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Roy AS, Chaillet N. Relation Between Initiation of Breastfeeding Success and Postpartum Depression. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024:102666. [PMID: 39322032 DOI: 10.1016/j.jogc.2024.102666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 08/23/2024] [Accepted: 09/11/2024] [Indexed: 09/27/2024]
Abstract
OBJECTIVE This study was designed to assess the effect of initiation of breastfeeding success on postpartum depression among women who gave birth in Quebec. METHODS Secondary analysis of the "Quality of Care, Obstetrics Risk Management, and Mode of Delivery" trial (QUARISMA trial), conducted in Quebec from 1 April 2008 to 31 October 2011 to reduce rates of cesarean delivery in Quebec. INCLUSION CRITERIA all women ≥ 18 years old who gave birth at the hospital of a single baby ≥ 37 weeks of gestation. Logistic regression was performed to investigate the impact of initation of breastfeeding success on postpartum depression rates. Outcome was reported using adjusted odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS A total of 151 708 women (21 525 women with unsuccessful initation of breastfeeding and 130 183 women with successful initation of breastfeeding) were selected to participate in this study. We observed a significant association between initation of breastfeeding success and a lower rate of postpartum depression (0.16% vs 0.29%) (OR: 0.57; 95% CI 0.41-0.79, P < 0.001). CONCLUSIONS Initation of breastfeeding success is significantly associated with a lower risk of postpartum depression.
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Affiliation(s)
- Anne-Sophie Roy
- Obstetrics and Gynecology, Faculty of Medicine, Laval University (Qc)
| | - Nils Chaillet
- Obstetrics and Gynecology, Faculty of Medicine, Laval University (Qc).
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Kim CY, Smith NP, Teti DM. Associations Between Breastfeeding, Maternal Emotional Availability, and Infant-Mother Attachment: The Role of Coparenting. J Hum Lact 2024; 40:455-463. [PMID: 38770794 PMCID: PMC11340236 DOI: 10.1177/08903344241247207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/29/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Breastfeeding is a parenting practice that combines close intimate contact with the opportunity to be sensitive and responsive to the infant, and may have direct and indirect relations with infant attachment. However, researchers have produced inconsistent findings, suggesting there may be other mechanisms involved. Coparenting may play a significant role, as it has been consistently associated with mother-infant relationships. RESEARCH AIMS The aims of this study were to examine: (1) whether breastfeeding would be directly associated with infant-mother attachment; (2) whether this association was also indirect, through mothers' quality of caregiving; and (3) whether partners' coparenting support moderates breastfeeding's indirect association with attachment. METHODS This was a prospective, longitudinal study that drew data from a larger NIH-funded study on sleep and family relationships (R01HD052809). Mothers reported on their feeding practices and coparenting relationships. Independent observations were used to assess mothers' emotional availability toward infants. A separate team of observers assessed infant-mother attachment. RESULTS Exclusive breastfeeding during the first 6 months, and longer duration of any breastfeeding across the 1st year, were directly associated with more secure infant-mother attachment. These associations were also indirect, through maternal emotional availability. Coparenting was a significant moderator, such that the influence of longer breastfeeding duration on improved emotional availability, and, in turn, on more secure attachment, was significant only for mothers who perceived coparenting quality to be low. CONCLUSION Findings highlighted the importance of breastfeeding on both the quality of mothering and infant attachment, but also emphasized that coparenting support may be particularly important for mothers who are unable to breastfeed.
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Affiliation(s)
- Christine Youngwon Kim
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA
| | - Nicole P. Smith
- Department of Biobehavioral Health, The Pennsylvania State University, University Park, PA, USA
| | - Douglas M. Teti
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA
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Lok KYW, Choi MSL, Ko RWT, Chau PPH, Lam CCO, Chang YS, Bick D. Effectiveness of a home-based peer support programme for Chinese mothers with low breastfeeding self-efficacy to increase the exclusivity and duration of breastfeeding: study protocol of a randomised control trial. BMJ Open 2024; 14:e081897. [PMID: 39043588 PMCID: PMC11268066 DOI: 10.1136/bmjopen-2023-081897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 07/07/2024] [Indexed: 07/25/2024] Open
Abstract
INTRODUCTION Breastfeeding is associated with many health benefits for both women and their newborns. Exclusive breastfeeding has been recommended for at least 6 months to optimise infant growth, development and health. In addition to standard care, community-based peer support is recommended to help mothers improve breastfeeding. A recent survey reveals that the rate of exclusive breastfeeding at 6 months post partum in Hong Kong is low, and half of all breastfeeding mothers never exclusively breastfeed. Taking into account the local practice for women to stay home during the first month post partum and social isolation during and post-COVID-19 pandemic, a home-based peer support programme with the aid of Zoom or Facetime is proposed. This study aims to evaluate the effectiveness of a home-based breastfeeding peer support programme in improving breastfeeding practices and achieving exclusive breastfeeding rate among women with low breastfeeding self-efficacy. METHODS AND ANALYSIS The study is a two-armed randomised control trial and will include a total of 442 participants. Potential cases will be recruited and screened at four postnatal wards in Hong Kong public hospital. Eligible and consented cases will be randomly allocated into intervention or control groups at a 1:1 ratio. Control group (n=221) will receive standard care, while the intervention group (n=221) will receive home-based peer support as well as standard care. Trained peer counsellors will provide breastfeeding-related support through Zoom or Facetime at 10 days and 1 month post partum. Telephone follow-ups will be conducted at 1 month, 2 months, 3 months and 6 months post partum. Breastfeeding status, mother's breastfeeding self-efficacy and postpartum depression will be assessed and compared between the two arms. ETHICS AND DISSEMINATION The study has been reviewed and approved by the Institutional Review Board of the University of Hong Kong and Hospital Authority Hong Kong West Cluster (UW 20-564). The findings will be updated in trial registries and disseminated in peer-reviewed journals and academic conferences. TRIAL REGISTRATION NUMBER NCT04621266.
