Contextual Assessment of the Maternity Experience: development of an instrument for cross-cultural research

Partner support for women's antidepressant treatment and its association with depressive symptoms in pregnant women, mothers, and women planning pregnancy

PURPOSE

To examine the association between partner support for women's antidepressant treatment and depressive symptoms in pregnant women, those planning pregnancy, and mothers who ever used antidepressants.

METHODS

We included 334 women (n=44 planners, n=182 pregnant, n=108 mothers) ever treated with antidepressants within the HEALTHx2 study, a web-based cross-sectional study conducted across Norway in June 2020 to June 2021. The Edinburgh Postnatal Depression Scale and two questions of the Patient Health Questionnaire measured depressive symptoms, by degree of severity and for depressed mood, anxiety, and anhedonia sub-dimensions. Partner support was measured using one item from the Antidepressant Compliance Questionnaire. Association was estimated via unadjusted and adjusted linear and logistic regression models.

RESULTS

Being unsupported by the partner was associated with increased odds of reporting moderate-to-very-severe depressive symptoms in mothers (adjusted odds ratio (aOR), 3.57; 95% confidence interval (CI), 1.04-12.19) and pregnant women (aOR, 3.26; 95% CI, 0.95-11.14), relative to being supported. Pregnant women (adjusted mean difference (β), 0.76; 95% CI, 0.14-1.38) and mothers (β, 0.93; 95% CI, 0.23-1.64) with no support for their antidepressant treatment presented greater symptoms of anhedonia; for women planning pregnancy, this association emerged in relation to anxiety symptoms (β among non-users of antidepressant, 2.58; 95% CI, 1.04-4.13).

CONCLUSIONS

Partner support for women's antidepressant treatment may play a key role in depressive symptoms severity and the subtypes of anhedonia and anxiety, among women planning pregnancy, pregnant women, and mothers. This highlights the importance of partner inclusion in the complex decision-making process for antidepressant treatment around the time of pregnancy.

A focus on postpartum depression among Jordanian mothers

BACKGROUND

The magnitude of postpartum depression in Jordan is under documented, and little is known about its potential sociodemographic and clinical correlates.

PURPOSE

The aim of this study was to explore the prevalence and risk factors associated with postpartum depression among Jordanian mothers in the first 18 months after delivery.

METHOD

This descriptive cross-sectional study was carried out from April to June 2020 in Jordan. A web-based survey was used for recruiting eligible participants. An Arabic version of the validated self-administered Edinburgh Postnatal Depression Scale questionnaire was used to measure postpartum depression with a cut-off score of ⩾12 which indicates probable depression.

RESULTS

A total of 1,071 Jordanian women participated in the study. Of those, 567 women had postpartum depression (52.9%). Multivariate logistic regression analysis revealed that postpartum depression was significantly associated with marital conflict (OR: 4.91; 95% CI: 2.36-10.20), negative attitude from the pregnancy (OR: 0.67; 95% CI: 0.45-0.99), unplanned pregnancies (OR: 1.73; 95% CI: 1.16-2.60), lack of social support (OR: 1.93; 95% CI: 1.12-3.32), time from last delivery (OR: 0.99; 95% CI: 0.98-1.00), insomnia (OR: 0.53; 95% CI: 0.35-0.82), and depression during the pregnancy (OR: 0.51; 95% CI: 0.33-0.78). Most of the participants (65.7%) sought social support to avoid, reduce, or treat postpartum depression.

CONCLUSIONS

Postpartum depression among Jordanian women was the highest in comparison to that of women in other countries in the region. Therefore, screening for the presence of depressive symptoms should be implemented during regular pregnancy care visits. Social support should be encouraged in order to avoid, reduce, or treat postpartum depression.

Increasing partner communication and understanding during pregnancy: evaluation of 'The Great Pregnancy Quiz'

OBJECTIVE

To evaluate a Quiz designed to enhance communication and understanding in expectant parents.

BACKGROUND

A supportive and understanding relationship is associated with better maternal mental health outcomes. Many services therefore advocate that couples should communicate openly with each other, particularly about worries or concerns either have. To facilitate this a quiz (The Great Pregnancy Quiz) was developed and evaluated in this project.

