Is difficult childbirth related to postpartum maternal outcomes in the early postpartum period?

Does Perceived Quality of Care Moderate Postpartum Depression? A Secondary Analysis of a Two-Stage Survey

OBJECTIVE

The purpose of this study was to examine if women's perceptions of the quality of hospital care during childbirth moderate their risks for symptoms of postpartum depression (PPD).

METHODS

This cross-sectional secondary analysis analyzed data from the Listening to Mothers III (2013) series surveys with a weighted sample size of 1057 of women surveyed from across the United States. PPD symptoms were defined according the Patient Health Questionnaire-2. Associations between risk factors and PPD symptoms were tested using logistic regressions with the moderating variable of perceived quality of care then added to models with significant risk factors.

RESULTS

Of the 22 potential risk factors for PPD symptoms, 10 were found to be significantly associated with PPD symptoms in this sample of women. Very good perceived quality of care moderated the following risk factors for PPD symptoms in a protective direction: relationship status (p = 0.01), pre-pregnancy BMI (p = 0.02), and pain that interfered with routine activities 2 months postpartum (p = 0.003).

CONCLUSIONS

These findings suggest risk factors for PPD symptoms are moderated by perceived quality of care and therefore, maternity providers can influence women's psychological wellbeing postpartum by providing very good perceived quality of care during the hospital stay for birth. However, these findings should be interpreted cautiously due to a lack of a direct, proven relationship between provider action and women's perceived quality of care.

Economic and Health Predictors of National Postpartum Depression Prevalence: A Systematic Review, Meta-analysis, and Meta-Regression of 291 Studies from 56 Countries

BACKGROUND

Postpartum depression (PPD) poses a major global public health challenge. PPD is the most common complication associated with childbirth and exerts harmful effects on children. Although hundreds of PPD studies have been published, we lack accurate global or national PPD prevalence estimates and have no clear account of why PPD appears to vary so dramatically between nations. Accordingly, we conducted a meta-analysis to estimate the global and national prevalence of PPD and a meta-regression to identify economic, health, social, or policy factors associated with national PPD prevalence.

METHODS

We conducted a systematic review of all papers reporting PPD prevalence using the Edinburgh Postnatal Depression Scale. PPD prevalence and methods were extracted from each study. Random effects meta-analysis was used to estimate global and national PPD prevalence. To test for country level predictors, we drew on data from UNICEF, WHO, and the World Bank. Random effects meta-regression was used to test national predictors of PPD prevalence.

FINDINGS

291 studies of 296284 women from 56 countries were identified. The global pooled prevalence of PPD was 17.7% (95% confidence interval: 16.6-18.8%), with significant heterogeneity across nations (Q = 16,823, p = 0.000, I2 = 98%), ranging from 3% (2-5%) in Singapore to 38% (35-41%) in Chile. Nations with significantly higher rates of income inequality (R2 = 41%), maternal mortality (R2 = 19%), infant mortality (R2 = 16%), or women of childbearing age working ≥40 h a week (R2 = 31%) have higher rates of PPD. Together, these factors explain 73% of the national variation in PPD prevalence.

INTERPRETATION

The global prevalence of PPD is greater than previously thought and varies dramatically by nation. Disparities in wealth inequality and maternal-child-health factors explain much of the national variation in PPD prevalence.

Birthing Failures: Childbirth as a Female Fault Line

In a qualitative study, 119 women completed an online, open-ended survey about their childbirth experiences. In response to the question, "What ways, if any, did you experience failure?," 65% of women identified feelings of failure. Overwhelmingly attributing the failures to themselves, participants reported that they experienced failures of mind, body, action/inaction, representing "what I feel," "who I am," and "what I did or didn't do" and leading some participants to conclude that they were "less of woman," "less of a mother," or ultimately failed the baby. Such perceived failures can be unintentionally perpetuated by a system that neglects to address the complex experiences and interpretations of birthing women. Helping women anticipate and process the psychosocial and emotional aspects of the birth experience may serve as a protective factor against women internalizing perceived failures as their own, and preventing long term consequences of such feelings. The findings of this study highlight the importance of assessing women's personal experiences and interpretations of childbirth during the prenatal phase to address expectations and increase preparedness.

Risk and protective factors for antepartum and postpartum depression: a prospective study

INTRODUCTION

Antepartum risk and protective factors for postpartum depression (PPD; the most common mental disorder after childbirth besides postpartum anxiety), have been frequently investigated in cross-sectional studies, but less often longitudinally. This study examined linear and moderator effects of risk and protective factors for peripartum depression. First, we investigated the predictive power of risk factors (physical problems during pregnancy, pregnancy-related anxiety, stressful life events, dysfunctional self-consciousness (DSC)) and protective factors (resilience, social support) for antepartum depression (APD) and PPD. Second, as DSC plays an important role in major depression, we examined whether the protective factors moderate the association between the risk factors DSC and APD as well as PPD.

METHODS

We conducted a prospective study with three measurement time points: six weeks antepartum (N = 297), as well as six weeks (N = 278) and twelve weeks (N = 266) postpartum. Direct and moderator effects on APD were analyzed using hierarchical regression analysis. Moderated mediation effects were investigated to explore whether the indirect, long-term effect of DSC on PPD six weeks after birth (PPD-6) and PPD twelve weeks after birth (PPD-12) is moderated by resilience.

RESULTS

Predictors for APD were high DSC, high concerns about one's appearance, low resilience and low social support. Resilience buffered (weakened) the impact of DSC on APD and affected PPD-6 and PPD-12 indirectly through APD.

