The University of Toledo The University of Toledo Digital Repository Master s and Doctoral Projects Postpartum depression in women : antepartum and postpartum factors Norma Jean Lake Medical College of Ohio Follow this and additional works at: http://utdr.utoledo.edu/graduate-projects This Scholarly Project is brought to you for free and open access by The University of Toledo Digital Repository. It has been accepted for inclusion in Master s and Doctoral Projects by an authorized administrator of The University of Toledo Digital Repository. For more information, please see the repository's About page.
Postpartum Depression in Women: Antepartum and Postpartum Factors Norma Jean Lake Medical College of Ohio 2004
ii DEDICATION I would like to dedicate this project to my husband Lee, for his love and encouragement. He has, without fail, supported me in every endeavor throughout this and all of my undertakings. This project also is dedicated to my children Susie and Alan, for taking on much more responsibility, and reminding me that there is a light at the end of the tunnel.
iii ACKNOWLEDGEMENTS I would like to thank Dr. Katherine Sink for her support, direction and hours spent helping me understand research and making this project a success. Thank you for sharing your data, wisdom, knowledge of research, time and friendship with me. I would also like to thank Dr. Judith Lamp for her encouragement and Dr. Deb Buchman for her assistance with statistics.
iv TABLE OF CONTENTS DEDICATION.ii ACKNOWLEDGEMENTS...iii TABLE OF CONTENTS..iv CHAPTER 1 Introduction.1 Statement of Problem..1 Statement of Purpose..2 Research Question..3 Identification of Nursing Theoretical Framework. 3 Conceptual Model. 4 Definition of Terms...5 Assumptions..8 Significance of Study... 9 CHAPTER 2 Literature Review 11 Nursing Theoretical Framework...11
Literature Review..16 v Summary..26 CHAPTER 3 Methods 28 Design..28 Setting, Inclusion, Exclusion Criteria...28 Instruments..30 Data Collection 33 Data Analysis..35 Summary..36 CHAPTER 4 Results..37 Participants..37 Findings 39 Summary.44 CHAPTER 5 45 Findings... 45
vi Theoretical Framework..49 Conclusions.50 Limitations 52 Implications..52 Recommendations for Future Research.54 Summary..55 REFERENCES 56 ABSTRACT.61
vii LIST OF FIGURES AND TABLES Figure 1.1 Conceptual Model of Postpartum Risk Factors 4 Table 4.1 Ages of Women.38 Table 4.2 Status of Relationships 38 Table 4.3 Education of Women 38 Table 4.4 Employment Status..39 Table 4.5 Incomes of Women..39 Table 4.6 Hospital Stay, Privacy, Room and Nursing Care.43
1 CHAPTER 1 Introduction Depression after the birth of a baby is a common cause of maternal morbidity. Thirteen percent of adult postpartum women experience this type of depression (Beck, 2001); thirty-two percent of these mothers are adolescent mothers (Misri & Duke, 1995). Having a new baby, by traditional beliefs, should be a joyful event. It is very distressing for women to feel emotionally low at a time when they are supposed to feel happiness and pleasure. Their feelings of guilt, shame and fear of negative consequences may prevent women from disclosing their emotional distress. New mothers often minimize their condition by ignoring or denying symptoms associated with postpartum depression (PPD). This chapter includes the problem statement of postpartum depression in women with identification of the theoretical framework. Additionally, the statement of purpose, research questions, significance to clinical nursing as well as the assumptions and limitations for this quantitative, secondary data analysis will be discussed. Statement of Problem Depression during pregnancy poses a risk to the fetus both directly and indirectly in terms of maternal nutrition, drugs, alcohol, smoking, and noncompliance with prenatal care plans (Deaves, 2001). The chances for obstetrical
2 complications such as intrauterine growth retardation, premature labor and placental abruption are increased, possibly due to increased catecholamine levels in the depressed mother (Miller, 2002). The emotional and physical well - being of the new mother is vital to the health of the entire family. For example, PPD can place a strain on the relationship between the woman and her partner and will make family life more stressful. In addition to the personal distress of feeling sad and unhappy, postpartum depression can have more insidious consequences, such as disturbed mother-infant relationships and impaired cognitive and emotional development of the children (Beck, 2001). Limited studies were found identifying antenatal and immediate postpartum factors in women who experience postpartum depression. Identifying factors that predict development of PPD early in the pregnancy and postpartum period would allow for the development and assessment of strategies for the prevention and treatment of this devastating mood disorder. Statement of Purpose The purpose of this study is to discover any factors in the antepartum and immediate postpartum period that may assist healthcare providers to identify the potential for PPD.