METHOD

English-speaking women (N = 442) and men (N = 146) were recruited from antenatal clinics or classes and were given the 'Great Pregnancy Quiz' to complete at home. Approximately 2-4 weeks (T2) later they participated in either a phone interview, an online survey, or a face-face interview, still during the pregnancy, concerning the impact of the Quiz. Data were available from 90 women and 46 men. Data were analysed using a mixed-methods single group post-test only design.

RESULTS

Most women (78 of the 90: 87%) and men (35 of the 46: 76%) reported that the Quiz had positively impacted either their understanding or knowledge of each other. For 30 of the 90 women (33%) and 3 of the 46 men (7%) one or other had implemented some new supportive behaviour due to the Quiz. Qualitative comments highlight the impacts of the Quiz.

CONCLUSION

Most couples who did the Quiz reported positive impacts on their communication and understanding. While the issue of low T2 contact rates may have skewed the results, the benefits associated with the quiz make this resource an inexpensive and easily implemented health promotion strategy.

Aims, measures, study sites and participant samples of the Transcultural Study of Postnatal Depression

Background

Although postnatal depression is a common condition, with adverse effects on the child, mother and partner, there has been no research to date linking analyses of its origins and consequences with studies of service provision in different national health and social systems.

Aims

The Transcultural Study of Postnatal Depression (TCS–ND)was setup to develop a set of instruments to facilitate such research.

Method

Seven research instruments were piloted in studies carried out in ten centres in eight countries. A qualitative study looked at the cross-cultural equivalence of the concept of postnatal depression.

Results

The results are reported in the individual papers in this supplement.

Conclusions

Reliable and culturally valid measures are now available for future comparative research into postnatal depression within different health systems and countries.

Health services research into postnatal depression: results from a preliminary cross-cultural study

Background

Little is known about the availability and uptake of health and welfare services by women with postnatal depression in different countries.

Aims

Within the context of a cross cultural research study, to develop and test methods for undertaking quantitative health services research in postnatal depression.

Method

Interviews with service planners and the collation of key health indicators were used to obtain a profile of service avail ability and provision. A service use questionnaire was developed and administered to a pilot sample in a number of European study centres.

Results

Marked differences in service access and use were observed between the centres, including postnatal nursing care and contacts with primary care services. Rates of use of specialist services were generally low. Common barriers to access to care included perceived service quality and responsiveness. On the basis of the pilot work, a postnatal depression version of the Service Receipt Inventory was revised and finalised.

Conclusions

This preliminary study demonstrated the methodological feasibility of describing and quantifying service use, highlighted the varied and often limited use of care in this population, and indicated the need for an improved understanding of the resource needs and implications of postnatal depression.

Adaptation of the Structured Clinical Interview for DSM-IV Disorders for assessing depression in women during pregnancy and post-partum across countries and cultures

Background

To date, no study has used standardised diagnostic assessment procedures to determine whether rates of perinatal depression vary across cultures.

Aims

To adapt the Structured Clinical Interview for DSM–IV Disorders (SCID) for assessing depression and other non-psychotic psychiatric illness perinatally and to pilot the instrument in different centres and cultures.

Method

Assessments using the adapted SCID and the Edinburgh Postnatal Depression Scale were conducted during the third trimester of pregnancy and at 6 months postpartum with 296 women from ten sites in eight countries. Point prevalence rates during pregnancy and the postnatal period and adjusted 6-month period prevalence rates were computed for caseness, depression and major depression.

Results

The third trimester and 6-month point prevalence rates for perinatal depression were 6.9% and 8.0%, respectively. Postnatal 6-month period prevalence rates for perinatal depression ranged from 2.1% to 31.6% across centres and there were significant differences in these rates between centres.

Conclusions

Study findings suggest that the SCID was successfully adapted for this context. Further research on determinants of differences inprevalence of depression across cultures isneeded.

