The impact of the Covid-19 pandemic on postnatal anxiety and posttraumatic stress: Analysis of two population-based national maternity surveys in England

BACKGROUND

Few studies have evaluated postnatal anxiety and posttraumatic stress (PTS) before and during the Covid-19 pandemic using comparable data across time. We used data from two national maternity surveys in England to explore the impact of the pandemic on prevalence and risk factors for postnatal anxiety and PTS.

METHODS

Analysis was conducted using population-based surveys carried out in 2018 (n = 4509) and 2020 (n = 4611). Weighted prevalence estimates for postnatal anxiety and PTS were compared across surveys. Adjusted risk ratios (aRR) were estimated for the association between risk factors and postnatal anxiety and PTS.

FINDINGS

Prevalence of postnatal anxiety increased from 13.7 % in 2018 to 15.1 % in 2020 (+1.4 %(95%CI:-0.4-3.1)). Prevalence of postnatal PTS increased from 9.7 % in 2018 to 11.5 % in 2020 (+1.8 %(95%CI:0.3-3.4)), due to an increase in PTS related to birth trauma from 2.5 % to 4.3 % (+1.8 %(95%CI:0.9-2.6); there was no increase in PTS related to non-birth trauma. Younger age (aRR = 1.31-1.51), being born in the UK (aRR = 1.29-1.59), long-term physical or mental health problem(s) (aRR = 1.27-1.94), and antenatal anxiety (aRR = 1.97-2.22) were associated with increased risk of postnatal anxiety and PTS before and during the pandemic, whereas higher satisfaction with birth (aRR = 0.92-0.94) and social support (aRR = 0.81-0.82) were associated with decreased risk.

INTERPRETATION

Prevalence of postnatal PTS was significantly higher during the pandemic, compared to before the pandemic, due to an increase in PTS related to birth trauma. Prevalence of postnatal anxiety was not significantly higher during the pandemic. Risk factors for postnatal anxiety and PTS were similar before and during the pandemic.

Validated tools to identify common mental disorders in the perinatal period: A systematic review of systematic reviews

BACKGROUND

Uncertainty remains regarding the validity of screening tools to detect common mental disorders (CMDs) during perinatal periods. This umbrella review aims to provide an up-to-date summary of psychometric properties of tools for the identification of perinatal CMDs.

METHODS

Reviews were identified via Ovid MEDLINE, PsychINFO, EMBASE, Global Health and Cochrane Database of Systematic Reviews electronic databases with no date or language restriction. Pooled sensitivity and specificity estimates and ranges were extracted and summarised using forest plots. Quality assessment was conducted using Measurement Tool to Assess Systematic Reviews (AMSTAR-2).

RESULTS

Of 7,891 papers identified, 31 reviews met inclusion criteria. 76 screening tools were identified; most frequently validated were Edinburgh Postnatal Depression Scale (EPDS) (n = 28 reviews), Beck's Depression Inventory (BDI) (n = 13 reviews) and Patient Health Questionnaire (PHQ) (n = 12 reviews). Forest plots demonstrated a pattern of decreasing sensitivity and increasing specificity with increasing cut-off scores. Sub-group analysis of data extracted from low quality reviews demonstrated wider 95% CIs and overall lower specificity. Validity also varied according to ethnicity, socio-economic background and age.

LIMITATIONS

Despite a low Covered Corrected Area (CCA) score the primary studies included within reviews overlapped; therefore we were unable perform meta-analysis.

CONCLUSIONS

The evidence suggests that the EPDS, PHQ and BDI are useful across a range of diverse settings but the context of tool application is a key factor determining validity. This review highlights that utilizing screening tools in clinical practice is complex and requires careful consideration of the population, context, and health system it will be used in.

Perinatal mental health in India: protocol for a validation and cohort study

BACKGROUND

Common mental disorders (CMD) are among the largest contributors to global maternal morbidity and mortality. Although research on perinatal mental health in India has grown in recent years, important evidence gaps remain, especially regarding CMD. Our study aims to improve understanding of CMD among perinatal and non-perinatal women of reproductive age across two settings in India: Bangalore (Karnataka) and Tanda (Himachal Pradesh).

