Psychosocial correlates of prepartum and postpartum depressed mood

Anxiety sensitivity as a predictor of labor pain

Psychosocial factors have been implicated in the pain experience during childbirth, which can have both short- and long-term consequences on the mother's health and her relationship with her infant. The present study evaluated important demographic, social, and psychological factors as predictors of multiple dimensions of labor pain among 35 mothers during childbirth. The results indicated that anxiety sensitivity (AS), as measured by the Anxiety Sensitivity Index, shared a significant relation with maximum pain during labor as well as sensory and affective components of pain as measured by the McGill Pain Questionnaire. AS predicted both maximum pain during labor and sensory aspects of pain above and beyond demographic and social factors as well as other theoretically important psychological factors (e.g., depression and state anxiety). These data replicate previous research that has demonstrated the significant impact of AS on pain responding in other areas (e.g., chronic pain) and extend knowledge in this literature to demonstrate the important role that AS serves among women and their experience of labor pain. Clinical implications are highlighted and discussed.

Impact of a prenatal cognitive-behavioral stress management intervention on salivary cortisol levels in low-income mothers and their infants

Recent findings suggest that elevated stress levels during the pre- and postpartum period are related to poor maternal and infant health outcomes; yet, few studies have prospectively examined the efficacy of stress management interventions on regulating stress levels among mothers and their infants. The current study examined whether a prenatal cognitive behavioral stress management (CBSM) intervention would be effective in regulating salivary cortisol (a biological marker of stress) and self-reported stress levels among mothers and their infants at six and 18 months postpartum, relative to two control groups. Our sample was comprised of predominantly Spanish-speaking, low-income women (80%; mean age=25±5 years) who were screened for depression during their second trimester of pregnancy (M=16±5 weeks of gestation). Women at high risk for depression [i.e., having either a past history of major depression or current elevated symptoms of depression (≥16 on CES-D)] were randomized to either a CBSM group (n=24) or a usual care (UC) group (n=33), while a low risk comparison (LRC) group (n=29) was comprised of women not meeting either depression criteria. ANCOVA analyses demonstrated that: (1) infants of women in the CBSM and LRC groups had significantly lower cortisol levels than infants of women in the UC group at six months postpartum (p<.001); and (2) women in the CBSM group had lower cortisol levels than women in the UC group at 18 months postpartum (p<.01). These results suggest that prenatal CBSM interventions may be efficacious in regulating biological markers of stress among mothers and their infants, thereby decreasing their risk for developing health complications over time.

Depressed mood in pregnancy: prevalence and correlates in two Cape Town peri-urban settlements

BACKGROUND

The disability associated with depression and its impact on maternal and child health has important implications for public health policy. While the prevalence of postnatal depression is high, there are no prevalence data on antenatal depression in South Africa. The purpose of this study was to determine the prevalence and correlates of depressed mood in pregnancy in Cape Town peri-urban settlements.

METHODS

This study reports on baseline data collected from the Philani Mentor Mothers Project (PMMP), a community-based, cluster-randomized controlled trial on the outskirts of Cape Town, South Africa. The PMMP aims to evaluate the effectiveness of a home-based intervention for preventing and managing illnesses related to HIV, TB, alcohol use and malnutrition in pregnant mothers and their infants. Participants were 1062 pregnant women from Khayelitsha and Mfuleni, Cape Town. Measures included the Edinburgh Postnatal Depression Scale (EPDS), the Derived AUDIT-C, indices for social support with regards to partner and parents, and questions concerning socio-demographics, intimate partner violence, and the current pregnancy. Data were analysed using bivariate analyses followed by logistic regression.

RESULTS

Depressed mood in pregnancy was reported by 39% of mothers. The strongest predictors of depressed mood were lack of partner support, intimate partner violence, having a household income below R2000 per month, and younger age.

CONCLUSIONS

The high prevalence of depressed mood in pregnancy necessitates early screening and intervention in primary health care and antenatal settings for depression. The effectiveness and scalability of community-based interventions for maternal depression must be developed for pregnant women in peri-urban settlements.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00972699.

Psychological science on pregnancy: stress processes, biopsychosocial models, and emerging research issues

Psychological science on pregnancy is advancing rapidly. A major focus concerns stress processes in pregnancy and effects on preterm birth and low birth weight. The current evidence points to pregnancy anxiety as a key risk factor in the etiology of preterm birth, and chronic stress and depression in the etiology of low birth weight. Key mediating processes to which these effects are attributed, that is neuroendocrine, inflammatory, and behavioral mechanisms, are examined briefly and research on coping with stress in pregnancy is examined. Evidence regarding social support and birth weight is also reviewed with attention to research gaps regarding mechanisms, partner relationships, and cultural influences. The neurodevelopmental consequences of prenatal stress are highlighted, and resilience resources among pregnant women are conceptualized. Finally, a multilevel theoretical approach for the study of pregnancy anxiety and preterm birth is presented to stimulate future research.

Postpartum depressive symptoms and the combined load of paid and unpaid work: a longitudinal analysis

PURPOSE

To investigate the effects of total workload and other work-related factors on postpartum depression in the first 6 months after childbirth, utilizing a hybrid model of health and workforce participation.

METHODS

We utilized data from the Maternal Postpartum Health Study collected in 2001 from a prospective cohort of 817 employed women who delivered in three community hospitals in Minnesota. Interviewers collected data at enrollment and 5 weeks, 11 weeks, and 6 months after childbirth. The Edinburgh Postnatal Depression Scale measured postpartum depression. Independent variables included total workload (paid and unpaid work), job flexibility, supervisor and coworker support, available social support, job satisfaction, infant sleep problems, infant irritable temperament, and breastfeeding.

RESULTS

Total average daily workload increased from 14.4 h (6.8 h of paid work; 7.1% working at 5 weeks postpartum) to 15.0 h (7.9 h of paid work; 87% working at 6 months postpartum) over the 6 months. Fixed effects regression analyses showed worse depression scores were associated with higher total workload, lower job flexibility, lower social support, an infant with sleep problems, and breastfeeding.

CONCLUSIONS

Working mothers of reproductive years may find the study results valuable as they consider merging their work and parenting roles after childbirth. Future studies should examine the specific mechanisms through which total workload affects postpartum depressive symptoms.

