Effects of Home Visits and Planned Education on Mothers Postpartum Depression and Quality of Life

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1 Volume 9 Number 3 September 2018 JOURNAL OF CLINICAL AND EXPERIMENTAL INVESTIGATIONS RESEARCH ARTICLE Effects of Home Visits nd Plnned Eduction on Mothers Postprtum Depression nd Qulity of Life Hvv Tel 1, Sukrn Ertekin Pinr 2, Gulseren Dglr 2 1 Cumhuriyet University Fculty of Helth Sciences, Nursing Deprtment, Sivs, Turkey 2 Cumhuriyet University Fculty of Helth Sciences, Midwifery Deprtment, Sivs, Turkey Correspondence: Sukrn Ertekin Pinr Cumhuriyet University Fculty of Helth Sciences, Sivs, Turkey E-mil: sepinr09@gmil.com ABSTRACT Objective: The present study ims t determining the effects of home visits nd plnned trining on mothers postprtum depression nd qulity of life. Mterils nd Methods: The smple of qusi-experimentl study ws consisted of 70 women. Study dt were collected by mens of personl informtion questionnire, the Edinburgh Postprtum Depression Scle nd the World Helth Orgniztion Qulity of Life Scle (WHOQOL-BREF). Results: The verge ge of the mothers is between 25.50±4.78. In repeted mesurements, sttisticlly significnt differences were found mong qulity of life scores of mothers (p<0.05), nd their qulity of life scores were found to be higher in the third mesurement when compred to the first mesurement. In ll repeted mesurements, sttisticlly significnt negtive reltionship ws found between depression nd qulity of life scores of mothers (p<0.05), nd mothers depression scores were seen to decrese s their qulity of life scores incresed. Sttisticlly significnt differences (p<0.05) were found mong depression scores ccording to mothers eduction level nd mong qulity of life scores ccording to their number of pregnncies. University grdute mothers depression scores decresed in the second mesurement nd scores were the sme in the third mesurement. In the third mesurement, primiprous mothers qulity of life scores were found to be higher thn in the first mesurement. Conclusions: The study findings demonstrte tht mothers re t risk of depression during the postprtum period, postprtum depression negtively ffects their qulity of life, nd home visits nd trining increse their qulity of life nd decrese their depression risk. Key Words: helth eduction, home visits, postprtum depression, qulity of life Received: , Accepted: DOI: /jcei INTRODUCTION The postprtum period, lso clled the fourth trimester, is the period in which the newborn becomes prt of the fmily, the womn experiences emotionl, physicl nd socil chnges, nd her responsibilities increse due to the newborn [1,2]. Although pregnncy nd the trnsition to the mternl role re importnt prts of womn s life, they re problemtic periods s well [3]. During the postprtum period, mothers re supposed to lern their new roles of communicting with their bbies, cring for them nd deling with issues relted to their bbies [1,4]. While mny women dpt themselves esily to the physiologicl, psychologicl nd socil chnges emerging due to pregnncy nd childbirth, some women my suffer emotionl problems t different levels [5]. Women hve twice s much risk of depression throughout their lifetime thn men. The higher rtes of depression in women re relted to their reproductive periods (pregnncy, postprtum period nd menopuse) [6,7]. Women re t risk of significnt psychitric diseses within the first yer fter birth. Even if womn hs no pregnncy or birth relted complictions, she my ber risk of being exposed to psychitric disorders prticulr to postprtum depression during the postprtum Copyright 2018 by Authors. Licensee Modestum Ltd., UK. OPEN ACCESS for ll. 119

2 period [8,9]. Bloch et l. (2006) reported tht the depression rte in women increses threefold during the first five weeks postprtum [8]. Fil et l. (2017) found prevlence of depressive symptoms s 11.8% t 6 weeks of postprtum nd 10.1% t 6 months of postprtum [10]. Ymn Efe et l. (2009) showed tht 23.4 percent of women in their fourth week postprtum in Turkey [11] re t risk of postprtum depression nd Husin et l. (2006) showed tht 36 percent of postprtum women re t risk of postprtum depression [12]. In the study of Üstgörül nd Ynıkkerem (2017) in which they exmined the studies conducted in Turkey, they found tht postprtum depression prevlence rnged from % [13]. High levels of estrogen nd progesterone throughout the pregnncy period ply role in the etiology of postprtum depression. The most importnt risk fctors re prentl depression nd nxiety, history of previous depression or bipolr ffective disorder, postprtum