Postpartum emotional distress: a controlled study of Nigerian women after caesarean childbirth

Safe recovery after cesarean in rural Africa: Technical consensus guidelines for post-discharge care

Despite increasing cesarean rates in Africa, there remain extensive gaps in the standard provision of care after cesarean birth. We present recommendations for discharge instructions to be provided to women following cesarean delivery in Rwanda, particularly rural Rwanda, and with consideration of adaptable guidelines for sub-Saharan Africa, to support recovery during the postpartum period. These guidelines were developed by a Technical Advisory Group comprised of clinical, program, policy, and research experts with extensive knowledge of cesarean care in Africa. The final instructions delineate between normal and abnormal recovery symptoms and advise when to seek care. The instructions align with global postpartum care guidelines, with additional emphasis on care practices more common in the region and address barriers that women delivering via cesarean may encounter in Africa. The recommended timeline of postpartum visits and visit activities reflect the World Health Organization protocols and provide additional activities to support women who give birth via cesarean. These guidelines aim to standardize communication with women at the time of discharge after cesarean birth in Africa, with the goal of improved confidence and clinical outcomes among these individuals.

Discharge instructions given to women following delivery by cesarean section in Sub-Saharan Africa: A scoping review

OBJECTIVE

A scoping review of discharge instructions for women undergoing cesarean section (c-section) in sub-Saharan Africa (SSA).

METHOD

Studies were identified from PubMed, Globus Index Medicus, NiPAD, EMBASE, and EBSCO databases. Eligible papers included research based in a SSA country, published in English or French, and containing information on discharge instructions addressing general postnatal care, wound care, planning of future births, or postpartum depression targeted for women delivering by c-section. For analysis, we used the PRISMA guidelines for scoping reviews followed by a narrative synthesis. We assessed quality of evidence using the GRADE system.

RESULTS

We identified 78 eligible studies; 5 papers directly studied discharge protocols and 73 included information on discharge instructions in the context of a different study objective. 37 studies addressed wound care, with recommendations to return to a health facility for dressing changes and wound checks between 3 days to 6 weeks. 16 studies recommended antibiotic use at discharge, with 5 specifying a particular antibiotic. 19 studies provided recommendations around contraception and family planning, with 6 highlighting intrauterine device placement immediately after birth or 6-weeks postpartum and 6 studies discussing the importance of counselling services. Only 5 studies provided recommendations for the evaluation and management of postpartum depression in c-section patients; these studies screened for depression at 4-8 weeks postpartum and highlighted connections between c-section delivery and the loss of self-esteem as well as connections between emergency c-section delivery and psychiatric morbidity.

CONCLUSION

Few studies in SSA directly examine discharge protocols and instructions for women following c-section. Those available demonstrate wide variation in recommendations. Research is needed to develop structured evidence-based instructions with clear timelines for women. These instructions should account for financial burden, access to resources, and education of patients and communities.

Perinatal Mental Health Problems in Rural China: The Role of Social Factors

Background: Perinatal mental health is important for the well-being of the mother and child, so the relatively high prevalence of perinatal mental health problems in developing settings poses a pressing concern. However, most studies in these settings focus on the demographic factors associated with mental health problems, with very few examing social factors. Hence, this study examines the prevalence of the depressive, anxiety and stress symptoms among pregnant women and new mothers in rural China, and the associations between these mental health problems and social factors, including decision-making power, family conflicts, and social support. Methods: Cross-sectional data were collected from 1,027 women in their second trimester of pregnancy to 6 months postpartum in four low-income rural counties in Sichuan Province, China. Women were surveyed on symptoms of mental health problems using the Depression, Anxiety, and Stress Scale (DASS-21) and social risk factors. Multivariate logistic regression analyses were conducted to examine social risk factors associated with maternal mental health problems, with results reported as odds ratios (OR) and 95% confidence intervals (CI). Results: Among all respondents, 13% showed symptoms of depression, 18% showed symptoms of anxiety, 9% showed symptoms of stress, and 23% showed symptoms of any mental health problem. Decision-making power was negatively associated with showing symptoms of depression (OR = 0.71, CI: 0.60-0.83, p < 0.001) and stress (OR = 0.76, CI: 0.63-0.90, p = 0.002). Family conflict was positively associated with depression (OR = 1.53, CI: 1.30-1.81, p < 0.001), anxiety (OR = 1.34, CI: 1.15-1.56, p < 0.001), and stress (OR = 1.68, CI: 1.41-2.00, p < 0.001). In addition, social support was negatively associated with depression (OR = 0.56, CI: 0.46-0.69, p < 0.001), anxiety (OR = 0.76, CI: 0.63-0.91, p = 0.002), and stress (OR = 0.66, CI: 0.53-0.84, p < 0.001). Subgroup analyses revealed that more social risk factors were associated with symptoms of anxiety and stress among new mothers compared to pregnant women. Conclusion: Perinatal mental health problems are relatively prevalent among rural women in China and are strongly associated with social risk factors. Policies and programs should therefore promote individual coping methods, as well as target family and community members to improve the social conditions contributing to mental health problems among rural women.

