms in comparison with women with minimal or no depressive symptoms in the third trimester and in the third month postpartum.

METHODS

This longitudinal, descriptive study followed 124 primiparous women from their last month of pregnancy through 3 months postpartum. Questionnaires on sleep and depressive symptoms were completed during the third trimester (Time 1), 1 month postpartum (Time 2), 2 months postpartum (Time 3), and during the third month postpartum (Time 4). Sleep measures in a subset of women with depressive symptoms were compared with those of women with minimal or no symptoms at Time 1 and Time 4.

RESULTS AND CONCLUSIONS

Sleep disturbance and depressive symptoms were associated at Time 1 and Time 4. For new mothers, a complaint of trouble falling asleep (delayed sleep onset latency) may be the most relevant screening question in relation to their risk for postpartum depression.

Negotiating sleep: a qualitative study of new mothers

OBJECTIVE

The purpose of this qualitative study was to learn from 20 mothers about their experience of sleep during pregnancy and the immediate months of becoming a new mother. The study was part of a larger randomized clinical trial on an intervention to improve sleep and well-being among new mothers.

METHODS

Semistructured, audiotaped interviews were conducted in which women were asked to describe the continuum of the sleep experience across the pregnancy and early postpartum and to describe strategies they found helpful as they established sleep patterns with their infant. Narrative analysis was used to interpret their stories, and data were managed with Atlas.ti qualitative software.

RESULTS AND CONCLUSIONS

Sleep disturbances were common to all of the mothers, and sleep became a negotiated behavior as they adjusted to the mothering role. All of the mothers were surprised at the level of disturbance and exhaustion they experienced. Strategies included enlistment of partners to facilitate naps, development of a "sleep consciousness," and bed-sharing. Mercer's stages of becoming a mother are used to describe the process of incorporating sleep changes into their lives.

Prenatal stress increases HPA axis activity and impairs maternal care in lactating female offspring: implications for postpartum mood disorder

Early life stress is believed to constitute a risk factor for the development of mood disorders later in life. In the present study, we hypothesized that prenatal stress (PS) exerts long-lasting effects in female rat offspring, resulting in impaired adaptations to stress during lactation and, as such, may be a contributory factor to postpartum mood disorders. PS increased anxiety in adult virgin females compared with controls. During lactation, PS dams nursed significantly less and spent less time with pups compared with controls, whereas dams did not differ in pup retrieval or maternal aggression. HPA axis reactivity was elevated in response to a mild stressor in PS dams compared to their controls, but not in virgins, with the delta corticosterone response returning to the higher level seen in virgins. Moreover, corticotropin-releasing hormone (CRH) mRNA expression within the parvocellular region of the paraventricular nucleus (PVN) was increased in both virgins and dams exposed to PS compared with the relative controls, while the attenuation in expression in lactating controls was abolished following PS. In addition, arginine vasopressin (AVP) mRNA was increased in the parvocellular, but not magnocellular part of the PVN, in both PS-exposed virgins and lactating dams compared with their relative controls; although expression was also higher in controls during lactation compared with virgins. Thus, the present study demonstrates that exposure to PS results in long-lasting behavioural and neuroendocrine alterations in the female offspring, which are manifested during the lactation period. Furthermore, it implicates PS as a potential risk factor for the development of postpartum mood disorders, and that alterations in the HPA axis reactivity, at least partially, are involved.

The impact of HIV on maternal quality of life in Uganda

To study the effect of HIV infection on quality of life (QOL) during pregnancy and puerperium, QOL was measured in a cohort study at St. Francis Hospital Nsambya, Kampala, Uganda. Dartmouth COOP charts were administered to 132 HIV-positive and 399 HIV-negative women at 36 weeks of pregnancy and six weeks post-partum. Responses were coded from 0 = best health-status to 4 = worst health-status and scores of 3-4 defined as poor. Odds ratios (OR) (95% confidence intervals(CI)) for poor scores were calculated and independent predictors of poor QOL examined using logistic regression. In pregnancy, HIV-positive women were more likely to have poor scores in feelings: OR = 3.2(1.9-5.3), daily activities: OR = 2.8(1.4-5.5), pain: OR = 2.1(1.3-3.5), overall health: OR = 1.7(1.1-2.7) and QOL: OR = 7.2(3.6-14.7), all p= <or= 0.01. Differences in physical fitness, change in health, social activities and social support were not statistically significant (all p>0.2). HIV infection was independently associated with poor QOL: OR = 8.5(3.8-19). Findings in puerperium were similar to those in pregnancy except more HIV-positive women had poor scores in social activities: OR = 2.5(1.4-4.7) and change in health: OR = 5.4(2-14.5) and infant death also predicted poor QOL: OR = 6.7(2.4-18.5). The findings reflect HIV's adverse impact on maternal QOL and the need for interventions to alleviate this infection's social and emotional effects.

Searching for the puerperal trigger: molecular genetic studies of bipolar affective puerperal psychosis

The available evidence suggests that the puerperium is a period of increased risk for acute episodes of illness in bipolar (BP) women and points to genetic factors as influencing vulnerability to postpartum triggering of such episodes. We have previously reported compelling evidence of familiarity of vulnerability to puerperal episodes in female sibs with BP disorder and find similar familial clustering for episodes of narrowly defined postpartum episodes in siblings with major depression. Molecular genetic approaches hold out the promise of uncovering the nature of the puerperal trigger leading to important improvements in the prevention and treatment of postpartum affective episodes. A research strategy focusing on positional and candidate gene approaches may prove fruitful in the search for susceptibility genes for both postpartum triggering in particular and for the affective disorder diathesis in general. We have identified the subset of families in the Wellcome Trust UK-Irish BP sib-pair molecular genetic linkage genome screen that include at least one female who has suffered an episode of puerperal psychosis. Analysis of this more homogeneous subgroup of families resulted in a genome-wide significant linkage signal (LOD = 4.07) on chromosome 16p13 and genome wide suggestive linkage on chromosome 8q24. We are undertaking association studies in women with postpartum psychosis at a number of candidate genes of interest in BP disorder with an emphasis on those for which the expression is influenced by steroid hormones.

Postpartum Fatigue in the Active‐Duty Military Woman

OBJECTIVE

(a) To describe fatigue levels in military active-duty women, (b) to describe the relationship among selected predictor variables of fatigue, and (c) to examine the relationship between predictor variables, fatigue levels, and performance (as measured by functional status) after childbirth.