METHODS

The study is embedded within the Maternal and Perinatal Health Research Collaboration India (MaatHRI). This mixed-methods observational study comprises three consecutive phases: (i) focus group discussions and individual interviews to explore women's knowledge and seek feedback on CMD screening tools; (ii) validation of CMD screening tools; and (iii) prospective cohort study to identify CMD incidence, prevalence and risk factors among perinatal and non-perinatal women. Results of the three phases will be analyzed using inductive thematic analysis, psychometric analysis and multivariable regression analysis, respectively.

CONCLUSION

Improving understanding, detection and management of CMD among women is key to improving women's health and promoting gender equality. This study will provide evidence of CMD screening tools for perinatal and non-perinatal women in two diverse Indian settings, produce data on CMD prevalence, incidence and risk factors and enhance understanding of the specific contribution of the perinatal state to CMD.

Prevalence and factors associated with postpartum posttraumatic stress in a population-based maternity survey in England

BACKGROUND

Studies on prevalence and factors associated with postpartum posttraumatic stress (PTS) typically do not distinguish between PTS related to childbirth (PTS-C) and PTS related to other stressors (PTS-O). This study aimed to describe the prevalence, clinical characteristics, and factors associated with PTS-C and PTS-O in postpartum women.

METHODS

The study was a cross-sectional population-based survey of 16,000 postpartum women, selected at random from birth registrations in England to receive a postal questionnaire, including the Primary Care Posttraumatic Stress Disorder Screen.

RESULTS

Questionnaires were returned by 4,509 women. The median age was 32 years (IQR=29-36), 64% were married, 77% were UK-born, and 76% were White-British. Prevalence of PTS-C was 2.5% (95%CI:2.0-3.0) and prevalence of PTS-O was 6.8% (95%CI:6.0-7.8). Women with PTS-C were significantly more likely to report re-experiencing symptoms (Chi-Square=7.69,p<0.01). Factors associated with PTS-C were: higher level of deprivation, not having a health professional to talk to about sensitive issues during pregnancy, and the baby being admitted for neonatal intensive care. Factors associated with PTS-O were: age ≤24 years, depression during pregnancy, and having a pregnancy affected by long-term health problems. Factors associated with both were: living without a partner, anxiety during pregnancy, pregnancy-specific health problems, and lower birth satisfaction.

CONCLUSIONS

PTS during the postpartum period is relatively common and, for many women, unrelated to childbirth. Increased awareness among health professionals of prevalence, clinical characteristics and factors associated with postpartum PTS-C and PTS-O will aid the development of appropriate management protocols to identify and support women during the perinatal period. Posttraumatic stress, posttraumatic stress disorder, postpartum PTSD/PTS, birth-related PTSD/PTS, birth trauma, perinatal mental health.

Current trends in Antenatal Screening Services: Results from a regional survey

OBJECTIVE

To identify variations in current antenatal screening programmes across one region and compare results with a previous survey.

DESIGN

A cross section descriptive survey.

SETTING

All maternity units within the region of Northern Ireland.

SAMPLE

Eleven maternity units were invited and ten agreed to participate.

MAIN OUTCOME MEASURES

The number of written policies for individual screening tests; the range of screening tests offered; the frequency of training opportunities for health professionals; and the information systems in place to record data.

RESULTS

There is variation in service provision across maternity units and, in particular, inconsistency in the offer of serum screening tests for Down syndrome. A lack of training opportunities for health professionals involved in offering screening was highlighted, and no common information system employed.

CONCLUSION

While improvements have been made since 2002, variations persist. This is leading to inequalities in the provision of antenatal screening services across Northern Ireland.

Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards

BACKGROUND

Despite the fact that outreach and early warning systems (EWS) are an integral part of a hospital wide systems approach to improve the early identification and management of deteriorating patients on general hospital wards, the widespread implementation of these interventions in practice is not based on robust research evidence.

OBJECTIVES

The primary objective was to determine the impact of critical care outreach services on hospital mortality rates. Secondary objectives included determining the effect of outreach services on intensive care unit (ICU) admission patterns, length of hospital stay and adverse events.

