Improving clinical care for women with endometriosis: qualitative analysis of women's and health professionals' views

PURPOSE

Endometriosis is a chronic condition where endometrial-like cells proliferate outside the uterus causing pain and disability. Limited treatments are available but symptom management is essential for social and economic participation. The aim was to compare women's and health professionals' perceptions of quality of endometriosis health care and opportunities for improvements.

METHODS

Women participated in closed moderated online discussion groups and health professionals in semi-structured telephone interviews. Discussion group text and interview transcripts were thematically analyzed using the Framework Analysis approach.

RESULTS

Forty-six women, 12 general practitioners (GPs), and 1 gynecologist participated. Endometriosis can have debilitating consequences. However, women reported that healthcare providers may dismiss symptoms, lack essential knowledge and provide inconsistent advice; treatments are seldom successful or without adverse side-effects. Health professionals acknowledged limitations in expertise, persistent myths, and challenges in achieving best practice. Enhancing collaborative care skills, individualized treatment plans, and local referral pathways to multi-disciplinary care may improve satisfaction with endometriosis care-giving and receiving.

CONCLUSIONS

This is the first comparison of patient and practitioner perceptions of endometriosis in primary healthcare. Models of multi-disciplinary, collaborative care need to be developed and evaluated against consumer-informed measures of women's wellbeing, quality of life and satisfaction with symptom management and health care.

Comparison of major depression diagnostic classification probability using the SCID, CIDI, and MINI diagnostic interviews among women in pregnancy or postpartum: An individual participant data meta-analysis

OBJECTIVES

A previous individual participant data meta-analysis (IPDMA) identified differences in major depression classification rates between different diagnostic interviews, controlling for depressive symptoms on the basis of the Patient Health Questionnaire-9. We aimed to determine whether similar results would be seen in a different population, using studies that administered the Edinburgh Postnatal Depression Scale (EPDS) in pregnancy or postpartum.

METHODS

Data accrued for an EPDS diagnostic accuracy IPDMA were analysed. Binomial generalised linear mixed models were fit to compare depression classification odds for the Mini International Neuropsychiatric Interview (MINI), Composite International Diagnostic Interview (CIDI), and Structured Clinical Interview for DSM (SCID), controlling for EPDS scores and participant characteristics.

RESULTS

Among fully structured interviews, the MINI (15 studies, 2,532 participants, 342 major depression cases) classified depression more often than the CIDI (3 studies, 2,948 participants, 194 major depression cases; adjusted odds ratio [aOR] = 3.72, 95% confidence interval [CI] [1.21, 11.43]). Compared with the semistructured SCID (28 studies, 7,403 participants, 1,027 major depression cases), odds with the CIDI (interaction aOR = 0.88, 95% CI [0.85, 0.92]) and MINI (interaction aOR = 0.95, 95% CI [0.92, 0.99]) increased less as EPDS scores increased.

CONCLUSION

Different interviews may not classify major depression equivalently.

A complex postnatal mental health intervention: Australian translational formative evaluation

Reducing the burden of postnatal maternal mental health problems is an international public health priority. We developed What Were We Thinking (WWWT), a psychoeducation programme for primary postnatal health care that addresses known but neglected risks. We then demonstrated evidence of its effects in a before-and-after controlled study in preventing maternal postnatal mental health problems among women without a psychiatric history participating in the intervention compared to usual care (AOR 0.43; 95% CI 0.21, 0.89) when conducted by specialist nurses. Testing its effectiveness when implemented in routine primary care requires changes at practitioner, organizational and health system levels. This paper describes a programme of translational formative evaluation to inform the protocol for a cluster RCT. Following the UK Medical Research Council (MRC) Guidance for evaluating complex interventions, we conducted a translational formative evaluation using mixed methods. Collection and analysis of postnatal health service documents, semi-structured interviews, group discussions and an online survey were used to investigate service provision, consumers' needs and expectations, clinicians' attitudes and clinical practice, and the implications for health service delivery. Participants were expectant parents, health care providers, health service managers and government policy makers. Results documented current clinical practice, staff training needs, necessary service modifications to standardize advice to parents and include fathers, key priorities and drivers of government health policy, and informed a model of costs and expected health and social outcomes. Implementation of WWWT into routine postnatal care requires adjustments to clinical practice. Staff training, modifications to service opening hours and economic implications for the health system also need to be considered. The MRC Guidance for developing and evaluating complex interventions is a useful framework for conceptualizing and reporting translational formative evaluation, which is an essential step in the evidence trajectory. The results of the evaluation will inform the protocol for a cluster RCT of WWWT and associated health economic evaluation.