DESIGN

Based on the Theory of Unpleasant Symptoms, a longitudinal, prospective design.

SETTING

A large military medical facility in the southwest United States.

PATIENTS/PARTICIPANTS

A convenience sample of 109 military active-duty women.

MAIN OUTCOME MEASURE

Postpartum fatigue.

RESULTS

Women were found to be moderately fatigued across time, with no change in fatigue levels from 2 to 6 weeks after delivery. All variables correlated with fatigue during hospitalization and at 2 weeks after delivery, and depression, anxiety, maternal sleep, and functional status correlated with fatigue at 6 weeks after delivery. Regression analyses indicated that maternal anxiety predicted fatigue at 6 weeks after delivery. Over half the women had not regained full functional status when they returned to work, and 40% still displayed symptoms of postpartum depression and anxiety.

CONCLUSIONS

Military women continue to experiencing postpartum fatigue when they return to the workplace. Future research is needed to examine issues surrounding fatigue and its associated variables during the first year after delivery.

New insights into fatigue and health-related quality of life after delivery

BACKGROUND

A delivery has a major impact on the health-related quality of life (HRQoL) of the new mother, especially on fatigue. A common complication during delivery that might have a relationship with maternal morbidity is blood loss. The objectives were to investigate fatigue and HRQoL in women after vaginal delivery (VD), elective caesarean section (CS) and emergency CS, and its relationship with postpartum hemoglobin (Hb) levels during the first 6 weeks postpartum.

METHODS

Some 141 patients (71 after VD, 36 after elective CS and 34 after emergency CS) completed the HRQoL questionnaires MFI and EQ-5D between 12 and 24 h after VD and 24-48 h after CS (t=0). At 1, 3 and 6 weeks postpartum these questionnaires were repeated, together with the SF36.

RESULTS

Patients after VD had higher mean physical HRQoL scores than after CS. The average period to reach full physical recovery was 3 weeks after VD, 6 weeks after elective CS, and >6 weeks after emergency CS. Mean mental HRQoL scores of the study groups were similar or even better compared to reference values. The significant correlation between Hb level and mean physical HRQoL scores found at t=0 had disappeared at 1 week postpartum.

CONCLUSIONS

Results of this study provided insights into the natural course of fatigue and HRQoL postpartum. Important differences in fatigue and HRQoL scores were observed between the 3 modes of delivery. These HRQoL measures can be used in future clinical trials to assess the effects of interventions postpartum.

Postnatal psychiatric morbidity: a validation study of the GHQ-12 and the EPDS as screening tools

OBJECTIVE

To assess the validity of the 12-Item General Health Questionnaire (GHQ-12) and the Edinburgh Postnatal Depression Scale (EPDS) in screening for the most common postnatal psychiatric morbidities (mood, anxiety and adjustment disorders).

METHOD

A two-phase cross-sectional study was designed. First, a sample of 1453 women visiting at 6 weeks postpartum completed the GHQ-12 and the EPDS questionnaires. Second, based upon EPDS outcomes, participants were stratified and randomly selected within each stratum for clinical evaluation [Structured Clinical Interview for DSM-IV (SCID)]. Receiver operating characteristic (ROC) analysis was used.

RESULTS

The concurrent validity was satisfactory (0.80). At optimum cut-off scores, both GHQ-12 and EPDS yielded very good sensitivity (80; 85.5) and specificity (80.4; 85.3), respectively. ROC curves showed that the performance of the EPDS (AUC=0.933) is slightly superior to that of GHQ-12 (AUC=0.904).

CONCLUSION

Both GHQ-12 and EPDS are valid instruments to detect postnatal depression as well as postnatal anxiety and adjustment disorders.

New parenthood as a risk factor for the development of obsessional problems

Research on emotional disturbance during pregnancy and the postpartum period has focused primarily on mood disorders and psychosis, yet preliminary evidence suggests that early parenthood is also associated with an increased risk for the development and exacerbation of obsessional problems. In this article we describe the nature of "postpartum obsessive-compulsive disorder" (ppOCD) and present a cognitive-behavioural model to account for these signs and symptoms. The model outlines features of early parenthood that might increase vulnerability to ppOCD and proposes a conceptual framework similar to that described in cognitive-behavioural models of OCD in general. The empirical status of the model described herein is discussed, along with suggestions for future research and implications for treatment.

Correlates of dietary quality and weight retention in postpartum women

The purpose of this study(1) was to identify correlates of dietary quality and postpartum weight retention in women and to examine the association of dietary quality and weight retention. A secondary analysis was conducted of data from 100 women who delivered singleton babies and were over 18 years of age. In sum, 44 women had adequate dietary quality. Most women had adequate intake of meat (79%), milk (66%), and fruit (51%) but not bread (14%) or vegetables (24%). Dietary quality was significantly associated with breast-feeding (rs = .378, p < .000). Dietary quality was not associated with postpartum weight retention. In all, 43% of the variance in postpartum retained weight was explained by weight gained during pregnancy and weight-related distress. A gap exists in the nutrition education and weight management of women after childbirth that allows for a reversal of the healthy eating patterns adopted during pregnancy and throughout the ensuing postpartum life transition.

Modification of the Perinatal PTSD Questionnaire to enhance clinical utility

OBJECTIVE

To enhance the clinical utility of the Perinatal Post-Traumatic Stress Disorder (PTSD) Questionnaire (PPQ), the current study sought to refine the measure by changing the item response options from dichotomous choices to a likert scale format.

STUDY DESIGN

Using a convergent/divergent validity design and two data sources (traditional survey and World Wide Web), 58 high-risk and 86 low-risk mothers answered four questionnaires.

RESULTS

Principal components analysis of items on the modified PPQ revealed three components conceptually similar to the diagnostic criterion associated with PTSD. In addition, convergent and divergent validity of the modified measure was supported. The clinical utility of the modified PPQ was established with a strong positive likelihood ratio.

CONCLUSION

The modified PPQ is a useful clinical tool for identifying mothers experiencing significant emotional distress during the postnatal period so they may be referred for mental health services.

