Health insurance status and mood during pregnancy and following birth: a longitudinal study of multiparous women

Prevalence of Postpartum Depression and Associated Predictors Among Taiwanese Women in a Mother-Child Friendly Hospital

Postpartum depression (PPD) is a highly prevalent disorder characterized by increased vulnerability to morbidity and mortality. This study explores the predictors and prevalence of PPD among Taiwanese women. A total of 914 postpartum women was recruited from a mother-child-friendly hospital. These participants completed self-report questionnaires at 1 month postpartum, and their medical records were also examined for relevant information. Multivariate analyses were used to identify independent predictors of PPD. At 1 month postpartum, 18.8% had developed PPD. Multivariate analysis showed that the odds ratios for PPD were significantly lower among women who were breastfeeding, had more family support, and attended a postpartum care center, while those who were younger, primiparous, and who experienced gestational complications had a higher prevalence of PPD. Meanwhile, structural equation modeling showed that family support from partners, parents, and parents-in-law diminished depression scores through direct effects.

Physical health, breastfeeding problems and maternal mood in the early postpartum: a prospective cohort study

This study aimed to investigate prospectively the contribution of maternal physical health and/or breastfeeding problems to maternal mood (depression, anxiety, fatigue, irritability, confusion, vigor) at 8-weeks postpartum. A prospective study was conducted. Participants were recruited antenatally from a public and a private maternity hospital in Melbourne, Australia. Nulliparous pregnant women (N = 229), ≥ 18 years of age, ≥ 36-week gestation, singleton pregnancy and with sufficient English were eligible. Data were collected by self-report questionnaire (pregnancy, weeks 1-4 postpartum) and telephone interview (week 8 postpartum). A high burden of physical problems was classified as ≥ 3 problems (caesarean/perineal pain; back pain; constipation; haemorrhoids; urinary and bowel incontinence) for ≥ 2 time points. A high burden of breastfeeding problems was having ≥ 2 problems (mastitis; nipple pain; frequent expressing; over- or under-supply of milk) for ≥ 2 time points. Multivariate linear regression was used to investigate the relationship between maternal mood, assessed using Profile of Mood States (8-week postpartum), and a high burden of breastfeeding and/or physical health problems. Forty-six women (20.1%) had a high burden of physical symptoms, 44 (19.2%) a high burden of breastfeeding problems only and 25 women (11.0%) had both. A high burden of breastfeeding problems alone (β = 10.6, p = 0.01) or with co-morbid physical problems (β = 15.35, p = 0.002) was significantly associated with poorer maternal mood at 8 weeks. Early, effective postnatal treatment of maternal health and breastfeeding problems could reduce women's risk for poor mental health.

Neonatal complications in public and private patients: a retrospective cohort study

OBJECTIVE

To use propensity score methods to create similar groups of women delivering in public and private hospitals and determine any differences in mode of delivery and neonatal outcomes between the matched groups.

DESIGN

Population-based, retrospective cohort study.

SETTING

Public and private hospitals in Western Australia.

PARTICIPANTS

Included were 93 802 public and 66 479 private singleton, term deliveries during 1998-2008, from which 32 757 public patients were matched with 32 757 private patients on the propensity score of maternal characteristics.

MAIN OUTCOME MEASURES

Neonatal outcomes were compared in the propensity score-matched cohorts using conditional logistic regression, adjusted for antenatal risk factors and mode of delivery. Outcomes included Apgar score <7 at 5 min, neonatal resuscitation (endotracheal intubation or external cardiac massage) and admission to a neonatal special care unit.

RESULTS

No significant differences in maternal characteristics were found between the propensity score-matched groups. Private patients were more likely than their matched public counterparts to undergo prelabour caesarean section (25.2% vs 18%, p<0.0001). Public patients had lower rates of neonatal unit admission (AOR 0.67, 95% CI 0.62 to 0.73) and neonatal resuscitation (AOR 0.73, 95% CI 0.56 to 0.95), but higher rates of low Apgar scores at 5 min (AOR 1.31, 95% CI 1.06 to 1.63) despite adjustment for antenatal factors. Additional adjustment for mode of delivery reduced the resuscitation risk (AOR 0.86, 95% CI  0.63 to 1.18) but did not significantly alter the other estimates.

CONCLUSIONS

Propensity score methods can be used to generate comparable groups of public and private patients. Despite the rates of low Apgar scores being higher in public patients, the rates of special care admission were lower. Whether these findings stem from differences in paediatric services or clinical factors is yet to be determined.