sdness nd postprtum depression in previous births, or fmily history [6,14]. Postprtum depression my negtively ffect mother s bilities, her interction with the child, the cre she gives, her reltionships with other fmily members, nd her responsibilities nd roles, nd my decrese her qulity of life [15 18]. Besides, not treting the postprtum depression cn cuse cognitive, behviorl nd emotionl negtive effects for the bby [18 20]. Severl studies hve shown tht the qulity of life of mothers with postprtum depressive symptoms is lower thn tht of mothers without depressive symptoms [17,21]. Erly dignosis nd tretment of depression experienced during the postprtum period is of gret importnce in ensuring mother-infnt helth nd helthy postprtum process. It is lso importnt for reducing the negtive impcts of depression on mother-infnt helth nd in developing preventive mentl helth services. Therefore, helth professionls re expected to mke plns to prevent postprtum depression or to tret it by n erly dignosis, nd to provide support nd counselling for mothers to dpt themselves through trining nd home visits [22]. In postprtum period, women re dischrged from hospitl fter 24 hours in our country. For this reson, if home visits nd mother-infnt follow-ups re performed effectively in the postprtum period, the depression symptoms tht cn be seen in this process cn be detected erly nd the mother cn get professionl support [23]. Home visits consist of continuously nd regulrly monitoring of fmilies who live in prticulr re by helthcre professionls. Home visits include observing whether the environment in which the fmily lives is pproprite for helth, collecting the necessry dt, providing eduction on helth, nd monitoring of groups t-risk (infnts nd children up to 5 yers old, women nd women in the ge group, pregnnt women nd puerpernts). By home visits, helth professionls should protect fmilies helth by identifying their helth problems, formulte tretment plns for them if they hve helth problems, nd increse their qulity of life [24]. Thus, individuls cn be evluted more relisticlly in their own environment, the existing risk fctors nd problems cn be identified, interventions cn be strted in the erly stges, serious mentl problems such s depression tht cn be experienced in postprtum period cn be prevented. In ddition, effective communiction of helthcre professionls with fmily members ensures tht the mother nd other members of the fmily re sfe [25]. In the postprtum period, mny prctices re crried out specific to the culture in Turkey. These prctices cn ffect the helth positively (not leving the mother lone, tking cre of the nutrition etc.) nd sometimes ffect the life negtively (not brestfeeding the bby for three pryer times, not giving the colostrum to the bby). Therefore, it is importnt for helth professionls to evlute women in the culturl environment they live in nd in the home environment [14]. Although there hve been severl studies on postprtum depression [3,11,26 28], there is gp in the literture concerning studies exmining mothers postprtum depression nd home visits during the postprtum period. This study ims t determining the effects of home visits nd plnned trining on mothers postprtum depression nd qulity of life. MATERIALS AND METHODS Smple nd setting The study ws conducted s pre-nd post-testing nd s qusi-experimentl between November 1, 2010 nd Mrch 1, The study smple consisted of 82 mothers who resided in city Centre, who hd experienced helthy pregnncy, who delivered helthy newborn either by vginl delivery or Cesren section, who hd no helth problems during the erly postprtum period, nd who greed to prticipte in the study. For ll power clcultions, we set lph = 0.05, bet = 0.20, 1-β= 0.80 nd p = The study included 82 mothers. Twelve mothers left the study for resons such s not ccepting home visits, not spring the time for them, hving different chores t visit times nd moving to different cities. The study ws completed with 70 mothers (35 primiprous, 35 multiprous). Dt collection Study dt were collected by mens of personl informtion questionnire, the Edinburgh Postprtum Depression Scle, nd the World Helth Orgniztion Qulity of Life Scle (WHOQOL- BREF). The personl informtion questionnire ws developed through literture review nd it included 24 items questioning the mother s socio-demogrphic chrcteristics, pregnncy, lbor nd postprtum period [23,28,29]. The Edinburgh Postprtum Depression Scle (EPDS) ws developed by Cox et l. (1987) [30] nd dpted to Turkish by 120 Copyright 2018 by Authors. Licensee Modestum Ltd., UK. OPEN ACCESS for ll.