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Affiliation(s)
- Kris Yuet Wan Lok
- School of Nursing, University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
| | - Martha Sin Lam Choi
- School of Nursing, University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
| | - Rachel Wai Tung Ko
- School of Nursing, University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
| | - Patsy P H Chau
- School of Nursing, University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
| | - Christine Chi Oi Lam
- Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Hong Kong, Hong Kong
| | - Yan-Shing Chang
- King's College London Florence Nightingale Faculty of Nursing Midwifery & Palliative Care, London, UK
| | - Debra Bick
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
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Dessì A, Pianese G, Mureddu P, Fanos V, Bosco A. From Breastfeeding to Support in Mothers' Feeding Choices: A Key Role in the Prevention of Postpartum Depression? Nutrients 2024; 16:2285. [PMID: 39064728 PMCID: PMC11279849 DOI: 10.3390/nu16142285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 07/09/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
The postpartum period represents a critical phase of profound transition for women. This timeframe encompasses the physical recuperation associated with childbirth, the intricate psychosocial adjustments inherent in assuming the role of motherhood and also important alterations in steroid and peptide hormones. Hence, as women navigate the reconfiguration of relationships and strive to address the diverse needs of their infants and family members, they concurrently grapple with dramatic transformations which are characteristic of the postpartum phase. In fact, relevant prevalence ranges are reported for maternity blues, a mild condition characterized by self-limited and transient depressive symptoms, but also a well-established risk factor for more serious postpartum mood disorders, such as depression (PPD), with an incidence of 10-15%. Unlike in the US, at the European level, there are no concrete recommendations for the routine integration of the assessment of the mother's emotional state by healthcare professionals, with a considerable risk of underdiagnosing or undertreating these conditions. In this regard, there is a growing body of scientific evidence on the important role of breastfeeding in reducing the risk of PPD and also of the importance of mothers' compliance with this practice. Indeed, sucking the baby regulates the circadian rhythm of the HPA axis and, together with the action of prolactin, the stress response is decreased. In addition, other positive consequences of breastfeeding, which are inversely correlated with the onset of PPD, include the regulation of sleep and waking patterns for mother and baby, the improvement of the mother's self-efficacy and her emotional involvement. It should also be considered that the request for support for breastfeeding can often conceal a request for support for motherhood itself and for the mother's emotional well-being. It therefore emerges that the personnel involved in primary pediatric care to provide adequate support in the transition to motherhood must support mothers in their breastfeeding choices, whether breastfeeding or formula feeding, so that each choice is made conscientiously and serenely. Therefore, neonatal feeding assumes a decisive role, since if, on the one hand, it regulates specific neurohormonal pathways that are protective for maternal emotional well-being (breastfeeding), on the other hand, support in mothers' breastfeeding choices, even in the case of formula feeding, means validating their being mothers in the absence of judgement and counteracting any feelings of inadequacy, conditions that are inversely correlated to DPP.
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Affiliation(s)
- Angelica Dessì
- Department of Surgical Sciences, University of Cagliari and Neonatal Intensive Care Unit, AOU Cagliari, 09124 Cagliari, Italy; (G.P.); (P.M.); (V.F.); (A.B.)
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Sharma V, Wood KN. Weaning and depression: a closer look. Arch Womens Ment Health 2024; 27:477-480. [PMID: 38300295 DOI: 10.1007/s00737-024-01432-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/21/2024] [Indexed: 02/02/2024]
Abstract
The association of weaning with depression has long been recognized. However, interest in the study of post-weaning depression has waned over the last few decades partly due to changes in the nosology of perinatal psychiatric disorders. In this paper, we review the relevant literature and conclude that post-weaning depression is a rare but severe complication of breastfeeding cessation. Given that post-weaning depression is an understudied and often undiagnosed clinical condition, research is needed to address this important unmet need.
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Affiliation(s)
- Verinder Sharma
- Department of Psychiatry, Western University, London, ON, Canada.
- Department of Obstetrics & Gynecology, Western University, London, ON, Canada.
- Parkwood Institute Mental Health, St. Joseph's Health Care, 550 Wellington Road, London, ON, N6C 0A7, Canada.