Assisted vaginal deliveries in mothers admitted as public or private patients in Western Australia

BACKGROUND

Mothers delivering as private patients in Australia have a high rate of assisted deliveries, which could lead to adverse infant outcomes in this group of patients. We investigated whether the risk of adverse infant outcomes after assisted deliveries was different for mothers admitted as public or private patients for delivery, when compared with unassisted deliveries.

METHODS AND FINDINGS

We included 158,241 vaginal, singleton, term birth admissions in our study where the infant was live born and without birth defects. The study population was identified from statutory birth and hospital data collections held by the Western Australian (WA) Department of Health. We estimated odds ratios and confidence intervals using logistic regression models adjusted for a range of maternal demographic, pregnancy and birth characteristics. Interaction was assessed by including interaction terms in the models. Outcomes included low Apgar scores at five minutes (< 7), neonatal resuscitation and special care admission. Mothers delivering as private patients had an increased risk of assisted vaginal delivery compared with public patients (adjusted OR 1.74, 95% CI  =  1.68-1.80). Compared with unassisted vaginal deliveries, assisted deliveries were associated with increased risk of Apgar scores at five minutes below 7 (OR 1.25, 1.08-1.45), neonatal resuscitation (OR  =  1.69, 1.42-2.00) and admission to special care nursery (OR  =  1.64, 1.53-1.76). The increased risk of neonatal resuscitation was higher for mothers admitted as private patients for delivery (OR  =  2.13) than public patients (OR  = 1 .55, p(interaction)  =  0.03).

CONCLUSIONS

Our results suggested that the high risk of neonatal resuscitation following assisted vaginal deliveries compared to unassisted is higher in private patients than public patients. Whether this phenomenon is due to the twofold higher rate of assisted vaginal deliveries in this group of patients or a higher rate of fetal indications for assisted vaginal delivery remains to be answered.

Age, mode of conception, health service use and pregnancy health: a prospective cohort study of Australian women

BACKGROUND

There is limited evidence about the ways in which maternal age and mode of conception interact with psychological, sociodemographic, health and health service factors in governing pregnancy health. The aim of this study was to establish in what ways maternal age and mode of conception are associated with, health behaviours, health service use and self-rated physical and mental health during pregnancy.

METHOD

A prospective cohort study was conducted in a collaboration between universities, infertility treatment services and public and private obstetric hospitals in Melbourne and Sydney, Australia,. Consecutive cohorts of nulliparous English-literate women at least 28 weeks pregnant who had conceived through ART (ARTC) or spontaneously (SC) in three age-groups: 20-30; 31-36 and at least 37 years were recruited. Data were obtained via structured individual telephone interviews and self-report postal questionnaires at recruitment and four months postpartum. Study-specific questions assessed: sociodemographic characteristics; reproductive health; health behaviours and health service use. Standardized instruments assessed physical health: SF 12 Physical Component Score (PCS) and mental health: SF12 Mental Component Score (MCS); State Trait Anxiety Inventory and Edinburgh Postnatal Depression Scale. The main outcome measures were the SF 12 PCS, SF12 MCS scores and pregnancy-related hospital admissions.

RESULTS

Of 1179 eligible women 791 (67%) participated, 27 had fertility treatment without oocyte retrieval and were excluded and 592/764 (78%) completed all pregnancy assessments. When other factors were controlled speaking a language other than English, having private health insurance and multiple gestation were associated with worse physical health and having private health insurance and better physical health were associated with better mental health. Pregnancy-related hospital admissions were associated with worse physical health and multiple gestation.

CONCLUSIONS

Maternal age and mode of conception are not associated with pregnancy health and health service use when sociodemographic factors are considered.

Neonatal outcomes after preterm birth by mothers' health insurance status at birth: a retrospective cohort study

Background

Publicly insured women usually have a different demographic background to privately insured women, which is related to poor neonatal outcomes after birth. Given the difference in nature and risk of preterm versus term births, it would be important to compare adverse neonatal outcomes after preterm birth between these groups of women after eliminating the demographic differences between the groups.

Methods

The study population included 3085 publicly insured and 3380 privately insured, singleton, preterm deliveries (32–36 weeks gestation) from Western Australia during 1998–2008. From the study population, 1016 publicly insured women were matched with 1016 privately insured women according to the propensity score of maternal demographic characteristics and pre-existing medical conditions. Neonatal outcomes were compared in the propensity score matched cohorts using conditional log-binomial regression, adjusted for antenatal risk factors. Outcomes included Apgar scores less than 7 at five minutes after birth, time until establishment of unassisted breathing (>1 minute), neonatal resuscitation (endotracheal intubation or external cardiac massage) and admission to a neonatal special care unit.

