Mothers' health post-partum and their patterns of seeking vaccination for their infants

Impact of maternal depression and anxiety on immunization status of children: a prospective cohort study

BACKGROUND

Maternal depression and anxiety can have a detrimental impact on birth outcomes and healthy child development; there is limited knowledge on its influence on immunization schedule adherence. Therefore, the objectives of this study were to determine the impact of maternal depression and anxiety in the perinatal period on prolonged vaccine delay of childhood vaccines.

METHODS

In this prospective cohort study, we analyzed linked survey and administrative data of 2,762 pregnant women in Calgary, Alberta, Canada. Data were collected at two time-points: prenatal (< 25 weeks of gestation) and postpartum (4 months postpartum). We used multivariable logistic regression to examine the association between depression and anxiety with prolonged immunization delay, adjusting for covariates.

RESULTS

In multivariable analysis, maternal depression at either time point was not associated with prolonged delay for DTaP-IPV-Hib (OR 1.16, 95% CI 0.74-1.82), MMR/MMRV (OR 1.03, 95% CI 0.72-1.48), or all routine childhood vaccines combined (OR 1.32, 95% CI 0.86-2.04). Maternal anxiety at either time point was also not associated with prolonged delayed for DTaP-IPV-Hib (OR 1.08, 95% CI 0.77-1.53), MMR/MMRV (OR 1.07, 95% CI 0.82-1.40), or all vaccines combined (OR 1.00, 95% CI 0.80-1.26). In both the depression and anxiety models, children of Canadian-born mothers had higher odds of prolonged delay, as did those with low-income mothers.

CONCLUSION

Health care providers can be reassured that maternal depression and anxiety do not appear to influence maternal commitment to routine immunization. Findings suggested that low income and household moves may influence adherence to vaccine schedules and health care providers may want to provide anticipatory guidance to these families.

Exploring the impact of mental health conditions on vaccine uptake in high-income countries: a systematic review

BACKGROUND

Vaccination is an essential public health intervention to reduce morbidity and mortality from infectious diseases. Despite being at higher at risk of infectious diseases, health inequalities towards vaccine uptake in people with mental health issues have not been systematically appraised.

METHODS

We searched 7 databases from 1994 to 26/03/2021. We included all studies with a relative measure of effect comparing a group with a mental health issue to a control group. All studies covering any mental health issue were eligible with no constraints to study population, vaccine type or region, provided in a high-income country for comparability of health care systems. The study outcomes were synthesised by study population, mental health issue and type of vaccine.

RESULTS

From 4,069 titles, 23 eligible studies from 12 different countries were identified, focusing on adults (n = 13) or children (n = 4) with mental health issues, siblings of children with mental health issues (n = 2), and mothers with mental health issue and vaccine uptake in their children (n = 6). Most studies focused on depression (n = 12), autism, anxiety, or alcoholism (n = 4 respectively). Many studies were at high risk of selection bias.

DISCUSSION

Mental health issues were associated with considerably lower vaccine uptake in some contexts such as substance use disorder, but findings were heterogeneous overall and by age, mental health issue or types of vaccine. Only individuals with mental health issues and physical comorbidities had consistently higher uptake in comparison to other adults. Mental health should be considered as a health inequality for vaccine uptake but more context specific research is needed focusing more on specific mental health issues and subgroups of the population to understand who misses vaccination and why.

Disparities in Emergency Department Utilization Among Women with Postpartum Mood Disorders (2006-2016)

INTRODUCTION

Postpartum mood disorders are associated with adverse outcomes for newborns and mothers and may require urgent evaluation. The emergency department is often a healthcare entry point, but factors associated with these emergency department visits are unknown.

METHODS

A longitudinal retrospective analysis using the Nationwide Emergency Department Sample to assess national estimates of emergency department visits by women ages 15-49 with primary diagnosis of a postpartum mood disorder between 2006 and 2016. Emergency department visit rates for postpartum mood disorders per 100,000 live births were calculated.

RESULTS

Emergency department visits related to postpartum mood disorders remained stable from 2006 to 2016 (5153 to 5390 respectively). Two-thirds of visits were by patients younger than 30. Approximately half of visits for postpartum mood disorders were funded by Medicaid (42.4-56.7%) compared to 27.4-41.2% funded by Medicaid for all other age-matched women. Of postpartum mood disorder visits 30.3% were by women from the lowest income quartile. The highest rate of emergency department visits occurred in the youngest patients (ages 15-19: 231 visits versus ages 35-49: 105 visits). Postpartum mood disorder admissions were higher than those for age-matched women with all other diagnoses (19.8% vs. 6.5%).