| | - Katelyn N Wood
- Parkwood Institute Mental Health, St. Joseph's Health Care, 550 Wellington Road, London, ON, N6C 0A7, Canada
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Alshowkan A, Shdaifat E. Factors influencing postpartum depression in Saudi women: a cross-sectional descriptive study. WOMEN'S HEALTH NURSING (SEOUL, KOREA) 2024; 30:164-173. [PMID: 38987920 PMCID: PMC11237367 DOI: 10.4069/whn.2024.06.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 06/18/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE This study aimed to investigate the prevalence of postpartum depression (PPD) and stress, as well as factors influencing PPD, among women in Saudi Arabia. METHODS This study employed a cross-sectional online survey and recruited participants during postpartum visits to the Clinic of Gynecology and Obstetrics in Al-Khobar, Saudi Arabia. Data collection was done using Arabic versions of the Edinburgh Postnatal Depression Scale, Perceived Stress Scale, and a sociodemographics and obstetric history questionnaire. Descriptive and inferential analyses were conducted, including multiple linear regression using a stepwise method. RESULTS Data from the 270 participants showed low levels of postpartum depressive symptoms with a mean score of 2.54±4.5 and low levels of perceived stress with a mean score of 2.49±6.2. While 94.4% of the participants reported low levels of stress and PPD, 5.6% reported elevated levels (≥10 for PPD, ≥14 for stress). The stepwise regression analysis showed significant results (p<.001), accounting for 34% of the variance in PPD. The factors significantly influencing PPD included the type of family, stress, number of abortions, disease during pregnancy, and family income. Importantly, perceived stress emerged as a factor influencing PPD. CONCLUSION Although the majority of participants exhibited low levels of PPD, about 1 in 18 showed elevated levels. The identification of significant influencing factors highlights the need for targeted interventions to effectively address mental health concerns in postpartum women.
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Affiliation(s)
- Amira Alshowkan
- Community Nursing Department, College of Nursing, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Emad Shdaifat
- Community Nursing Department, College of Nursing, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Carvalho Hilje C, Bauer NH, Reis D, Kapp C, Ostermann T, Vöhler F, Längler A. The role of breastfeeding and formula feeding regarding depressive symptoms and an impaired mother child bonding. Sci Rep 2024; 14:11417. [PMID: 38763963 PMCID: PMC11102907 DOI: 10.1038/s41598-024-62168-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 05/14/2024] [Indexed: 05/21/2024] Open
Abstract
Associations between depressive symptoms and breastfeeding are well documented. However, evidence is lacking for subdivisions of feeding styles, namely exclusive breastfeeding, exclusive formula feeding and a mixed feeding style (breastfeeding and formula feeding). In addition, studies examining associations between mother-child-bonding and breastfeeding have yielded mixed results. The aim of this study is to provide a more profound understanding of the different feeding styles and their associations with maternal mental health and mother-child-bonding. Data from 307 women were collected longitudinally in person (prenatally) and by telephone (3 months postnatally) using validated self-report measures, and analyzed using correlational analyses, unpaired group comparisons and regression analyses. Our results from a multinomial regression analysis revealed that impaired mother-child-bonding was positively associated with mixed feeding style (p = .003) and depressive symptoms prenatal were positively associated with exclusive formula feeding (p = .013). Further studies could investigate whether information about the underlying reasons we found for mixed feeding, such as insufficient weight gain of the child or the feeling that the child is unsatiated, could help prevent impaired mother-child-bonding. Overall, the results of this study have promising new implications for research and practice, regarding at-risk populations and implications for preventive measures regarding postpartum depression and an impaired mother-child-bonding.
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Affiliation(s)
- Clara Carvalho Hilje
- Department of Pediatrics, Gemeinschaftskrankenhaus Herdecke, Herdecke, Germany
- Professorship for Integrative Pediatrics, Institute for Integrative Medicine, Witten/Herdecke University, Witten, Germany
| | - Nicola H Bauer
- Institute of Midwifery Science, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Daniela Reis
- Department of Pediatrics, Gemeinschaftskrankenhaus Herdecke, Herdecke, Germany.
- Professorship for Integrative Pediatrics, Institute for Integrative Medicine, Witten/Herdecke University, Witten, Germany.
| | - Claudia Kapp
- Department of Psychology and Psychotherapy, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Thomas Ostermann
- Department of Psychology and Psychotherapy, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Franziska Vöhler
- Department of Obstetrics, Gemeinschaftskrankenhaus Herdecke, Herdecke, Germany
| | - Alfred Längler
- Department of Pediatrics, Gemeinschaftskrankenhaus Herdecke, Herdecke, Germany
- Professorship for Integrative Pediatrics, Institute for Integrative Medicine, Witten/Herdecke University, Witten, Germany
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Fang YW, Chen SF, Wang ML, Wang MH. Effects of traditional Chinese medicine-assisted intervention on improving postpartum lactation: A systematic review and meta-analysis. Heliyon 2024; 10:e27154. [PMID: 38524574 PMCID: PMC10957381 DOI: 10.1016/j.heliyon.2024.e27154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 02/23/2024] [Accepted: 02/26/2024] [Indexed: 03/26/2024] Open
Abstract