Risks and Protective Factors Associated With Symptoms of Depression in Low-Income African American and Caucasian Women During Pregnancy

This article describes the risks and protective factors for symptoms of depression in pregnancy among low-income African American and Caucasian women. Data were collected from 130 women who were between 16 and 28 weeks' gestation and enrolled in an urban prenatal clinic. The questionnaires used in the face-to-face interviews consisted of sociodemographic items, the Beck Depression Inventory (BDI-II), the Prenatal Psychosocial Profile (PPP), 3 items from the Jarel Spiritual Well-Being Scale, the Spiritual Perspective Scale, and 4 items on health risk behaviors. Twenty-seven percent of the women reported depressive symptoms at levels indicating risk for clinical depression. However, there were no significant differences between African American and Caucasian women. Sociodemographic factors accounted for 13% of the variance (P < .01) in BDI-II scores. Psychosocial and behavioral risk factors accounted for an additional 19% of the BDI-II variance (P < .001), and psychosocial and spiritual resources accounted for 7% of the variance (P < .001), resulting in these variables accounting for 54% of the total variance in BDI-II scores. Higher levels of stress, lower levels of self-esteem and social support, and higher religiosity had a significant relationship with more symptoms of depression. This supports the need to routinely screen for and to assess factors associated with depressive symptoms in pregnant low-income women.

Social stressors associated with antepartum depressive symptoms in low-income African American women

OBJECTIVES

To describe depressive symptomatology and examine the relationship between social stressors and depressive symptoms in pregnant African American women.

DESIGN AND SAMPLE

Cross-sectional study of 119 women receiving care at 2 prenatal clinics in Northern California.

MEASURES

Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D). Social stress variables included discrimination, trauma exposure, social conflict, and economic stress.

RESULTS

In this sample, mean CES-D score was 15.88. Forty-two percent of the women had CES-D scores ≥ 16 (possible risk), and 23% had CES-D scores ≥ 23 (probable risk). There were significantly positive relationships between the social stress variables (discrimination, trauma exposure, social conflict, economic stress) and CES-D scores. Stepwise multiple regression analysis indicated that together discrimination and social conflict accounted for 36% of the variance in antepartum depressive symptoms.

CONCLUSIONS

Discrimination and social conflict are considerable sources of stress that contribute to levels of antepartum depressive symptoms in African American women. While the results reinforce the importance of universal prenatal screening, comprehensive strategies are also needed to help ameliorate the impact that social stressors such as discrimination and social conflict have on the mental health of pregnant African American women.

Depression during pregnancy: prevalence and risk factors among women attending a public health clinic in Rio de Janeiro, Brazil

Depression is the most prevalent psychiatric disorder during pregnancy and is associated with psychosocial and clinical obstetric factors. Despite being an important public health issue, there are few studies about this issue in Brazil. A cross-sectional study was carried out, involving 331 pregnant women attending a public primary health service over a one-year period in Rio de Janeiro city, Brazil. Participants were interviewed about their socio-demographic status, obstetric/medical conditions, life events and violence during pregnancy. Depression was assessed using the Composite International Development Interview. The prevalence of depression during pregnancy was 14.2% (95%CI: 10.7-18.5) and associated factors included: previous history of depression and any psychiatric treatment, unplanned pregnancy, serious physical illness and casual jobs. These data emphasize the need for screening for depression and its risk factors during pregnancy in settings where care is available. Psychosocial interventions and social policies need to be devised for this population.

The prevalence and determinants of antepartum mental health problems among women in the USA: a nationally representative population-based study

Mental health problems disproportionately affect women, particularly during childbearing years. We sought to estimate the prevalence of antepartum mental health problems and determine potential risk factors in a representative USA population. We examined data on 3,051 pregnant women from 11 panels of the 1996-2006 Medical Expenditure Panel Survey. Poor antepartum mental health was defined by self report of mental health conditions or symptoms or a mental health rating of "fair" or "poor." Multivariate regression analyses modeled the odds of poor antepartum mental health; 7.8% of women reported poor antepartum mental health. A history of mental health problems increased the odds of poor antepartum mental health by a factor of 8.45 (95% CI, 6.01-11.88). Multivariate analyses were stratified by history of mental health problems. Significant factors among both groups included never being married and self-reported fair/poor health status. This study identifies key risk factors associated with antepartum mental health problems in a nationally representative sample of pregnant women. Women with low social support, in poor health, or with a history of poor mental health are at an increased risk of having antepartum mental health problems. Understanding these risk factors is critical to improve the long-term health of women and their children.

The association between prenatal depression and obstetric outcome in Taiwan: a prospective study

BACKGROUND AND METHODS

The present follow-up study aims to assess the association between depressive symptomatology during the second or third trimester of pregnancy and obstetric-neonatal outcomes in Taiwan. Follow-up evaluations of delivery and birth records in the immediate postpartum period were carried out on 265 nondepressed, 107 mildly to moderately depressed, and 59 severely depressed women and their newborns in three hospitals in Southern Taiwan. Prenatal depression was identified using the Edinburgh Perinatal Depression Scale (EPDS). The medical records of the participant women and their newborns were reviewed after delivery.

RESULTS

Prenatally depressed women reported significantly lower marital satisfaction than nondepressed women. Follow-up examination of the women's obstetric birth records revealed that prenatal depression had no statistically significant association with obstetric outcome (type of delivery, use of epidural anesthesia, or instrument-assisted delivery), nor did depression influence the neonatal outcome (incidence of prematurity, birth weight, and Apgar score).

CONCLUSIONS

Prenatal depression does not lead to unfavorable obstetric outcomes. However, the finding between marital satisfaction and prenatal depression may have implications in terms of social support.

Mother's anxiety and depression and associated risk factors during early pregnancy: effects on fetal growth and activity at 20-22 weeks of gestation

To examine effects of mother's anxiety and depression and associated risk factors during early pregnancy on fetal growth and activity. Repeated measures of mother's anxiety (State-Anxiety Inventory (STAI-S)) and depression (Edinburgh Postnatal Depression Scale (EPDS)) and related socio demographics and substance consumption were obtained at the 1st and 2nd pregnancy trimesters, and fetus' (N = 147) biometric data and behavior was recorded during ultrasound examination at 20-22 weeks of gestation. Higher anxiety symptoms were associated to both lower fetal growth and higher fetal activity. While lower education, primiparity, adolescent motherhood, and tobacco consumption predicted lower fetal growth, coffee intake predicted lower fetal activity. Vulnerability of fetal development to mother's psychological symptoms as well as to other sociodemographic and substance consumption risk factors during early and mid pregnancy is suggested.