DISCUSSION

The high rate of women that are young and with public insurance visiting the emergency department for postpartum mood disorders demonstrates an increased risk for these disorders in these populations and an opportunity for targeted intervention by policymakers and providers. Higher admission rates for postpartum mood disorders compared to all other diagnoses reveals a chance to optimize outpatient screening and treatment.

Severe mental disorders and vaccinations - a systematic review

OBJECTIVES

People with severe mental illnesses (SMI: schizophrenia, depressive disorder, bipolar disorder) have a high risk of being infected by viruses and suffer a more severe infection illness course than the general population. The aim of this literature review was to elucidate rates as well as immunogenicity and side effects of vaccinations in SMI.

METHODS

All studies in the English or German language, which investigated either prevalence rates or effects of vaccinations in the target groups, were systematically searched in the databank PubMed by three independent authors using the PRISMA guidelines and discussed in more detail.

RESULTS

The search found 24 studies reporting epidemiological data and 16 investigating immunogenicity of vaccinations. The results on prevalence rates, antibody production, inflammation response and side effects were inconsistent. About interactions with psychotropic medication, only two studies on clozapine were found.

CONCLUSIONS

Only a few trials with heterogeneous samples have investigated prevalence and effects of vaccinations in SMI. Sex, age and other factors such as somatic comorbidities and special vaccination programmes have not been considered continuously and may influence rates as well. As individuals with SMI might be at special risk, further research on the willingness to be vaccinated as well as efficacy of vaccinations is needed.

Parental mental illness, attendance at preventive child healthcare and dental caries in the offspring: a nation-wide population-based cohort study

PURPOSE

Severe mental illness (SMI) may interfere with parental caregiving practices and offspring development. Adhering to preventive well-child visits and maintaining good oral hygiene during early childhood requires parental involvement. Whether these activities are affected by parental SMI is unclear. The purpose of the present study was to determine whether children exposed to parental SMI are at increased risk of non-attendance to preventive well-child visits and vaccinations at age 0-5 years and of child dental caries experience at age 5 years. Furthermore, interactions between maternal psychiatric and sociodemographic variables in relation to an adverse child outcome were assessed.

METHODS

Data were obtained from national Danish health registers. All children born in Denmark between January 1997 and December 2010 were followed from birth until their 6th birthday.

RESULTS

679,339 children were included in the study (51% male). Of these, 49,059 children (7.8%) had at least one parent with a lifetime SMI diagnosis. Children of parents with SMI had elevated odds of missing well-child visits and vaccinations (OR 1.41; 95% CI 1.39-1.44, p < 0.0001), and of child dental caries (OR 1.58; 95% CI 1.55-1.62, p < 0.0001). In the presence of maternal SMI, low socioeconomic classification and single-mother status added more to the elevated risk than specific maternal diagnosis or timing of last psychiatric contact.

CONCLUSION

Parents with SMI are less compliant with preventive child healthcare activities than parents without SMI. This indicates a need for practical support to these families in order to prevent inequality in health among their offspring.

Prevalence and correlates of vaccine attitudes and behaviors in a cohort of low-income mothers

The US is facing a rise in vaccine hesitancy, delay, and refusal, though little is known about these outcomes in socio-economically disadvantaged populations. This study examines the prevalence and correlates of vaccine attitudes and behaviors in a diverse cohort of low-income mothers receiving home visiting services. Survey data were collected from 813 recipients of evidence-based home visiting services in Wisconsin from 2013 to 2018. Analyses were performed to describe outcome measures of vaccine attitudes and self-reported completion, and multivariate regressions were used to test associations between vaccine-related outcomes and hypothesized correlates. Most women (94%) reported their children were up to date on vaccines; 14.3% reported having ever delayed vaccination. A small minority disagreed that vaccines are important (5.0%), effective (5.4%), and safe (6.2%), though a larger proportion responded ambivalently (10.9%–21.9%). Participants with greater trust in health care providers reported more positive overall vaccine attitudes (B = 0.24; 95% CI = 0.17, 0.31), a lower likelihood of vaccine delay (OR = 0.57; 95% CI = 0.46, 0.73), and a greater likelihood of being up to date on vaccines (OR = 1.79, 95% CI = 1.30, 2.44). Women with greater trust in a home visitor also rated vaccines more positively (B = 0.09; 95% CI = 0.02, 0.15), and women who reported better mental health were more likely to report their children were up to date (OR = 1.05; 95% CI = 1.02, 1.09). Compared to non-Hispanic whites, American Indians and non-Hispanic blacks had poorer vaccine-related outcomes. More research on vaccine attitudes and behaviors among higher-risk populations is needed to develop tailored strategies aimed at addressing vaccine hesitancy and underimmunization.