The role of cognitive factors in the pathogenesis of obsessive–compulsive symptoms: A prospective study

Cognitive models of obsessive-compulsive disorder (OCD) posit that specific kinds of dysfunctional beliefs (e.g., pertaining to responsibility and the significance of intrusive thoughts) underlie the development of this disorder. The present study was designed to prospectively evaluate whether dysfunctional beliefs thought to underlie OCD act as a specific vulnerability factor in the pathogenesis of obsessive-compulsive symptomatology. Eighty-five individuals were prospectively followed over a period of time thought to be associated with an increased onset of OCD symptoms -- childbirth and the postpartum. The majority of these new mothers and fathers experienced intrusive infant-related thoughts and performed neutralizing behaviors similar to, but less severe than, those observed in OCD. Scores on a measure of dysfunctional beliefs thought to underlie OCD predicted the development of obsessive-compulsive symptoms after controlling for pre-existing OCD symptoms, anxiety, and depression. Dysfunctional beliefs also predicted the severity of checking, washing, and obsessional OCD symptom dimensions, but not neutralizing, ordering, or hoarding symptom dimensions. These data provide evidence for specific dysfunctional beliefs as risk factors in the development of some types of OCD symptoms.

Women's experience of revealing perinatal bladder function--implications for midwifery care

Comments of women engaged in a longitudinal study of urinary leaking from first trimester to 12 months following birth provide the data for this paper. Useful insights into the factors contributing to the maintenance of silence and ways to break the barriers to discussion of urinary incontinence before, during and following pregnancy were revealed. Given the prevalence of 30% of Australian women experiencing urinary leaking following pregnancy, it is imperative that midwives engage in discussion and support prevention of this unwelcome outcome of childbirth.

Intervention fidelity: Lessons learned from an unsuccessful pilot study

Although the design of the study we undertook was randomized, the groups were statistically similar, the intervention was based on evidence of previous efficacy, and the treatment was delivered exactly as planned, this pilot study on an intervention to promote motivation for weight loss in new mothers failed to produce an effect. A closer examination using criteria for intervention fidelity revealed a number of weaknesses. Both treatment integrity and differentiation merit careful consideration in intervention design.

"In a black hole": the (negative) space between longing and dread: Home-based psychotherapy with a traumatized mother and her infant son

This paper offers fragments from the first year of a home-based mother-baby psychotherapy, in which I attempted to help a traumatized and dissociated mother to emotionally engage with her infant son. The treatment was organized in part around certain developmental objectives common to both attachment and psychoanalytic theory. These include: The ability to name and metabolize feelings, to evoke a soothing maternal introject, and to relate to the partner's mind as a separate, understandable center of initiative and intention. In addition, attachment theory, with its emphasis on the critical psychobiological role of containing fear and distress in infancy, was a useful guide in formulating the treatment. The paper reviews research findings on mother-infant pairs described as frightened-disorganized, discusses some of the challenges encountered in home-based mother-infant psychotherapy and then discusses the case of Mary and John. The case illustrates how mother-infant psychotherapy may interrupt the intergenerational transmission of disorganized attachment by working within the couple to name, metabolize and flexibly respond to painful, dissociated or frightening experiences.

Stages of change, processes of change, and social support for exercise and weight gain in postpartum women

OBJECTIVES

To test the extent to which social support and variables included in the Transtheoretical Model were explanatory for exercise initiation and weight maintenance in postpartum women.

DESIGN

A cross-sectional descriptive design.

SETTING

Data were collected in the participant's homes.

PARTICIPANTS

Postpartum women who had normal pregnancies were interviewed and measured on body fat, physical activity, and psychosocial scales.

MAIN OUTCOME MEASURE

(a) Stages of exercise change measure, (b) Seven Day Recall, (c) Friend and Family Support for Exercise Scale, (d) Processes of Change Questionnaire, and (e) body fat measures including body mass index and percent body fat.

RESULTS

Forty percent reported engaging in vigorous activity less than 1 hour daily, 55% walked less than four city blocks daily, and 52% engaged in less than 2 hours of vigorous weekend activity. Multilinear regression showed that the processes of change contributed 36% to the body mass index, and 21% of the variance in waist-thigh ratio. Of the processes of change, environmental reevaluation correlated significantly with body mass index.

CONCLUSION

The impact of a woman's weight on others as well as information concerning the health effects of obesity and physical activity could enhance the initiation of exercise in the postpartum woman.

A model for postpartum smoking resumption prevention for women who stop smoking while pregnant

Behavior change models and theories have been useful in our efforts to help people stop smoking. However, models that were developed for the general population do not always fit special populations such as pregnant women. Many women stop smoking while pregnant, but most resume smoking after giving birth. To help women who stop smoking while pregnant to stay smoke-free, a model for tailoring a smoking resumption-prevention intervention to the special needs of pregnant and postpartum women is proposed. The intervention begins during pregnancy, continues postpartum, and addresses pregnancy and parenting contextual factors in women's lives. The model is based on motivational theory and includes conducting patient assessments, developing risk profiles, triaging women to different levels of intervention intensity, and matching intervention strategies to women's risk profiles.

Postpartum smoking relapse and becoming a mother

PURPOSE

To propose an innovative, theoretically-derived conceptual framework for studies of postpartum smoking relapse including concepts of smoking abstinence self-efficacy and becoming a mother.

METHODS

Presentation of an existing research paradigm followed by evidence from intervention research and studies of factors associated with postpartum smoking behavior, leading to a new approach to postpartum smoking relapse.

FINDINGS

Effectiveness of current interventions to prevent relapse is limited. Variables associated with becoming a mother are missing from studies of postpartum smoking relapse.

CONCLUSIONS

Context-specific variables that influence a woman's progression through the stages of becoming a mother might include protective or risk factors that should be incorporated into the design of postpartum smoking relapse studies.

Fatores relacionados à prevalência de morbidades psiquiátricas menores em mulheres selecionadas em um Centro de Saúde no Rio de Janeiro, Brasil

O objetivo foi investigar fatores potencialmente associados às morbidades psiquiátricas menores, incluindo variáveis do estado nutricional materno. Foi estudada uma coorte com 479 mulheres entre 15 45 anos. O General Health Questionnaire (GHQ) reduzido (12 itens) foi aplicado, aos nove meses pós-parto, nas 312 mulheres que completaram o seguimento. A presença de morbidades psiquiátricas menores foi definida como valores do escore derivado do GHQ > 4 pontos, sendo analisada como variável dependente. As análises foram realizadas com modelos de regressão logística multivariados hierarquizados. A prevalência de morbidades psiquiátricas menores foi de 54,2% (IC95%: 48,6-59,7). Os resultados do modelo final revelaram que as seguintes variáveis permaneceram estatisticamente associadas: nível 1: renda familiar (1º quartil: OR = 2,71; IC95%: 1,42-5,19; 2º quartil: OR = 2,13; IC95%: 1,13-4,04); nível 3: gordura corporal > 30% (OR = 1,66; IC95%: 1,03-2,65). Conclui-se que a baixa renda e a obesidade foram os únicos fatores potencialmente associados à probabilidade de ocorrência de morbidades psiquiátricas menores, mesmo após o controle para variáveis de confusão, e que são escassos os estudos relacionando estado nutricional materno e morbidades psiquiátricas menores.