Prevention of postnatal mental health problems in women: knowledge exchange in primary care in Victoria, Australia

ISSUE ADDRESSED

What Were We Thinking (WWWT) is a psychoeducation group program for the primary prevention of postnatal mental health problems in women. It addresses two neglected risks for postnatal depression and anxiety: unsettled infant behaviour and adjustments in the partner relationship after the birth of a first baby. WWWT has evidence of efficacy when facilitated by specialist nurses. It is designed to be facilitated by trained nurses as part of standard postnatal primary care. The aim of this study is to assess nurses' understanding of their role in prevention of postnatal mental health problems, the requirements for and feasibility of implementing WWWT, and nurses' current practice and specific training needs.

METHODS

Maternal and Child Health (MCH) coordinators emailed nurses at all Victorian MCH centres an invitation to participate in a study about parent-infant mental health. Semi-structured interviews and group discussions were conducted. Responses were analysed thematically.

RESULTS

MCH nurses demonstrated a willingness to implement a structured mental health-promotion intervention into clinical practice. Successful implementation will require changes to enable routine attendance of fathers at group sessions and recommendations to parents about the use of infant behaviour management strategies.

CONCLUSIONS

This study contributes to comprehensive knowledge exchange about the implementation of a complex intervention in standard primary care. This knowledge is essential for generating practice-based evidence of the WWWT mental health-promotion program's effectiveness. SO WHAT?: The findings will inform a training program for WWWT nurse facilitators and the protocol for a cluster randomised control trial (RCT) to test the effectiveness of WWWT in standard postnatal care.

The growth of maternal-fetal emotional attachment in pregnant adolescents: a prospective cohort study

STUDY OBJECTIVE

To describe self-reported maternal-fetal emotional attachment in adolescent women over the course of pregnancy, compare it with adult pregnant women, and identify risk factors for poor attachment.

DESIGN

A prospective cohort study.

SETTING

Young mothers' clinics in 2 public hospitals in metropolitan Melbourne, Australia.

PARTICIPANTS

English-speaking young women aged 20 years and under attending their first antenatal visit.

METHODS

Self-report questionnaires were completed in each trimester. Validated measures were used to assess anxiety and depression symptoms and maternal-fetal emotional attachment. Data were analyzed with existing data from pregnant adults. Regression analyses were conducted to establish factors independently associated with higher mean first-trimester attachment score and lowest-quartile third trimester score adjusting for confounding variables.

MAIN OUTCOME MEASURE

Maternal-fetal emotional attachment, assessed by the Quality and Intensity subscales and Global score on Maternal Antenatal Attachment Scale (MAAS).

RESULTS

165/194 (85%) completed the first questionnaire; 130/165 (79%) provided complete data. Mean anxiety but not depression scores were significantly higher in adolescents than adults across pregnancy. Mean (95%CI) first-trimester adolescent Global MAAS was significantly lower than adults (70.3 (68.4, 72.2) vs 76.8 (75.4, 78.2) P < .01), but there were no significant second- or third-trimester between-group differences. Adjusted odds of a lowest-quartile third-trimester MAAS score was significantly associated with lower first-trimester score (P < .001), previous abortion (P = .02) and being born overseas (P = .002).