Importance Breast milk is the safest food for infants and has many psychological and physical benefits for infants and mothers. However, problems encountered during the breastfeeding process can reduce postpartum women's willingness to breastfeed. Lactation and engorgement may be improved through Traditional Chinese Medicine auxiliary therapy. However, the overall efficacy of various Traditional Chinese Medicine auxiliary therapies and the relevant meridians and acupuncture points for treating breast milk deficiency remain unclear. Objective To investigate Traditional Chinese Medicine auxiliary therapy's effectiveness and acupoints for postpartum women who experience problems during the breastfeeding process. Methods Data were sourced from Embase, Web of Science, CINAHL, Cochrane, CNKI, PubMed, and the Airiti Library Central Register of Controlled Trials and Clinical Trials from the database inception to October 2022. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Main outcome measures The primary outcomes were overall efficiency, prolactin level, milk volume, and breast engorgement in postpartum women with lactation deficiency after-assisted therapies and the correlation between meridian points and milk secretion. Results A total of 1,516 studies were initially identified, and 357 articles were assessed. In the final analysis, 20 studies were included, covering various Traditional Chinese Medicine therapies (acupuncture, acupressure, scrapping, moxibustion cupping, etc.) to stimulate relative acupoints without any acupoint stimulation. The overall efficiency (odds ratio [OR] = 14.17, 95% confidence interval [CI] = 6.49 to 30.92), prolactin level (standardized mean difference [SMD] = 0.36, 95% CI = 0.074 to 0.64), improvement of milk volume (SMD = 0.94, 95% CI = 0.59 to 1.29), reduction of engorgement level (OR= 18, 95% CI = 8.34 to 38.82) demonstrated that Traditional Chinese Medicine therapies can effectively improve lactation and breast fullness, thereby helping patients with breast milk deficiency. The most common acupuncture points used to treat agalactia were classified as the Stomach Meridian, Small Intestine Meridian, and Conception Vessel, with the common acupoints CV17: Danzhong, ST18: Rugen, SI1: Shaoze, ST36: Zusanli, and ST16: Yingchuang. Conclusion Adjuvant Traditional Chinese Medicine therapy can improve lactation and breast engorgement, thereby increasing the willingness to breastfeed. Clinical Finding: 1. The best time for Traditional Chinese Medicine acupoint intervention for breast deficiency treatment is within 24 h 2. The most effective acupuncture points for improving milk deficiency and bloating pain are ST18: Rugen, ST16: Yingchuang, ST36: Zusanli, SI1: Shaoze, CV17: Danzhong. 3. Traditional Chinese Medicine is non-invasive and effective techniques such as scraping, cupping, acupressure and ear peas. 4. Traditional Chinese Medicine can be combined with other different acupuncture points according to the different constitutions of post-partum women. Breast acupressure, ear acupuncture, scrapping, cupping, and moxibustion are noninvasive treatments that can effectively help patients during lactation, and their clinical practice should be considered and widely promoted.
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Affiliation(s)
- Yu-Wen Fang
- Department of Health Administration, Tzu Chi University of Science and Technology, Hualien, Taiwan
| | - Shu-Fen Chen
- Department of Nursing, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Ming-Ling Wang
- Researcher, School of Nursing, International Ph. D. Program in Gerontology and Long-term Care, Taipei Medical University, Taipei, Taiwan
| | - Mei-Hua Wang
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
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Holstad Y, Johansson B, Lindqvist M, Westergren A, Poromaa IS, Christersson C, Dellborg M, Trzebiatowska-Krzynska A, Sörensson P, Thilén U, Wikström AK, Bay A. Breastfeeding in primiparous women with congenital heart disease - a register study. Int Breastfeed J 2024; 19:19. [PMID: 38509505 PMCID: PMC10956229 DOI: 10.1186/s13006-024-00627-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/07/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND The number of pregnant women with congenital heart disease (CHD) is rising, and the disease poses increased risks of cardiovascular and obstetric complications during pregnancy, potentially impacting breastfeeding success. This study aimed to investigate breastfeeding in primiparous women with CHD compared to primiparous women without CHD, and to examine potential hindering factors for breastfeeding in women with CHD. METHODS The data were gathered between 2014 and 2019 and obtained by merging the Swedish Congenital Heart Disease Register (SWEDCON) with the Swedish Pregnancy Register. Primiparous women ≥ 18 years of age with CHD (n = 578) were matched by age and municipality to 3049 women without CHD, giving birth after 22 gestational weeks. Multivariable logistic regression analysis was used to identify factors associated with non-breastfeeding in women with CHD. RESULTS Fewer women with CHD breastfed than women without CHD two days (94% vs. 97%, p = 0.001) and four weeks after birth (84% vs. 89%, p = 0.006). When all women were analysed, having CHD was associated with non-breastfeeding at both two days and four weeks after birth. For women with CHD, body mass index (BMI) ≥ 30 (OR 3.1; 95% CI 1.4, 7.3), preterm birth (OR 6.4; 95% CI 2.1, 19.0), self-reported history of psychiatric illness (OR 2.4; 95% CI 1.2, 5.1), small for gestational age (OR 4.2; 95% CI 1.4, 12.2), and New York Heart Association Stages of Heart Failure class II - III (OR 6.0; 95% CI 1.4, 26.7) were associated with non-breastfeeding two days after birth. Four weeks after birth, factors associated with non-breastfeeding were BMI ≥ 30 (OR 4.3; 95% CI 2.1, 9.0), self-reported history of psychiatric illness (OR 2.2; 95% CI 1.2, 4.2), and preterm birth (OR 8.9; 95% CI 2.8, 27.9). CONCLUSIONS The study shows that most women with CHD breastfeed, however, at a slightly lower proportion compared to women without CHD. In addition, factors related to the heart disease were not associated with non-breastfeeding four weeks after birth. Since preterm birth, BMI ≥ 30, and psychiatric illness are associated with non-breastfeeding, healthcare professionals should provide greater support to women with CHD having these conditions.