No Association Between Maternal Post-partum Depression and Vaccination Uptake of Infants: A Matched Cohort Study in a Large Health Maintenance Organization Database in Israel

BACKGROUND

Maternal post-partum depression is one of the most common medical complications around childbirth. One of its consequences is a possible association with children's receipt of preventive health care, including immunization. This study aimed to explore the association between maternal postpartum depression and children's immunization rates.

METHODS

A retrospective cohort study of Maccabi Healthcare Services (HMO) members comparing immunization rates between children born between 2006 and 2019 to mothers with post-partum depression and children born to mothers with no documented depression. Post-partum depression was assessed by Edinburgh Postnatal Depression Scale, a 10-item questionnaire considered the screening tool of choice in Israel for early Post-partum detection. 1:1 matching was conducted according to criteria: age of the mother ± 2 years, child's year of birth, the newborn baby's gender, the baby's birth order and socioeconomic index. The primary outcome was defined as non-vaccination and the exposure was defined as depression. A sub-analysis was performed, comparing immunization rates of children born to mothers treated with antidepressant medications to rates of children born to untreated mothers.

RESULTS

A total of 709 subjects in the exposed cohort (children born to mothers with post-partum depression symptoms) and 681 subjects in the matched cohort were analyzed. The relative risks among children born to depressed mothers compared with children born to healthy mothers for not receiving any vaccine at 2 months, three doses of pertussis vaccine up to 7 months and four doses of DTaP-Hib-IPV vaccine up to 18 months were 1.15 (95% CI 0.74-1.78), 1.11 (95% CI 0.94-1.31) and 0.82 (95% CI 0.56-1.95), respectively. The relative risks among 139 infants born to treated mothers compared with 570 infants born to untreated mothers for not receiving any vaccine at 2 months, three doses of pertussis vaccine up to 7 months and four doses of DTaP-Hib-IPV vaccine up to 18 months were 1.28 (0.64-2.54), 0.78 (0.57-1.06) and 0.42 (0.17-1.03), respectively.

CONCLUSION

We found no significant association between maternal post-partum depression and uptake of child Immunization.

The influence of maternal mental illness on vaccination uptake in children: a UK population-based cohort study

Reduced vaccination uptake is a growing and global public health concern. There is limited knowledge about the effect of maternal mental illness (MMI) on rates of childhood vaccination. This retrospective cohort study examined 479,949 mother-baby pairs born between 1993 and 2015 in the Clinical Practice Research Datalink (CPRD GOLD), a UK-based, primary health-care database. The influence of MMI on children’s vaccination status at two and five years of age was investigated using logistic regression adjusting for sex of the child, child ethnicity, delivery year, maternal age, practice level deprivation quintile and region. The vaccinations were: 5-in-1 (DTaP/IPV/Hib) and first dose MMR by the age of two; and all three doses of 5-in-1, first and second dose of MMR vaccines by the age of five. Exposure to MMI was defined using recorded clinical events for: depression, anxiety, psychosis, eating disorder, personality disorder and alcohol and substance misuse disorders. The likelihood that a child completed their recommended vaccinations by the age of two and five was significantly lower among children with MMI compared to children with mothers without mental illness [adjusted odds ratio (aOR) 0.86, 95% CI 0.84–0.88, p < 0.001]. The strongest effect was observed for children exposed to maternal alcohol or substance misuse (at two years aOR 0.50, 95% CI 0.44–0.58, p < 0.001). In the UK, an estimated five thousand more children per year would be vaccinated if children with MMI had the same vaccination rates as children with well mothers. Maternal mental illness is a hitherto largely unrecognised reason that children may be missing vital vaccinations at two and five years of age. This risk is highest for those children living with maternal alcohol or substance misuse.

Development of a cumulative metric of vaccination adherence behavior and its application among a cohort of 12-month-olds in western Kenya

OBJECTIVES

The timely receipt of the recommended vaccination regimen, i.e. vaccination maintenance, is an underexplored, but important, indicator of public health. There is currently no standardized method for quantifying cumulative vaccination maintenance, however, and no simple way to explore predictors of adherence to vaccination schedules. We therefore sought to (1) develop a Vaccination Maintenance Score (VMS) and (2) apply this score to determine the predictors of vaccination behavior among infants in western Kenya (n = 245).

METHODS

Women in western Kenya were enrolled during pregnancy and surveyed repeatedly through one year postpartum. Data were collected on a range of sociodemographic and health indicators and vaccinations. For each infant, we analyzed receipt of 11 vaccines recommended by the Kenyan Ministry of Health. We operationalized VMS as the total number of vaccines received on schedule. Vaccines that were not received or received off schedule were scored 0. VMS was modeled using multivariable tobit regression models.

RESULTS

We found that 85.7% of infants were fully immunized, but only 42.4% had optimal VMS, i.e. scored 11. The median (IQR) VMS was 10 (3). In multivariable regression, each one-point increase in maternal quality of life score (range: 0-32) was associated with a 0.22-point increase in VMS; each additional child in the household was associated with a 0.34-point increase in VMS; and initiating breastfeeding at birth was associated a 2.01-point increase in VMS.