CONCLUSION

Adolescents report slower development of antenatal emotional attachment than adults. Women with risk factors for poor attachment in late pregnancy are identifiable in early pregnancy and may benefit from additional multidisciplinary care.

Postpartum emotional support: a qualitative study of women's and men's anticipated needs and preferred sources

Australian health policy emphasises prevention, early intervention and improved pathways to treatment for perinatal mental disorders. Primary care is vital to achieving these aims. The aim of this study was to understand the anticipated needs and preferred sources of mental health information and support of men and women expecting their first baby. Nulliparous English-speaking expectant parents attending childbirth education programs in public and private hospitals participated in single sex small group discussions in late pregnancy. Discussions were audio-recorded, transcribed and analysed thematically using the group as the unit of analysis. Eight groups (22 women; 16 men) encompassing diverse socioeconomic circumstances were conducted. Analyses showed idealised fantasies consistently tempered with realistic expectations about adjustment to life with a baby. However, there were diverse and gendered views about whether primary care providers should discuss mental health with parents of infants and willingness to complete written questionnaires or be referred for specialist mental health care. Men regard primary family care as mother not father inclusive. Expectant parents readily anticipate realistic postnatal adjustment and need for emotional support. Increased provision of services that meet men's needs and public understanding and acceptance of Australian integrated models of primary postnatal mental health care are needed.

Paid parental leave supports breastfeeding and mother-infant relationship: a prospective investigation of maternal postpartum employment

OBJECTIVE

To investigate the association between the mother-infant relationship, defined as maternal-infant emotional attachment, maternal separation anxiety and breastfeeding, and maternal employment status at 10 months following first childbirth.

METHOD

Samples of employed, pregnant women, over 18 years of age and with sufficient English literacy were recruited systematically from one public and one private maternity hospital in Victoria. Data were collected by structured interview and self-report questionnaire in the third trimester, and at 3 and 10 months postpartum. Socio-demographic, employment, and breastfeeding information was collected. Participants completed standardised assessments of maternal separation anxiety and mother-to-infant emotional attachment.

RESULTS

Of 205 eligible women, 165 (81%) agreed to participate and 129 (78%) provided complete data. A reduced odds of employment participation was independently associated with continuing to breastfeed at 10 months (OR=0.22, p=0.004) and reporting higher maternal separation anxiety (OR=0.23, p=0.01) when maternal age, education, occupational status and use of paid maternity leave and occupational status were adjusted for in analyses.

CONCLUSION

Employment participation in the first 10 months postpartum is associated with lower maternal separation anxiety, and shorter breastfeeding duration.

IMPLICATIONS

Paid parental leave has public health implications for mothers and infants. These include permitting sufficient time to protect sustained breastfeeding, and the development of optimal maternal infant attachment, reflected in confidence about separation from her infant.

Unsettled infant behaviour and health service use: a cross-sectional community survey in Melbourne, Australia

AIMS

To investigate factors associated with health service use by women and their infants in Victoria, Australia.

METHODS

Cross-sectional screening survey of 875 women with 4-month-old infants attending immunisation clinics in five local government areas in Melbourne between May 2007 and August 2008. The self-report instrument assessed socio-demographic characteristics, unsettled infant behaviour, maternal mood (Edinburgh Postnatal Depression Scale) and, the outcome, health service use during the first 4 months post-partum.

RESULTS

Mothers and their infants used on average 2.8 different health services in the first 4 months post-partum (range 0-8). After adjustment for other factors, high health service use (defined as >3 different services) was more common in mothers whose infants were unsettled with persistent crying, resistance to soothing and poor sleep. A one-point increase on the unsettled infant behaviour measure was associated with an 8% (2-14%) increase in the use of >3 services, 9% (3-16%) in use of emergency departments, 7% (2-13%) in use of telephone helplines and 9% (3-14%) of parenting services. Poorer maternal mental health was also implicated with a one-point increase on the Edinburgh Postnatal Depression Scale associated with a 4% (0.4-8%) increase in the likelihood of using more than three services.