"I felt like I was left on my own": A mixed-methods analysis of maternal experiences of cesarean birth and mental distress in the United States

BACKGROUND

Postpartum depression (PPD) is the most common complication of childbearing. Understanding potential contributors, such as cesarean deliveries, is essential to improving maternal mental health. This study investigated the relationship between unplanned versus planned cesarean birth and postpartum depressive symptoms.

METHODS

We employed a sequential, mixed-methods approach wherein the Edinburgh Postnatal Depression Scale (EPDS) was first administered to participants who had experienced a cesarean birth within the previous 12 months. EPDS scores among those in the unplanned vs. planned cesarean groups were compared by means of SPSS. Twenty-five participants with EPDS scores >8 were then interviewed to provide subjective measures of maternal well-being. Interview data were subjected to thematic qualitative analysis using a modified grounded theory approach.

RESULTS

The average EPDS score from 120 participants with unplanned cesareans was 10.7 ± 6.4, with 68.5% scoring >8. The average EPDS score from 93 participants with planned cesarean births was 8.96 ± 5.7, with 52.7% scoring >8. The difference in mean score was statistically significant (P < 0.05). Interview findings revealed several important themes including: support, medical interaction, stress, recovery, breastfeeding, and sleep. In several cases, participants were not properly screened, or screening tool responses were ignored. Numerous participants reported medical interactions where they felt ignored by practitioners, including one interviewee who stated, "I got my tubes tied because it was so traumatizing that I never wanted to give birth again."

DISCUSSION

Findings suggest that unplanned cesareans have a higher incidence and severity of postpartum depressive symptoms. Interview analyses highlight important areas for improvement and concern about the current state of postpartum mental health care and physician-guided supports in this US sample.

Maternal mental health and child well-being in Nigeria: A systematic review

Maternal mental health distress has a disease burden of severe adverse effects for both mother and child. This review identified maternal mental health concerns, their impact on child growth and the current practice of maternal healthcare for both mothers and their children in Nigeria. The Population, phenomenon of Interest and Context (PICo) model was adopted to formulate the review strategy, and five databases were searched for published articles between 1999 and 2019. Databases include Scopus, PubMed, ProQuest, Applied Social Science Index and Abstracts and Web of Science. Boolean operators (AND/OR/NOT) helped to ensure rigorous use of search terms which include 'maternal', 'pre/peri/postnatal', 'mental health', 'mental illness', 'disorders', 'intervention,' 'Nigeria', 'child', 'infant growth', and 'wellbeing'. Thirty-four studies met the inclusion criteria, and extracted data were qualitatively synthesised and analysed thematically. Five themes emerged. These include (i) marital difficulties, (ii) relationship status of the mother, (iii) child's gender, (iv) mode of child delivery and (v) child growth and development. The review showed a significant paucity of literature on the impact of specific maternal mental health problems on child physical growth and cognitive development. We concluded that culturally appropriate and evidence-based psychological interventions for maternal mental health problems would benefit Nigerian indigenous mothers. Therefore, the study recommends randomised controlled trials that are culturally appropriate and cost-effective for distressed mothers with children.