Pre- and postnatal psychological wellbeing in Africa: a systematic review

BACKGROUND

Perinatal mental health disorders are recognised as an important public health issue in low-income countries as well as in developed countries. This paper reviews evidence on the prevalence and risk factors of maternal mental health disorders in African women living in Africa.

METHODS

A systematic review of the literature was conducted. Studies were mainly located through computerised databases, and additionally through hand searching references of identified articles and reviews. Thirty-five studies, with a total of 10,880 participants, were identified that reported prevalence rates of maternal psychological health in eight African countries.

RESULTS

Depression was the most commonly assessed disorder with a weighted mean prevalence of 11.3% (95% CI 9.5%-13.1%) during pregnancy and 18.3% (95% CI 17.6%-19.1%) after birth. Only a small number of studies assessed other psychological disorders. Prevalence rates of pre- and postnatal anxiety were 14.8% (95% CI 12.3%-17.4%) and 14.0% (95% CI 12.9%-15.2%), respectively; and one study reported the prevalence of PTSD as 5.9% (95% CI 4.4%-7.4%) following childbirth. Lack of support and marital/family conflict were associated with poorer mental health. Evidence relating sociodemographic and obstetric variables to mental health was inconclusive.

LIMITATIONS

Most studies included in this review were cross-sectional and measures of mental health varied considerably.

CONCLUSIONS

This paper demonstrates that maternal mental health disorders are prevalent in African women, and highlights the importance of maternal mental health care being integrated into future maternal and infant health policies in African countries.

The influence of prior perinatal loss on parents' psychological distress after the birth of a subsequent healthy infant

OBJECTIVE

To evaluate the long-term influence of a previous perinatal loss on parents' psychological distress during a subsequent childbearing experience.

DESIGN AND SAMPLE

A cohort design was used to examine 36 couples with a history of prior perinatal loss. Data were collected during the third trimester of pregnancy, 3 months postpartum, and again 8 months after birth.

MEASURES

Outcome measures included posttraumatic stress (The Impact of Event Scale), depressive symptoms (Center for Epidemiologic Studies-Depression Scale), anxiety (Spielberger State-Trait Anxiety Inventory), and parental concerns and attitudes (Maternal/Paternal Attitudes Questionnaire).

RESULTS

Levels of depressive symptoms (p<.001), anxiety (p<.001), and posttraumatic stress (p=.046) significantly decreased over time in this population. However, levels of posttraumatic stress remained in the moderate range even at 8 months after birth. Depression was significantly correlated with posttraumatic stress at each time point. In addition, depression was significantly related to posttraumatic stress, anxiety, and concerns parents had about their infant's well-being at T3.

CONCLUSION

While levels of anxiety and depressive symptoms decreased for parents who have experienced a previous perinatal loss, posttraumatic stress levels remained moderately high. It is unclear how this compares to parents without losses. These may be the unique symptoms and concerns these parents have about their new infant. Parents with a history of prior loss should have assessments carefully tailored to their experiences to anticipate continued psychological distress.

Predictors of maternal depression in the first year postpartum: marital status and mediating role of relationship quality

Existing literature has documented the associations between marital status and maternal depression within the first year postpartum. Using data that is representative of urban non-marital births in the United States with a large over-sample of non-marital births, we investigate the association of maternal depression with not only marital status but also relationship quality with the father of the baby. Quality is independently associated with maternal depression after controlling for marital status and other variables that have been documented as risk factors for maternal depression. In addition, relationship quality explains away the associations between marital status and maternal depression. After controlling for relationship quality, single women were no more likely to be depressed compared to married or cohabiting women.

Risk factors for depressive symptoms during pregnancy: a systematic review

The purpose of this study was to evaluate risk factors for antepartum depressive symptoms that can be assessed in routine obstetric care. We evaluated articles in the English-language literature from 1980 through 2008. Studies were selected if they evaluated the association between antepartum depressive symptoms and > or =1 risk factors. For each risk factor, 2 blinded, independent reviewers evaluated the overall trend of evidence. In total, 57 studies met eligibility criteria. Maternal anxiety, life stress, history of depression, lack of social support, unintended pregnancy, Medicaid insurance, domestic violence, lower income, lower education, smoking, single status, and poor relationship quality were associated with a greater likelihood of antepartum depressive symptoms in bivariate analyses. Life stress, lack of social support, and domestic violence continued to demonstrate a significant association in multivariate analyses. Our results demonstrate several correlates that are consistently related to an increased risk of depressive symptoms during pregnancy.

Recurrence of depression during pregnancy: psychosocial and personal functioning correlates

BACKGROUND

This study examined psychosocial and personal functioning during pregnancy in women at risk for depression recurrence based on having had at least one major depressive episode (MDE) preceding the pregnancy.

METHODS

Three groups of women, who differed in recurrence of depression during pregnancy, were compared: (1) women who had at least one recurrent episode meeting diagnostic criteria for a MDE (n=23), (2) women who had a recurrence of clinically significant levels of depressive symptoms but did not meet criteria for a MDE (n=18), and (3) women who had no recurrence of depression (n=38) during pregnancy.

RESULTS

Results indicated that recurrences of depression during pregnancy are associated with a range of psychosocial and personal functioning correlates. Furthermore, the correlates of depression during pregnancy were the same for women who met diagnostic criteria for MDE and women who had subthreshold levels of depression.

CONCLUSIONS

The findings support extending psychosocial models of depression to depression recurrence during pregnancy with an emphasis on the broader context within which depression occurs. The findings also have implications for understanding subclinical depression during pregnancy as being associated with problems in functioning equal in severity and breadth to episodes of major depression.

Major and minor depression in pregnancy

OBJECTIVE

To evaluate the time to onset, duration, and risk factors for major and minor depression in pregnant women attending the Centers for Prenatal Care.

METHODS

The presence of depressive symptoms and their severity were evaluated at monthly intervals in 154 pregnant women, using the Primary Care Evaluation of Mental Disorders and the Hospital Anxiety and Depression Scale. Comparisons between women with major and minor depression and nondepressed women were performed using the one-way analysis of variance with Bonferroni post-hoc analysis for continuous variables and with Fisher exact test for categorical variables.