Measurement of mother-infant interactions and the home environment in a European setting: preliminary results from a cross-cultural study

Background

Infant development is adversely affected in the context of postnatal depression. This relationship may be mediated by both the nature of early mother-infant interactions and the quality of the home environment.

Aims

To establish the usefulness of the Global Ratings Scales of Mother–Infant Interaction and the Infant–Toddler version of the Home Observation for the Measurement of the Environment (IT–HOME), and to test expected associations of the measures with characteristics of the social context and with major or minor depression.

Method

Both assessments were administered postnatally in four European centres; 144 mothers were assessed with the Global Ratings Scales and 114 with the IT–HOME. Affective disorder was assessed by means of the Structured Clinical Interview for DSM–IV Disorders.

Results

Analyses of mother–infant interaction indicated no main effect for depression but maternal sensitivity to infant behaviour was associated with better infant communication, especially for women who were not depressed. Poor overall emotional support also reduced sensitivity scores. Poor support was also related to poorer IT–HOME scores, but there was no effect of depression.

Conclusions

The Global Ratings Scales were effectively applied but there was less evidence of the usefulness of the IT–HOME.

The Stafford Interview : A comprehensive interview for mother-infant psychiatry

This article describes an interview exploring the social, psychological and psychiatric events in a single pregnancy and puerperium. It has been in development since 1992 and is now in its 6th edition. It takes approximately 2 h to administer and has 130 compulsory probes and 185 ratings. It is suitable for clinical practice, teaching and research.

Antenatal depressive symptoms associated with specific life events and sources of social support among Italian women

This study aimed to identify different kinds of stressful life events and social support associated with antenatal depressive symptoms in a sample of pregnant Italian women. We conducted the study at a primary health-care centre in an urban area (northeast Italy). Mainly recruited at antenatal classes, 404 eligible pregnant women completed a socio-demographic questionnaire that included questions about the present pregnancy, the Edinburgh Depression Scale (EDS) to estimate the prevalence of depressive symptoms, the Multidimensional Scale of Perceived Social Support and List of Threatening Experiences Questionnaire to investigate the quality and nature of social support and recent negative life events. Of the 404 women, 60 (14.9 %) scored 13 or higher on the EDS. This group reported significantly lower social support from various sources-family, friends, and significant others; only in primiparous women were depressive symptoms significantly related to lower support from friends. Women with EDS scores equal or higher than 13 also reported a higher occurrence of recent stressful life events-specifically, death or a serious problem with a close friend or relative, unemployment, financial problems, and moving or housing difficulties. Regression analyses showed that women with high levels of social support or with a positive experience of pregnancy were less likely to experience antenatal depressive symptoms. Our results underscore the associations among antenatal depression, specific life stressors, and low social support from various sources. Clinical attention to these psychosocial correlates is recommended toward detecting vulnerability to antenatal depressive symptoms.

Cross-Cultural Approach of Postpartum Depression: Manifestation, Practices Applied, Risk Factors and Therapeutic Interventions

It is a well known fact that postpartum depression (PPD) is a global phenomenon that women may experience, regardless of cultural identity and beliefs. This literature review presents the cultural beliefs and postnatal practices around the world, in each continent and people's origins, looking through the extent to which they contribute positively or negatively to the onset of the disease. 106 articles were used in this research, through a systematic electronic search of Pubmed (Medline) and Scopus. Comparison is also made between the prevalence, the risk factors and the different ways of appearance of the disease around the world and among immigrants. Finally, the initiatives and interventions made so far by the governments and institutions with a view to prevent and address this global problem are presented. The results showed (a) that different cultures share the same risk factors towards the disease (b) significant differences in the prevalence of the disease among both Western and non Western cultures and between the cultures themselves (c) more tendencies for somatization of depressive symptoms in non-Western cultures, (d) different postnatal practices between cultures, which are not always effective (e) the more non-West a culture is, the less interventions concern on mental health; the same phenomenon is observed on populations burdened by immigration. The beliefs held by culture should be taken seriously in detecting of PPD, as well as the assessment of the needs of women who have recently given birth.