SEARCH STRATEGY

The review authors searched the following electronic databases: EPOC Specialised Register, The Cochrane Central Register of Controlled Trials (CENTRAL) and other Cochrane databases (all on The Cochrane Library 2006, Issue 3), MEDLINE (1996-June week 3 2006), EMBASE (1974-week 26 2006), CINAHL (1982-July week 5 2006), First Search (1992-2005) and CAB Health (1990-July 2006); also reference lists of relevant articles, conference abstracts, and made contact with experts and critical care organisations for further information.

SELECTION CRITERIA

Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series designs (ITS) which measured hospital mortality, unanticipated ICU admissions, ICU readmissions, length of hospital stay and adverse events following implementation of outreach and EWS in a general hospital ward to identify deteriorating adult patients versus general hospital ward setting without outreach and EWS were included in the review.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data and two review authors assessed the methodological quality of the included studies. Meta-analysis was not possible due to heterogeneity. Summary statistics and descriptive summaries of primary and secondary outcomes are presented for each study.

MAIN RESULTS

Two cluster-randomised control trials were included: one randomised at hospital level (23 hospitals in Australia) and one at ward level (16 wards in the UK). The primary outcome in the Australian trial (a composite score comprising incidence of unexpected cardiac arrests, unexpected deaths and unplanned ICU admissions) showed no statistical significant difference between control and medical emergency team (MET) hospitals (adjusted P value 0.640; adjusted odds ratio (OR) 0.98; 95% confidence interval (CI) 0.83 to 1.16). The UK-based trial found that outreach reduced in-hospital mortality (adjusted OR 0.52; 95% CI 0.32 to 0.85) compared with the control group.

AUTHORS' CONCLUSIONS

The evidence from this review highlights the diversity and poor methodological quality of most studies investigating outreach. The results of the two included studies showed either no evidence of the effectiveness of outreach or a reduction in overall mortality in patients receiving outreach. The lack of evidence on outreach requires further multi-site RCT's to determine potential effectiveness.

Improvement in neonatal intensive care in Northern Ireland through sharing of audit data

PROBLEM

Ten percent of infants born will require admission to a neonatal facility. Coordinated activity to monitor and improve the quality of care for this high risk, high cost group of infants is considered a high priority. At the time of initiation of this project no system for collection and analysis of neonatal data existed in Northern Ireland.

DESIGN

In 1994 an ongoing prospective centralised data collection system was implemented to facilitate quality improvement and research in neonatal care. We aim to ascertain if there has been a demonstrable improvement in the quality of care provided since the initiation of this system.

SETTING

All nine Northern Ireland neonatal intensive care units returned prospectively collected socioeconomic, obstetric and neonatal episode data.

KEY MEASURES FOR IMPROVEMENT

Achievement of the agreed quality indicators relating to transfer patterns, thermoregulation, antenatal steroid administration, and timing of administration of surfactant during the period 1 April 1999 to 31 March 2000 were compared with data for the period 1 April 1994 to 31 March 1996.

STRATEGIES FOR CHANGE

Monitoring included audit and annual feedback of timely clear and relevant data where results were provided confidentially as standardised reports, together with anonymised comparisons with other similar sized units. Draft recommendations were made at regional level and units were asked to adopt finalized consensus guidelines at the local level and to implement changes to clinical practice.

EFFECTS OF CHANGE

The proportion of transfers taking place in utero increased from 26% to 42% and antenatal steroid administration from 68% to 82%. Normothermia on first admission improved from 66% to 71% for inborn infants. The proportion of infants receiving surfactant where the first dose was given within an hour of birth increased from 13% to 66%.

LESSONS LEARNT

A multi-professional regional care network can facilitate the development of agreed standards and a culture of regular evaluation leading to quality improvement.

More and earlier surfactant for preterm infants

Surfactant administration to infants born at less than 32 weeks gestation was compared between two time periods (1 April 1994 to 31 March 1996 and 1 April 1999 to 31 March 2001). Overall administration increased significantly from 41% to 54%, and within one hour of birth from 13% to 60%. Regional data collection and feedback helps promote quality improvement and implementation of published evidence and guidelines.