3 Research Questions 1) What differences in the antepartum period and the immediate postpartum period can be identified in women who experience postpartum depression from those who do not experience postpartum depression? 2) What hospital environmental factors predict PPD? Identification of Nursing Theoretical Framework The theoretical framework utilized for this project is Imogene King's Systems Framework and her Theory of Goal Attainment. King (1981) defines nursing as " a process of human interactions between the nurse and woman whereby each perceives the other and the situation; and through communication, they set goals, explore means and agree on means to achieve goals" (p. 88). Perception and communication are very important where PPD is concerned. The accuracy of perceptions by both the nurse and the woman will increase or decrease the effectiveness of communication and goal setting. The goal, therefore, of the nurse and woman's interaction is to identify PPD and implement a treatment plan. Social systems, or support systems, are groups of people within the community or society that share common goals, interests and values (King, 1981). The woman suffering from PPD may turn to her family, church, health care provider, or support group for support.
4 Conceptual Model Thirteen percent of postpartum women experience postpartum depression (Beck, 2001). Factors that could contribute to PPD may include experiences that occur in the antepartum and/or immediate postpartum period. Perception and communication may help lead to the goal of identifying PPD early so that treatment may be initiated during pregnancy or immediately after the birth. PERCEPTION ANTEPARTUM FACTORS PPD RISK IMMEDIATE PP FACTORS COMMUNICATION SUPPORT CONCEPTUAL MODEL OF PPD RISK FACTORS
5 Definition of Terms The terms used in the theoretical model of this study are adapted from King's (1981) theory for nursing and are defined as follows: Antepartum factors: In this study, antepartum factors were conceptualized as physical, emotional and social occurrences that a woman who is pregnant experiences, causing her to live her life in a particular manner. King (1981) offers that an individual are is a dynamic human being whose perception of objects, persons and events influence his/her behavior, social interaction and health. Antepartum factors were operationally defined as experiences the woman could encounter while pregnant. Examples of these antepartum factors include: a history of depression, previous pregnancy loss or termination, unplanned/unwanted pregnancy, history of emotional, physical or sexual abuse, previous PPD, level of social support, fatigue, martial status, employment status, education, and age of the mother. Immediate postpartum factors: In this study, immediate postpartum factors were conceptually defined as experiences occurring during labor, delivery or during the immediate postpartum period. Immediate postpartum factors were operationally defined as factors the woman encountered while in the hospital both before and after delivery. Examples of these postpartum experiences include birth of the infant, labor and
6 delivery experiences, perceived pregnancy experience, self-confidence, fatigue, support received from her significant other and friends, and support of the health care provider. Perception: In this study, the conceptual definition of perception is based on King s definition of perception. King (1981) defines perception as each person's representation of reality, or the awareness of objects, situations and persons. The operational definition of perception in this study relates how the nurse and woman become sensitive to and understand each other. The accuracy of the perceptions of each by the other is important toward increasing the effectiveness of communication; therefore, achieving the goal of identifying differences in women who may or may not experience postpartum depression. Communication: In this study, the conceptual definition of communication is to make known by an interchange of thoughts, information and opinions. King (1981) defines communication as the means by which information is given in specific nursing situations to identify concerns and/or problems and to share information that assists individuals in making decisions that lead to goal attainment. The operational definition of communication used in this study is how the nurse, health care provider and the woman discuss antepartum experiences, labor and delivery experiences, postpartum experiences and symptoms of PPD.
7 Postpartum Depression: In this study, the conceptual definition of postpartum depression is a major depressive episode that is associated with childbirth. It is characterized by a persistently depressed mood that lasts more than two weeks (Miller, 1996). Postpartum depression may occur up to one year after delivery (Beck, 2001). The operational definition of postpartum depression include those women who stated that they were experiencing PPD or were diagnosed with PPD. Also included were women who scored 18 or greater on the Edinburgh Postnatal Depression Scale in the original study. Social Support: In this study, the conceptual definition of social support is a wellintentioned action that is given willingly to a person with whom there is a personal relationship, and that produces an immediate or delayed positive response in the recipient (Logsdon & Usui, 2001). According to King, social systems are groups of people within a community or society that share common goals, interests and values. They provide a framework for social interactions and relationships, and establish rules of behavior and courses of action (1981). The operational definition of social support is a marital relationship, relationship with significant other or partner, parent or parents, family, intimate confidante or friend, nurse or health care provider. The perception of social support is evaluated by the woman as the importance of a particular type of support and how much of that support is received.
8 Nursing support during labor influences a woman's perception of coping and satisfaction with the birth experience. Emotional support behavior (making the woman feel confident and cared for, giving praise and respect) by the health care provider were most important in contributing to a positive birth experience (Fowles, 1998). A nurse who shares valuable time with the woman is perceived as caring. Caring involves nurses' making an extra effort to provide continuity of care for the mother (Shaw, 2001). This caring nursing support may decrease the potential for postpartum depression and helps the new mother accept the role of motherhood (Hodnet ED, 2002). In summary, the conceptual model of PPD factors shows that factors that could contribute to PPD may include experiences that occur in the antepartum and/or immediate postpartum period. Perception, communication and support may help lead to the goal of early identification of PPD so that treatment may be initiated. Assumptions Assumptions of this study include: 1) Women prefer not to experience the symptoms of PPD. 2) Women want to enjoy being a mother (traditional belief).