CONCLUSIONS

Unsettled infant behaviour is associated with increased use of multiple health services. The high use of emergency departments by families with unsettled infants found in this study suggests that enhancement of primary health-care capacity might be required.

Breastfeeding after assisted conception: a prospective cohort study

AIM

The aims were to investigate the prevalence of breastfeeding after conception with assisted reproductive technology (ART) and identify risk factors for breastfeeding duration <6 weeks and cessation of breastfeeding before the baby is 8 months old.

METHODS

A consecutive cohort of women who had conceived at one of two ART centres in Melbourne, Australia, was recruited in early pregnancy. The women completed telephone interviews and postal questionnaires in pregnancy and 3, 8 and 18 months after the birth.

RESULTS

Of 239 eligible women, 183 (77%) agreed to take part. Participants were more likely than the general population of childbearing Australian women to initiate breastfeeding (89% vs 83.3%, p=0.05) but by 3 months, a smaller proportion was breastfeeding exclusively (46% vs 57.3%, p=0.004). The proportions not providing any breast milk at 6 weeks and 8 months were 23% and 57%, respectively. More anxiety in late pregnancy and sub-optimal breastfeeding advice predicted breastfeeding duration <6 weeks and breastfeeding cessation before 8 months.

CONCLUSION

The predictors of less favourable breastfeeding outcomes after ART identified may be modifiable. Antenatal strategies to reduce anxiety in pregnancy and postnatal strategies to ensure consistent breastfeeding advice may improve breastfeeding outcomes among women who give birth after ART.

Development of a universal psycho-educational intervention to prevent common postpartum mental disorders in primiparous women: a multiple method approach

BACKGROUND

Prevention of postnatal mental disorders in women is an important component of comprehensive health service delivery because of the substantial potential benefits for population health. However, diverse approaches to prevention of postnatal depression have had limited success, possibly because anxiety and adjustment disorders are also problematic, mental health problems are multifactorially determined, and because relationships amongst psychosocial risk factors are complex and difficult to modify. The aim of this paper is to describe the development of a novel psycho-educational intervention to prevent postnatal mental disorders in mothers of firstborn infants.

METHODS

Data from a variety of sources were synthesised: a literature review summarised epidemiological evidence about neglected modifiable risk factors; clinical research evidence identified successful psychosocial treatments for postnatal mental health problems; consultations with clinicians, health professionals, policy makers and consumers informed the proposed program and psychological and health promotion theories underpinned the proposed mechanisms of effect. The intervention was pilot-tested with small groups of mothers and fathers and their first newborn infants.

RESULTS

What Were We Thinking! is a psycho-educational intervention, designed for universal implementation, that addresses heightened learning needs of parents of first newborns. It re-conceptualises mental health problems in mothers of infants as reflecting unmet needs for adaptations in the intimate partner relationship after the birth of a baby, and skills to promote settled infant behaviour. It addresses these two risk factors in half-day seminars, facilitated by trained maternal and child health nurses using non-psychiatric language, in groups of up to five couples and their four-week old infants in primary care. It is designed to promote confidence and reduce mental disorders by providing skills in sustainable sleep and settling strategies, and the re-negotiation of the unpaid household workload in non-confrontational ways. Materials include a Facilitators' Handbook, creatively designed worksheets for use in seminars, and a book for couples to take home for reference. A website provides an alternative means of access to the intervention.

CONCLUSIONS

What Were We Thinking! is a postnatal mental health intervention which has the potential to contribute to psychologically-informed routine primary postnatal health care and prevent common mental disorders in women.