DISCUSSION

The results suggest that PPD-12 is influenced directly and indirectly through PPD-6 by APD, but that this effect depends upon risk and protective factors, especially on the combined effects of resilience and DSC. The key finding of our study is the moderating (i.e. weakening) effect of resilience on the relationship between DSC and depression. Resilience and DSC may be an important issue for depression prevention and treatment programs in the peripartum period.

Perspective of Postpartum Depression Theories: A Narrative Literature Review

Postpartum depression is the most prevalent emotional problem during a women's lifespan. Untreated postpartum depression may lead to several consequences such as child, infant, fetal, and maternal effects. The main purpose of this article is to briefly describe different theoretical perspectives of postpartum depression. A literature search was conducted in Psych Info, PubMed, and Science Direct between 1950 and 2015. Additional articles and book chapters were referenced from these sources. Different theories were suggested for developing postpartum depression. Three theories, namely, biological, psychosocial, and evolutionary were discussed. One theory or combinations of psychosocial, biological, and evolutionary theories were considered for postpartum depression. The most important factor that makes clinicians’ choice of intervention is their theoretical perspectives. Healthcare providers and physicians should help women to make informed choices regarding their treatment based on related theories.

Postpartum Mental Health in First-Time Mothers: A Cohort Study

Background

Post-partum depression (PPD) can produce adverse symptoms that make motherhood one of the most tumultuous events in a female’s life. First-time mothers who have problems adapting themselves to the mother’s role are more vulnerable to PPD.

Objectives

The current study aimed to explore the extent of social support and parental self-efficacy on PPD, this study was conducted among the first-time pregnant women.

Patients and Methods

A prospective cohort study assessed the depressive symptoms and related factors among 838 first-time not depressed pregnant women from third trimester of pregnancy to 12 weeks postpartum who attended primary health centers (Jan to July 2009). The study employed Edinburgh postnatal depression scale, social support appraisals scale, network orientation scale, marital inventory, parental expectation survey and socio-demographic questionnaires. Logistic regression was used for data analysis.

Results

The incidence of depression was 10.7% at three months post-partum. The adjusted odds ratio showed the PPD was associated with perceived social isolation (OR = 1.06; 95% CI = 1.01 - 1.12), lack of marital satisfaction (OR = 0.91; 95% CI = 0.86 - 0.97) and low parental self-efficacy (OR = 0.74; 95% CI = 0.65 - 0.85).

Conclusions

A high incidence of PPD was identified among the first-time mothers which makes PPD one of the major health problems in females. The important effects of perceived social isolation, maternal parental self-efficacy, and marital satisfaction on reducing the risk of PPD should be considered.

Functional status of women with and without severe maternal morbidity: A prospective cohort study

BACKGROUND

Little is known regarding the impact on maternal functional status in women who have survived severe obstetric complications.

OBJECTIVE

To compare the maternal functional status score between women with and without severe morbidity at one month and six months postpartum in Kelantan, Malaysia.

METHODS

A prospective cohort study design was applied at two tertiary referral hospitals over a six-month period. The study population included all postpartum women who gave birth in 2014. Postpartum women with severe maternal morbidity and without severe maternal morbidity were selected as the exposed and non-exposed group, respectively. Functional ability based on the Inventory of Functional Status after Childbirth was used as the main outcome measure. Repeated measure analysis of variance was performed.

RESULTS

A total of 145 and 187 women with and without severe maternal morbidity, respectively, were measured. There were significant differences in Inventory of Functional Status after Childbirth score changes (P<0.001) between women with and without severe maternal morbidity at one month and at six months. Functional ability score of women with severe maternal morbidity was lower at one month postpartum (P=0.001). The most affected domain was infant care (P=0.002).

CONCLUSIONS

Healthcare providers are recommended to assess the short-term functional ability of severe morbid mother in addition to existing routine physical examination. Provision of physical support from spouse and family of the high risk mothers particularly on infant care during their early postpartum period is crucial to optimise health and minimise the negative health outcomes.

Magnitude and risk factors for postpartum symptoms: a literature review

BACKGROUND

The prevalence of postpartum depression worldwide varies from 0.5% to 60.8% in the first 12 months postpartum using self-reported questionnaire. This review aims to update the current magnitude of postpartum depression based on self-reported questionnaire and clinical interview and explore its associated factors in developed and developing countries.

METHODS

A literature search conducted between 2005 and 2014 identified 203 studies, of which 191 used self-reported questionnaire in 42 countries and 21 used structured clinical interview in 15 countries. Nine studies used a combination of self-reported questionnaire and clinical interview.

RESULT

The prevalence of postpartum depression varies from 1.9% to 82.1% in developing countries and from 5.2% to 74.0% in developed countries using self-reported questionnaire. Structured clinical interview shows a much lower prevalence range from 0.1% in Finland to 26.3% in India. Antenatal depression and anxiety, previous psychiatric illness, poor marital relationship, stressful life events, negative attitude towards pregnancy, and lack of social support are significant contributors to postpartum depression.

LIMITATION

All studies are included irrespective of the methodological quality, such as small sample size and their inclusion could affect the generalizability of the results.

CONCLUSION

The current prevalence of postpartum depression is much higher than that previously reported, and similar risk factors are documented. A culturally sensitive cut-off score with adequate psychometric properties of the screening instruments should be available. In future studies, examining the physical, biological, and cultural factors in qualitative studies and in those with adequate methodological qualities is recommended.