RESULTS

Major depression was diagnosed in 19 women (12.3%) and minor depression in 28 (18.1%), whereas the remaining 107 did not show any depressive symptoms. Depression was later in onset and had a longer duration in women with major depression (mean+/-standard deviation 5.6+/-2.8 months and 2.3+/-1.7 months, respectively) than in women with minor depression (3.5+/-2.2 months and 1.6+/-0.7, respectively; P=.007 and P=.04). The risk of developing major depression was predicted at the beginning of pregnancy by the presence of previous depressive episodes (odds ratio [OR] 9.5, 95% confidence interval [CI] 2.5-29.2) and conflicts with husband/partner (OR 7.8, 95% CI 1.02-62.7), whereas the risk of developing minor depression was predicted by being a housewife (OR 7.2, 95% CI 2.3-22.1), presence of previous depressive episodes (OR 4.7, 95% CI 1.4-15.3) and whether the pregnancy was unwanted (OR 2.4, 95% CI 1.0-5.7).

CONCLUSION

Our study confirms that major and minor depression frequently affect pregnant women, particularly those with a history of depression, and they have different risk factors and onset and duration times. In most women, these disorders are present in a mild form (short duration and mild severity).

LEVEL OF EVIDENCE

III.

Depressive symptomatology in pregnant and postpartum women. An exploratory study of the role of maternal antenatal orientations

Little is known about how an expecting woman's view of pregnancy, the child, and motherhood relates to antenatal and postpartum depressive symptomatology. In this study, we investigated the influence of the maternal orientations, as described by Raphael-Leff (Psychological processes of childbearing. The Anna Freud Centre, London, 2005), on the prevalence of depressive symptoms in pregnant and postpartum women. Four hundred three pregnant women participated in a longitudinal study and completed the EPDS and the HADS-D in each pregnancy trimester and between 8 to 12 and 20 to 25 weeks postpartum. In addition, measures of maternal orientation (PPQ), personality (NEO-FFI), coping styles (UCL), adult attachment (RQ), and parental bonding (PBI) were completed antenatally. Bivariate and multivariate analyses revealed that Neuroticism and the Regulator orientation are positively associated with the EPDS and HADS-D in both pregnant and postpartum women. These associations decreased in strength but remained significant after controlling for previous responses on the EPDS and HADS-D. Small negative associations were found between the Facilitator orientation and the HADS-D scores during pregnancy and the early postpartum period. However, this association did not hold its statistical significance within the hierarchical multiple regression models. The maternal orientations have a small but significant and independent contribution in the variance of depressive symptomatology in pregnant and postpartum women.

The association of depressive, anxiety, and stress symptoms and postpartum relapse to smoking: a longitudinal study

INTRODUCTION

The aim of this prospective repeated measures, mixed-methods observational study was to assess whether depressive, anxiety, and stress symptoms are associated with postpartum relapse to smoking.

METHODS

A total of 65 women who smoked prior to pregnancy and had not smoked during the last month of pregnancy were recruited at delivery and followed for 24 weeks. Surveys administered at baseline and at 2, 6, 12, and 24 weeks postpartum assessed smoking status and symptoms of depression (Beck Depression Inventory [BDI]), anxiety (Beck Anxiety Inventory [BAI]), and stress (Perceived Stress Scale [PSS]). In-depth interviews were conducted with women who reported smoking.

RESULTS

Although 92% of the participants reported a strong desire to stay quit, 47% resumed smoking by 24 weeks postpartum. Baseline factors associated with smoking at 24 weeks were having had a prior delivery, not being happy about the pregnancy, undergoing counseling for depression or anxiety during pregnancy, and ever having struggled with depression (p < .05). In a repeated measures regression model, the slope of BDI scores from baseline to the 12-week follow-up differed between nonsmokers and smokers (-0.12 vs. +0.11 units/week, p = .03). The slope of PSS scores also differed between nonsmokers and smokers (-0.05 vs. +0.08 units/week, p = .04). In qualitative interviews, most women who relapsed attributed their relapse and continued smoking to negative emotions.

DISCUSSION

Among women who quit smoking during pregnancy, a worsening of depressive and stress symptoms over 12 weeks postpartum was associated with an increased risk of smoking by 24 weeks.

Evaluation of a social support measure that may indicate risk of depression during pregnancy

BACKGROUND

Strong social support has been linked with positive mental health and better birth outcomes for pregnant women. Our aim was to replicate the psychometric properties of the Kendler Social Support Interview modified for use in pregnant women and to establish the inventory's relationship to depression in pregnancy.

METHODS

The modified Kendler Social Support Interview (MKSSI) was evaluated using principal components analysis. The association with depression was used as an indicator of external validity and was assessed by logistic regression.

RESULTS

Data from 783 subjects were analyzed. One large principal component, termed "global support," (eigenvalue=6.086) represented 22.5% of the total variance. However, 6 of the 27 items (frequency of contact with spouse, siblings, other relatives, and friends, and attendance at church and clubs) had low levels of association (<0.4) and thus were excluded from suggested items for a total score. Varimax rotation of the remaining 21 items resulted in subscales that fell into expected groupings: mother, father, siblings, friends, etc. One unit and two unit increases in the global support score were associated with 58.3% (OR=0.417, 95% CI=0.284-0.612) and 82.6% (OR=0.174, 95% CI=0.081-0.374) reductions in odds for depression, respectively.

LIMITATIONS

The ability of this social support scale to predict future depression in pregnancy has not yet been established due to cross-sectional design.

CONCLUSION

The MKSSI is reliable and valid for use in evaluating social support and its relationship to depression in pregnant women.

The experiences of prenatal depression among Taiwanese women

AIM

This paper is a report of a study to describe Taiwanese women's experiences of prenatal depression.

BACKGROUND

Despite its long-term adverse effects for both mother and child, prenatal depression has received less scholarly attention than postpartum depression. Studies to date have proposed structured measures for quantifying prenatal depression, but the characteristics of this phenomenon have not been qualitatively analysed.

METHOD

A convenience sample of 12 Taiwanese pregnant women scoring above 15 on the Edinburgh Perinatal Depression Scale participated in in-depth interviews during 2005. The interviews were transcribed verbatim and analysed using content analysis.