9 3) A common belief of the general population is that PPD is not real and that women who experience PPD use it as an excuse for unacceptable behavior (Ugarriza, 2000). 4) A degree of PPD is normal (Epperson, 1999). 5) Women who experience PPD have difficulty seeking help from healthcare providers, family and friends (Beck & Gable, 2001). 6) Health care providers do not routinely screen for PPD (Beck & Gable, 2000). 7) Health care providers do not know to whom to turn to for help (Beck & Gable 2001). Significance of the Study Primary prevention of PPD is not just a matter of identifying symptoms, but looking for all predisposing factors that increase the mother's vulnerability to developing PPD. Early recognition by the health provider of antepartum and postpartum factors experienced by the mother will allow for the development and assessment of strategies for early treatment of the mother, with the goal of prevention and reducing the morbidity associated with this disorder. This study contributes to nursing knowledge and practice by assisting nurses in identifying factors that may indicate the risk for PPD. Nurses are well positioned to assess the mental health and identify early depressive symptoms of
10 mothers. Additionally, nurses are effective support systems that should be able to problem solve and seek solutions to identified problems including making referrals to appropriate professionals for further management.
11 CHAPTER 2 Literature Review King's (1981) nursing theoretical framework and application of her concepts to women who may experience postpartum depression is presented in this chapter. Additionally, a literature review synthesizes and critiques the literature pertaining to women who experience postpartum depression. The literature review is divided into the following categories: Symptoms of PPD, symptoms of fatigue, identified antenatal and immediate postpartum factors in women who experience PPD, and validated screening instruments that could be administered by health care providers. Nursing Theoretical Framework Imogene King's (1981) Systems Framework is the theoretical framework used in this quantitative nursing research study. The central focus of King's framework is the dynamic human being whose perceptions of objects, persons and events influence his/her behavior, social interaction and, ultimately, health. Human beings, in this study, women, are open systems that are in constant interaction with the environment. These interacting systems include: 1) the personal system - the woman or the nurse, 2) the interpersonal system - or the woman and nurse interacting with each other, and 3) the social system - or family, religious, educational, health care, work or community systems that shares common goals and values.
12 The interacting systems are composed of concepts. The concepts associated with the personal system are perception, self, body image, growth and development, space and time (King, 1981). King viewed perception as the most important concept of the personal system because perception of objects, persons and events ultimately influence the individual's behavior, social interaction and health. Disturbances in a woman's perception of self, body image, space and time can occur during pregnancy and during the postpartum period. A pregnant woman or a new mother may experience feelings of loss. She may perceive a loss of self, a loss of control, a loss of a slim figure or a loss of physical attractiveness while pregnant which may extend into the postpartum period. She may feel confined or overwhelmed after the birth related to caring for the baby, herself, her family, and having the feeling of having no time for herself. These disturbances in perceptions could lead to postpartum depression. As Nicholson (1990) states, "the loss of self includes loss of sexuality, changes in body image, loss of personal space, perceived loss of intellectual ability and memory, loss of power in the family, loss of occupation, occupational status, loss of friends and of being a traditional woman" (p. 693). The concepts associated with the interpersonal systems include interaction, transaction, communication, role and stress. Communication is the means by which information is given to identify concerns and/or problems and to share information that assists individuals in making decisions that lead to
13 attaining a goal, most commonly that of health in patient nurse communications (King, 1981). Communication can be verbal, spoken or written, or non-verbal, touch, eye contact, posture and facial expressions. Good communication skills are imperative for the nurse and health care provider. Social stigma is attached to postpartum depression. Perceived feelings of guilt, shame and possibly the fear of negative consequences may prevent women from disclosing their emotional distress following what is supposed to be a joyous event. The nurse and health care provider must be knowledgeable and proactive in educating the pregnant woman about PPD and in making her aware of the signs and symptoms of postpartum depression. Development of good communication and a trusting relationship between the provider and the woman may encourage the woman to talk to her health care provider if symptoms of PPD occur. When women and health care providers perceive, communicate and interact with each other, goals and the means to achieve them can be identified. Poor communication skills lead to ineffective interactions and transactions between them, and therefore effective goal attainment may not be achieved. The concepts associated with the social system include organization, authority, power, status and decision-making (King 1981). Social systems are groups of people within the community or society that share common goals, interests and values. The woman suffering from PPD makes decisions based on her perception of her experiences. She has many choices for social interaction