Results

Compared with infants of privately insured women, infants of publicly insured women were more likely to receive a low Apgar score (ARR = 2.63, 95% CI = 1.06-6.52) and take longer to establish unassisted breathing (ARR = 1.61, 95% CI = 1.25-2.07), yet, they were less likely to be admitted to a special care unit (ARR = 0.84, 95% CI = 0.80-0.87). No significant differences were evident in neonatal resuscitation between the groups (ARR = 1.20, 95% CI = 0.54-2.67).

Conclusions

The underlying reasons for the lower rate of special care admissions in infants of publicly insured women compared with privately insured women despite the higher rate of low Apgar scores is yet to be determined. Future research is warranted in order to clarify the meaning of our findings for future obstetric care and whether more equitable use of paediatric services should be recommended.

Subjective well-being and adaptation to life events: a meta-analysis

Previous research has shown that major life events can have short- and long-term effects on subjective well-being (SWB). The present meta-analysis examines (a) whether life events have different effects on affective and cognitive well-being and (b) how the rate of adaptation varies across different life events. Longitudinal data from 188 publications (313 samples, N = 65,911) were integrated to describe the reaction and adaptation to 4 family events (marriage, divorce, bereavement, childbirth) and 4 work events (unemployment, reemployment, retirement, relocation/migration). The findings show that life events have very different effects on affective and cognitive well-being and that for most events the effects of life events on cognitive well-being are stronger and more consistent across samples. Different life events differ in their effects on SWB, but these effects are not a function of the alleged desirability of events. The results are discussed with respect to their theoretical implications, and recommendations for future studies on adaptation are given.

Employment conditions and maternal postpartum mental health: results from the Longitudinal Study of Australian Children

Maternal postpartum mental health is influenced by a broad range of risk and protective factors including social circumstances. Forty percent of Australian women resume employment in the first year postpartum, yet poor quality employment (without security, control, flexibility or leave) has not been investigated as a potential social determinant of maternal psychological distress. This paper examines whether poor quality jobs are associated with an increased risk of maternal postpartum psychological distress. Data were collected from employed mothers of infants ≤12 months (n = 1,300) participating in the Longitudinal Study of Australian Children. Logistic regression analyses estimated the association between job quality and maternal psychological distress, adjusting for prior depression, social support, quality of partner relationship, adverse life events and sociodemographic characteristics. Only 21% of women reported access to all four optimal job conditions. After adjustment for known risk factors for poor maternal mood, mothers were significantly more likely to report psychological distress (adjusted OR = 1.39, 95% CI 1.09, 1.77) with each reduction in the number of optimal employment conditions. Interventions for maternal postpartum affective disorders are unlikely to be successful if major risk factors are not addressed. These results provide strong evidence that employment conditions are associated with maternal postpartum mood, and warrant consideration in psychosocial risk assessments and interventions.

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

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

A pilot study to reduce risk for antepartum depression among women in a public health prenatal clinic

This pilot study evaluated the feasibility, effectiveness, and helpfulness of Insight-Plus, a brief culturally-tailored cognitive behavioral intervention for African-American and Caucasian rural low-income women at risk for APD [Edinburgh Postnatal Depression Scale (EPDS) > or = 10]. Forty two percent (63/149) of women in this non-randomized study were at risk for APD and 41% (26/63) of women, who met all eligibility criteria, initially agreed to participate. Seventeen participants completed all six intervention sessions. Ninety-four percent (16/17) who completed their one-month post-intervention interviews had an antepartum recovery rate of 81% (13/16, EPDS < or = 10). Participants reported that many aspects of the program were helpful and they continued to use the intervention exercises after the sessions ended.

Understanding social support and the couple's relationship among women with depressive symptoms in pregnancy

This qualitative study explored the experiences of seven couples where the female partner experienced depressive symptoms during pregnancy. Female and male partners were interviewed together and data was collected and analyzed according to Colaizzi's ( 1978 ) phenomenological research design. The interviews yielded the following themes: (a) Challenges and stressors associated with depressive symptoms during pregnancy, (b) Pregnancy's effect on mood states, (c) Relationship dynamics that influence moods, (d) Pregnancy and the influence of mood on relationship dynamics, and (e) Reliance on external sources of support. The findings extend current research and provide insight into possibilities of how to enhance assessment and intervention for women who are depressed during pregnancy by including a relational component. Findings, clinical implications, and future research are discussed.

Antenatal mood and fetal attachment after assisted conception

OBJECTIVE

Australian women conceiving with ART are at fourfold risk of admission to early parenting treatment programs compared with those conceiving spontaneously. This study aimed to identify prevalence and determinants of antenatal mood disturbance and other risks for early parenting difficulties after assisted conception.

DESIGN

A prospective longitudinal investigation from conception to 18 months postpartum using telephone interviews and self-report questionnaires.