Women's psychosocial outcomes following an emergency caesarean section: A systematic literature review

Background

Given the sudden and unexpected nature of an emergency caesarean section (EmCS) coupled with an increased risk of psychological distress, it is particularly important to understand the psychosocial outcomes for women. The aim of this systematic literature review was to identify, collate and examine the evidence surrounding women’s psychosocial outcomes of EmCS worldwide.

Methods

The electronic databases of EMBASE, PubMed, Scopus, and PsycINFO were searched between November 2017 and March 2018. To ensure articles were reflective of original and recently published research, the search criteria included peer-reviewed research articles published within the last 20 years (1998 to 2018). All study designs were included if they incorporated an examination of women’s psychosocial outcomes after EmCS. Due to inherent heterogeneity of study data, extraction and synthesis of both qualitative and quantitative data pertaining to key psychosocial outcomes were organised into coherent themes and analysis was attempted.

Results

In total 17,189 articles were identified. Of these, 208 full text articles were assessed for eligibility. One hundred forty-nine articles were further excluded, resulting in the inclusion of 66 articles in the current systematic literature review. While meta-analyses were not possible due to the nature of the heterogeneity, key psychosocial outcomes identified that were negatively impacted by EmCS included post-traumatic stress, health-related quality of life, experiences, infant-feeding, satisfaction, and self-esteem. Post-traumatic stress was one of the most commonly examined psychosocial outcomes, with a strong consensus that EmCS contributes to both symptoms and diagnosis.

Conclusions

EmCS was found to negatively impact several psychosocial outcomes for women in particular post-traumatic stress. While investment in technologies and clinical practice to minimise the number of EmCSs is crucial, further investigations are needed to develop effective strategies to prepare and support women who experience this type of birth.

Massage as adjuvant therapy in the management of post-cesarean pain and anxiety: A randomized clinical trial

OBJECTIVE

The present study was conducted to determine the effect of massage on post-cesarean pain and anxiety.

METHODS

The present single-blind clinical trial was conducted on 156 primiparous women undergone elective cesarean section. The participants were randomly divided into three groups, including a hand and foot massage group, a foot massage group and a control group (n = 52 per group). The patients' intensity of pain, vital signs and anxiety level were measured before, immediately after and 90 min after the massage.

RESULTS

A significant reduction was observed in the intensity of pain immediately and 90 min after massage (P < 0.001). Moreover, changes in some of the physiological parameters, including blood pressure and respiration rate, were significant after massage (P < 0.001); however, this change was not significant for pulse rate. A significant reduction was also observed in the level of anxiety (P < 0.001) and a significant increase in the frequency of breastfeeding (P < 0.001) after massage.

CONCLUSION

As an effective nursing intervention presenting no side-effects, hand and foot massage can be helpful in the management of postoperative pain and stress.

Risk factors affecting child cognitive development: a summary of nutrition, environment, and maternal-child interaction indicators for sub-Saharan Africa

An estimated 200 million children worldwide fail to meet their development potential due to poverty, poor health and unstimulating environments. Missing developmental milestones has lasting effects on adult human capital. Africa has a large burden of risk factors for poor child development. The objective of this paper is to identify scope for improvement at the country level in three domains--nutrition, environment, and mother-child interactions. We used nationally representative data from large-scale surveys, data repositories and country reports from 2000 to 2014. Overall, there was heterogeneity in performance across domains, suggesting that each country faces distinct challenges in addressing risk factors for poor child development. Data were lacking for many indicators, especially in the mother-child interaction domain. There is a clear need to improve routine collection of high-quality, country-level indicators relevant to child development to assess risk and track progress.

Mode of delivery and postpartum depression: the role of patient preferences

OBJECTIVE

The purpose of this study was to explore the relationship between strength of preference for vaginal delivery, delivery mode undergone, and postpartum depression.