CONCLUSIONS

Coverage of the recommended vaccinations (85.7%) was nearly twice as high as cumulative timely receipt (42.4%). The VMS satisfies a need for a location-specific but easily adaptable metric of vaccination adherence behavior. It can be used to complement traditional methods of vaccination coverage and timeliness to better understand underlying behaviors that influence vaccination events, and thereby inform interventions to improve vaccination rates and decrease the burden of vaccine-preventable disease.

CLINICAL TRIAL REGISTRATION

NCT02974972 and NCT02979418.

Health related quality of life (HRQoL) in mothers of premature infants at NICU discharge

BACKGROUND

Premature delivery and a potential Neonatal Intensive Care Unit admission may be associated with the risk of poor maternal health. We aimed to examine the mothers' health-related quality of life (HRQoL) at the time of infant discharge.

STUDY DESIGN

Fifty mothers completed the Medical Outcomes Study-Short Form 12. It has a Physical Component Score (PCS) and Mental Component Score (MCS), both with a mean of 50 and standard deviation of 10. Analysis included infant, maternal, and pregnancy-related characteristics.

RESULTS

In multivariable analyses, a household income of <150K lowered the PCS by 10 points (p = 0.003) compared to those with higher incomes. Marginal significance was noted in GA, for every week gained the PCS score was lower by 1.5 points.

CONCLUSION

Several risk factors are associated with lower physical health ratings in mothers of preterm infants at discharge. This information can be used to inform providers in their anticipatory guidance to the family and follow-up plans.

Web-based versus home-based postnatal psychoeducational interventions for first-time mothers: A randomised controlled trial

BACKGROUND

Besides physical and mental changes from childbirth, first-time mothers are also confronted with challenges associated with the demands of adapting to their roles as new parents. While positive effects of home-based psychoeducation intervention for mothers have been demonstrated, limited studies have developed and examined more accessible and cost-effective web-based psychoeducational interventions for mothers.

OBJECTIVE

To examine the effectiveness of web-based and home-based postnatal psychoeducational interventions for first-time mothers during the early postpartum period.

METHODS

A randomized controlled three-group pre-test and post-tests experimental design was adopted. Data were collected over five months, from October 2016 to August 2017, in a public tertiary hospital in Singapore from 204 primiparas who were randomly allocated to the web-based psychoeducation group, the home-based psychoeducation group, or the control group. The measured outcomes included maternal parental self-efficacy, social support, psychological well-being, satisfaction with postnatal care, and cost-effectiveness evaluation. Data were collected at four time points: the baseline, and three post-tests at one month, three and six months post-delivery.

RESULTS

When compared to the control group, the web-based intervention improved self-efficacy at post-test 1 (mean difference = 2.68, p = 0.028) and reduced postnatal depression at post-test 3 (mean difference = -1.82, p = 0.044), while the home-based intervention did not show significant effect on these two outcomes at all post-tests. Both web-based and home-based interventions helped mothers to get better social support at all post-tests than those in the control group. Mothers in both web-based and home-based intervention groups were more satisfied with the postnatal care than those in the control group at all post-test time points (except for web-based group at post-test 1). There were no differences in anxiety scores among the three groups. When compared to the home-based intervention, the web-based intervention showed noninferior effect on all outcomes at all post-tests.

CONCLUSION

The web-based intervention had better effects on improving self-efficacy, social support, and postnatal depression, which should be introduced to first-time mothers for better postnatal care.

Attendance of routine childcare visits in primary care for children of mothers with depression: a nationwide population-based cohort study

BACKGROUND

Depression is a common and potentially debilitating illness worldwide. Attendance to routine childcare appointments is a key point of interest in the effort to improve the health and care for families facing depression.

AIM

To evaluate the association between maternal depression and offspring non-attendance to the Danish childcare and vaccination programme (CCP) for children from 0-5 years of age. The CCP consists of seven separate visits and several vaccinations. To investigate if exposure to recent and previous depression may affect attendance differently.

DESIGN AND SETTING

Population-based cohort study using Danish nationwide registers.

METHOD

Participants were all live-born children (n = 853 315) in Denmark in the period from 1 January 2000 until 31 August 2013, and their mothers. The outcome of interest was non-attendance of each one of the seven scheduled childcare visits and two vaccination entities in the CCP. Exposure was maternal (both previous and recent) depression. All information was obtained from Danish national registries.