Clinical characteristics of perinatal psychiatric patients: a chart review study

Although postpartum depression and other perinatal disorders have been the subject of increased research attention, important questions remain regarding women who actively seek psychiatric treatment during pregnancy and the postpartum period. In this study, we examined clinical records of 500 perinatal psychiatric patients who received treatment in a psychiatric day hospital (N = 398) or outpatient behavioral health clinic (N = 102). Patients' presenting diagnoses, psychiatric history, treatment course, and depressive symptoms were recorded. The majority of women had major depression as their primary diagnosis, with an average Edinburgh Postnatal Depression Scale score of over 20. Many depressed patients were diagnosed with comorbid anxiety and substance abuse disorders. Although most women were willing to take psychotropic medications, a sizable minority were not, particularly those who were breast-feeding. For more than a third of the sample, the treatment sought while pregnant or postpartum represented their first contact with the mental health system. Treatment implications are discussed.

Postpartum feeding attitudes, maternal depression, and breastfeeding in Barbados

Maternal feeding attitudes, maternal moods and infant feeding practices during the first 6 months postpartum were assessed in 226 healthy, well-nourished Barbadian mother-infant dyads. Factor analysis of the feeding attitudes questionnaire resulted in six independent factors. The belief that breastfeeding was better than bottle-feeding was associated with higher family income, more information seeking behavior and older maternal age at the time of her first pregnancy. Women who believed that breastfeeding was better at 7 weeks postpartum were also more likely to breastfeed at concurrent and later ages, up to 6 months postpartum. This belief was also associated with less maternal depression at 7 weeks and 6 months. The association between feeding attitudes and actual feeding practices was significant even after correcting for maternal moods and other background variables. Conversely, after controlling for feeding attitudes, maternal mood at 7 weeks was still significantly associated with infant feeding practices at 6 months. Thus, feeding attitudes and maternal moods were closely linked, but each contributed independently and uniquely to different aspects of breastfeeding, especially at 6 months. These findings suggest that early intervention addressing maternal feeding attitudes, may improve the extent of breastfeeding and the health of children in this setting.

Unfulfilled expectations: How circumstances impinge on women's reproductive choices

Throughout Europe women are having fewer babies, but more of them are being delivered by caesarean section. There is some evidence that this major surgical procedure discourages women and/or their partners from having further children. This study is aimed at ascertaining the extent to which mode of delivery in first confinement affected women's decision-making about having another child. This paper reports results from (1) a questionnaire sent to 5300 women who delivered their first baby in Aberdeen in northeast Scotland between 1980 and 1995, but who did not have another viable pregnancy within 5 years, and (2) in-depth interviews with a stratified random sample of 82 of these respondents which covered experiences of birth, decision-making about subsequent pregnancies and infertility. Verbatim transcripts were analysed thematically. Questionnaires were returned by 3204 women (60%). Among those who had no further pregnancies, 1182 (71%) had deliberately limited their fertility. Of those who had a second child, 696 (66%) deliberately left a gap of 5 or more years between them. The factors which apparently influenced the decision to limit fertility included early intention, experience of the first, or index birth, health, lifestyle, influence of partner, age, first child and fertility problems. In interviews, women presented these factors as constraints on their behaviour, which restrained them from freely choosing to have more children and in some cases to have the number they had planned. As the decision to have only one child or to leave a large gap between children is unusual, women may have been presenting their choices in this way to make their actions appear more socially acceptable and their motivations as blameless.

What is the effect of overactive bladder symptoms on woman's quality of life during and after first pregnancy?

OBJECTIVE

To evaluate the effect of overactive bladder symptoms (OAB) on women's quality of life (QoL) during and after the first pregnancy, using self-reported symptom-based QoL questionnaires.

PATIENTS AND METHODS

In a prospective cohort study, 474 women were asked to complete four self-reported questionnaires. Urogenital symptoms were assessed with the Urogenital Distress Inventory (UDI) and the Incontinence Impact Questionnaire (IIQ). A women was considered to experience 'dry' OAB if she replied positively to the following two questions: 'do you experience a strong feeling of urgency to empty your bladder?'; and 'do you experience frequent urination?'. A women was considered to experience 'wet' OAB if she replied positively to all of the following questions: 'do you experience a strong feeling of urgency to empty your bladder?'; 'do you experience frequent urination?'; and 'do you experience urine leakage related to the feeling of urgency?'.

RESULTS

In all, 344 (72.6%) women who returned all four questionnaires were included in the analysis. After first childbirth there was a rapid decline in the prevalence of dry OAB (45.2% to 7.9%, P < 0.001). In pregnancy the prevalence of wet OAB increased significantly, but a year after childbirth the prevalence of wet OAB decreased and was similar to that at 12 weeks of gestation (P = 0.289). Women with wet OAB had higher scores on all IIQ domains than those with no OAB symptoms at 36 weeks of gestation. Women with dry or wet OAB all had higher scores on the mobility domain than those with no OAB. The scores on the physical, social and emotional functioning domains were low, suggesting a minimal restriction of lifestyle.

CONCLUSION

OAB symptoms are common during pregnancy; dry OAB had no negative effect on QoL, whereas wet OAB compromised QoL both during and after pregnancy, mainly in the 'mobility' and 'embarrassment' domains. The urge urinary incontinence symptom in wet OAB seems to profoundly compromise QoL. Apparently, in young mothers with wet OAB, limitations in mobility are especially stressful and these symptoms can be embarrassing.