STUDY DESIGN

We conducted a secondary analysis of data from a longitudinal study of delivery-mode preferences. During an interview between 24-36 weeks of gestation, participants were asked whether they preferred vaginal or cesarean delivery; the strength of this preference was measured by the standard gamble metric. Depression was assessed antepartum and at 8-10 weeks and 6-8 months after delivery by using the Patient Health Questionnaire (PHQ-9). The primary outcome was PHQ-9 score at 8-10 weeks after delivery. We used multivariable regression analysis to assess the effect of strength of preference for vaginal delivery and delivery mode undergone on postpartum depression.

RESULTS

Of 160 participants, 33.1% were nulliparous, and 30.6% had a previous cesarean delivery. Most of the participants (92.4%) preferred vaginal delivery, but the strength of preference varied substantially. The mean strength-of-preference score (0-1 scale; higher scores denote stronger vaginal delivery preference) was 0.658 (SD, ±0.352). A significant interaction emerged between the effects of delivery mode and vaginal delivery preference score on postpartum PHQ-9 score (P = .047). Specifically, a stronger preference for vaginal delivery was associated with higher PHQ-9 scores among women who underwent cesarean delivery (P = .027) but not among women who underwent vaginal delivery (P = .761). The interaction between delivery mode and vaginal delivery preference score was no longer significant at 6-8 months after delivery.

CONCLUSION

Women who have a strong antepartum preference for vaginal delivery and deliver by cesarean may be at increased risk for depression in the early postpartum period.

The effect of educational intervention on prevention of postpartum depression: an application of health locus of control

AIMS AND OBJECTIVES

To assess the effectiveness of application of health locus of control in pregnant women for prevention of postpartum depression in Iran.

BACKGROUND

Nearly 10-15% of women suffer postnatal depression by the end of the second week after delivery, which creates problems in caring for the child that may affect child's future learning and concentration.

DESIGN

Pre-post experimental design.

METHODS

Two hundred and thirty volunteer women were randomly divided into experimental and control groups. The data collection tools included a demographic questionnaire, the Multidimensional Health Locus of Control Scale and the Edinburg Depression Scale. Based on the associations found in the pretest, intervention programme was planned and carried out in the focused group discussion method. Data were collected after the end of scheduled sessions, immediately and one month later. The data were analysed with SPSS-16 using statistical methods including anova, chi-square test, Student's t-test and paired t-test.

RESULTS

Chance health locus of control significantly reduced and internal health locus of control significantly increased, immediately after intervention. Also, a month after intervention, a significant difference was observed between the two groups in reducing postpartum depression.

CONCLUSIONS

The planned participatory intervention led to empowerment and increased awareness and internalisation of health control beliefs and less tendency towards external health control beliefs, especially chance, improvement in general health leading to improved psychological health for prevention of postpartum depression in mothers.

RELEVANCE TO CLINICAL PRACTICE

Clinicians might assess chance and internal health locus of control to identify the women at risk of developing depression during their pregnancy and to develop prevention and treatment plans.

Effect of mode of delivery on postpartum depression in Iranian women

AIM

The aim of this study was to determine the relation between mode of delivery (cesarean section [CS] or unassisted vaginal delivery) and postpartum depression (PPD).

MATERIAL AND METHODS

In a prospective study, 300 women who had experienced vaginal delivery (VD) or CS were recruited in Kashan, Iran. PPD was measured using the Edinburgh Postnatal Depression Scale (EPDS). A score of 13 or more was defined as PPD. Data collection was conducted at two assessment points: 2 months and 4 months postpartum. Mean scores of EPDS and PPD were compared between the VD and CS groups.

RESULTS

Differences in mean scores of EPDS between CS (n = 150) and VD (n = 150) groups at the first and the second assessments were not significant. The depression mean scores differences from the first to the second assessment were compared between the two groups; VD group showed more decrease on EPDS score (P = 0.006). Comparing the two assessments, the VD group showed a more decreased EPDS from the first to the second one. PPD prevalence rates (score ≥ 13) among the VD and CS groups were 24% and 20.7% for the first and 14.7% and 16.7% for the second assessment, respectively, which were not significantly different. The logistic regression showed that an unwanted pregnancy and PPD 2 months after delivery were determinants for PPD 4 months after delivery.