Emotional Rejection of the Infant: Status of the Concept

Emotional rejection of the infant is a morbid, clinical phenomenon, central to mother-infant psychiatry. It occurs in about 1% of births in the general population, but much more often in mothers referred to specialist services. It has severe consequences for children, but responds well to treatment. It is now better recognized, but research is required, especially cohort studies and neuroscientific investigations.

Modifiable partner factors associated with perinatal depression and anxiety: a systematic review and meta-analysis

BACKGROUND

Perinatal distress is a significant public health problem that adversely impacts the individual and their family. The primary objective of this systematic review and meta-analysis was to identify factors that partners can modify to protect each other from developing perinatal depression and anxiety.

METHOD

In accordance with the PRISMA statement, we reviewed the risk and protective factors associated with perinatal depression and anxiety symptoms that partners can potentially modify without professional assistance (PROSPERO reference CRD42014007524). Participants were new or expectant parents aged 16 years or older. The partner factors were sub-grouped into themes (e.g., instrumental support) based on a content analysis of the scale items and measure descriptions. A series of meta-analyses were conducted to estimate the pooled effect sizes of associations.

RESULTS

We included 120 publications, reporting 245 associations with depression and 44 with anxiety. Partner factors with sound evidence that they protect against both perinatal depression and anxiety are: emotional closeness and global support. Partner factors with a sound evidence base for depression only are communication, conflict, emotional and instrumental support, and relationship satisfaction.

LIMITATIONS

This review is limited by the lack of generalizability to single parents and the inability to systematically review moderators and mediators, or control for baseline symptoms.

CONCLUSION

The findings suggest that future prevention programs targeting perinatal depression and anxiety should aim to enhance relationship satisfaction, communication, and emotional closeness, facilitate instrumental and emotional support, and minimize conflict between partners.

Cultural differences in perinatal experiences for women with low socioeconomic status

In this study, similarities and differences in perinatal experiences between women with low socioeconomic status (SES) by race, ethnicity, and nativity were explored. The objective was to better understand the sociocultural and environmental contexts ofperinatal experiences and potential implications for screening and assessment among women with low SES. A purposive stratified sample of 32 women who were likely to be screened for perinatal depression participated in four focus groups organized by African American, white, Hmong, or Latina race or ethnicity. A descriptive study design was used to collect and evaluate focus-group data using qualitative content analysis. Women understood their perinatal experiences through the stressors in their environment. The stressors of insufficient socioeconomic resources and interpersonal support were relatively consistent across the focus groups. However, women's understanding of these stressors and their meaning differed between groups. Racially and ethnically diverse women with low SES experienced a complex interaction of sociocultural and environmental factors in the perinatal period. The findings highlight the need for health and social work practitioners to conduct depression screenings in conjunction with a com- prehensive psychosocial assessment, informed by cultural competence.

Predictors of postpartum depression among rural women in Minia, Egypt: an epidemiological study

OBJECTIVES

To study the prevalence of postpartum depression (PPD) in a certain rural area in Upper Egypt, identifying the factors that might be involved in its genesis.

STUDY DESIGN

The current study is a cross-sectional community-based study.

METHODS

The study was conducted in El-Burgaia village, 5 km north to El-Minia city over a period of three months. Systematic random sampling was used to interview 200 female subjects, who gave birth within the last 14 months preceding interview. The Edinburgh Postnatal Depression Scale (EPDS) was applied to these females to identify the presence of PPD.

RESULTS

The sample size analysed was 200 females, 99 (49.5%) of them had PPD (29.5% had minor PPD and 20% had major PPD). The age of the study subjects ranged between 19 and 45 years old (mean age 29 ± 5.2 years). PPD occurred more significantly among wives of less educated husbands (P = 0.03). PPD was more common among those previously diagnosed of having depression or prescribed antidepressants (P = 0.02), in addition to those females experiencing financial problems after delivery (P = 0.0001). PPD was even more common among females having complications after delivery (P = 0.01). Using logistic regression analysis, total household income, child sleeping hours, complications after delivery and support of husband after delivery were found to be statistically associated with PPD.