FINDINGS

Unbalanced commitment to motherhood was the primary theme of the life experiences of prenatal depression in these Taiwanese women, which summarized their feelings of engagement and ambivalence towards their experiences of transition to motherhood. Five recurring sub-themes were identified: multiple conflicting roles, lack of social support, dissatisfaction with body image, future uncertainty and emotional instability.

CONCLUSION

Prenatal depression is a painful growth experience represented by silent and unbalanced commitment during the maternal role transition. Our findings may help healthcare professionals to understand the vulnerable experiences of pregnant women and devise preventive intervention strategies, such as prenatal education for both parents and comprehensive screening for prenatal depression in at-risk pregnant women, so that they are better prepared for the transition to motherhood.

Prenatal multivitamins containing folic acid do not decrease prevalence of depression among pregnant women

Several studies have reported an association between depression and folic acid deficiency. We investigated whether intake of prenatal multivitamins containing folic acid (MVandFA) was associated with decreased rates of depression among pregnant women. A questionnaire was given to 1,314 low-risk pregnant women. Of them, 1,277 (97.2%) women completed the questionnaire. The overall prevalence of depression was 8.1%. Of 652 participants who did not take MVandFA, 9.4% had depression, whereas 6.9% of 624 women who had MVandFA had depression (p = 0.11). In a multivariate logistic regression analysis, family history of depression (adjusted OR 3.7; 95% CI 1.9-7.3) and premenstrual syndrome (adjusted OR 3.0, 95% CI 1.8-4.8) were identified as risk factors for depression during pregnancy. In conclusion, intake of MVandFA was not associated with lower rates of depression during pregnancy whereas family history of depression and personal history of premenstrual syndrome were significant risk factors.

A qualitative study of mild to moderate psychological distress during pregnancy

BACKGROUND

Psychological distress is common in the antenatal period. In England, psychological distress is classified as mild, moderate or severe but only those who suffer severe psychological distress are referred to the specialist mental health services. Those who suffer mild to moderate psychological distress are managed by the primary care services. However, little is know about the psychosocial experiences of pregnant women who suffer from mild-moderate psychological distress.

OBJECTIVE

This study explored the experiences of pregnant women who self-reported mild to moderate psychological distress during antenatal care.

DESIGN

A qualitative study. Data were collected using digitally recorded, face-to-face, semi-structured interviews. Data were analysed using framework analysis.

SETTING

A large teaching maternity hospital in North West England.

PARTICIPANTS

Twenty-four pregnant women who self-reported mild to moderate psychological distress to their midwife during routine antenatal care.

RESULTS

Three main themes emerged: the causes of, impact of, and ways of controlling self-reported mild to moderate psychological distress. A range of experiences caused psychological distress including past life and childbearing experiences, and current pregnancy concerns. Mild to moderate psychological distress took over the lives of these pregnant women. The strategies used to control mild to moderate psychological distress included both positive and negative coping elements.

CONCLUSIONS

Psychological distress that is categorised as mild to moderate can be extremely debilitating for pregnant women. Identification of these women in clinical practice is crucial so that effective interventions can be targeted appropriately. Screening criteria that has the efficacy to identify depression and anxiety is needed. We recommend that a multidisciplinary approach to the management of care is developed to address the range of experiences that pregnant women who suffer mild to moderate prenatal psychological distress may have.

Anxiety symptoms during late pregnancy and early parenthood following assisted reproductive technology

OBJECTIVE

To evaluate the relationship between assisted reproduction technology (ART) and anxiety symptoms during late pregnancy and early parenthood.

METHOD

Women with ART pregnancies were prospectively compared to their partners and to women with spontaneous pregnancies. The sample of 87 subjects, 48 ART (25 mothers and 23 fathers) and 39 non-ART mothers were given the ASQ-IPAT Anxiety Scale at 30-32 weeks of gestation, and at one week and three months after delivery.

RESULTS

The main socio-demographic and obstetrical characteristics were similar between groups. ART women showed higher scores for latent anxiety than non-ART women at three months after birth and showed no difference from ART men in all assessments. Manifest anxiety scores in ART women were higher, compared to non-ART women during the third trimester of pregnancy and one week after birth and were higher in all assessments when compared to ART men. Overall level of anxiety was higher in ART women in all assessments when compared to non-ART women and higher than in ART men during the two postnatal assessments.

CONCLUSION

We confirm the higher level of anxiety that characterizes the pregnancy-birth process in ART pregnancies. In addition, the higher manifest anxiety present before delivery and one week post-partum can be explained by the special nature of these pregnancies. Psychological support should be offered to ART patients because anxiety is an important risk factor for maternal post-partum depression and can lead to negative effects on the neonate and on child emotional and behavioral development.

Maternal depression and neurobehavior in newborns prenatally exposed to methamphetamine

BACKGROUND

The effects of maternal depression on neonatal neurodevelopment in MA exposed neonates have not been well characterized.

OBJECTIVE

To determine the neurobehavioral effects of maternal depressive symptoms on neonates exposed and not exposed to methamphetamine (MA) using the NICU Network Neurobehavioral Scale (NNNS).

DESIGN

The purpose of the IDEAL study is to determine the effects of prenatal MA exposure on child outcome. IDEAL screened 13,808 subjects, 1632 were eligible and consented and 176 mothers were enrolled. Only biological mothers with custody of their child at the one-month visit (n=50 MA; n=86 comparison) had the Addiction Severity Index (ASI) administered. The NNNS was administered to the neonate by an examiner blinded to MA exposure within the first five days of life. General Linear Models tested the effects of maternal depression and prenatal MA exposure on NNNS outcomes, with and without covariates. Significance was accepted at p<.05.

RESULTS

After adjusting for covariates, regardless of exposure status, maternal depressive symptoms were associated with lower handling and arousal scores, elevated physiological stress scores and an increased incidence of hypotonicity. When adjusting for covariates, MA exposure was associated with lower arousal and higher lethargy scores.

CONCLUSIONS

Maternal depressive symptoms are associated with neurodevelopmental patterns of decreased arousal and increased stress. Prenatal MA exposure combined with maternal depression was not associated with any additional neonatal neurodevelopmental differences.