[Psychiatric disorders in pregnant and puerperal women]

The most frequently occurring pre- and postpartum psychiatric disorders are depression and, to a lesser degree, panic disorder and psychosis. Apart from the negative effects on the psychological well-being of the mother, these psychiatric disorders may also result in obstetric complications and an impaired mother-infant relationship. In order to prevent these negative effects, mothers who are at risk for major psychiatric disorders need to be identified early, preferably before or during pregnancy. The most important risk factor is a history of psychiatric disorders. Obstetric risk factors for depression are unplanned or unwanted pregnancy, pregnancy-related hypertension, emergency caesarean section and early discharge from the hospital. Other factors are low socioeconomic status, recent life event, negative self-image, little social support, immigration in the last 5 years, feelings of loss of control during pregnancy and feeding problems with the child. For treatment, pregnant or puerperal women with a possible psychiatric disorder based on the presence of a serious risk factor, such as a previously experienced psychiatric disorder (related to pregnancy or not), serious current psychiatric symptoms or long-time use of psychoactive drugs, should be referred preferably to a combined psychiatric/obstetric clinic or, if unavailable, to a psychiatrist in a general hospital.

Differences in parenting stress between married and single first time mothers at six to eight weeks after birth

Parenting stress has been shown to affect relationships between mothers and their infants. Single mothers may experience more parenting stress due to exposure to stressors that are unique to their environment. The purpose of this secondary analysis was to determine the differences between married and single first-time mothers on the Parenting Stress Index/Short Form (PSI/SF Abidin, 1995). A convenience sample of 22 single and 52 married first-time mothers were recruited from postpartum units in two large metropolitan hospitals in the southeastern United States. During hospitalization, participants completed a demographic sheet and at six weeks postpartum, were mailed the PSI/SF. T-tests were assessed for differences between mean scores. Study findings indicate significant differences between single and married first-time mothers on the Parental Distress subscale (t = -3.468, p = .001), the Difficult Child subscale (t = -2.032, p = .046), and Defensive Responding subscale (t = -3.720, p = .000), with single mothers consistently scoring higher than married mothers; however, there was not a significant statistical difference between mothers on the Parent-Child Dysfunctional Interaction subscale (t = -1.290, p = .201). Overall, single mothers scored higher on the Total Parenting Stress scores of the PSI/SF than married mothers (t = -2.858, p = .005), suggesting that single women experience more stress as a new mother than married new mothers. It is important to understand the specific stressors of new, single mothers and to develop nursing interventions that decrease parenting stress in single mothers.

Associations between maternal childhood maltreatment and psychopathology and aggression during pregnancy and postpartum

OBJECTIVE

This study examines the association between maternal childhood maltreatment and psychopathology and aggression in intimate relationships during pregnancy and the postpartum period.

METHOD

Forty-four pregnant women who were recruited from an obstetric clinic and local advertising periodical completed questionnaires about childhood maltreatment and psychopathology during their first trimester of pregnancy. Approximately 1 year after the birth of the child, 32 of the original participants completed these same questionnaires. Regression models were used to test the relationship between childhood maltreatment and psychopathology and aggression during pregnancy and 1 year postpartum.

RESULTS

Sexual abuse and emotional neglect were related to psychopathology during pregnancy, and emotional neglect and physical abuse and neglect predicted poorer maternal outcomes 1 year postpartum. Contrary to expectations, physical abuse was related to less aggression during pregnancy, and emotional abuse was associated with less pathology postpartum.

CONCLUSIONS

The results of this study indicate that childhood maltreatment is associated with poorer maternal mental health during pregnancy and 1 year postpartum and points to the need to improve targeting and treatment of psychopathology during this time.

Shared obsessive-compulsive disorder

BACKGROUND

Shared psychotic disorder (folie à deux) is an uncommon entity reported mainly in the context of delusions. Obsessions and compulsions occur very rarely as shared psychopathology.

MATERIAL AND METHODS

We present two sisters who manifested shared obsessive-compulsive disorder.

RESULTS

Both sisters were managed in keeping with their shared obsessive-compulsive disorder leading onto a similar pattern of response.

CONCLUSIONS

Shared obsessions could represent the continuum concept of obsessions and delusions, and their relationship needs to be evaluated in greater detail.

[Medical-social aspects pregnancy, labor and puerperium in patients the solitary mother home in Karwowo near Szczecin]

PURPOSE

Solitary maternity is a significant problem of modern times requiring socio-economic and psychological, as well as perinatological studies. The twentieth anniversary of the Maternity Home managed by the Benedictine Samaritan Sisters motivated the present study.

MATERIAL AND METHODS

Hospital discharge summaries of 429 women (group DSM) who lived at the Maternity Home between 26 July 1983 and 26 February 2002 were analyzed. This documentation was supplemented with hospital data on 177 women who gave birth at two Szczecin hospitals and on 13 who left the Home before delivery.

RESULTS

Residents of the Home came from all regions of Poland and from urban and rural societies. They were between 14 and 43 years of age (mean 22.6 +/- 5.7). 87.4% of them were single and 63.7% were primipara. 50.4% of them failed to complete primary education while 3.4% had university-level education. 6% were mentally and/or psychologically handicapped and 42.7% had no profession. The major causes of admission into the Home were: desire to hide the pregnancy, family conflicts, homelessness, difficult material situation, mental or physical disability, violence or alcoholism in the family. The control group comprised 400 women (group K) who gave birth at the Department of Obstetrics and Perinatology, Pomeranian Medical University in Szczecin. 51.5% of them were primipara. The mean age in this group was 27.4 +/- 5.4 (17-44). 71.3% were married. The Majority had secondary (41.9%) or university (32.5%) education. Most of them worked as artisans, teachers or economists. Neurological or psychiatric diseases dominated in group DSM but otherwise no severe disease at all could be disclosed. Satisfactory prenatal care was provided to 33.1% of DSM patients and to 78% of group K. No prenatal care was provided to 9.5% of DSM patients and to 1.7% of group K. EPH gestosis was more often observed in DSM patients and imminent abortion, premature birth, PROM, urinary tract infection, and anaemia were more frequent in controls. More DSM patients had no treatment during pregnancy than controls. The use of tocolytics was significantly more frequent in DSM patients. Antibiotics and drugs accelerating maturation of the respiratory system were applied with similar frequency in both groups. Frequency of immature and mature births was similar in both groups. 84.2% of DSM patients and 68.8% of controls had natural delivery. Cesarian section was twice more frequent in group K. Immediate indications dominated in both groups (74.1% in DSM; 57.4% in K). No medication was used during delivery in 30% of patients. DSM patients more often required strong analgesics. Antibiotics and agents increasing uterine tension more often were used in K patients. Deliveries in both groups were usually without complications. Female genital tract injury was more frequent in DSM patients (20.9% in DSM; 14.8% in K). Delivery duration was similar in both groups, but the second part of delivery was longer in K primipara. Mean neonatal weight in the 1000-2500 g range was similar in both groups but was significantly higher in controls for 2501-4000 g neonates. The difference for newborns weighing more than 4000 g was not significant. There were no neonates weighing less than 1000 g. The clinical condition of newborns measured with the Apgar scale was worse in the DSM group after the 1st min, as well as after the 3rd and 5th min and the difference in each case was significant. Puerperium was usually uncomplicated. However, urinary tract infection was more frequent in DSM patients and anaemia was more frequent in controls. The duration of hospitalisation was similar in both groups (mean = 6 days). 120 of 177 DSM mothers left hospital together with their children, as compared to 99.3% in the control group. 87 children of mothers from the Maternity Home were offered for adoption.