Innovative psycho-educational program to prevent common postpartum mental disorders in primiparous women: a before and after controlled study

BACKGROUND

Universal interventions to prevent postnatal mental disorders in women have had limited success, perhaps because they were insufficiently theorized, not gender-informed and overlooked relevant risk factors. This study aimed to determine whether an innovative brief psycho-educational program for mothers, fathers and first newborns, which addressed salient learning needs about infant behaviour management and adjustment tasks in the intimate partner relationship, prevented postpartum mental health problems in primiparous women.

METHODS

A before and after controlled study was conducted in primary care in seven local government areas in Victoria, Australia. English-speaking couples with one-week old infants were invited consecutively to participate by the maternal and child health nurse at the universal first home visit. Two groups were recruited and followed sequentially: both completed telephone interviews at four weeks and six months postpartum and received standard health care. Intervention group participants were also invited to attend a half-day program with up to five couples and one month old infants, facilitated by trained, supervised nurses. The main outcome was any Composite International Diagnostic Interview (CIDI) diagnosis of Depression or Anxiety or Adjustment Disorder with Depressed Mood, Anxiety, or Mixed Anxiety and Depressed Mood in the first six months postpartum. Factors associated with the outcome were established by logistic regression controlling for potential confounders and analysis was by intention to treat.

RESULTS

In total 399/646 (62%) women were recruited; 210 received only standard care and 189 were also offered the intervention; 364 (91%) were retained at follow up six months postpartum. In women without a psychiatric history (232/364; 64%), 36/125 (29%) were diagnosed with Depression or Anxiety or Adjustment Disorder with Depressed Mood, Anxiety, or Mixed Anxiety and Depressed Mood in the control group, compared with 16/107 (15%) in the intervention group. In those without a psychiatric history, the adjusted odds ratio for diagnosis of a common postpartum mental disorder was 0.43 (95% CI 0.21, 0.89) in the intervention group compared to the control group.

CONCLUSIONS

A universal, brief psycho-educational group program for English-speaking first time parents and babies in primary care reduces de novo postpartum mental disorders in women. A universal approach supplemented by an additional program may improve effectiveness for women with a psychiatric history.

TRIAL REGISTRATION

ACTRN 12605000567628.

The contribution of Australian residential early parenting centres to comprehensive mental health care for mothers of infants: evidence from a prospective study

BACKGROUND

Australia's public access residential early parenting services provide programs to assist parents who self-refer, to care for their infants and young children. Treatment programs target infant feeding and sleeping difficulties and maternal mental health. There is limited systematic evidence of maternal and infant mental health, psychosocial circumstances or presenting problems, or the effectiveness of the programs. The aim of this study was to contribute to the evidence base about residential early parenting services.

METHODS

A prospective cohort design was used. A consecutive sample of mothers with infants under one year old recruited during admission to a public access residential early parenting service for a 4 or 5 night stay in Melbourne, Australia was recruited. They completed structured self-report questionnaires, incorporating standardised measures of infant behaviour and maternal mood, during admission and at one and six months after discharge. Changes in infant behaviour and maternal psychological functioning after discharge were observed.

RESULTS

79 women completed the first questionnaire during admission, and 58 provided complete data. Women admitted to the residential program have poor physical and mental health, limited family support, and infants with substantial behaviour difficulties. One month after discharge significant improvements in infant behaviour and maternal psychological functioning were observed (mean (SD) daily crying and fussing during admission = 101.02 (100.8) minutes reduced to 37.7 (55.2) at one month post discharge, p < 0.001; mean (SD) Edinburgh Postnatal Depression Scale at admission = 11.3 (5.7) reduced to 6.78 (4.44), at one month, p < 0.001) which were sustained at six months. Participant satisfaction with the program was high; 58 (88%) found the support of the nurses and 50 (75%) the social support of other mothers very helpful.

CONCLUSIONS

This psycho-educational approach is an effective and acceptable early intervention for parenting difficulties and maternal mood disturbance, and contributes to a system of comprehensive mental health care for mothers of infants.