A depression preventive intervention for rural low-income African-American pregnant women at risk for postpartum depression

Postpartum depression (PPD) is a major health problem for many women, including rural low-income African-American women. Researchers have documented the long lasting consequences of PPD. The purpose of this pilot study was to examine the initial acceptability, feasibility, and effectiveness of the ROSE Program, a brief, interpersonally-based intervention in a group of low-income, rural African-American pregnant women at risk for PPD. Participants were 36 African-American pregnant women at risk for PPD who attended a rural hospital-affiliated prenatal clinic. Participants were randomly assigned to the ROSE Program or to treatment as usual (TAU). Outcomes included measures of depressive symptoms, postpartum adjustment, and parental stress at 3 months postpartum. At 3 months postpartum, the study found no significant differences between the two conditions in degree of depressive symptoms or level of parental stress. The women in the intervention condition reported significantly better postpartum adjustment at 3 months postpartum than women in the TAU group. Those in the ROSE Program reported improvement in depressive symptoms over time, whereas women in the TAU group did not evidence such changes. These results provide initial effectiveness for the ROSE Program in improving postpartum functioning in a group of low-income, rural African-American pregnant women.

Discrimination and symptoms of depression in pregnancy among African American and White women

PURPOSE

Depressive symptomatology during pregnancy has been associated with negative health outcomes for both the mother and child. This study examines the potential associations between depression and depressive symptoms in poor women and African-American women and their lifelong experiences of discrimination.

METHODS

Data from 2,731 African-American and White participants in the Pregnancy Outcomes and Community Health Study were analyzed. Multiple regression analyses were used to investigate relations between depressive symptoms and total discrimination, and between depressive symptoms and 3 discrimination types (gender, race, and socioeconomic).

MAIN FINDINGS

Initial results showed that African-American women had higher levels of depressive symptoms than White women. Self-reported total discrimination and discrimination types were each positively associated with depressive symptomatology in all women. After adjusting for sociodemographic characteristics (maternal age, education, employment status, partner status, and Medicaid status) and examining significant interactions, the race difference in depressive symptomatology was evident only in employed women. The addition of total discrimination to the multicovariate model eliminated race differences in the adjusted mean level of depressive symptoms. When the 3 discrimination types were modeled simultaneously with all other covariates, only gender and economic discrimination remained positively associated with depressive symptoms in African-American and White women.

CONCLUSIONS

These results should be cautiously interpreted because of 1) the study design--namely, ascertainment of maternal discrimination and depressive symptoms at a single time point; and 2) limitations of the discrimination measure. Despite these limitations, the study points to potential links between lifetime discrimination and depressive symptoms in pregnancy.

Interventions (other than pharmacological, psychosocial or psychological) for treating antenatal depression

BACKGROUND

Although pregnancy was once thought of as a time of emotional well-being for many women, conferring 'protection' against psychiatric disorders, a recent meta-analysis of 21 studies suggests the mean prevalence rate for depression across the antenatal period is 10.7%, ranging from 7.4% in the first trimester to a high of 12.8% in the second trimester. Due to maternal treatment preferences and potential concerns about fetal and infant health outcomes, non-pharmacological treatment options are needed.

OBJECTIVES

To assess the effects, on mothers and their families, of non-pharmacological/psychosocial/psychological interventions compared with usual antepartum care in the treatment of antenatal depression.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2007), the Cochrane Collaboration Depression Anxiety and Neurosis Group's Trials Registers (CCDANCTR-Studies and CCDANCTR-References) (January 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 3), MEDLINE (1966 to January 2007), EMBASE (1980 to January 2007) and CINAHL (1982 to January 2007). We scanned secondary references and contacted experts in the field to identify other published or unpublished trials.

SELECTION CRITERIA

All published, unpublished and ongoing randomised controlled trials of non-pharmacological/psychosocial/psychological interventions to treat antenatal depression.

DATA COLLECTION AND ANALYSIS

All review authors independently participated in the evaluation of methodological quality and data extraction. .

MAIN RESULTS

We included one US three-armed randomised controlled trial in this review, incorporating 61 outpatient antenatal women who met Diagnostic and Statistical Manual for Mental Disorders-IV criteria for major depression. Maternal massage, compared to non-specific acupuncture (control group), did not significantly decrease the number of women diagnosed with clinical depression immediately post-treatment (one trial, n = 38; risk ratio (RR) 0.80, 95% confidence interval (CI) 0.25 to 2.53) or at final assessment at 10 weeks' postpartum (one trial, n = 32; RR 1.93, 95% CI 0.37 to 10.01). Acupuncture specifically treating symptoms of depression, compared to non-specific acupuncture, did not significantly decrease the number of women diagnosed with clinical depression immediately post-treatment (one trial, n = 35; RR 0.48, 95% CI 0.11 to 2.13) or at final assessment at 10 weeks' postpartum (one trial, n = 32; RR 0.64, 95% CI 0.06 to 6.39).

AUTHORS' CONCLUSIONS

The evidence is inconclusive to allow us to make any recommendations for massage therapy or depression-specific acupuncture for the treatment of antenatal depression. The included trial was too small with a non-generalisable sample, to make any recommendations.

The Effect of Exercise During Pregnancy on Maternal Outcomes: Practical Implications for Practice

The American College of Obstetricians and Gynecologists recommends that women with low-risk pregnancies participate in moderate-intensity exercise during their pregnancy. Currently, only 15.1% of pregnant women exercise at the recommended levels, which is significantly lower than the general population's 45%. One potential reason is that exercise during pregnancy is perceived as risky. In this article, the authors provide a critical review of the literature examining the effect of exercise on preeclampsia, gestational diabetes, weight gain, labor and birth, and other issues associated with pregnancy. Overall, the evidence indicates that exercise during pregnancy is safe and perhaps even reduces the risk of preeclampsia and gestational diabetes. The evidence for weight gain and labor and birth (rates of cesarean sections, duration of labor) is mixed. Unfortunately, much of the research examining exercise during pregnancy is observational, and the few randomized controlled trials that do exist are small and inadequately powered. Taken together, given the potential benefits of exercise during pregnancy and the lack of evidence for harmful effects on the mother and newborn, practitioners should encourage their healthy pregnant patients to exercise. Practical guidelines for recommending exercise to pregnant women are presented.

Prediction of postpartum depression by sociodemographic, obstetric and psychological factors: a prospective study

AIM

Many studies have documented serious effects of postpartum depression. This prospective study sought to determine predictive factors for postpartum depression.