RESULTS

The risk of not attending CCP was higher for children of mothers with depression. For children of mothers with previous depression, the relative risk (RR) was 1.01 (95% confidence interval [CI] = 0.98 to 1.03) at the 5-week childcare visit, and 1.12 (95% CI = 1.09 to 1.14) at the 5-year childcare visit. For children of mothers with recent depression, the RR was 1.07 (95% CI = 1.03 to 1.13) at the 5-week visit, and 1.15 (95% CI = 1.13 to 1.17) at the 5-year visit. Furthermore, the risk of missing at least four of the seven childcare visits was higher for children of females with maternal depression (RR = 1.16, 95% CI = 1.13 to 1.19).

CONCLUSION

Maternal depression seems to compromise CCP attendance. These findings suggest a need for careful clinical attention to these vulnerable families, even years after a diagnosis of depression.

Integrating Maternal Mental Health Care in the Pediatric Medical Home: Treatment Engagement and Child Outcomes

Maternal depression is associated with an array of poor child health outcomes, and low-income women face many barriers to accessing treatment. In this pilot study, we assessed treatment engagement in a maternal mental health clinic staffed by a case manager and psychiatrist in an urban pediatric practice. We also examined factors associated with engagement as well as child health outcomes and health care use. Nearly half of the women enrolled attended at least 4 sessions with a psychiatrist in 6 months. Text messaging with the case manager was associated with a greater compliance with psychiatrist sessions. Comparing index children with their siblings prior to enrollment, a higher percentage had immunizations up to date at 1 year of age (82% vs 43%, P = .01), and well-child visit compliance trended toward significance (65% vs 35%, P = .06). The pediatric setting holds promise as an innovative venue to deliver maternal mental health care.

Determinants of under-immunization and cumulative time spent under-immunized in a Quebec cohort

BACKGROUND

Under-immunization refers to a state of sub-optimal protection against vaccine preventable diseases. Vaccine coverage for age may not capture intentional or non-intentional spacing of vaccines in the recommended provincial immunization guidelines. We aimed to identify factors associated with coverage and under-immunization and to determine the number of days during which children were under-immunized during their first 24months of life.

METHODS

Secondary analysis of children ≤3years recruited through active surveillance for gastroenteritis from three Quebec pediatric emergency departments from 2012 to 2014. Vaccination status for children at least 24months of age was determined using provincial immunization guidelines. Cumulative days under-immunized were calculated for DTaP-VPI-Hib, PCV, MMR, and Men-C-C. Factors associated with up-to-date (UTD) status at 24months of life and for under-immunization ≥6months were analyzed using logistic regression.

RESULTS

Of 246 eligible children, 180 (73%) were UTD by 24months of life. The mean cumulative days under-immunized for MMR was 107days, for PCV 209days, for Men-C-C 145days, and for DTaP-VPI-Hib 227days. Overall, 149 children (60%) experienced delay for at least 1 vaccine. Factors associated with both an UTD status at 24months and concurrently associated with being under-immunization ≥6months, included timely initiation of immunization (OR=5.85; 95% CI: 2.80-12.22) and (OR=0.13; 95% CI: 0.07-0.24), failure to co-administer 18-month vaccines (OR=0.15; 95% CI: 0.10-0.21) and (OR=3.29; 95% CI: 2.47-4.39), and having a household with ≥3 children under 18years ((OR=0.50; 0.28-0.86) and (OR=2.99; 1.45-6.22), respectively.

CONCLUSION

Paired with an unexpected low level of coverage at 24months of life, the majority of our cohort also experienced a state of under-immunization for a least one vaccine. Estimates of coverage do not capture intentional or non-intentional gaps in protection from vaccine preventable illnesses. Timely preventive care should be prioritized.

Understanding Peripartum Depression Through Neuroimaging: a Review of Structural and Functional Connectivity and Molecular Imaging Research

PURPOSE OF REVIEW

Imaging research has sought to uncover brain structure, function, and metabolism in women with postpartum depression (PPD) as little is known about its underlying pathophysiology. This review discusses the imaging modalities used to date to evaluate postpartum depression and highlights recent findings.

RECENT FINDINGS

Altered functional connectivity and activity changes in brain areas implicated in executive functioning and emotion and reward processing have been identified in PPD. Metabolism changes involving monoamine oxidase A, gamma-aminobutyric acid, glutamate, serotonin, and dopamine have additionally been reported. To date, no studies have evaluated gray matter morphometry, voxel-based morphometry, surface area, cortical thickness, or white matter tract integrity in PPD. Recent imaging studies report changes in functional connectivity and metabolism in women with PPD vs. healthy comparison women. Future research is needed to extend these findings as they have important implications for the prevention and treatment of postpartum mood disorders.