14 and support including spiritual insight and/or communication with her support system or health care provider. She may turn to her partner, mother, family, friends, health care provider or support groups such as Depression after Delivery (DAD) for help. Research has shown that a supportive relationship during PPD is associated with a reduction of depressive symptoms (Misri & Duke, 1995). Support groups may be helpful for those mothers who have feelings of isolation and loneliness as the groups affirm the reality of the situation by sharing feelings among the members (Misri & Duke, 1995). The groups give hope to the woman that her depression can end and she can gain control of her life. However, women who have PPD may choose isolation instead of seeking support. Beck (1992) has suggested that unfortunately women may distance themselves from support because they perceived family and friends do not understand their experiences. Therefore, the family is also an important social system for the mother. Family members should be recipients of nursing care because all family members are affected when any one individual within the family is suffering or ill. The health care provider should include the family members with explanations, supportive information and recommendations to help them cope with the impact of depression. King proposes that nursing is a process that involves caring for human beings with health and well-being as the ultimate goal. Nursing support during labor influences a woman's perception of coping and satisfaction with the birth
15 experience. Emotional support behavior (making the woman feel confident and cared for, giving praise and respect) by the health care provider were most important in contributing to a positive birth experience (Fowles, 1998). A nurse who shares valuable time with the woman is perceived as caring. Caring involves nurses making an extra effort to provide continuity of care for the mother (Shaw, 2001). This caring nursing support may decrease the potential for postpartum depression and help the new mother accept her new role of motherhood (Hodnet, 2002). Nurses, health care providers and women mutually share some of their perceptions in order to identify problems and concerns, and then set goals. They perceive each other and the situation and then make individual judgments based on their perceptions. By communicating, concerns and/or problems are identified and information is shared, allowing the woman to make decisions which lead to attaining health goals. Once goals are set, the nurse, health care provider and the woman collaborate to formulate the means to achieve these goals. Usually, the goal is to maintain the state of health that will permit the woman to function in her role as woman and mother, and insure the health and safety of her newborn. Because of the communication and interaction with her family, health care provider, psychologist and/or support group, the woman with PPD may develop healthy coping skills, and thus promote a healthier sense of self. In summary, King's General Systems Framework is a useful guide in working with women at risk for PPD or suffering from PPD. The nurse, health
16 care provider and the woman need to communicate clearly and agree on goals that assist the woman to a state of health and well-being. Literature Review Literature related to PPD, from a multidisciplinary approach and within the qualitative and quantitative paradigm will be reviewed. The review is divided into the following categories: symptoms of PPD, symptoms of fatigue, antepartum factors that may suggest PPD, and validated instruments to screen women for the potential for development of PPD. Symptoms of postpartum depression PPD is characterized by tearfulness, mood swings, despondency, inability to cope with the care of the baby, dissatisfaction with labor and delivery experiences and increased guilt about their performance as a mother. General fatigue, complaints of ill health, irritability, impaired concentration, feeling overwhelmed, experiencing uncontrollable anxiety, poor memory and obsessive or suicidal thoughts can also be present (Ugarriza, 2000; McIntosh, 1993). In addition, PPD may be associated with an excessive anxiety and concern regarding the woman s own health. There may be feelings of diminished libido and fear of loosing control. They may even develop a lack of interest in the baby, fear of harming the baby, or develop an excessive anxiety and concern regarding the baby s health (Kennedy & Suttenfield, 2001). According to Beck & Gable (2001), only half of the women who felt seriously depressed sought professional help. Mothers felt embarrassed or
17 ashamed to talk to family or health care providers about their feelings. They felt that health care providers tended to trivialize the matter, making them feel as though they were unfit mothers, or mentally ill. Additionally, professionals were often perceived as threatening or uncaring. The following quote from Beck's (1992) phenomenological study describes women's terrifying bouts with PPD. "Postpartum depression was a living nightmare filled with uncontrolled anxiety attacks, consuming guilt and obsessive thinking. Mothers contemplated not only harming themselves but also their infants. The mothers were enveloped in loneliness and the quality of their lives was further compromised by a lack of emotions and all previous interests. Fear that their lives would never return to normal was all encompassing" (p. 45). Pregnancy, childbirth and the postpartum period are critical life experiences that bring about massive changes in the biological and psychological systems of the mothers. Sichel and Driscoll (2000) developed one explanation, the earthquake model, of why a woman's unique brain and hormone chemistry results in her vulnerability to mood disorders at critical times in her life. Sichel and Driscoll (2000) equate a woman's basic brain biochemistry to a fault line. Earthquakes occur when the internal pressures on a weakened subterranean fault line become overwhelmed. To relieve the intense pressure, the fault line gives way with great force and the earthquake erupts, breaking through the earth's surface and creating chaos and destruction above. Smaller tremors before an earthquake indicate that there are indeed pressures building
18 on the unstable rock formations underground. These induce modest but detectable shudders above ground, reminding residents of the instability below (Sichel & Driscoll p. 99). Similarly, stressful life events and hormonal events can disrupt the delicate balance of the brain biochemistry resulting in an emotional earthquake, such as PPD. Symptoms of fatigue The physical, situational and psychological stresses of childbirth and the demands of parenting may be overwhelming and fatiguing for women who have just given birth. Fatigue is defined as a subjective, multidimensional phenomenon with physical, behavioral and psychological components (Gardner & Campbell, 1991). There are consistent studies that show a strong relationship between persistent fatigue and symptoms of depression (Cahill, 1999; Fuhrer & Wessely, 1995). It is difficult to determine if depression is the cause of, or the result of fatigue. The objective and subjective symptoms of both are similar, for example, lethargy, body slumping, listlessness and sleepiness. According to Gardner and Campbell (1991), four categories of fatigue exist. Normal fatigue occurs with a labor longer than 30 hours, a difficult or high exertion labor and or delivery, or the woman's perception of a lot of pain. Pathophysiologic fatigue includes postpartum hemorrhage, anemia, any secondary illness such as diabetes, pre-eclampsia, laceration, a cesarean birth, or substance abuse. Psychological fatigue includes the individual stating that they had perceptions of having fatigue, sleeping difficulties, no supportive