CONCLUSION

By studying unwed maternity it was observed that a holistic approach is the only way to disclose all the problems which are often unusually complex and concealed but which determine the normal development of an individual in the society. Analysis of the factors involved may help in attaining goals that serve the good of the society.

[The impact of education in birthing schools on the course of pregnancy, labor, puerperium, and neonatal care]

INTRODUCTION

Pregnancy represents a special period in the life of a woman. It is the time of many joyous, sublime, and touching moments experienced by the family although not free from anxiety, uncertainty and doubt in the minds of the future parents. It is also the time of an intense quest for answers to annoying questions and a motivating factor to search for information on the physiology of pregnancy, as well as on labor, puerperium and child care. A birthing school is nowadays the most important institution which prepares for parenting in a most professional way. This form of education is gaining widespread acceptance. This study was designed to: 1. Study the effects of participation in birthing school classes on the course of pregnancy, labor, and puerperium. 2. Search for relationships between the birthing school program and motivation of mothers to breast feeding. 3. Determine the influence of education in a birthing school on the ability of mothers to cope with problems during puerperium.

MATERIAL AND METHODS

The study was done in 294 women hospitalized at the Obstetrics Ward of the Chair and Department of Obstetrics and Perinatology, Pomeranian Medical University in Szczecin, between June 2001 and December 2002. Two groups were formed: group I--"study group"--comprised 129 gravida who participated in birthing school classes during at least one pregnancy but not earlier than two years before the present study; group II--"control group"--included 165 gravida who never participated in any organized form of birthing education. A questionnaire was developed consisting of 105 questions. Answers were recorded by the researcher and the results in both groups were compared statistically.

CONCLUSIONS

Participation in birthing school classes helps develop healthy attitudes during pregnancy, reduced the feeling of pain and blood loss during labor, but does not alter the duration of labor in primipara nor has any effect on problems related to puerperium. Graduates of birthing schools are better motivated to start breast feeding, less often switch to artificial feeding during puerperium, and cope better with problems encountered during puerperium.

The role of estrogen therapy in postpartum psychiatric disorders: an update

OBJECTIVES

The aim of this review is to assess and summarize the existing literature data about the efficacy of estrogen replacement therapy (ERT) in preventing and treating postpartum psychiatric disorders.

METHODS

An extensive and unrestrictive computerized search (from 1970 to June 2005) on MEDLINE/PubMed, TOXNET, EMBASE, and Cochrane Databases was conducted with the following search terms: estradiol, estrogen-treatment, hormonal treatment, therapy, postpartum depression, postnatal depression, puerperal depression, postpartum blues, postpartum psychosis, lactation, and breastfeeding.

RESULTS

In assessing available literature information about the role of ERT in preventing and treating puerperal psychiatric diseases, all reviewed studies were found to suffer from severe methodological limitations.

CONCLUSION

Well-designed and strictly focused multicenter trials are warranted in order to firmly establish the effectiveness of ERT in puerperal psychiatric disorders.

Differences between exclusive breastfeeders, formula-feeders, and controls: a study of stress, mood, and endocrine variables

The purpose of this study was to examine relationships among lactational status, naturalistic stress, mood, and levels of serum cortisol and prolactin and plasma adrenocorticotropic hormone (ACTH). Eighty-four exclusively breastfeeding, 99 exclusively formula-feeding, and 33 nonpostpartum healthy control women were studied. The postpartum mothers were studied cross-sectionally once between 4 and 6 weeks after the birth. Stress was measured using the Perceived Stress Scale, the Tennessee Postpartum Stress Scale, and the Inventory of Small Life Events. Mood was measured using the Profile of Mood States. Serum prolactin, plasma ACTH, and serum cortisol levels were measured by commercial ELISA (enzyme-linked immunosorbent assay) kits. Results indicate that breastfeeding mothers had more positive moods, reported more positive events, and perceived less stress than formula-feeders. Reports of stressful life events were generally equivalent in the two groups. Serum prolactin was inversely related to stress and mood in formula-feeders. When breast and formula-feeders were compared to controls, they had higher serum cortisol, lower stress, and lower anxiety. Breastfeeders had lower perceived stress than controls. Breastfeeders had lower depression and anger and more positive life events reported than formula-feeders. However, there were few correlations among stress, mood, and the hormones in postpartum mothers, and those only in formula-feeders, whereas strong relationships were found between serum ACTH and a number of stress and mood variables in controls. Postpartum mothers reported a range of stress and negative moods at 4 to 6 weeks, and in formula-feeders, serum prolactin was related to some of the stress and mood variables. Breastfeeding appears to be somewhat protective of negative moods and stress.

[Psychiatric disorders and psychopathologic manifestations associated with pregnancy and postpartum in Cameroon]

This retrospective study was conducted from Januaty 1, 2002 to May 31, 2004 to ascertain the sociodejnographlc profile of women phychiatric disorders and psychopathologic manifestations during puerperiuni and determine the most common clinical entities at the Jamot Hospital in Yaounde, Cameroon. Study included 40 paturient women who presented psychiatric disorders related to pregnancy, postpartum, abortion, or breastfeeding. Most patients (80%) were less than 34 years of age including 50% under 20 years. Psychiatric disorders were often observed in married women (62.5%) but one of three women (30%) in this study was single. Most of these women (85%) had no income. Primagravid women accounted for 35% of the cohort. Manifestations generally began after delivery (80%) but sometimes appeared during pregnancy (12.5%). A particularly noteworthy finding of this study is the high rate of late postpartum or breastfeeding psychosis. In 40% of cases symptoms appeared between 1 and 6 months after delivery. Acute psychosis was by far the most frequent disorder (77.5%) followed by depression (15%) and manic fits (7.5%). With regard to symbolic representations and social implications, we concur with the Bell people in considering that these manifestations are related to anemia resulting from massive blood loss after delivery. This occurs during the traditional hot water massages performed to eliminate lochia (blood and debris). This sudden blood loss is called "esere meld" in the Ewondo language. In contrast it is considered as lochia retention due to the lack of massage by the Bassa people who use the term "ndjeg gwal" or delivery madness.