3 Engindeniz et l. (1996) [31]. The scle ims t ssessing women s postprtum depression levels nd consists of ten items rted on four-point Likert scle rnging from 0 to 3. The lowest nd highest obtinble scores from the scle re 0 nd 30 respectively. In evlution, while the first, second nd fourth items re scored s 0, 1, 2 nd 3, the third, fifth, sixth, seventh, eighth, ninth nd tenth items re scored inversely s 3, 2, 1 nd 0. The cut-off point of the scle is 12/13. Scores over 12/13 indicte the presence of depression risk. The Cronbch s lph coefficient of the originl scle ws found to be 0.79 [31]. The World Helth Orgniztion Qulity of Life Scle (WHOQOL-BREF), developed by the World Helth Orgniztion, ws used in the study. This scle consists of 27 items nd hs five-point rting system. It is evluted s 1 = very bd, 2 = slightly bd, 3 = neither good nor bd, 4 = quite good nd 5 = very good. WHOQOL-BREF includes physicl, mentl, socil, environmentl nd ntionl environmentl domins. Possible obtinble scores from the subscle rnge from 0 to 20. As the scores increse, so does the qulity of life. Eser et l. in 1999 [32] conducted the relibility nd vlidity study of the Turkish version of the scle. In the vlidity nd relibility study, Eser nd collegues found Cronbch s lph coefficient of 0.83 for the physicl re, 0.66 for the psychologicl re, 0.53 for the socil re, 0.73 for the environmentl re nd 0.73 for the ntionl environmentl re [32]. Procedure We met with mothers who greed to prticipte in the study before they were dischrged from the hospitl nd lso rrnged home visits. In the second week postprtum, we met mothers t their homes nd ll the dt collection tools were dministered through fce-to-fce interviews (first home visit/first mesurement). We guided mothers who were detected s crrying risk of depression by the EPDS (mothers whose depression scores were over 13) to specilist psychitrists nd dvised them to receive tretment nd consultncy. During visits, we monitored mothers tretment processes. In the third week postprtum, we telephoned the mothers nd informed them bout issues they wnted to be enlightened bout. In the fourth week postprtum (second home visit), we visited mothers for the second time nd gve them plnned trining considering the dt obtined from the first home visit. Our gol in plnned trining is to increse the qulity of life by ensuring tht the mother cn del with problems both physiclly nd emotionlly relted to herself nd the bby. In the content of trining for mothers, nutrition, sleep problems, movement, fmily plnning methods, stress nd coping with stress methods, respirtion nd muscle relxtion exercises re included. In the content of trining for bbies, topics such s bthing, gs extrction, vccintions, thrush nd rsh cre, weight gin, heptitis nd other diseses re included. Demonstrtion nd question-nswer methods were used in the trining method nd the trining lsted for minutes. In the fifth week postprtum, we clled them gin nd informed them bout issues they wnted to be enlightened bout. In the sixth nd twelfth weeks postprtum, we mde the third home visits (second mesurement) nd fourth home visits (third mesurement), respectively. In the third nd fourth home visits, we received feedbck from mothers on the plnned trining, nswered their questions nd informed them on issues on which they lcked knowledge. Then we re-dministered the EPDS nd the WHOQOL-BREF (see Figure 1). Before home visits, we telephoned mothers to mke n ppointment. Figure 1. The flowchrt of the study Copyright 2018 by Authors. Licensee Modestum Ltd., UK. OPEN ACCESS for ll. 121

4 Ethics pprovl Written nd verbl consent ws obtined from the ptients who prticipted in this study. Ethics committee pprovl ws received for this study from the institutionl ethics committee (Decision number: 10/114). The study ws conducted in ccordnce with the Declrtion of Helsinki. Sttisticl nlysis Anlyses were performed using the Sttisticl Pckge for Socil Sciences (SPSS 14.0). During nlysis of the dt, the reltionship between the mothers postprtum depression nd qulity of life scores ws evluted using Person s correltion nlysis. Anlysis of vrince (ANOVA) ws used for repetitive comprison of the postprtum depression nd qulity of life scores nd for comprison of the eductionl sttus of the prticipnts with postprtum depression scores. In ddition, t-test ws used to show the reltionship between the number of the pregnncies nd the prticipnts qulity of life nd depression scores. Significnce level ws tken s p<0.05 for the