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Affiliation(s)
- Ylva Holstad
- Department of Nursing, Umeå University, Umeå, Sweden.
| | - Bengt Johansson
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Maria Lindqvist
- Department of Nursing, Umeå University, Umeå, Sweden
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | | | | | | | - Mikael Dellborg
- Department of Clinical and Molecular Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Peder Sörensson
- Department of Medicine, Solna, Department of Cardiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ulf Thilén
- Department of Clinical Sciences, Cardiology, Lund University, Lund, Sweden
| | - Anna-Karin Wikström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Annika Bay
- Department of Nursing, Umeå University, Umeå, Sweden
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Neupane S, de Oliveira CVR, Palombo CNT, Buccini G. Association between breastfeeding cessation among under six-month-old infants and postpartum depressive symptoms in Nevada. PLoS One 2024; 19:e0297218. [PMID: 38277396 PMCID: PMC10817202 DOI: 10.1371/journal.pone.0297218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 12/29/2023] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND Postpartum depression affects 13% of women after childbirth in the United States. Mothers who experience depression are less likely to breastfeed than those who do not experience depression. On the other hand, breastfeeding may have a positive effect on maternal mental health. RESEARCH AIM We aimed to analyze whether breastfeeding cessation is associated with postpartum depression symptoms among mothers of infants under six months old in Clark County, Nevada. METHOD A cross-sectional study was conducted in 2021 using a purposive sample of 305 mother-infant dyads. Postpartum depression symptoms were assessed using the Patient Health Questionnaire-2 (PHQ-2), and the breastfeeding cessation was determined through a 24-hour dietary recall. Descriptive, bivariate, and multivariate logistic regression analyses were conducted. RESULTS Most participants were between 25 and 34 years old (n = 183, 60.0%), multiparous (n = 167, 55.1%), and had a vaginal delivery (n = 204, 70.6%). High frequency of postpartum depressive symptoms was found among mothers who were young (18-24 years) (24.2%), without a partner (25.0%), had unplanned pregnancies (12.7%), and were primiparous (13.2%). Breastfeeding cessation was independently associated with postpartum depressive symptoms (AOR = 3.30, 95% CI: 1.16-9.32) after controlling for sociodemographic, environmental, and obstetric characteristics. CONCLUSION Breastfeeding cessation is strongly associated with postpartum depressive symptoms among mother-infant dyads in Nevada. Early identification of postpartum depressive symptoms and the promotion of breastfeeding can create a positive feedback loop to foster the well-being of mothers and infants.
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Affiliation(s)
- Smriti Neupane
- Department of Social and Behavioral Health, School of Public Health, University of Nevada, Las Vegas, Nevada, United States of America
| | | | | | - Gabriela Buccini
- Department of Social and Behavioral Health, School of Public Health, University of Nevada, Las Vegas, Nevada, United States of America
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Rodríguez-Gallego I, Vila-Candel R, Corrales-Gutierrez I, Gomez-Baya D, Leon-Larios F. Evaluation of the Impact of a Midwife-Led Breastfeeding Group Intervention on Prevention of Postpartum Depression: A Multicentre Randomised Clinical Trial. Nutrients 2024; 16:227. [PMID: 38257120 PMCID: PMC10821517 DOI: 10.3390/nu16020227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/06/2024] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
Postpartum depression is a significant health issue affecting both mothers and newborns during the postpartum period. Group support interventions during this period have proven effective in helping women cope with depression and improving breastfeeding rates. This study aimed to assess the effectiveness of a midwife-led breastfeeding support group intervention on breastfeeding rates, postpartum depression and general self-efficacy. This was a multicentric cluster randomised controlled trial with control and intervention groups and was not blinded. It was conducted in Andalusia (southern Spain) from October 2021 to May 2023. A total of 382 women participated in the study. The results showed a significant difference in exclusive breastfeeding rates at 4 months postpartum between the groups (control 50% vs. intervention 69.9%; p < 0.001). Additionally, there was a lower mean score on the Edinburgh Postnatal Depression Scale in the intervention group (12.49 ± 3.6 vs. 13.39 ± 4.0; p = 0.044). Similarly, higher scores of general self-efficacy were observed among breastfeeding women at 2 and 4 months postpartum (77.73 ± 14.81; p = 0.002 and 76.46 ± 15.26; p < 0.001, respectively). In conclusion, midwife-led breastfeeding support groups enhanced self-efficacy, prolonged breastfeeding and reduced postpartum depression 4 months after giving birth.
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Affiliation(s)
- Isabel Rodríguez-Gallego
- Foetal Medicine, Genetics and Reproduction Unit, Virgen del Rocío University Hospital, 41009 Seville, Spain;
- Red Cross Nursing University Centre, University of Seville, 41013 Seville, Spain
| | - Rafael Vila-Candel
- Faculty of Health Sciences, Universidad Internacional de Valencia (VIU), 46002 Valencia, Spain
- La Ribera Primary Health Department, 46600 Alzira, Spain
- Foundation for the Promotion of Health and Biomedical Research in the Valencian Region (FISABIO), 46020 Valencia, Spain
| | - Isabel Corrales-Gutierrez
- Surgery Department, Faculty of Medicine, University of Seville, 41009 Seville, Spain
- Foetal Medicine Unit, Virgen Macarena University Hospital, 41009 Seville, Spain
| | - Diego Gomez-Baya
- Department of Social, Developmental and Educational Psychology, Universidad de Huelva, 21007 Huelva, Spain;
| | - Fatima Leon-Larios
- Nursing Department, School of Nursing, Physiotherapy and Podiatry, University of Seville, 41009 Seville, Spain;
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12
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Henshaw EJ. Breastfeeding and Postpartum Depression: A Review of Relationships and Potential Mechanisms. Curr Psychiatry Rep 2023; 25:803-808. [PMID: 37906349 DOI: 10.1007/s11920-023-01471-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2023] [Indexed: 11/02/2023]
Abstract
PURPOSE OF REVIEW Postpartum depression (PPD) and breastfeeding are important, interrelated health factors. It is established that women who breastfeed exclusively have lowered likelihood of developing significant PPD. Yet, many questions remain around what factors are involved. The purpose of this review is to provide updated information about the relationship between PPD and breastfeeding. RECENT FINDINGS Both psychological and physiological factors have emerged as important moderators and mechanisms of the relationship between postpartum depression and breastfeeding. Breastfeeding self-efficacy, self-compassion, and engagement with the infant during feeding all modify or mediate the relationship, and a complex dynamic relationship among cortisol, oxytocin, progesterone, and estrogen is involved. Importantly, recent intervention studies suggest psychosocial interventions may impact both breastfeeding and mood. Providers and researchers should recognize the interrelationship between the breastfeeding and PPD and apply this understanding to patient care through integrated education and care for both mood and breastfeeding enhancement.