SETTING

Melbourne IVF and Royal Women's Hospital Reproductive Services, Victoria, Australia.

PATIENT(S)

A consecutive cohort of English-speaking women with ultrasound-confirmed ART-conceived pregnancies.

MAIN OUTCOME MEASURE(S)

Standardized psychometric measures of mood, quality of marital relationship, mother-to-fetus emotional attachment, and personality.

INTERVENTION(S)

None.

RESULT(S)

Of the 288 women with confirmed pregnancies, 239 were contactable, and 183 (77%) were recruited, 95% of whom completed both early and late pregnancy assessments. Participants were socioeconomically advantaged, had very good pregnancy health, exceptional marital relationships, normal personality styles, and intense affectionate attachment to the fetus. Very few (<5%) had clinically significant mood disturbance in late pregnancy.

CONCLUSION(S)

There were low rates of antenatal mood disturbance and other risk factors for postpartum depression. Pregnancy and motherhood might be idealized after ART conception, and preparation for the realities of infant care might then be insufficient.

Employee entitlements during pregnancy and maternal psychological well-being

BACKGROUND

Antenatal psychological well-being is multifactorially determined, including by social circumstances. Evidence suggests that workplace conditions are salient determinants of mental health, but it is not known whether employment conditions influence antenatal psychological well-being.

AIMS

To investigate the relationship between employment conditions and antenatal psychological well-being in Australian women.

METHODS

A sociodemographically diverse consecutive cohort of employed nulliparous women was recruited in late pregnancy. Data were collected by a structured interview assessing sociodemographic characteristics, employment arrangements, experience of pregnancy-related discrimination, and access to maternity leave entitlements. Participants completed two standardised psychometric measures of maternal mood: the Edinburgh Depression Scale (EDS) and the Profile of Mood States (PoMS). Comparisons of self-reported mood were made between women by experience of workplace adversity, using a composite measure of workplace events.

RESULTS

Of 205 eligible women, 165 agreed to participate. Of these, 114 of 165 (69%) reported at least one form of workplace adversity during pregnancy. More women without private health insurance (78%) reported workplace adversity than those who were privately insured (57%) (chi2(1)=6.95, P=0.008). Women experiencing workplace adversity had significantly worse psychological well-being as indicated by the EDS score (7.7+/-5.1) than those who were experiencing no workplace adversity (5.5+/-3.4), mean difference (95% CI)=-2.2 (-3.7 to -0.8), P=0.003. Similar results were reported for the PoMS.

CONCLUSIONS

Workplace adversity during pregnancy is associated with poorer maternal psychological well-being. Workplace conditions and entitlements are salient factors for consideration in assessments of antenatal psychosocial well-being.

When giving life starts to take the life out of you: women's experiences of depression after childbirth

OBJECTIVE

To capture the missing voices of mothers who are suffering postnatal depression.

DESIGN

Qualitative methodology using in-depth interviews.

SETTING

Melbourne, Victoria, Australia.

PARTICIPANTS

10 women who had been clinically diagnosed and admitted to a large hospital mother and baby unit in Australia.

FINDINGS

Stigma is frequently attached to women who are unhappy after the birth of their child, because they are not coping with the demands of motherhood or do not instantly bond with, and love, their baby. As a result, postnatal depression can be a terrifying and isolating experience for women. It is also a complex illness with varying degrees, reasons for onset and medical treatments.

IMPLICATIONS FOR PRACTICE

In this study, we have captured the emotions and feelings of women first hand, allowing us and health-care practitioners who are treating women to truly understand this debilitating illness. It is hoped that, in making the wider community aware of depression after childbirth, fewer women will suffer in silence.

Prevalence of mood symptoms and depressions during pregnancy: implications for clinical practice and research

A review of the literature demonstrates that the incidence of new mental disorders and their prevalence during pregnancy is similar to the 12-month incidence of mental disorders in women during other periods of their lives. The prevalence of severe mood, behavior, and cognitive symptoms during pregnancy is rather high. Severe mental symptoms during pregnancy have been reported to be associated with an increased rate of complications during pregnancy and delivery, preterm deliveries, low birth weight, a higher rate of postpartum depression, and a longer-term impact on the offspring's development. Several pre-pregnancy risk factors to develop dysphoric symptoms have been reported, but their utility for primiparous women with no previous history of mental disorders is unclear. The association of mental symptoms with general symptoms and biological changes during pregnancy is also unclear. Given the short- and long-term impact of dysphoric symptoms and stress during pregnancy on mother and child, efficacious, efficient, and safe prevention and treatment modalities are essential and achievable. Clarification of the nature and phenotyping of mental and general symptoms during pregnancy is an important step for the development of effective interventions.