A prospective cohort study comparing hospital admission for gastro-enteritis with home management

OBJECTIVES

To compare physical and psychological outcomes in children presenting at Accident and Emergency Departments (A&E), diagnosed with gastro-enteritis and admitted to hospital with those of a similar age, sex and severity of illness discharged home. The physical and psychological well-being of children in these two groups, in the month after the episode, were compared as was further use of health care services.

DESIGN

A prospective cohort study.

METHODS

A comparison of 116 children aged 1-6 years with gastro-enteritis, presenting at A&E over a 6 months period. Admitted children were compared with children discharged, of a similar age, sex and illness severity (triage score) with follow-up at 1 week and 1 month. Clinical history, psychosocial factors, investigations and outcomes were recorded at presentation and physical, psychological and family outcomes at 1 week and 1 month.

RESULTS

Of 116 children, 112 (97%) completed the study (56 in each group). No differences were detected in psychosocial factors, socio-economic status, family factors, time of arrival at A&E or waiting times. Parental perception of illness was greater in the admitted group (P < 0.005), but was recorded after the decision on admission was made. At 1 week follow-up admitted children had increased separation anxiety compared with children who were discharged (P < 0.05), but this difference disappeared at 1 month. Clinical outcomes were the same for both groups, although admitted children had more investigations (91% vs. 39%). Parents were equally satisfied with their child's treatment, but one-third of children in both groups sought further consultation with a health professional in the following week.

CONCLUSIONS

There is no statistically significant difference in socio-demographic data, time of arrival at A&E, waiting times, clinical and psychosocial outcomes in children with acute gastro-enteritis admitted to hospital compared with a group of children of similar age, gender and severity of illness managed at home. However, parents seek reassurance and follow-up of acutely ill children, even if the child is admitted to hospital, which has service and resource implications.

Admission to neonatal intensive care with respiratory morbidity following 'term' elective caesarean section

Delaying the timing of elective caesarean section (ELCS) from 37/38 weeks to 39/40 weeks reduces the risk of respiratory morbidity in otherwise healthy neonates. The aims of this study were to clarify the number and clinical details of term infants delivered by ELCS who were admitted to neonatal intensive care (NIC) from 1st April 2001 to 31st March 2002 in Northern Ireland, to record the level of care required by these infants and to identify infants who were diagnosed with transient tachypnoea of the newborn (TTN) and/or Respiratory Distress Syndrome (RDS). Two hundred and ten (8%) of babies born by ELCS were admitted to NIC. Term infants delivered by ELCS used 343 days of level 1 & 2 care with 230 (68%) of these days being used by infants with RDS/TTN (n=105) the majority of whom were delivered at 37/38 weeks. Definitions of 'term' and clinical indications for ELCS urgently need to be debated to avoid unnecessary morbidity following ELCS in so called 'term' infants.

Are children with recessive dystrophic epidermolysis bullosa of low birthweight?

To compare the birthweight of children affected by recessive dystrophic epidermolysis bullosa (RDEB) to a sibling control group, we designed a questionnaire-based case-control study. As participants we used patients with RDEB attending the Great Ormond Street Hospital for Children, London, England, and their nearest unaffected siblings. We found that children with RDEB are of significantly lower birthweight than their unaffected siblings, with 30% being small for their gestational age compared to 12% of controls (McNamar chi2 = 4.9, d f = 1, p = 0.02). A conditional logistic regression model was used to examine the possible effects of confounding variables. The relationship between the RDEB and standardized birthweight groups, smoking status of the mother at the time of birth, and the previous number of live births showed that the standardized birthweight group was the only significant variable in the model and was unaffected by confounding variables. Based on these findings, we concluded that the compromise in growth seen in RDEB begins in utero.

Making information available for quality improvement and service planning in neonatal care

We describe a prospective two year study aimed at assessing information collected throughout a geographically defined region as a basis for clinical governance, quality improvement and service planning in neonatal intensive and special care. All 13 Northern Ireland units returned a range of socio-demographic, obstetric and neonatal data for all admissions or readmissions within 28 days of life. 8.2% of all live births required neonatal intensive or special care, with a requirement of 374 and 645 days per 1,000 births for intensive and special care respectively. In total there were 4,205 episodes of care provided for 3,946 infants (18,072 days of intensive and 31,141 days of special care). Complications arising during intensive care episodes included the following: septicaemia/bacteraemia (7.6%), necrotising enterocolitis (2.8%), pneumothorax (4.6%), patent ductus arteriosus (6.5%) and seizures (6.9%). Opportunities for quality improvement exist in a number of areas with potential for further reduction in morbidity. Comparisons with published criteria demonstrate the value of this type of information for local, regional and national quality improvement initiatives and service planning.