CONCLUSION

There was no relation between delivery mode and PPD at 2 and 4 months after delivery; however, the VD group showed greater decrease in EPDS score from 2 to 4 months after delivery.

Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review

OBJECTIVE

To review the evidence about the prevalence and determinants of non-psychotic common perinatal mental disorders (CPMDs) in World Bank categorized low- and lower-middle-income countries.

METHODS

Major databases were searched systematically for English-language publications on the prevalence of non-psychotic CPMDs and on their risk factors and determinants. All study designs were included.

FINDINGS

Thirteen papers covering 17 low- and lower-middle-income countries provided findings for pregnant women, and 34, for women who had just given birth. Data on disorders in the antenatal period were available for 9 (8%) countries, and on disorders in the postnatal period, for 17 (15%). Weighted mean prevalence was 15.6% (95% confidence interval, CI: 15.4-15.9) antenatally and 19.8% (19.5-20.0) postnatally. Risk factors were: socioeconomic disadvantage (odds ratio [OR] range: 2.1-13.2); unintended pregnancy (1.6-8.8); being younger (2.1-5.4); being unmarried (3.4-5.8); lacking intimate partner empathy and support (2.0-9.4); having hostile in-laws (2.1-4.4); experiencing intimate partner violence (2.11-6.75); having insufficient emotional and practical support (2.8-6.1); in some settings, giving birth to a female (1.8-2.6), and having a history of mental health problems (5.1-5.6). Protective factors were: having more education (relative risk: 0.5; P = 0.03); having a permanent job (OR: 0.64; 95% CI: 0.4-1.0); being of the ethnic majority (OR: 0.2; 95% CI: 0.1-0.8) and having a kind, trustworthy intimate partner (OR: 0.52; 95% CI: 0.3-0.9).

CONCLUSION

CPMDs are more prevalent in low- and lower-middle-income countries, particularly among poorer women with gender-based risks or a psychiatric history.

Postnatal depression and its effects on child development: a review of evidence from low- and middle-income countries

INTRODUCTION OR BACKGROUND

It is well established that postnatal depression (PND) is prevalent in high-income countries and is associated with negative personal, family and child developmental outcomes.

SOURCES OF DATA

Here, studies on the prevalence of maternal PND in low- and middle-income countries are reviewed and a geographical prevalence map is presented. The impact of PND upon child outcomes is also reviewed.

AREAS OF AGREEMENT

The available evidence suggests that rates of PND are substantial, and in many regions, are higher than those reported for high-income countries. An association between PND and adverse child developmental outcomes was identified in many of the countries examined.

AREAS OF CONTROVERSY

Significant heterogeneity in prevalence rates and impact on child outcomes across studies means that the true extent of the disease burden is still unclear.

AREAS TIMELY FOR DEVELOPING RESEARCH

Nonetheless, there is a compelling case for the implementation of interventions to reduce the impact of PND on the quality of the mother-infant relationship and improve child outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

The effect of caesarean section on self-esteem amongst primiparous women in South-Western Nigeria: a case-control study

OBJECTIVE

This study aims to assess the level of self-esteem of newly delivered mothers who had caesarean section (CS) and evaluate the sociodemographic and obstetrics correlates of low self-esteem in them.

METHODS

Newly delivered mothers who had CS (n = 109) and who had spontaneous vaginal delivery (SVD) (n = 97) completed questionnaires on sociodemographic and obstetrics variables within 1 week of delivery. They also completed the Rosenberg self-esteem scale. RESULTS. Women with CS had statistically significant lower scores on the self-esteem scale than women with SVD (p = 0.006). Thirty (27.5%) of the CS group were classified as having low self-esteem compared with 11 (11.3%) of the SVD group (p = 004). The correlates of low self-esteem in the CS group included polygamy (odd ratio (OR) 4.99, 95% confidence interval (95% CI) 1.62-15.33) and emergency CS (OR 4.66, 95% CI 1.55-16.75).

CONCLUSIONS

CS in South-Western Nigerian women is associated with lowered self-esteem in the mothers.