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Affiliation(s)
- Erin J Henshaw
- Department of Psychology, Denison University, 100 West College Street, Granville, OH, 43023, USA.
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13
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Papadopoulou SK, Pavlidou E, Dakanalis A, Antasouras G, Vorvolakos T, Mentzelou M, Serdari A, Pandi AL, Spanoudaki M, Alexatou O, Aggelakou EP, Giaginis C. Postpartum Depression Is Associated with Maternal Sociodemographic and Anthropometric Characteristics, Perinatal Outcomes, Breastfeeding Practices, and Mediterranean Diet Adherence. Nutrients 2023; 15:3853. [PMID: 37686885 PMCID: PMC10490519 DOI: 10.3390/nu15173853] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/01/2023] [Accepted: 09/02/2023] [Indexed: 09/10/2023] Open
Abstract
Postpartum depression, with a prevalence ranging between 14% and 25% worldwide, has been considered an urgent health concern that negatively affects both mothers' and their infants' health. Postpartum depression may negatively affect maternal sociodemographic and anthropometric parameters and lifestyle factors. Nutrition has recently been identified as a crucial factor for the management and co-treatment of postpartum depression. This survey aims to determine the possible association of postpartum depression with mothers' socio-demographic and anthropometric characteristics, perinatal outcomes, breastfeeding practices, and Mediterranean diet (MD) adherence. METHODS This is a cross-sectional survey, which was performed on 3941 women during the postpartum period. Postpartum depression was assessed by the Edinburgh Postnatal Depression Scale (EPDS). Anthropometric parameters and perinatal outcomes were retrieved from mothers' medical records. Sociodemographic data and breastfeeding practices were recorded by face-to-face interviews between enrolled mothers and trained personnel. Mediterranean diet adherence was assessed by MedDietScore. Both univariate and multivariate binary logistic regression were applied for analyzing our data. RESULTS Postpartum depression was significantly associated with lower educational level, Greek nationality, higher prevalence of multiparity and overweight/obesity postpartum, higher incidence of caesarean section and not breastfeeding, and lower levels of MD adherence. In multivariate analysis, postpartum depression was independently associated with mothers' educational level, postpartum BMI status, type of delivery, breastfeeding practices, and MD adherence after adjusting for multiple confounding factors. CONCLUSIONS This study has provided evidence that elevated MD compliance was related to a decreased risk of postpartum depression. Additionally, postpartum depression was associated with multiple sociodemographic and anthropometric parameters, perinatal outcomes, and breastfeeding practices. Future well-designed, prospective studies with high-quality methodology should be performed to obtain conclusive results.
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Affiliation(s)
- Sousana K. Papadopoulou
- Department of Nutritional Sciences and Dietetics, School of Health Sciences, International Hellenic University, 57400 Thessaloniki, Greece;
| | - Eleni Pavlidou
- Department of Food Science and Nutrition, School of the Environment, University of the Aegean, 81400 Myrina, Lemnos, Greece; (E.P.); (G.A.); (M.M.); (A.-L.P.); (O.A.); (E.-P.A.); (C.G.)
| | - Antonios Dakanalis
- Department of Mental Health, Fondazione IRCCS San Gerardo dei Tintori, 20900 Monza, Italy;
- School of Medicine and Surgery, University of Milano-Bicocca, 20900 Monza, Italy
| | - Georgios Antasouras
- Department of Food Science and Nutrition, School of the Environment, University of the Aegean, 81400 Myrina, Lemnos, Greece; (E.P.); (G.A.); (M.M.); (A.-L.P.); (O.A.); (E.-P.A.); (C.G.)
| | - Theofanis Vorvolakos
- Department of Psychiatry, School of Health Sciences, University General Hospital of Alexandroupolis, Democritus University of Thrace, 68100 Alexandroupolis, Greece;
| | - Maria Mentzelou
- Department of Food Science and Nutrition, School of the Environment, University of the Aegean, 81400 Myrina, Lemnos, Greece; (E.P.); (G.A.); (M.M.); (A.-L.P.); (O.A.); (E.-P.A.); (C.G.)
| | - Aspasia Serdari
- Department of Psychiatry and Child Psychiatry, School of Medicine, Democritus University of Thrace, 68100 Alexandroupolis, Greece;
| | - Aimilia-Lynn Pandi
- Department of Food Science and Nutrition, School of the Environment, University of the Aegean, 81400 Myrina, Lemnos, Greece; (E.P.); (G.A.); (M.M.); (A.-L.P.); (O.A.); (E.-P.A.); (C.G.)