Impact of pregnancy on health related quality of life evaluated prospectively in pregnant women with rheumatic diseases by the SF-36 health survey

OBJECTIVE

To gain insight into patient experience of the disease course and health related quality of life during and after pregnancy in women with rheumatoid arthritis and ankylosing spondylitis.

METHODS

10 patients with rheumatoid arthritis, 10 patients with ankylosing spondylitis, and 29 age matched healthy pregnant controls were evaluated by the medical outcomes study short form 36 (SF-36) health survey once at each trimester and at 6, 12, and 24 weeks postpartum. A group of non-pregnant age matched female patients (40 rheumatoid arthritis, 16 ankylosing spondylitis) was studied for comparison.

RESULTS

Impaired physical dimensions as well as increased bodily pain was observed in healthy women in late pregnancy. Patients with rheumatoid arthritis showed improved physical functioning scores in the second trimester and reduced pain in the third trimester. Among pregnant patients, those with ankylosing spondylitis suffered the greatest impairment of health related quality of life during pregnancy. In all patient groups the physical impairment in the third trimester was less pronounced than in healthy controls. Mental health scores remained stable even with persisting active disease during pregnancy, or with a postpartum flare.

CONCLUSIONS

Pregnancy reduced physical functioning in healthy women and patients, but had no impact on mental and emotional health, even at times of disease aggravation. The pregnancy experience documented in our patients may be helpful when counselling patients contemplating pregnancy.

Depressive symptoms in mothers of infants identified as genetically at risk for type 1 diabetes

OBJECTIVE

This study describes maternal depression associated with newborn genetic screening for type 1 diabetes after risk notification.

RESEARCH DESIGN AND METHODS

Mothers of at-risk infants (n = 192), identified through newborn genetic screening as part of the Prospective Assessment of Newborns for Diabetes Autoimmunity study, were administered a structured telephone interview assessing maternal depressive symptoms 1 and 3.5 months after risk notification. Statistical analyses were conducted to examine predictors and correlates of maternal depressive symptoms.

RESULTS

For the total sample, maternal depressive symptoms in response to infant risk status were not elevated at 1 and 3.5 months after risk notification. However, at the first interview, mothers from ethnic minority backgrounds (P < 0.002), with limited education (P < 0.001), and with postpartum depression symptomatology (P < 0.001) reported significantly more depressive symptoms in response to risk notification (r2 = 0.354). At the second interview, postpartum depression symptomatology remained a powerful predictor of depressive symptoms in response to risk notification (P < 0.001). In addition, certain coping styles (wishful thinking, self-blame, and seeking social support) were associated with increased depressive symptoms. A history of major depression was a correlate of both postpartum depressive symptomatology (r = 0.26) and maternal depressive response to risk notification (r = 0.21).

CONCLUSIONS

For the most part, mothers of infants genetically at risk for type 1 diabetes do not appear to evidence elevated depressive symptoms. This suggests that most mothers are resilient when notified of infant risk. However, certain maternal characteristics such as ethnic minority status, less than a high school education, postpartum depression symptomatology, a history of major depression, and certain coping strategies (wishful thinking, self-blame, and seeking social support) appear to be associated with a more difficult maternal response to the news of an infant's increased genetic risk for type 1 diabetes.

Have we forgotten the significance of postpartum iron deficiency?

The postpartum period is conventionally thought to be the time of lowest iron deficiency risk because iron status is expected to improve dramatically after delivery. Nonetheless, recent studies have reported a high prevalence of postpartum iron deficiency and anemia among ethnically diverse low-income populations in the United States. In light of the recent emergence of this problem in the medical literature, we discuss updated findings on postpartum iron deficiency, including its prevalence, functional consequences, risk factors, and recommended primary and secondary prevention strategies. The productivity and cognitive gains made possible by improving iron nutriture support intervention. We therefore conclude that postpartum iron deficiency warrants greater attention and higher quality care.

Women's experiences of managing mastitis

The first paper in this series (last month), discussed study methodology and the measurement of the incidence of mastitis, which was shown to peak at four and 12 weeks. It concluded that the reporting pattern by women experiencing mastitis affects the measurement of reported incidence. This paper presents the qualitative data generated through interviews with 56 women. It analyses their theories of causation that may account for the two peaks in incidence. Factors most likely to contribute to the risk of developing mastitis were identified by women as incorrect positioning and incomplete emptying. Expressing by hand or pump, and hurried or infrequent feeding patterns, were also thought to be practices associated with mastitis. They considered that these practices were associated with social pressures such as the care of older children. The study concluded that respondents' theories about causation illustrate the interactive nature of anatomical, physiological, pathological and social risk factors. The two peaks in incidence occur at times when the intensity of this interaction increases. Existing research findings support these theories and present opportunities to change and develop professional practice.

Timing of mental illness onset and motherhood

The timing of mental illness onset in relationship to birth of children was explored as a possible indicator of the extent to which mothers experienced difficulties in parenting and functioning. Analyses employed data from a longitudinal study of urban-based, primarily minority mothers with mental illness (N = 379) who had parenting responsibility for their minor children. We found that women who were parents first and experienced mental illness onset after the birth of all their children showed the most positive trajectories over the study course. Mothers whose mental illness onset occurred before the birth of any of their children also showed improvements in functioning and symptomatology over time. In contrast, mothers whose mental illness onset had occurred in temporal proximity to the birth of a child showed little improvement. They also were younger, on average, at first birth, and had the largest number of children. Thus, timing of mental illness onset and childbirth may be predictive of longer-term maternal functioning and therefore may be useful in clinical assessment and treatment.

Infanticide: contrasting views

BACKGROUND

The subject of infanticide is met with complex reactions. Paradoxically, the very same society that practices gender selection may also prosecute a mother for killing an infant. The author reviews historical, cultural, and political views on infanticide.