CONCLUSIONS

PPD is relatively common among rural females of El-Minia Governorate. Certain factors in these females, in the mere gestation and delivery after which they become depressed, and in the environment in which they live in, may all come to play a part in the emergence of their psychiatric illness.

An innovative screen-and-advice model for psychopathology and psychosocial problems among urban pregnant women: an exploratory study

BACKGROUND

Increased adverse pregnancy outcomes related to psychiatric and psychosocial problems can be observed for urban areas when compared to national averages. We developed a personal digital assistant (PDA)-based self-report screening model that produces tailored intervention advices. After having adapted the model to local care pathways, we tested the reliability, validity and feasibility of the model in routine antenatal care.

METHODS

Observational study among pregnant women in a Dutch urban area included women with a booking visit. Women answered questions posed by the PDA-tool while waiting for their appointment. If the tool suggested specific interventions (screen result), this was discussed during booking visit. A randomly selected subsample of participants completed the questionnaire again at a subsequent pregnancy check (retest). After the study was conducted, prenatal caregivers and assistants were interviewed for feasibility judgments. Psychometric and diagnostic performance of this approach was established.

RESULTS

Response rate among invited pregnant women was 94% on weighted average (n=621). Internal reliability ranged 0.88-0.90, test-retest reliability ranged 0.64-1.00. Positive predictive value was 86% and negative predictive value was 97%. No interpractice psychometrical differences were observed. Migrant women more often received an intervention advice than native women (p<0.001). The approach was well accepted among prenatal caregivers for its time efficiency and patient-friendliness.

CONCLUSION

Psychometric properties of our screen-and-advice tool were favorable under routine conditions, and the feasibility of this integral approach appeared good. The technical flexibility renders the model suitable for broader application. Local care pathways can easily be incorporated. We suggest implementation of this model in prenatal care in urbanized settings in order to make tailored mental healthcare broadly available.

The prevalence and clinical presentation of antenatal depression in rural South Africa

BACKGROUND

Although the prevalence of depression is similar in pregnant, postpartum and non-pregnant women, the onset of new depression is higher during the perinatal period. Women of low-income, and those living in low and middle income countries, are known to be at particularly high risk. Early identification and treatment of antenatal depression may improve pregnancy outcomes and could serve as an early indicator of postnatal depression. Culturally sensitive and accurate diagnostic tools are urgently needed.

METHODS

A consecutive series of 109 pregnant women were recruited in the third trimester at a primary health clinic, in a rural part of South Africa, with a high HIV prevalence. A cross sectional assessment of depression was completed using a structured clinical interview method and DSM-IV diagnostic criteria. Qualitative data on women's descriptions of depressive symptoms was also collected. The aim was to examine the prevalence of depression and to better understand the presentation of depressive symptomatology in this population.

RESULTS

Prevalence of depression was high, 51/109 (47%), with over half of the depressed women 34/51(67%) reporting episode duration greater than two months. 8/51 reported a prior history of depression. Women used psychological language to describe symptoms and, as a result, standardised diagnostic tools were culturally sensitive. Somatic pregnancy symptoms were frequently reported, but did not overestimate depression. Both HIV positive (27/51) and HIV negative (24/51) women were at risk of being depressed.

LIMITATIONS

The study is limited by the small sample size and possible attrition biases.

CONCLUSION

Antenatal depression is high and clinical presentation is similar to high income countries. Standardised diagnostic tools are culturally sensitive and adequate for early detection.

Development and validation of a scale to assess social support in the postpartum period

The development, reliability, and validity of a new instrument designed to assess aspects of social support specifically relevant to the postpartum period, the Postpartum Social Support Questionnaire (PSSQ), is described. The PSSQ was administered to 126 women at 2, 4, 6, and 12 months postpartum. Results indicate that it has high test-retest reliability and internal consistency. Factor analyses suggest that the scale consists of four factors: partner support, parent support, in-law support, and extended-family and friends support. In addition, the PSSQ scores of depressed and nondepressed women were compared at 2, 4, 6, and 12 months postpartum. Women who met diagnostic criteria for depression at 2 months postpartum reported less partner support than the nondepressed women at each assessment. The instrument appears to be a valid and reliable measure that should be useful in studies examining the role of social support in postpartum adaptation.