19 partner, an ill newborn, an infant born with an anomaly, history of depression, or expression of high anxiety. Situational fatigue includes no help with childcare, no household help, family stress or crisis, poor adjustment to maternal role, lack of attachment to the newborn, or being an adolescent mother. Antepartum factors Antepartum risk factors of PPD identified in the following studies can be used by health care providers as indicators that a woman may be at risk for developing PPD. It must be emphasized, however, that the research has also demonstrated that the presence of risk factors does not necessarily lead to PPD, nor does their absence ensure that it will not occur. Deaves (2001) studied 94 antenatal mothers who were given the Edinburgh Postnatal Depression Scale (EPDS) in the sixth month of pregnancy. The risk factors identified were difficult, unsupportive relationships, pre-existing mental illness, loss of a mother or mother role model, unemployment, physical or chronic diseases, single parenting, social difficulties, and increased maternal age of being over 30 years along with one other risk factor. Posner, Unterman, Williams & Williams (1997) developed the Antepartum Questionnaire (APQ) to screen for PPD in the antepartum period. Multiple characteristics were explored, most of which were psychosocial in nature. These investigators found in their study of 205 pregnant women similar findings of Deaves (2001) that risk factors for development of PPD included marital instability or an unstable relationship with partner and an insufficient income or
20 unemployment. Other APQ items which suggest PPD include: past or present unavailability of a warm, loving and caring parent or parents, history of emotional instability, poor self-image, dissatisfaction with education status, history of dysmenorrhea and either severe or absent nausea or vomiting during pregnancy. In a meta-analysis by Beck (2001), 84 studies were analyzed to determine the magnitude of the relationship between PPD and 13 risk factors. She agrees with Deaves (2001) and Posner, et. al (1997) that risk factors for development of PPD include marital status, marital relationship, socioeconomic status, selfesteem, history of previous depression and lack of social support. Other PPD risk factors identified in the meta-analysis included prenatal depression, prenatal anxiety, childcare stress, maternity "blues" and having an unwanted or unplanned pregnancy. Additional findings from various studies include those of Logsdon and Usui (2001) who found that the importance of support, perception of support and closeness to the woman s partner were significant predictors of positive selfesteem and therefore the lack of these were potential for development of depression. Social resources may be very important for the mental health of women in the antepartum and postpartum periods due to the high stress of childbearing and parenting (Hall, Kotch, Browne & Rayens, 1996; O'Hara & Swain, 1996). Sichel and Driscoll (2000) identify history of abuse, traumatic birth experience and family history of alcoholism as antepartum risk factors. Stamp, Williams and Crowthers (1996) reported that obstetrical complications including
21 operative births, premature births and sick neonates were associated with PPD, whereas Posner (1997) found no such correlation with obstetrical complications. Hayes, Muller and Bradley (2001) reflected on the importance of prenatal classes for primiparous women in increasing their knowledge and confidence and decreasing their anxiety about childbirth. These investigators suggest that many childbirth educators include information about the "baby blues" or feeling depressed after the delivery, but do not go into depth about the subject. Their study proposed that an education program for women in the antepartum period pertaining to depressive symptoms would reduce PPD. However, these investigators found that there was no difference when comparing the educated group of women with the control group that got the standard information and concluded that education did not reduce depression either antenatally or postpartum. However, Ugarriza (2000) encourages educating the mother about postpartum affective disorders so that the mother can feel free to openly discuss her feelings and discomfort with her health care provider. In order for the health care provider to appropriately intervene and treat PPD, Ugarriza proposes that all health care providers get the education needed for understanding and keeping updated in treatment options. Screening instruments There are several validated instruments currently used for screening for PPD. The following section describes the Edinburgh Postnatal Depression Scale
22 (Cox, Holden, & Sagovsky, 1987), the Anepartum Questionnaire (Posner, 1997), the Beck Depression Inventory (Beck, 1961), the Postpartum Depression Screening Scale (Beck & Gable, 2001), the Postpartum Depression Predictors Inventory (C. Beck, 1998) and the Postpartum Fatigue Assessment Scale (Gardner & Campbell, 1991). Cox, Holden and Sagovsky, to screen for PPD, developed the in 1987. The Edinburgh Postnatal Depression Scale (EPDS) was developed because Cox, Holden and Sagovsky proposed that established depression-screening instruments were sub-optimal when applied to postpartum women (Eberhard- Gran, Eskild, Tambs, Opjordsmoen & Samuelson, 2002). The10-item questionnaire is easy to use, taking about five minutes to complete, and is acceptable to mothers. This leads to a high rate of return. Health care providers and nurses who do not have psychiatric expertise can administer the instrument. It is easy to score. Validation studies with various populations demonstrated that the EPDS revealed 100% sensitivity and 95.7% specificity for major depression and 100% sensitivity and 90.4% specificity to minor depression (Stamp, et al 1996). Sensitivity relates to the stability of the instrument to correctly measure the concept that one is seeking, or, the proportion of persons with the disease who correctly test positive. Specificity is the ability of the instrument to determine the proportion of persons without the disease who correctly test negative (Burns & Groves, 2001).