The costs of 'being with the woman': secondary traumatic stress in midwifery

OBJECTIVE

it is widely acknowledged that caring can cause emotional suffering in health-care professionals. The concepts of compassion fatigue, post-traumatic stress disorder and secondary traumatic stress are used to describe the potential consequences of caring for people who are or have experienced trauma. Empathy between the professional and patient or client is a key feature in the development of secondary traumatic stress. The aim of this paper is to contribute to the conceptual development of theory about dynamics in the midwife-woman relationship in the context of traumatic birth events, and to stimulate debate and research into the potential for traumatic stress in midwives who provide care in and through relationships with women.

METHOD

the relevant literature addressing secondary traumatic stress in health-care professionals was reviewed.

FINDINGS

it is argued that the high degree of empathic identification which characterises the midwife-woman relationship in midwifery practice places midwives at risk of experiencing secondary traumatic stress when caring for women experiencing traumatic birth. It is suggested that this has harmful consequences for midwives' own mental health and for their capacity to provide care in their relationships with women, threatening the distinct nature of midwifery care.

CONCLUSIONS

opportunities for research to establish the existence of this phenomenon, and the potential implications for midwifery practice are identified.

The Edinburgh Postnatal Depression Scale detects but does not distinguish anxiety disorders from depression in mothers of infants

Specific screening tests to detect postpartum anxiety are as yet unavailable. The aim of this study was to test the ability of the Edinburgh Postnatal Depression Scale (EPDS) to detect anxiety disorders in women admitted to residential early parenting centres. Consecutive cohorts of English speaking women admitted with their infants to two centres in Melbourne, Australia completed the Composite International Diagnostic Interview and the Edinburgh Postnatal Depression Scale (EPDS). Anxiety and depression diagnoses were compared with EPDS scores. Of the 145 women (78% recruitment rate), 138 (95%) provided complete data of whom 35 (25%) had at least one anxiety disorder. EPDS scores over 12 correctly identified 28 women (44%) as having major depression, either alone or co-morbid with an anxiety disorder but 10 (16%) had only an anxiety disorder and were not depressed. All of the 26 (41%) women with EPDS scores over 12 with neither diagnosis met diagnostic criteria for minor depression or an adjustment disorder. EPDS scores were unable to distinguish between these diagnostic groups. The presumption that EPDS scores over 12 indicate only probable depression is an oversimplification. Current national initiatives recommend that EPDS scores over 12 warrant treatment for depression, which may lead to inappropriate labeling and therapy.

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.

Are pregnant Australian women well informed about prenatal genetic screening? A systematic investigation using the Multidimensional Measure of Informed Choice

BACKGROUND

Ethical practice requires that decisions to participate in medical care be well informed. Investigations into prenatal genetic screening for Down syndrome have assessed women's knowledge but have not examined whether being well informed about the potential consequences of screening, such as subsequent diagnostic testing, diagnosis and termination, is associated with psychological distress for women.

AIMS

To assess informed choice to participate in second trimester maternal serum screening (2MSS) in pregnant women using a validated measure and to compare anxiety levels in women who were well informed versus poorly informed.

METHODS

A prospective cohort study where pregnant women completed the Multidimensional Measure of Informed Choice and the Hospital Anxiety and Depression Scale immediately prior to the offer of 2MSS. Follow-up questionnaires assessing psychological symptomatology were completed at 20 and 30 weeks gestation.

RESULTS

Only 37% of decisions were informed; those who participated in screening were more likely to have made an informed decision than those who did not (P = 0.01); 31% did not know that miscarriage was a possible consequence of diagnostic testing subsequent to an increased risk screening result and only 62% correctly identified that termination of pregnancy would be offered if Down syndrome were to be diagnosed. Short-term anxiety levels in those who were well informed were not significantly different from those who were poorly informed (P = 0.14).

CONCLUSIONS

Health promotion strategies, which are readily applicable in clinical settings and address diverse learning needs and attitudes of pregnant women, are needed. The impact of antenatal screening on other dimensions of pregnancy psychology remains to be investigated.