A multirisk approach to predicting chronicity of postpartum depression symptoms

BACKGROUND

Persistence of postpartum depression (PPD) carries potential adverse implications for the emerging mother-child relationship and for child development.

METHODS

This study was designed to investigate factors related to the onset and persistence of PPD; in particular, we examined the cumulative effect of a range of psychosocial risk factors in predicting chronic PPD symptoms. One hundred and five women were interviewed at three assessment periods: within the first days after childbirth, at 6 months, and at 18 months postpartum.

RESULTS

Depressive symptoms at 6 months predicted 18 months depressive symptoms, even when controlling for the contribution of maternal depression at birth. Psychosocial risk had a moderating influence on the stability of depressive symptomatology. Women with two or more risk factors at birth were more likely to have stable depressive symptomatology across the infants' first 18 months of life.

CONCLUSION

To prevent a chronic course of PPD it may be necessary to identify both depressive symptoms and relevant psychosocial risk factors.

Women's perceptions of partner support and conflict in the development of postpartum depressive symptoms

AIM

This paper reports a study examining the influence of maternal perceptions of conflict and relationship- and postpartum-specific support from the partner on the development of depressive symptoms in the first 8-weeks postpartum.

BACKGROUND

Although the quality of a woman's relationship with her partner has been associated with risk for postpartum depression, few studies have examined which elements of partner-specific support and conflict are determinants of maternal mental health.

METHODS

Self-administered measures of partner support (Social Provisions Checklist, Postpartum Partner Support Scale), partner conflict (Quality of Relationships Inventory), and depression (Edinburgh Postnatal Depression Scale) were mailed postnatally to a population-based sample of 396 mothers between April 2001 to January 2002. Differences in partner support and conflict at 1 and 4-weeks postpartum were examined between those women who met criteria for probable depression (Edinburgh Postnatal Depression Scale > 9) and those who did not meet criteria for probable depression at 8-weeks postpartum.

FINDINGS

Women with depressive symptoms at 8-weeks postpartum had significantly lower perceptions of relationship-specific and postpartum-specific partner support and significantly higher levels of relationship conflict than women with no depressive symptoms. Multiple regression analyses revealed that three variables, perceived social integration, partner encouragement to obtain help when needed, and partner agreed with infant care, significantly explained the variance in Edinburgh Postnatal Depression Scale scores.

CONCLUSIONS

Maternal perceptions of social integration and partner provision of problem-focused informational support and positive feedback are important in determining maternal mental health. Therefore, in the antenatal period healthcare professionals should teach couples appropriate ways to provide feedback and communicate expectations, especially those relating to infant care strategies. The importance of appraisal and emotional support should be highlighted in order to foster maternal feelings of acceptance and being cared for. Partners should also be encouraged to participate actively in household tasks and infant care activities to protect the mother from becoming overwhelmed.

Assessing psychosocial risk in pregnant/postpartum women using the Contextual Assessment of Maternity Experience (CAME)--recent life adversity, social support and maternal feelings

BACKGROUND

The Contextual Assessment of Maternity Experience (CAME) interview was developed to characterise the psychosocial context relevant to the maternity experience by providing a detailed picture of women's lives during the transition to motherhood. More specifically, it was designed to enable the assessment of major risk factors for emotional disturbances in pregnant and postpartum women, especially depression, within the same instrument and using a coherent methodological framework.

METHOD

The CAME assesses three domains relevant to motherhood: 1) recent life adversity or stressors; 2) the quality of social support and key relationships including partner relationship; and 3) maternal feelings towards pregnancy, motherhood and the baby. Two high-risk samples of inner-city London women were used to test the psychometric qualities of the CAME components.

RESULTS

Overall, the internal consistencies of the relevant components were high in both samples examined. The validity of the three components of the measure was evidenced by their association with either maternal characteristics or parenting assessments.

CONCLUSION

It was concluded that the CAME shows promise as a measure of the psychosocial risk factors involved in the maternity experience for future research in this field.