23 The instrument lists ten statements describing symptoms of depression, each graded on a 4-point scale according to severity. Women are unable to completely describe their symptoms, but must check which of the four possible responses, from not at all to all of the time, is closest to how she has been feeling in the previous seven days. The validation study showed that mothers who scored above threshold 92.3% were likely to be suffering from a depressive illness of varying severity (Cox, 1987). Stamp (1996) and Deaves (2001) found that the EPDS might reflect a general state of depression or anxiety not specific to PPD. Therefore, the EPDS score should not override clinical judgment since it is meant to screen, and not diagnose PPD. A careful assessment should be made to confirm the diagnosis. Posner (1997) developed the antepartum questionnaire (APQ) used in the antepartum period to screen for factors that may predict PPD. The 61-item questionnaire was self-administered, user- friendly and took ten minutes to complete. Of the 61 items, the tool listed seven items that appear to suggest a potential for developing PPD: an unstable relationship with partner, unavailability of a loving parent either in the past or in the present, history of PPD in the woman s mother, history of emotional instability, poor self-image, insufficient income and lack of satisfaction with educational status. In Posner's population, the APQ was prospectively validated as a screening device, with the sensitivity of 80-82% and the specificity of 78-82%.
24 The questions were found to significantly correlate (p<.05) with PPD. According to Posner, further refinement of the APQ may be required once its usefulness is verified in various socio-economically and ethnically diverse populations. Aaron Beck developed the Beck Depression Inventory (BDI) in 1961 to gauge major depression in general but this instrument has been used in many studies of PPD. It is a 21-item, self-administered, forced-choice inventory that includes categories of symptoms and attitudes. The questions are scored by severity of symptoms. It has been established as an effective screening tool. According to Ugarrizi (2000), the BDI is sensitive to symptoms that are part of the normal changes that occur with childbirth such as sleep disturbances, fatigue, change in body image and loss of libido. The BDI however, fails to grasp the symptoms most frequently associated with PPD, such as irritability, anxiety, the feeling of being overwhelmed, tearfulness, guilt about performance as a mother and thoughts of harming the baby. Holcomb (1996) on the other hand, concluded that the BDI can serve as a rapid screening test for depression during pregnancy. However, Holcomb suggests that a higher cut-off value is should be used for pregnant women than is customarily used outside pregnancy since none of the items are written in the context of new motherhood. Beck and Gable (2001) developed the Postpartum Depression Screening Scale (PDSS), where all items are written in the context of new motherhood. In the PDSS, five symptoms were obtained from themes revealed in her phenomenological study (1992) which are unique to her instrument. These items
25 include: feelings of loss of control, feelings of loss of self, feelings of loneliness, obsessive thinking, loneliness and cognitive impairment. The PDSS is a 35-item instrument that indicates the degree of agreement or disagreement. The woman circles the answer that best describes how she has felt over the last two weeks. Reliability was rated from.80-.91. The PDSS' sensitivity was 94% and specificity was 98%. C. Beck (1998) developed the Postpartum Depression Predictors Inventory (PDPI) after conducting a meta-analysis in 1996. This meta-analysis synthesized and integrated the results of many research studies on the topic of PPD. The PDPI can be used in the prenatal and postpartum periods and was designed to be administered as an interview. The interview encourages the woman to discuss her experiences and any problems she may be encountering. According to Misri and Duke (1995), women may keep the signs and symptoms of PPD a secret out of shame unless directly asked about them. The PDPI gives the health care provider the opportunity to use probes as needed. The inventory has questions pertaining to prenatal depression, life stress, lack of social support, prenatal anxiety, marital dissatisfaction, and history of previous depression throughout the pregnancy. Questions pertaining to childcare stress and maternity blues can be added after the birth of the baby. Beck encourages the checklist be completed every trimester because a woman's life stress and/or prenatal depression can change at any time throughout the pregnancy.
26 Childbirth and the responsibilities of parenting after birth require a great deal of energy, which can frequently result in fatigue. Gardner and Campbell developed the Postpartum Fatigue Assessment Scale (PFAS) in 1991 to assess the situational category of fatigue (for example, relationship stress or family crisis) and the psychological category of fatigue (for example, anxiety or depression). Content validity is established due to routine utilization on hospital postpartum units. The thirty questions require a yes or no answer. These instruments may identify symptoms that the health care provider and nurse can use to recognize women at risk for PPD. It is crucial to identify these women and provide treatment as early as possible to help prevent detrimental effects of PPD on mothers, their children and families. Summary In summary, the literature illustrates the significance and complexity of PPD. Early recognition of the antepartum and immediate postpartum factors by the health care provider and/or nurse will allow for development and assessment of strategies for early treatment and prevention with the goal of reducing the morbidity associated with this disorder. Effective support systems should be in place to deal with identified problems. This chapter describes Imogene King's General Systems Framework and its usefulness as a guide to identifying predisposing factors in women who may experience postpartum depression. Application of King s theory to the current study includes the personal system, being either the expectant or new mother;
27 the interpersonal system of the mother and nurse or health care provider interacting with each other; and the social systems of the mother including her family, health care providers, friends and support groups. According to Husband (1988), King's theory addresses interpersonal relationships. "In today's technical, high paced health care system, the psychological needs of the client sometimes are forgotten" (p.8). Understanding, compassion and caring by the health care provider and nurse is imperative to the well being of women worldwide.