METHODS

Pregnant women (n = 239) were enrolled before 24 weeks in their pregnancy. At 6 weeks postpartum, 30 women who had postpartum depression and 30 non-depressed mothers were selected. The Edinburgh Postnatal Depression Scale (EPDS), the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI), the Rosenberg Self-Esteem Scale (RSES) Marital Satisfaction Scale (MSS), and the Childcare Stress Inventory (CSI) were administered to all 60 mothers at 24 weeks pregnancy, 1 week postpartum, and 6 weeks postpartum.

RESULTS

The differences in most of the diverse sociodemographic and obstetric factors assessed were not statistically significant. There were significant differences in MSS scores at 24 weeks pregnancy (P = 0.003), and EPDS (P < 0.001; P = 0.002), BDI (P = 0.001; P = 0.031), and BAI (P < 0.001; P < 0.001) at both 24 weeks pregnant and 1 week postpartum, while there was no significant difference in the RSES scores at 24 weeks pregnant (P = 0.065). A logistic regression analysis was performed on the following factors: 'depressive symptoms immediately after delivery' (EPDS and BDI at 1 week postpartum), 'anxiety' (BAI prepartum), 'stress factors from relationships' (MSS prepartum and CSI at 1 week postpartum) or 'self-esteem' (RSES prepartum). When these four factors were added individually to a model of the prepartum depressive symptoms (EPDS and BDI prepartum), no additional effect was found.

CONCLUSIONS

The optimum psychological predictor is prepartum depression, and other psychological measures appear to bring no significant additional predictive power.

The relationship between women's attachment style and perinatal mood disturbance: implications for screening and treatment

To investigate women's attachment style in relation to risk for pregnancy-specific distress and perinatal depression. During the 2nd trimester, 186 women were evaluated for Axis I psychiatric disorders. In the 3rd trimester they self-reported: attachment style, pregnancy experience, current life stress, and symptoms of depression and anxiety. At 4 months post partum, a sub-sample of them (n = 56) repeated the self-report questionnaires. Wariness of attachments (high on fear dimension) was associated with greater 'hassles' compared to 'uplifts' in the assessment of pregnancy (r = 0.31, p Collapse

Key Words

• perinatal depression
• postpartum depression
• attachment style

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MESH Headings

• Adult
• Anxiety/diagnosis
• Anxiety/psychology
• Depression/diagnosis
• Depression, Postpartum/diagnosis
• Depression, Postpartum/psychology
• Female
• Humans
• Infant, Newborn
• Life Change Events
• Mother-Child Relations
• Mothers/psychology
• Object Attachment
• Perinatal Care/methods
• Pregnancy
• Self Concept
• Surveys and Questionnaires
• Time Factors

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Grants

• K23 MH001928 NIMH NIH HHS
• MH01928 NIMH NIH HHS

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Affiliation(s)

Catherine Monk Behavioral Medicine Program, Department of Psychiatry, College of Physicians and Surgeons, Columbia University Medical Center, New York, NY 10032, USA.
Kristin L Leight
Yixin Fang

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A 6-month study of postpartum depression and related factors in Athens Greece

INTRODUCTION

Postpartum depression (PPD) affects women in various sociocultural environments around the world during a sensitive period of their lives. The purpose of this study was to investigate the prevalence and time course of PPD in a Greek urban environment as well as possible relations of PPD with certain clinical and sociodemographic factors.

METHOD

The study was performed on a sample of 402 women that were recruited from a university obstetric clinic in Athens, Greece, during the first 24 hours after delivery. The women completed the Edinburgh Postnatal Depression Scale through telephone interviews. The telephone interviews were conducted the first week as well as the first, third, and sixth month after delivery. The first day after delivery, all women completed the Montgomery-Asberg Depression Rating Scale, the List of Threatening Experience, the State-Trait Anxiety Inventory, the Whitley Index, the Schalling-Sifneos Personality Scale, and the Maudsley Obsessive-Compulsive Inventory. In addition, the Blues Questionnaire was administered the first 3 days and the seventh day after delivery. Other clinical and sociodemographic data were obtained through questionnaires and personal interviews.

RESULTS

A cutoff point of 12 in the Edinburgh Postnatal Depression Scale was used to define PPD. Eighty (19.8%) of the women in the sample experienced PPD during the first 6 months after delivery. The development of PPD was related significantly to the following factors: stressful events during pregnancy (P = .01), maternity blues on the seventh day after delivery (P = .01), obsessive preoccupation with cleaning (P = .04), and judgment that the baby is crying excessively at the first month interview (P = .02).

CONCLUSION

The women's emotional condition before and after delivery, obsessionality, and difficulties in regulating the infant's emotions appear to contribute to the development of PPD during the first 6 months after delivery.

Risk factors for antenatal depression, postnatal depression and parenting stress

BACKGROUND

Given that the prevalence of antenatal and postnatal depression is high, with estimates around 13%, and the consequences serious, efforts have been made to identify risk factors to assist in prevention, identification and treatment. Most risk factors associated with postnatal depression have been well researched, whereas predictors of antenatal depression have been less researched. Risk factors associated with early parenting stress have not been widely researched, despite the strong link with depression. The aim of this study was to further elucidate which of some previously identified risk factors are most predictive of three outcome measures: antenatal depression, postnatal depression and parenting stress and to examine the relationship between them.

METHODS

Primipara and multiparae women were recruited antenatally from two major hoitals as part of the beyondblue National Postnatal Depression Program 1. In this subsidiary study, 367 women completed an additional large battery of validated questionnaires to identify risk factors in the antenatal period at 26-32 weeks gestation. A subsample of these women (N = 161) also completed questionnaires at 10-12 weeks postnatally. Depression level was measured by the Beck Depression Inventory (BDI).

RESULTS

Regression analyses identified significant risk factors for the three outcome measures. (1). Significant predictors for antenatal depression: low self-esteem, antenatal anxiety, low social support, negative cognitive style, major life events, low income and history of abuse. (2). Significant predictors for postnatal depression: antenatal depression and a history of depression while also controlling for concurrent parenting stress, which was a significant variable. Antenatal depression was identified as a mediator between seven of the risk factors and postnatal depression. (3). Postnatal depression was the only significant predictor for parenting stress and also acted as a mediator for other risk factors.

CONCLUSION

Risk factor profiles for antenatal depression, postnatal depression and parenting stress differ but are interrelated. Antenatal depression was the strongest predictor of postnatal depression, and in turn postnatal depression was the strongest predictor for parenting stress. These results provide clinical direction suggesting that early identification and treatment of perinatal depression is important.