The synergistic effect of breastfeeding discontinuation and cesarean section delivery on postpartum depression: A nationwide population-based cohort study in Korea

BACKGROUND

The relationships between breastfeeding discontinuation and cesarean section delivery, and the occurrence of postpartum depression (PPD) remain unclear. Therefore, we aimed to investigate the association of breastfeeding discontinuation and cesarean section delivery with PPD during the first 6 months after delivery.

METHODS

Data were extracted from the Korean National Health Insurance Service-National Sample Cohort for 81,447 women who delivered during 2004-2013. PPD status was determined using the diagnosis code at outpatient or inpatient visit during the 6-month postpartum period. Breastfeeding discontinuation and cesarean section delivery were identified from prescription of lactation suppression drugs and diagnosis, respectively. Cox proportional hazards models were used to calculate adjusted hazard ratios.

RESULTS

Of the 81,447 women, 666 (0.82%) had PPD. PPD risk was higher in women who discontinued breastfeeding than in those who continued breastfeeding (hazard ratio=3.23, P<0.0001), in women with cesarean section delivery than in those with vaginal delivery (hazard ratio=1.26, P=0.0040), and in women with cesarean section delivery who discontinued breastfeeding than in those with vaginal delivery who continued breastfeeding (hazard ratio=4.92, P<0.0001).

LIMITATIONS

Study limitations include low PPD incidence; use of indirect indicators for PPD, breastfeeding discontinuation, and working status, which could introduce selection bias and errors due to miscoding; and potential lack of adjustment for important confounders.

CONCLUSIONS

Breastfeeding discontinuation and cesarean section delivery were associated with PPD during the 6-month postpartum period. Our results support the implementation of breastfeeding promoting policies, and PPD screening and treatment programs during the early postpartum period.

Health status and quality of life in postpartum women: a systematic review of associated factors

Since health care is becoming more and more patient centered, patient-reported outcomes such as quality of life (QOL) and health status (HS) are becoming increasingly important. The aim of this systematic review was to provide an overview of physical, psychological, and social domains of QOL and HS in postpartum women, and to assess which factors are associated with QOL and HS domains postpartum. A computerized literature search was performed using the PubMed, PsycINFO, and Cochrane databases. Studies were selected if the three domains of QOL or HS were measured in a (sub)group of postpartum women, by using validated standardized questionnaires. The methodological quality of the 66 included studies was examined by two independent reviewers. All three domains of QOL were impaired in postpartum women with urinary incontinence, with even worse QOL in women with mixed urinary incontinence. Mental QOL was impaired in women with urge urinary incontinence after cesarean section. Social QOL was decreased in HIV-positive women. HS was impaired in all three domains in postpartum depressed women. Physical HS was impaired after cesarean section for at least two months postpartum. Additional supportive interventions from health care social support were not associated with improved HS. Urinary incontinence and being HIV-positive seemed to be associated with impaired QOL. Postpartum depression and a cesarean section seemed to be associated with impaired HS. Prospective longitudinal research is needed in order to draw valid conclusions regarding postpartum HS and QOL, and the predictive value of the associated factors.

Clinical guidelines for postpartum women and infants in primary care-a systematic review

Background

While many women and infants have an uneventful course during the postpartum period, others experience significant morbidity. Effective postpartum care in the community can prevent short, medium and long-term consequences of unrecognised and poorly managed problems. The use of rigorously developed, evidence-based guidelines has the potential to improve patient care, impact on policy and ensure consistency of care across health sectors. This study aims to compare the scope and content, and assess the quality of clinical guidelines about routine postpartum care in primary care.

Methods

PubMed, the National Guideline Clearing House, Google, Google Scholar and relevant college websites were searched for relevant guidelines. All guidelines regarding routine postpartum care published in English between 2002 and 2012 were considered and screened using explicit selection criteria. The scope and recommendations contained in the guidelines were compared and the quality of the guidelines was independently assessed by two authors using the AGREE II instrument.

Results

Six guidelines from Australia (2), the United Kingdom (UK) (3) and the United States of America (USA) (1), were included. The scope of the guidelines varied greatly. However, guideline recommendations were generally consistent except for the use of the Edinburgh Postnatal Depression Scale for mood disorder screening and the suggested time of routine visits. Some recommendations lacked evidence to support them, and levels or grades of evidence varied between guidelines. The quality of most guidelines was adequate. Of the six AGREE II domains, applicability and editorial independence scored the lowest, and scope, purpose and clarity of presentation scored the highest.

Conclusions

Only one guideline provided comprehensive recommendations for the care of postpartum women and their infants. As well as considering the need for region specific guidelines, further research is needed to strengthen the evidence supporting recommendations made within guidelines. Further improvement in the editorial independence and applicability domains of the AGREE ll criteria would strengthen the quality of the guidelines.