| | - Maria Spanoudaki
- Department of Nutritional Sciences and Dietetics, School of Health Sciences, International Hellenic University, 57400 Thessaloniki, Greece;
| | - Olga Alexatou
- Department of Food Science and Nutrition, School of the Environment, University of the Aegean, 81400 Myrina, Lemnos, Greece; (E.P.); (G.A.); (M.M.); (A.-L.P.); (O.A.); (E.-P.A.); (C.G.)
| | - Exakousti-Petroula Aggelakou
- Department of Food Science and Nutrition, School of the Environment, University of the Aegean, 81400 Myrina, Lemnos, Greece; (E.P.); (G.A.); (M.M.); (A.-L.P.); (O.A.); (E.-P.A.); (C.G.)
| | - Constantinos Giaginis
- Department of Food Science and Nutrition, School of the Environment, University of the Aegean, 81400 Myrina, Lemnos, Greece; (E.P.); (G.A.); (M.M.); (A.-L.P.); (O.A.); (E.-P.A.); (C.G.)
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14
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Segre G, Clavenna A, Cartabia M, Bonati M. Postpartum depression screening in mothers and fathers at well-child visits: a feasibility study within the NASCITA cohort. BMJ Open 2023; 13:e069797. [PMID: 37355274 PMCID: PMC10314581 DOI: 10.1136/bmjopen-2022-069797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 05/23/2023] [Indexed: 06/26/2023] Open
Abstract
OBJECTIVE To assess the feasibility of the family paediatrician's (FP) role in identifying the signs of postpartum depression in parents in time to guarantee child well-being. DESIGN, SETTING AND PARTICIPANTS Data for this observational prospective study were collected within the NASCITA (NAscere e creSCere in ITAlia) cohort. During the first visit, paediatricians collected sociodemographic data regarding the parents and information about their health status, the pregnancy and the delivery. Whooley questions were administered during the first and second visits (scheduled 60-90 days after childbirth). Moreover, on the third visit (5-7 months after childbirth) the FP was asked to answer 'yes' or 'no' to a question on the parental postpartum depression, based on his knowledge and on the acquired information. RESULTS In 2203 couples who completed the assessment, 529 mothers (19.9%), 141 fathers (6.3%) and 110 (5%) couples reported any depressive symptomatology. Of these, 141 mothers (5.3% of the total sample) and 18 fathers (0.8% of the total sample) were classified as 'likely depressed'. An association was found between maternal postnatal depressive symptoms and having a diagnosed psychiatric disorder during pregnancy (OR 9.49, 95% CI: 3.20 to 28.17), not exclusively breastfeeding at hospital discharge (OR 1.76, 95% CI: 1.19 to 2.61) and the presence of child sleeping disorders at 3 (OR 2.46, 95% CI: 1.41 to 4.28) and 6 months (OR 2.18, 95% CI: 1.37 to 3.47). Another significant predictor of postpartum depression was being primiparous (OR 1.99, 95% CI: 1.31 to 3.02). Concerning the fathers, a significant association was reported only between likely depressed fathers and child sleeping disorders at 3 months (OR 7.64, 95% CI: 2.92 to 19.97). Moreover, having a likely depressed partner was strongly associated with depressive symptoms in fathers (OR 85.53, 95% CI 26.83 to 272.69). CONCLUSIONS The findings of this study support the feasibility of an active screening programme for parental postnatal depression during well-child visits as an integral part of postpartum care. TRIAL REGISTRATION NUMBER NCT03894566; Pre-results.
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Affiliation(s)
- Giulia Segre
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Antonio Clavenna
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Massimo Cartabia
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Maurizio Bonati
- Laboratory for Mother and Child Health, Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
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15
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Wells T. Postpartum Depression: Screening and Collaborative Management. Prim Care 2023; 50:127-142. [PMID: 36822723 DOI: 10.1016/j.pop.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Perinatal mood disorders are a leading cause of disability worldwide and suicide is a leading cause of maternal death in the first year after giving birth. The three categories of perinatal mood disorders are postpartum blues, postpartum depression, and postpartum psychosis. Identifying risk factors may allow clinicians to provide patients with interventions to potentially prevent development of these disorders. Universal screening for perinatal mood disorders can lead to earlier identification and treatment. Collaborative care methods, incorporating the entire family into treatment, therapy service, and providing support services are recommended as first-line intervention strategies before moving on to pharmacologic management.
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16
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Zhu J, Jin J, Tang J. Oxytocin and Women Postpartum Depression: A Systematic Review of Randomized Controlled Trials. Neuropsychiatr Dis Treat 2023; 19:939-947. [PMID: 37096027 PMCID: PMC10122502 DOI: 10.2147/ndt.s393499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/05/2023] [Indexed: 04/26/2023] Open
Abstract
Previous studies have demonstrated that oxytocin was a viable therapy option for postpartum depression. However, the role remains controversial. To evaluate the efficacy of oxytocin on women postpartum depression, we searched PubMed, Web of Science, Cochrane Library, and EmBase for literatures from inception of the database to April 18th, 2022. Randomized controlled trials (RCTs) that investigated the effects of oxytocin on postpartum depression were selected for this study. Six RCTs (195 women) were gathered. The effects of oxytocin were roughly divided into emotion and cognition. The modulation of oxytocin to women's emotion was demonstrated in four of the trials. The results were conflicting: One trial showed that oxytocin alleviated the depressive mood; two trials showed that oxytocin had no effect (but reduce negative thoughts in healthy mothers, or decrease the narcissistic trait); another trial showed that oxytocin aggravated depression. Women's cognition was shown to be regulated by oxytocin in four of the trials. In general, oxytocin enhanced postpartum depressive women's perception of their relationship with the infants. This systematic review showed that the effect of oxytocin on postpartum depression is still uncertain. We partly support that exogenous oxytocin might improve the cognition of women with postpartum depression to their infants, while the effect on emotion is still controversial. Further RCTs with larger samples and more diversified evaluation criteria are needed to better reveal its efficacy on postpartum depression.