Techniques and materials for skin closure in caesarean section

BACKGROUND

Caesarean section is a common operation with no agreed standard on operative techniques and materials to use. The skin layer can be repaired by sub cuticular stitch immediately below the skin layer, an interrupted stitch or with skin staples. A great variety of materials and techniques are used for skin closure after caesarean section and there is a need to identify which provide the best outcomes for women.

OBJECTIVES

To compare the effects of skin closure techniques and materials on maternal outcomes and time taken to perform a caesarean section.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (August 2002).

SELECTION CRITERIA

All randomised comparisons of skin closure techniques in caesarean section.

DATA COLLECTION AND ANALYSIS

Three papers were identified from the search. Data were extracted independently by two reviewers. On further inspection two were not considered to be randomised controlled trials.

MAIN RESULTS

Only one small randomised controlled trial, involving 66 women, was included in the review. Frishman et al compared staples with absorbable sub-cuticular suture for closure following caesarean section. While operating time was significantly shorter when using staples, the use of absorbable sub cuticular suture resulted in less postoperative pain and yielded a better cosmetic result at the post-operative visit.

REVIEWER'S CONCLUSIONS

There is no conclusive evidence about how the skin should be closed after caesarean section. Questions regarding the best closure technique and material and the outcomes associated with each remain unanswered. The appearance and strength of the scar following caesarean section is important to women and the choice of technique and materials should be made by women in consultation with their obstetrician based on the limited information currently available.

Attitudes toward clinical guidelines among obstetricians in Northern Ireland

OBJECTIVES

To evaluate the attitudes of, and the influences on decisions made by, obstetricians in Northern Ireland in order to understand the feasibility of applying guidelines to obstetric practice.

DESIGN

Cross-sectional postal survey.

SETTING

Northern Ireland.

POPULATION

Consultants, senior registrars, registrars, and senior house officers in obstetrics in Northern Ireland (n = 170). Responses were received from 68 x 8% (n = 117), with complete data available for 67 x 1% (n = 114).

MAIN OUTCOME MEASURES

An attitudes score was constructed by consolidating responses to a variety of statements about guidelines. Individual responses to guidelines statements and the standardised attitudes T-score were analysed by demographic and practice characteristics.

RESULTS

Attitudes toward guidelines were generally positive, with women practitioners more likely to have positive attitudes toward guidelines than did their male counterparts. Younger obstetricians were more likely to report that practitioners should incorporate guidelines into their practices. Doctors who responded that their decisions were influenced by specific tools related to guidelines, such as computerised databases, during the previous three months had more positive attitudes toward guidelines than doctors who did not use such tools. Furthermore, doctors based in teaching hospitals were more likely than others to have been influenced by the guidelines of professional societies.

CONCLUSIONS

Generally guidelines appear to be quite well received, with doctors reporting that their practice often is influenced by them. Doctors who reported that their decisions were influenced by guidelines had an especially positive attitude toward them. However, some tools which target the application of evidence-based methods (e.g. computerised databases) are used infrequently by obstetricians. The challenge remains to encourage the further development of guidelines and tools that are useful and appropriate for practitioners.

A survey of women's experiences of vaginal loss from 24 hours to three months after childbirth (the BLiPP study)

OBJECTIVE

To describe the range of normal vaginal loss as reported by women from 24 hours after delivery until three months postnatally.

SETTING

Two health districts in the south of England.

METHODS

A prospective survey of women's experiences and expectations of the duration, amount and colour of vaginal loss after childbirth. The term vaginal loss includes all types of fluid loss from the vagina following childbirth.