Prediction of maternal quality of life on preterm birth and low birthweight: a longitudinal study

Background

Preterm birth is a significant cause of newborn morbidity and mortality and strains society’s healthcare resources due to its long-term effects on the health of the newborn. Prenatal maternal quality of life (QoL) may be related to the occurrence of preterm birth and low birthweight infants. Few studies, however, have investigated maternal QoL, especially throughout the continuum of pregnancy and the immediate postpartum period. Therefore, the purposes of this longitudinal study were to measure the levels of QoL during and immediately after pregnancy in women with uncomplicated pregnancies, investigate the relationships between the dimensions of QoL, and determine whether prenatal QoL can predict preterm birth and low birthweight.

Methods

Using convenience sampling in one hospital in Taiwan, we recruited 198 pregnant women without pregnancy complications after 24 gestational weeks and followed up monthly until one-month postpartum. The Duke Health Profile was used to measure QoL. Data were analyzed using descriptive statistics, the Mann–Whitney U test, the Kruskal-Wallis test, generalized estimation equations, Pearson correlations, and hierarchical logistic regression.

Results

Pregnant women did not perceive that they had a high level of QoL. Women at late pregnancy experienced a significant decrease in their level of physical and general health. After childbirth, although the mothers had better physical health, they had poorer social health. Poor QoL at late pregnancy predicted preterm birth. Employment, parity, educational level, and happiness about pregnancy were related to prenatal maternal QoL; employment was a factor related to postpartum maternal QoL.

Conclusions

Early assessment of QoL, including its dimensions, of pregnant women may help us to understand women’s health status. Based on this understanding, healthcare professionals can develop interventions to promote pregnant women’s QoL and to lessen the occurrence of preterm birth and low birthweight infants. Further, an emphasis on the positive aspects of pregnancy may increase maternal QoL.

Outcomes from implementing systematic antepartum depression screening in obstetrics

This study was developed to evaluate the feasibility of implementing systematic depression screening in a large obstetric practice and to evaluate the degree that detection and referral led to linkage with behavioral healthcare. Depression screening was conducted using the Edinburgh Postnatal Depression Scale, administered at the initial pregnancy care appointment. Patients at or above a predetermined score of 14 were advised to seek further behavioral health assessment through the patient's behavioral healthcare coverage. Within 4 weeks of screening, those referred were contacted by telephone, by clinic staff, to determine whether they had pursued behavioral healthcare as recommended. Limited available data for newly established postdelivery screening were similarly evaluated. All 2,199 newly presenting pregnant women who were seen in our obstetric clinics from September 2008 to May 2009 were screened for depression, and 102 (4.6%) scored at or above an EPDS of 14. Follow-up calls revealed that none had pursued further behavioral health assessments. Of these 2,199, screening and follow-up data were available for 569 women at their 6-week postdelivery visit. Of these, 28 (4.9%) were above EPDS of 14, and 5 (17.9%) reported pursuit of further behavioral healthcare following screening and referral. Peripartum depression can be addressed with systematic screening, and the electronic medical record can readily be used to monitor results. Detection and referral at the beginning of pregnancy did not lead to intended linkage with behavioral healthcare, but detection and referral postdelivery had a modest influence. Barriers to pursuing behavioral healthcare need to be discovered and addressed.

Association between perinatal depression in mothers and the risk of childhood infections in offspring: a population-based cohort study

Background

Previous studies have suggested that children of mothers who experience depression during the perinatal period may have more infections, but such studies are few in number and none have been carried out in the United Kingdom (UK) population. The aim of this study was to investigate the association between perinatal depression in mothers and the risk of childhood infections in offspring in the UK general population.

Methods

We used data from The Health Improvement Network (THIN), a large database of electronic primary care medical records to conduct a cohort study among all first-born singleton children born and enrolled in THIN between 1988 and 2004. We used Poisson regression to compare the incidence of gastrointestinal infections and lower respiratory tract infections reported between birth and age 4 years among children of mothers with a record of perinatal depression with those born to mothers with no such history.

Results

Children of mothers with perinatal depression had a 40% increased risk of gastrointestinal infections and a 27% increased risk of lower respiratory tract infections compared with children of mothers without perinatal depression (incidence rate ratios = 1.40 and 1.27; 95% confidence intervals 1.37-1.42 and 1.22-1.32, respectively). On restricting to antibiotic-treated infections there was a slight increase in the magnitude of association with gastrointestinal infections but a decrease in that with lower respiratory tract infections (incidence rate ratios = 1.47 and 1.19; 95% confidence intervals 1.34-1.61 and 1.11-1.27, respectively).

Conclusions

Maternal perinatal depression is associated with increased rates of childhood gastrointestinal infections, particularly more severe infections, and lower respiratory tract infections in the UK. Preventing maternal perinatal depression may avoid substantial morbidity among offspring, although further work is also needed to investigate the detailed reasons for these findings.