OBJECTIVE

Using the case of Andrea Yates, the author illustrates the outcome of an infanticide case in American Judicial System in which a floridly psychotic mother serves a life in prison. This work explores contemporary worldwide experiences of infanticide and investigates culture specific attitudes towards causes, facilitation, and punishment of this tragic cause of infant mortality. The work illustrates the intricate relationship between a society's construction of parenthood and mothering, and its experience of infanticide.

RESULTS

Infanticide is deeply embedded in, and responsive to the societies in which it occurs. Causes vary from poverty to stigma, dowry and insanity. The worldwide experience of infant murder reaches from facilitation of gender determination in China and Asia to lethal execution of mothers as perpetrators in the United States.

CONCLUSION

Infanticide must be viewed against the political, cultural, social and legal backgrounds of societies that treat women with disregard. It is a reflection of social and cultural norms governing motherhood, a constant that links these seemingly disparate acts. The overall association of infanticide with crime, postpartum illness, population and sex selection speaks to unjust discrimination against women and children. We as a world society can do a far better job of protecting motherhood.

Postnatal euphoria: are 'the highs' an indicator of bipolarity?

Research into postnatal mood disorders to date has concentrated on depressive syndromes of varying severity and full-blown acute puerperal mania. However, clinical experience, backed up by a review of the literature, indicates that milder hypomanic symptoms also occur in the early puerperium. Although these symptoms may often be regarded as clinically insignificant, there is evidence that the experience of minor puerperal elation may be a predictor of later postpartum depression. In addition, studying mild puerperal high mood may provide insights into the pathophysiology of more severe puerperal mania and psychosis. This paper critically reviews the literature on milder forms of high mood occurring in the puerperium and discusses the potential clinical and research significance of 'the highs'.

[Sexual problems in women after surgical interventions]

Sexual disorders following operative interventions have a variety of causes. Apart from functional disturbances (e.g. as a result of the formation of scar tissue, hormone deficiencies, etc.), problems arising from the psychological problem of coping with the intervention itself also play an important role. A major course of conflict lies in communication problems between the partners involved. Potential sexual disorders should be discussed in the preoperative period, with the aim of enabling the patient to come to terms with the postoperative situation. However, it remains a task of the physician after the operation to actively support the patient in dealing with the traumatization she has experienced.

Perceived Stress and Support of the Chinese Postpartum Ritual “Doing the Month”

"Doing the month" is the traditional ritual for Chinese postpartum women. A qualitative study involving in-depth interviews with 20 Hong Kong Chinese women was conducted to examine the women's perceptions of stress and support in "doing the month." Four central themes were identified as follows: bound by the environmental constraints, difficulties in following the prescriptions of the rituals, conflicts between the parties involved, and attainment of the maternal role. The study revealed that "doing the month" is not necessarily protective and supportive of the postpartum women. It raises the critical question of how women can adapt the ritual to fit modern life. The study findings suggest that midwives and health care providers should provide culturally appropriate advice for new mothers. Suggestions are given on bridging the gap between traditional and modern postpartum practices.

Cortisol response to ovine corticotropin-releasing hormone in a model of pregnancy and parturition in euthymic women with and without a history of postpartum depression

Hypothalamic-pituitary-adrenal axis abnormalities have been reported in depressed women and those with postpartum blues, compared with nondepressed women. We investigated the effect of gonadal steroids on the hormonal response to ovine CRH in women with (n = 5) and without (n = 7) a past history of postpartum depression (PPD) by creating an endocrine model of pregnancy and the postpartum. Ovine CRH (1 microg/kg) stimulation tests were performed in the baseline follicular phase, during hormone add-back (leuprolide acetate plus supraphysiologic doses of estradiol and progesterone-mimicking pregnancy), and after precipitous withdrawal of hormone replacement (mimicking the puerperium). Significant phase by time (P < 0.005) and phase by diagnosis (P < 0.05) interactions were observed, reflecting increased stimulated cortisol during the supraphysiologic phase, particularly in subjects with a history of PPD. Cortisol area under the curve also showed a significant phase by diagnosis effect (P < 0.05). Significant increases during the supraphysiologic phase were also seen for urinary free cortisol (P < 0.05), cortisol area under the curve (P < 0.001), and plasma corticosteroid-binding globulin (P < 0.05). Our data show that in humans, as in animals, supraphysiologic gonadal steroid levels enhance pituitary-adrenal axis activity, and, further, that women with a history of PPD have an enhanced sensitivity of the pituitary-adrenal axis to gonadal steroids.

Long-term outcome of offspring after maternal severe puerperal disorder

OBJECTIVE

To study adult mental health in offspring of mothers who experienced severe puerperal disorder.

METHOD

Mothers, followed up a mean of 23 years after puerperal disorder requiring hospitalization, were interviewed regarding adult psychiatric illness, childhood neurotic symptoms and conduct problems of 48 offspring of the index episode and 62 additional siblings.

RESULTS

In these predominantly young adults the lifetime rate of ICD-10 adult psychiatric illness was 26%, and was higher in offspring of puerperal episodes (35% vs. 15%, P = 0.07). There were also high rates of childhood symptoms and problems.

CONCLUSION

There are high lifetime rates of adult psychiatric illness in young adult offspring of mothers with puerperal disorder, which are likely to increase further with time, and warrant special attention.

Postpartum sexual functioning and method of delivery: summary of the evidence

Short-term postpartum sexual problems are highly prevalent, ranging from 22% to 86%; however, there are few studies that address how mode of delivery affects sexual functioning after childbirth. The objective of this study was to perform a systematic review of the literature on selected postpartum sexual function outcomes as affected by cesarean, assisted vaginal, and spontaneous vaginal delivery. We searched PubMed, CINAHL, and Cochrane databases from January 1990 to September 2003 and focused on mode of delivery and the most commonly reported sexual health outcomes, which included perineal pain, dyspareunia, resumption of intercourse, and self-reported perception of sexual health/sexual problems. The studies all showed increased risks of delay in resumption of intercourse, dyspareunia, sexual problems, or perineal pain associated with assisted vaginal delivery. Some studies showed no differences in sexual functioning between women with cesarean delivery and those with spontaneous vaginal delivery, whereas others reported less dyspareunia for women with cesarean delivery. A systematic review of the literature suggests an association between assisted vaginal delivery and some degree of sexual dysfunction. Reported associations between cesarean delivery and sexual dysfunction were inconsistent. Continued research is necessary to identify modifiable risk factors for sexual problems related to method of delivery.