28 CHAPTER 3 Methods The objective of this study is to identify factors in women who may experience postpartum depression. The research seeks to gain an improved understanding and identification of factors that may lead to PPD while the woman is pregnant and/or while hospitalized during the birthing process. This identification would allow for the assessment and development of screening strategies for prevention and treatment. Chapter 3 includes the design of the study, description of the sample, steps of data collection and analysis of the data. Design The data for this quantitative research study will be obtained by secondary analysis of a small portion of Katherine Sink's Doctoral Dissertation (2001): Perceptions, Informational Needs and Feelings of Competence of New Parents. The original data was collected over a two-year period from 1999-2000, and assists in capturing both prenatal and postnatal factors. Although the original study was both quasi-experimental and descriptive, only a descriptive design will be used in the current study to explore differences in antenatal and postpartum factors in women who may experience postpartum depression (PPD). PPD risk factors were not an outcome measure in the original study. Setting, Inclusion, Exclusion Criteria In the Sink (2001) study, expectant mothers were recruited within 6 weeks of their delivery from a purposive convenience sample of pregnant women
29 enrolled in Lamaze classes at two Midwestern, metropolitan hospitals. All mothers were contacted four times: once in Lamaze class and three times after delivery, the last at approximately 2-3 weeks postpartum. Inclusion criteria was that women had to be at least 18 years old, speak English and have a telephone. The sample consisted of 89 women who experienced a relatively uneventful birth with a hospital stay no longer than 24 hours past the expected stay of 24 to 28 hours for a vaginal delivery. Exceptions that were considered "normal" variations of the birth experience included cesarean births, mothers requiring antibiotics due to premature rupture of membranes, or newborns that needed transitioning in the Neonatal Intensive Care Unit for a short period, but overall were considered healthy. Exclusion criteria in the original study included: fetal demise, unhealthy newborns admitted to the NICU, mothers having prenatal health conditions such as pregnancy induced hypertension toward the end of the pregnancy, or delivering at a hospital not approved by the IRB where recruited. In the current study, the entire sample of 89 women was used in this secondary analysis. The potential for postpartum depression was explored by comparing data using the Edinburgh Postnatal Depression Scale (EPDS), the Postpartum Fatigue Scale (PFS) and the Total Depression Scale (TDS) where the first two scales were combined.
30 Instruments 1. Demographic information was obtained in the prenatal period from the first questionnaire women received. Personal information included age, parity, marital status, number of children, employment status, education, income, and religious and ethnic backgrounds. The current study will use the demographic criteria of age, marital status, education, employment status and income of the mothers. 2. Resources of social support were divided into two groups: Nonprofessionals and professionals in the original study. Non-professional persons offering support of assistance and information to the women in the original study included spouses, parents and in-laws, relatives, friends and co-workers. Professional persons who were available to offer support identified in Sink's dissertation included the woman's healthcare provider, newborn's healthcare provider, nurses at either healthcare provider's, community visiting nurses, Lamaze instructors, the original investigator, and/or telephone calls to a professional telephone network provided by the hospital. Content validity was established by development of questions that pertained to social support documented in the nursing literature (Miller, 2002; Hall, et al., 1996; Epperson, 1999; Beck, 1998 and Logsdon & Usui, 2001). In the current study, the social support data from the original study will be used as the literature has established that social supports are important to the mental health of the woman (O Hara & Swain, 1996). Professional support persons identified will be limited to the woman's healthcare provider, newborn's
31 healthcare provider, nurses at either healthcare providers, nurses at the hospitals and Lamaze instructors. 3. The woman's perceived level of postpartum depression was measured in the original study using the Edinburgh Postnatal Depression Scale (Cox, Holden & Sagovsky, 1987) administered at three to four weeks into the postpartum period. The EPDS was designed specifically to measure symptoms of PPD and takes into account that the normal postnatal symptoms, such as changes in appetite and sleep as well as loss of energy and fatigue could be misconstrued as depression. The performance of the EPDS is well established as an effective screening tool for major and minor postpartum depression. The EPDS has a reliability of.83 (Cox, Holden & Sagovsky, 1987). The 10-item questionnaire is easy to use and is acceptable to women and nurses. The instrument lists ten statements describing symptoms of depression, each graded on a 4-point scale according to severity. Women are unable to completely describe their symptoms, but must choose the response that best indicates how they have felt in the past week. Women who score 12 or more on the scale are considered at risk for PPD (Cox, Holden & Sagovsky, 1987; Beck & Gable, 2001). In the original study, the scale was modified from a 4-point Likert-scale to a 5-point scale to conform to the other instruments used in the study. The last question from the instrument related to thoughts of harming oneself was omitted