Impact of maternal anxiety level on the childhood vaccination coverage

The mother's mental state as a risk factor for the children's vaccination status in developing countries has received little attention. The aim of this study was to determine the association between childhood vaccination coverage and maternal anxiety. A total of 195 consecutive infants and their mothers attending a tertiary teaching hospital, department of pediatric outpatient center between January 2008 and September 2009 were included in the study. One hundred five infants who have incomplete vaccination schedule (according to the National Immunization Schedule) were matched with 90 controls (fully vaccinated) and their mothers self-report measure of anxiety level using the State-Trait Anxiety Inventory (STAI), a psychiatric screening instrument. The chi-square test and the logistic regression were used in the statistical analysis. High maternal anxiety levels determined by STAI was associated with increased risk of incomplete vaccination status in infants (odds ratio 4.35, 95% confidence interval 1.87-8.79).This association remained significant after controlling for sociodemographic factors. High maternal anxiety scores may result in incomplete vaccination status in children younger than 3 years.

No health without mental health

About 14% of the global burden of disease has been attributed to neuropsychiatric disorders, mostly due to the chronically disabling nature of depression and other common mental disorders, alcohol-use and substance-use disorders, and psychoses. Such estimates have drawn attention to the importance of mental disorders for public health. However, because they stress the separate contributions of mental and physical disorders to disability and mortality, they might have entrenched the alienation of mental health from mainstream efforts to improve health and reduce poverty. The burden of mental disorders is likely to have been underestimated because of inadequate appreciation of the connectedness between mental illness and other health conditions. Because these interactions are protean, there can be no health without mental health. Mental disorders increase risk for communicable and non-communicable diseases, and contribute to unintentional and intentional injury. Conversely, many health conditions increase the risk for mental disorder, and comorbidity complicates help-seeking, diagnosis, and treatment, and influences prognosis. Health services are not provided equitably to people with mental disorders, and the quality of care for both mental and physical health conditions for these people could be improved. We need to develop and evaluate psychosocial interventions that can be integrated into management of communicable and non-communicable diseases. Health-care systems should be strengthened to improve delivery of mental health care, by focusing on existing programmes and activities, such as those which address the prevention and treatment of HIV, tuberculosis, and malaria; gender-based violence; antenatal care; integrated management of childhood illnesses and child nutrition; and innovative management of chronic disease. An explicit mental health budget might need to be allocated for such activities. Mental health affects progress towards the achievement of several Millennium Development Goals, such as promotion of gender equality and empowerment of women, reduction of child mortality, improvement of maternal health, and reversal of the spread of HIV/AIDS. Mental health awareness needs to be integrated into all aspects of health and social policy, health-system planning, and delivery of primary and secondary general health care.

Detection of maternal alcohol use problems in the pediatric emergency department

BACKGROUND

Maternal alcohol use problems may impact the health and well-being of children, but often remain unrecognized. Mothers of young children seldom seek outpatient care for themselves; thus, pediatric settings may present an opportunity for the detection of maternal alcohol use problems. This study examines the feasibility of screening for and prevalence of alcohol use problems in mothers of young children in the context of seeking pediatric emergency care. We also examined the relationship of maternal alcohol use problems with use of pediatric emergency care.

METHODS

A total of 361 English-speaking mothers of children aged 7 and younger completed screening measures during their child's emergency care visit. TWEAK was used to screen for alcohol use problems. The screening survey also included information on children's health status and health care use, demographics, and the Center for Epidemiological Studies Depression Scale.

RESULTS

Of the women approached, 90% agreed to complete the screening measure. On the basis of cutoff score of 2 or more, 7% of women had elevated TWEAK scores. Those women with a TWEAK score > 2 reported greater use of the pediatric emergency department (PED) than women scoring below the cutoff. On the basis of multivariate analyses, significant predictors of recent PED use included the presence of child chronic illness, younger maternal age, and TWEAK score.

CONCLUSIONS

Screening for alcohol use problems among mothers of young children using the TWEAK appears to be feasible in a busy PED setting. The PED setting is promising for identifying risk drinking among women who may be less likely to be otherwise detected and for whom alcohol use may be impacting child outcomes.

Continuing education module: postpartum maternal health care in the United States: a critical review

Postpartum maternal health care is a neglected aspect of women's health care. This neglect is evident in the limited national health objectives and data related to maternal health. Missed opportunities for enhancing the health care of postpartum women occur in the scope of routine postpartum care. Differing perceptions of maternal needs between nurses and new mothers also contribute to inadequate health care. Therefore, collecting national data on postpartum maternal morbidity, reforming postpartum care policies, providing holistic and flexible maternal health care, encouraging family support and involvement in support groups, and initiating educational programs are recommended. Further research is needed on issues related to postpartum maternal health.