Depressive symptoms and symptoms of post-traumatic stress disorder in women after childbirth

This study examined the course of psychological problems in women from late pregnancy to six months postpartum, the rates of psychiatric, especially depressive and post-traumatic stress symptoms and possible related antecedent variables. During late pregnancy, one to three days postpartum, six weeks and six months postpartum, 47 of the 60 participating women completed a battery of questionnaires including the General Health Questionnaire, the State-Trait Anxiety Inventory, the Edinburgh Postnatal Depression Scale, and the PTSD Symptom Scale. In general, most women recovered from psychiatric and somatic problems over the period of investigation. However, depressive and post-traumatic stress symptoms in particular were not found to decline significantly. Six weeks postpartum, 22% of the women had depressive symptoms, with this figure remaining at 21.3% six months postpartum. In addition, 6% of the women studied reported clinically significant PTSD symptoms at six weeks postpartum with 14.9% reporting such symptoms at six months postpartum. The most important predictor for depressive and post-traumatic stress symptoms was the block variable "anxiety in late pregnancy". Other predictors were the variables "psychiatric symptoms in late pregnancy", "critical life events" and the "experience of delivery". The results of our study show a high prevalence rate of psychiatric symptoms in women after childbirth and suggest, besides the experience of the delivery itself, a vulnerability or predisposing history that makes the development of psychiatric symptoms after childbirth more probable.

A multirisk approach to predicting chronicity of postpartum depression symptoms

BACKGROUND

Persistence of postpartum depression (PPD) carries potential adverse implications for the emerging mother-child relationship and for child development.

METHODS

This study was designed to investigate factors related to the onset and persistence of PPD; in particular, we examined the cumulative effect of a range of psychosocial risk factors in predicting chronic PPD symptoms. One hundred and five women were interviewed at three assessment periods: within the first days after childbirth, at 6 months, and at 18 months postpartum.

RESULTS

Depressive symptoms at 6 months predicted 18 months depressive symptoms, even when controlling for the contribution of maternal depression at birth. Psychosocial risk had a moderating influence on the stability of depressive symptomatology. Women with two or more risk factors at birth were more likely to have stable depressive symptomatology across the infants' first 18 months of life.

CONCLUSION

To prevent a chronic course of PPD it may be necessary to identify both depressive symptoms and relevant psychosocial risk factors.

Depression scores and associated factors in pregnant and non-pregnant women: a community-based study in Turkey

The aims of this study were to evaluate and compare the depression scores of pregnant and non-pregnant women, and to identify the factors associated with depression scores in the two groups. This community-based study was conducted in a primary health care center catchment area in Ankara (population: 17,838) in January 2003. At the beginning of the study, the trimesters of all pregnant women (n = 66) were determined and as a control group (n = 138), two non-pregnant women matched for age and parity characteristics living in the same area were selected for each pregnant woman. Each participant completed a questionnaire and the Beck Depression Inventory (BDI). One-way ANOVA, univariate correlation, and multiple linear regression analyses were used in statistical evaluation. Depression scores of pregnant and non-pregnant women, and women at different trimesters of pregnancy were similar. Using a cut-off score > or = 18 on the BDI, 26.5% of non-pregnant women, 27.3% of pregnant women, 25.0% of pregnant women in their first and second trimester, and 30.0% of third trimester pregnant women were found to be depressive. According to multiple linear regression analysis, age, age at marriage, and the number of people living in the home were associated with depression in both groups. Depression scores were similar in pregnant women and non-pregnant controls. There were different associations between depression score and the study groups' characteristics.

Depression, anxiety and influencing factors in pregnancy: a study in a Turkish population

OBJECTIVES

to determine the prevalence of depression in pregnancy and the factors that influence the development of depression and anxiety in pregnancy in a Turkish population.

DESIGN

a descriptive, correlational study.

SETTING

a public hospital in Ankara Province Centre, Ankara, Turkey.

PARTICIPANTS

1,039 pregnant women selected using a convenience sampling method.

FINDINGS

27.9% (n=290) of the 1,039 women were found to be experiencing depression at a level requiring treatment. In a stepwise multiple linear regression analysis model developed for depression and anxiety, the following were found to be statistically significant factors influencing the experience of both depression and anxiety: perceived social support; recent experience of marital or emotional problems during and before this pregnancy; recent experience of life stress; having a negative self-perception; experience of physical violence; and experience of physical problems during pregnancy. Statistically significant factors influencing depression were marital dissatisfaction, being a housewife, having an unwanted pregnancy, and having a formal marriage. The correlation between total anxiety and depression scores was at a medium level (Pearson correlation=0.592).

KEY CONCLUSIONS

many factors influenced the development of depression and anxiety in pregnancy, and a positive correlation was found between depression and anxiety. Midwives and nurses can evaluate pregnant women for these risk factors, and arrange for additional follow-up. They can also offer preventive care and, when necessary, assist with early diagnosis and treatment to improve the health of mothers and babies.

Depression during pregnancy and the postpartum period in adolescent and adult Portuguese mothers

OBJECTIVE

To study prevalence as well as risk factors for pregnancy and postpartum depression in a sample of adolescent and adult Portuguese mothers.

METHODS

The Edinburgh Postnatal Depression Scale (EPDS) was administered to 108 (54 adult and 54 adolescent) Portuguese women at 24-36 weeks of pregnancy and at 2-3 months postpartum.

RESULTS

Rates for EPDS > 12 are high during the 3(rd) trimester of pregnancy (18.5%) and at 2-3 months postpartum (17.6%), and not significantly different between these two periods; more than 1/4 of the sample (27.8%) had an EPDS > 12 before or after delivery. Adolescent mothers presented more depressive symptoms as well as more EPDS > 12 than adult mothers, both in pregnancy (25.9% versus 11.1%) and at 2-3 months postpartum (25.9% versus 9.3%); moreover, when considering other socio-demographics, adolescent mothers were still at risk for depressive symptoms during pregnancy as well as for postpartum depression. Women depressed in pregnancy, and ones who are under 18 years old and who live with the partner, were at risk for postpartum EPDS > 12.

CONCLUSION

Adolescent mothers seem particularly at risk for depression during pregnancy and the postpartum period, therefore, just like the women who are depressed during pregnancy, they should be better targeted in preventive and intervention measures.