32 from the study. The original investigator was not in a position to treat the ramifications of someone considering suicide for several reasons. First, the investigator had built-in safeties in her design of the study for recognizing and referring anyone who had baby blues or signs and symptoms of depression at the two-week postpartum telephone contact. Second, the data collection for this study was ongoing for over a year and some of the data was not analyzed immediately upon return of the data. Third, the investigator had discovered literature from other studies in which graduate student investigators had been permitted to remove the question and the reliability of the instrument had maintained a high rating. The reliability of the modified tool remained high (alpha =.82) in Sink s (2001) study. Thirty-two (36%) of the new mothers were at risk for PPD. 4. Exertion, sleep loss and physiological changes all contribute to feelings of fatigue and can affect both the new mother's health and her capacity to care for her newborn and cope with the demands of parenting. Adapting select questions from the Postpartum Fatigue Assessment Form (PFAF) (Gardner & Campbell, 1991) assessed the situational category of fatigue (relationship stress or family crisis) and psychological category of fatigue (anxiety or depression). In the original study, the response categories were changed from "yes" or "no" to the same 5-point Likert scale for maintaining conformity with the other questions. Questions pertaining to feelings of fatigue were obtained both in the antepartum period and between three to four weeks post delivery. The prenatal questions
33 had a moderate reliability (alpha=.73). Likewise, the postpartum questions had a moderate reliability (alpha=.70). There are consistent studies that show a strong relationship between persistent fatigue and symptoms of depression (Cahill, 1999: Fuhrer & Wessely, 1995). For that reason, the postpartum fatigue questions were combined with the EPDS to create the Total Depression Scale (TDS) which had a reliability of.834. Data Collection In the original study, all procedures and questionnaires were reviewed and approved by the University of Michigan, Institutional Review Board for Health, and the Institutional Review Board at the Medical College of Ohio. Additionally, the procedures and questionnaires were reviewed and approved by the Institutional Review Boards at the two hospitals where recruitments were made. Each hospital requested a liaison for the study. The liaison at one institution was the nurse in charge of Lamaze instruction; the liaison at the second institution was the nurse manager for the childbirth units. At both hospitals, a hospital representative agreed to check the hospital births and compare them with updated lists of the expectant mothers who agreed to be in the study. When the mothers delivered, the representative gave the new mother a congratulatory letter and notified the primary investigator of the birth. Expectant mothers were recruited near their last Lamaze class to participate in the study. They were informed of the purpose, procedures, and
34 randomization of subjects into groups, benefits and risks of the study. Consent forms were then signed. Women were selected with consideration of the inclusion and exclusion criteria. They were randomly assigned into one of three study groups. All three groups received a prenatal questionnaire, a congratulatory letter at the time of delivery and a telephone call at 14 days postpartum. Group 1 was the control group that received the letter and contact by telephone at 14 days postpartum. Group 2 received a letter listing topics that the parents may have wanted information about included within their congratulatory letter, encouragement to call the investigator using her pager number, and contact by telephone at 14 days postpartum. Group 3 received three telephone calls from the investigator within the first two to three weeks after coming home with the newborn (Sink, 2001). The second questionnaire was mailed at approximately 14 days postpartum and the mother was given the option of returning it in the post-paid envelope or answering the questionnaire over the telephone. All returned the questionnaire by mail. The mean day of return was 28 days (SD 15.68). Only a small portion of the original study data was used in the current quantitative research study. The entire sample of eighty-nine mothers were included in the current secondary analysis. The coded computer data used in the secondary analysis was de-identifiable data. No medical charts were reviewed.
35 In the original study, protection of subjects was assured by obtaining consent from the Institutional Review Board for Health at the University of Michigan. Additionally, the procedures and questionnaires were reviewed and approved by the Institutional Review Boards at the two hospitals where subjects were recruited, as well as Medical College of Ohio. Women were informed of the purpose, procedures, benefits and risks of the study and consent forms were signed in the original study. There were no costs to participate or compensation given for participation. In the current study, no consents were needed or risks involved because the design is secondary analysis of dissertation data. In the current study, an exempt approval was obtained through the Institutional Review Board at the Medical College of Ohio. Data Analysis The data obtained for this secondary analysis was analyzed using SPSS11.5 for Windows Statistical Package. Assistance with Statistical Analysis was obtained from the Center for Nursing Research at the Medical College of Ohio School of Nursing. Descriptive statistics were analyzed for all demographic data. Analysis of Variance (ANOVA) was used to explore the differences in women who may develop PPD by comparing various antepartum and postpartum factors within the data with the EPDS, the PFAS and the TDS. Regression was used to evaluate environment issues such as privacy, a comfortable room and personable nursing care related to predicting PPD.