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Affiliation(s)
- Jialei Zhu
- Department of Pharmacy, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, People’s Republic of China
| | - Jing Jin
- Department of Pharmacy, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, People’s Republic of China
| | - Jing Tang
- Department of Pharmacy, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, People’s Republic of China
- Correspondence: Jing Tang, Department of Pharmacy, Obstetrics and Gynecology Hospital of Fudan University, 128 Shenyang Road, Yangpu District, Shanghai, 200090, People’s Republic of China, Tel +86-21-33189900, Email
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17
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Chen J, Lai X, Zhou L, Retnakaran R, Wen SW, Krewski D, Huang L, Li M, Xie RH. Association between exclusive breastfeeding and postpartum post-traumatic stress disorder. Int Breastfeed J 2022; 17:78. [PMID: 36419193 PMCID: PMC9685859 DOI: 10.1186/s13006-022-00519-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/05/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Research on the association between breastfeeding and postpartum post-traumatic stress disorder (PTSD) is sparse. This study aimed to examine the association between exclusive breastfeeding up to 42 days after childbirth and postpartum PTSD. METHODS An epidemiologic study was conducted in a tertiary hospital in China between October 2019 and October 2020. Eligible mothers were recruited at 3 days after childbirth and assessed using the Post-Traumatic Stress Disorder Checklist - Civilian version (PCL-C) for PTSD at 42 days postpartum. The independent association between exclusive breastfeeding up to 42 days after childbirth and postpartum PTSD was estimated using log-binomial regression models, after adjusting for potential confounders. RESULTS Ninety-two of 759 (12.1%) mothers developed postpartum PTSD within 42 days after childbirth. Compared with partially breastfeeding mothers, exclusively breastfeeding mothers had lower risks of postpartum PTSD (relative risk [RR] 0.28; 95% confidence interval [CI] 0.13, 0.59), re-experience (RR 0.48; 95% CI 0.30, 0.76), avoidance (RR 0.55; 95% CI 0.32, 0.97), and hyperarousal (RR 0.52; 95% CI 0.34, 0.78). After adjustment for family support, parity, mode of delivery, perceived birth trauma, early contact / suckling, and rooming-in, associations between exclusive breastfeeding and postpartum PTSD remained significant: the overall PTSD adjusted relative risk [aRR] was 0.31; (95% CI 0.15, 0.66), with a re-experience aRR of 0.48; (95% CI 0.30, 0.77) and hyperarousal aRR of 0.56; (95% CI 0.37, 0.85). CONCLUSION Exclusive breastfeeding up to 42 days after childbirth was associated with reduced risk of postpartum PTSD. While the potential for reverse causation cannot be ruled out, strategies to improve rates of exclusive breastfeeding through teaching, counselling, and support may benefit mothers and their infants by reducing the risk of postpartum PTSD.
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Affiliation(s)
- Jingfen Chen
- grid.284723.80000 0000 8877 7471School of Nursing, Southern Medical University, Guangzhou, China
| | - Xiaolu Lai
- grid.284723.80000 0000 8877 7471School of Nursing, Southern Medical University, Guangzhou, China
| | - Lepeng Zhou
- grid.284723.80000 0000 8877 7471School of Nursing, Southern Medical University, Guangzhou, China
| | - Ravi Retnakaran
- grid.416166.20000 0004 0473 9881Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Toronto, Ontario Canada ,grid.250674.20000 0004 0626 6184Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario Canada ,grid.17063.330000 0001 2157 2938Division of Endocrinology, University of Toronto, Toronto, Ontario Canada
| | - Shi Wu Wen
- grid.412687.e0000 0000 9606 5108Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario Canada ,grid.28046.380000 0001 2182 2255Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario Canada ,grid.28046.380000 0001 2182 2255School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario Canada
| | - Daniel Krewski
- grid.28046.380000 0001 2182 2255School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario Canada ,grid.28046.380000 0001 2182 2255McLaughlin Centre for Population Health Risk Assessment, University of Ottawa, Ottawa, Ontario Canada ,Risk Science International, Ottawa, Ontario Canada
| | - Liping Huang
- grid.284723.80000 0000 8877 7471Department of Obstetrics and Gynecology, Southern Medical University Nanfang Hospital, Guangzhou, China
| | - Meng Li
- grid.284723.80000 0000 8877 7471The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China ,grid.284723.80000 0000 8877 7471Department of Obstetrics, The Seventh Affiliated Hospital, Southern Medical University, Foshan, China
| | - Ri-hua Xie
- grid.284723.80000 0000 8877 7471Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University, Foshan, China ,grid.284723.80000 0000 8877 7471School of Nursing, Southern Medical University, Guangzhou, China ,grid.28046.380000 0001 2182 2255The Telfer School of Management, University of Ottawa, Ottawa, Ontario Canada
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