sttisticl tests. RESULTS Socio-demogrphic chrcteristics of mothers The study included 70 mothers ged between 16 nd 37. Their verge ge ws 25.50±4.78 yers; 45.7% of the mothers were in the ge group, 47.1% were primry school grdutes, 88.6% were housewives; 37.1% hd been mrried for 2 5 yers, 61.4% hd nucler fmilies, 50% were primiprous, 50% were multiprous, 52.9% stted their socio-economic sttus s good, nd 78.6% gve birth vginlly. Results relted to mothers depression nd qulity of life In repeted mesurements, sttisticlly significnt difference ws found in the qulity of life scores of mothers (p<0.05) nd their qulity of life scores were found to be higher in the third mesurement when compred to the first mesurement. There ws no sttisticlly significnt difference in depression scores of mothers in repeted mesurements (p>0.05), but their pre-eduction depression scores were found to be higher (Tble 1). In ll repeted mesurements, sttisticlly significnt negtive reltionship ws found between depression nd the qulity of life scores of mothers (p<0.05), nd mothers depression scores were seen to decrese s their qulity of life scores incresed (Tble 2). There ws sttisticlly significnt difference in depression scores ccording to mothers eduction levels (p<0.05). University grdute mothers depression scores decresed in the second mesurement nd scores were the sme in the third mesurement (Tble 3). There ws sttisticlly significnt difference in qulity of life scores of mothers ccording to their number of pregnncies (p<0.05). In the third mesurement, primiprous mothers qulity of life scores were found to be higher thn in the first mesurement (Tble 4). There ws no sttisticlly significnt difference in depression scores of mothers ccording to their number of pregnncies (p>0.05). There ws no sttisticlly significnt difference between the mothers depression nd qulity of life scores in terms of such vribles s ge, durtion of mrrige, profession, fmily type nd type of delivery (p>0.05). Tble 1. Depression, qulity of life nd informtion scores of mothers Depression scores Qulity of life scores F p 8.51 ± ± ± 5.78 F=1.272 p= ± ± ± 9.75 F=4.393 p=0.014 b One-wy ANOVA test; b p significnt t < 0.05;SD: Stndrd devition Tble 2. Reltionship between mothers depression nd their qulity of life nd knowledge scores First EPDS mesurement r= p=0.004 b r= r= p=0.017 b r= Obtined from Person s correltion nlysis test; b p significnt t < 0.05 EPDS: The Edinburgh Postprtum Depression Scle WHOQOL-BREF (TR) Second mesurement r= p=0.005 b r= r= p=0.011 b Third mesurement r= p=0.004 b r= r= Copyright 2018 by Authors. Licensee Modestum Ltd., UK. OPEN ACCESS for ll.

5 Tble 3. Depression scores by eduction sttus of mothers Eduction sttus Primry school High school University F, p depression scores 8.81 ± ± ± 6.14 F=0.166, p=0.848 depression scores 9.27 ± ± ± 4.03 F=4.488, p=0.015 b depression scores 9.15 ± ± ± 6.69 F=2.136, p=0.126 One-wy ANOVA test; b p significnt t < 0.05 SD: Stndrd devition Tble 4. Depression nd qulity of life scores by the number pregnncies of mothers Primiprous Multiprous t, p ± ± t=0.059, p=0.953 Primiprous 8.34±5.45 Multiprous 8.68±4:67 t, p t= p=0.778 Independent smples t-test; b p significnt t < 0.05; SD: Stndrd devition Qulity of life scores ± ± t=-0.123, p=0.903 Depression scores 7.48± ±5.08 t= p= ± ± t=2.108, p=0.039 b 7.22± ±5.21 t= p=0.473 DISCUSSION Postprtum depression is common mjor helth problem ffecting the lives nd life qulities of mothers, their fmilies nd their bbies development. In the present study, the qulity of life scores of mothers in the postprtum period were determined to be lower t the first mesurement nd significntly higher t the third mesurement. Home cre provides some opportunities for the postprtum womn. Help from the womn s fmily is lso n dvntge in developing her skills to better tke cre of herself nd her bby. Ensuring the physicl cre of the mother nd the bby, identifying complictions erlier, voiding problems likely to rise, supporting the mother in difficult situtions, helping the mother dpt to the mternl role nd cope with problems, nd reducing nxiety nd stress re the min purposes of postprtum cre [4]. In study conducted with primiprous mothers, we observed n increse in mothers knowledge scores fter trining them bout infnt cre following delivery in hospitl environment [4]. As home cretes sfer nd more comfortble tmosphere for women in terms of interction nd control, informing women through home visits is expected to be more effective [2]. Helthcre given to the mothers in their own homes, ctive prticiption of mothers in trining, nd prcticl nd ccurte solutions to mothers problems were mong the fctors tht contributed to n increse in the qulity of life scores of mothers t the second nd third mesurements. Since mothers crry high risk of postprtum depression, supporting them through home visits, especilly during the first four months postprtum, is very importnt [33]. Postprtum depression reduces mothers qulity of life nd prevents them from fulfilling their dily ctivities, mternl role nd responsibilities [28]. In this present study, the mothers qulity of life incresed s their depression levels decresed, which ws consistent with the results of other studies in the literture. Severl studies hve shown highly significnt reltionship between depression nd qulity of life, nd postprtum depression dversely ffects the qulity of life [9,34 36]. Durukn et l. (2011) showed tht postprtum depression ffected mothers qulity of life significntly nd mothers qulity of life scores decresed s their depression scores incresed [28]. On the other hnd, Tmki (2008) showed tht home visits hd positive effect on women s qulity of life [33] nd Tezel nd Gözüm (2005) showed tht nursing cre given t home reduced the depression risk in women dignosed with postprtum depression [23]. In this present study, no significnt correltion ws found between postprtum depression nd the eduction level of the mothers in the first mesurement. In the second mesurement, the university grdute mothers depression scores were found to be significntly lower thn their scores in the first mesurement. This cn be explined by the fct tht s the womn s eduction level increses, she cn hve more effective control over her own life, mke her own decisions, pln her life better, hve better Copyright 2018 by Authors. Licensee Modestum Ltd., UK. OPEN ACCESS for ll. 123

6 socil support nd higher self-esteem, nd she cn dopt wht she hs lerned from the trining into her life more effectively. These results regrding the effects of eduction level on depression seem to vry from one study to nother. While some studies hve shown tht eduction levels do not ffect depression scores [28,33], others hve found tht low eduction level of the mother is risk fctor for postprtum depression. As depression scores decrese, mothers eduction level increses [37 39]. Qulity of life scores for primiprous mothers were higher in the third mesurement thn in the first nd higher thn multiprous mothers scores. Primiprous mothers need more informtion bout infnt cre nd professionl nursing support [40]. Tht the primiprous mothers qulity of life scores were low in the first mesurement is probbly due to lck of experience in bby cre, not knowing wht to do when they encounter problem, not feeling competent enough to tke cre of bby nd not feeling redy for motherhood. Yıldız nd Albyrk (2014) showed tht primiprous mothers hd difficulty tking cre of the bby, hd understnding issues relted to the bby s growth, development nd problems, nd did not feel competent enough to del with chnges in the bby nd in themselves [4]. As the physicl effects of birth significntly decresed fter the third week postprtum, mothers could tke on more responsibility for their own cre nd meet the infnt s needs [41]. This contributed to the increse in the qulity of life scores of the mothers t the third mesurement. Arsln (2001) showed tht counselling nd eduction services provided during pregnncy nd the postprtum period promoted the qulity of life of primiprous mothers [42]. This result is similr to the findings of the present study. The present study, which ws crried out to determine the effects of home visits nd plnned trining on mothers postprtum depression nd qulity of life, showed tht there is negtive significnt reltionship between depression level nd qulity of life, nd tht s depression scores decrese, qulity of life scores increse. Mothers qulity of life scores were found to be lower in the first mesurement but higher in the third; university grdute mothers depression scores decresed in the second mesurement, nd primiprous mothers qulity of life scores were found to be higher in the third mesurement thn in the first. In line with these results, we propose the following recommendtions: () Mothers should be evluted in terms of postprtum depression nd should be provided with informtion nd counselling before they re dischrged from the hospitl. 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