FINDINGS

Five hundred and twenty-four women were recruited to the survey in 1995. Vaginal loss, as reported by the women, was considerably more varied in duration, amount and colour than descriptions in current midwifery textbooks. The median number of days reported for the duration of vaginal loss was 21 days and the interdecile range (10th to 90th percentile) was 10-42 days. For colour of lochia, women overall reported their vaginal loss to be more predominantly red/brown in colour and the traditional descriptions of the timing and colour phases of lochia rubra, serosa and alba are not supported by the majority of the women's experiences. Primiparous women were significantly more likely to report feelings of surprise or shock about their experiences of vaginal blood loss after the birth (odds ratio 4 [95% Confidence Interval 2-9]). Seven primiparous women (2%) were unaware that they would have a blood loss at all after the birth.

IMPLICATIONS FOR PRACTICE

The findings from this survey have been used to develop information leaflets for women and health professionals about vaginal loss following childbirth. These leaflets include descriptions of normal ranges for the colour, amount and duration of vaginal loss in the first three months after childbirth.

The feasibility of using a postal survey method to assess the health and development of 7 year old children of different birth weight

STUDY OBJECTIVE

To test the feasibility of using a postal survey to assess health and development in 7 year old children of different birth weights and to examine the response and any resulting response bias.

DESIGN

A multi-stage postal survey, using a sample stratified by birth weight.

SETTING

The four counties of Oxfordshire, Buckinghamshire, Berkshire, and Northamptonshire, which make up the former Oxford NHS Region.

SAMPLE

All children born in 1985 to the residents of the former Oxford region who weighed either under 1500 g or over 5000 g at birth and all those with unstated birth weight were included. Samples of approximately 130 live births were randomly selected from each 500 g birth weight band between 1500 g and 5000 g. The total sample size was 1319.

METHODS

The children in the sample were identified from birth registration and traced through the National Health Service Central Register (NHSCR). Self administered questionnaires were sent through the relevant Family Health Service Authority (FHSA) and then via the child's general practitioner (GP) to the child's parent(s). When parents' permission was given, self administered questionnaires were also sent to the child's GP and teacher.

MAIN RESULTS

Of the 1319 children, 1169 were alive at the age of 7 and were successfully traced. Questionnaires were forwarded by GPs to parents of 1071 children and completed questionnaires were obtained from parents of 805 children. Parents of 753 children gave permission to approach the child's teacher and replies were received for 695. Parents of 770 children gave permission to send a questionnaire to the child's GP and 724 were returned completed. Response bias was assessed for the parents' questionnaire using data recorded about all births at birth registration. Response rates varied by sex of child, social class, and country of birth of the father. In addition, parents with a child with a serious motor or sensory deficit appeared to be more likely to respond.

CONCLUSIONS

Response rates at each stage of the survey were good. The bias in response to the parents' questionnaire needs to be taken into consideration in future work. The method was found to be feasible and could be applied more widely than in monitoring child health.

Birthweight and health and development at the age of 7 years

This study was set up to compare the frequency of health, educational and behavioural problems in a geographically defined birth cohort of 7-year-old children grouped by weight at birth. The study design was based on a multi-stage postal survey, with sampling stratified by birthweight. It took place in the four counties of Oxfordshire, Buckinghamshire, Berkshire and Northamptonshire which make up the former Oxford region. We studied 1319 live births to women resident in the former Oxford region in 1985, including all those with birthweights under 1500 g, or whose weight was not recorded, and a sample of those who weighed 1500-2499 g, and of those who weighed 2500 g or more at birth. The children in the sample were traced through the National Health Service Central Register (NHSCR) and self-administered questionnaires were sent to their parents, general practitioners (GP) and teachers. Of the 1169 children who were alive at the age of 7 years and were successfully traced, 805 (75%) were followed up by postal survey. The use of health services, and of additional educational support was higher, and school performance was poorer among children who had weighed less than 1500 g at birth than among children who had weighed 2500 g or more, with the rates for children who had weighed 1500-2499 g falling in between. This survey method identifies the higher rate of health and educational problems in children weighing under 2500 g at birth, particularly those with birthweight under 1500 g, compared with other children. The method could be developed to provide a way of monitoring any changes over time in the prevalence of these problems. This information can be used to assess the health and educational needs of 7-year-old children in the population.