ARE WOMEN WITH SEVERE BLUES AT INCREASED RISK OF POSTPARTUM DEPRESSION?

Carol Henshaw, D Foreman, S O'Brien, J Cox
Dept of Psychiatry and Obstetrics & Gynaecology, Keele University, Stoke-on-Trent, UK

Postpartum blues are traditionally thought to be benign and self-limiting. There are reports in the literature of associations with postnatal depression (PND) but there was no study which prospectively controlled for the presence or absence of blues. 103 primiparous women with severe postpartum blues and their controls with no blues matched for age, marital status and social class were followed for 6 months postpartum in order to determine the relationship between blues and PND. The women were recruited at 30+ weeks gestation and completed a baseline Edinburgh Postnatal Depression Scale (EPDS). Following delivery, they were assigned to subject (severe blues) or control (no blues) on the basis of scores on the Blues Questionnaire completed on the 3rd and 5th postpartum days. Both groups completed monthly postal EPDS and at the end of the protocol, the Schedule for Schizophrenia and Affective Disorders was administered to high scores and a 1 in 5 sample of low scores. Diagnoses were made according to Research Diagnostic Criteria.

Results: The 6 month period prevalence of depression in subjects was 40.8% (n=42) and 10.7% (n=11) in controls (X2=24.4, p<.001). Subjects with postpartum depressive episodes were significantly more likely to have an illness with onset in the first 2 weeks postpartum than controls (Fishers exact test, p<.01) and to have a major rather than minor depression (Fishers exact test, p<.05).

Conclusions: Women with severe blues are at an increased risk of a subsequent depressive episode. This finding has implications for the aetiology of some postnatal depressions. In addition, the identification of an at risk group has implications for clinical practice.

CHILDBIRTH RELATED STRESS DISORDERS FOLLOWING DELIVERY OF VERY PRE-TERM BABIES

Susan Priest, R Hagan, S Pope, R Rooney, S Evans, P Stephenson
Dept of Obstetrics & Gynecology, University of Western Australia

This presentation will review several recent reports of childbirth related stress disorders (CRSD) before presenting some findings from the Postnatal Depression Prevention Study (PND Study), funded by Healthway (1992-1995) in Perth, Western Australia. Difficult childbirth has already been implicated as a risk factor for PND, and overwhelming pain is a strong predictor for puerperal psychoses. The subjective and objective aspects of labour and delivery which can trigger a stress disorder are less well understood. Our research carried out with mothers who delivered very low birth weight and very preterm infants sheds light on some of the processes involved. During the PND Study, 222 women who delivered very preterm infants were assessed on self report measures (EPDS, GHQ, Impact of Events) and by structured psychiatric interview (SADS) over a one year period. At 2-3 weeks postpartum using DSM-IV criteria, 19 (8.5%) were diagnosed with Acute Stress Disorder (ASD), 5 (26%) of whom went on to a diagnosis of PTSD. 16 women (7.2%) were diagnosed with an Adjustment Disorder (ADJ). Psychological test results were significantly different for those with ASD compared with controls. Of the 19 women with ASD, 7 (37%) received a diagnosis of PND during the first year after delivery compared with 61 (30%) of women who did not have ASD. Implications of these findings will be discussed in relation to (1) Comorbidity; (2) Obstetric practices; and (3) Psychological care of women after delivery.

PSYCHOLOGICAL AND SOCIAL CHARACTERISTICS OF PARENTS WITH INFANTS PERCEIVED TO BE AT RISK OF SUDDEN DEATH

Jane Fisher, K Brasher, J MacLeod, A Stocky, M Adamson, Key Centre for Women's Health, Vic

Infants who are born following the sudden infant death of a sibling or who have had an apparent life-threatening event may be perceived as being at risk of sudden death. Parents of these children can use apnoea monitors at home to alert them to potentially life-threatening events and to manage anxiety. To date, there has been limited systematic examination of the psychological aspects of home monitoring. This paper will report some of the findings of a recently completed prospective longitudinal study of 146 parents who either used or considered using a home apnoea monitor. In this study parents completed structured interviews and a range of psychometric questionnaires at the time of deciding whether or not to monitor and at three points in the following year. At the first assessment point there were significant psychological differences between those who chose to monitor their at risk infants, those who chose not to monitor and a control group who monitored infants who were not at risk. There were no sociodemographic differences between the three groups and the findings indicate that at this time mothers of at risk infants are highly distressed and that those who chose not to monitor have more depressive symptoms, less knowledge about home monitoring and less social support than those who chose to monitor.

A PROFILE OF WOMEN SUFFERING FROM POSTNATAL DEPRESSION IN CAPE TOWN DRAWN FROM A FORMALISED INTAKE INTERVIEW

Liz Mills, 3 Visser Avenue, Kenilworth, W Cape, South Africa

An analysis of the information recorded over some years drawn from formalised PND Assessment Intake Interviews, which presents a profile of the women who have attended Support Groups in Cape Town. These interviews take a minimum of 90 minutes to conduct, and explore a fairly detailed case history of each woman, covering a wide range of subjects including relationships with her original family, her current situation, birth experiences, available support systems, stress factors etc, as well as scores on the EPDS.

POSTNATAL DEPRESSION: AN APPLICATION OF A STRESS AND COPING MODEL

Amanda Smith, K Pakenham
Dept of Psychology, University of Queensland, St Lucia, QLD

The study aims to test the utility of a stress and coping model to predict postnatal depression in a sample of 100 women. Data was collected during the 3rd trimester of pregnancy (Time 1), and at 4 weeks (Time 2) and 8 weeks (Time 3) after the birth. Follow-up data will also be collected at 1 year after the birth. The study aims to extend on recent findings (Terry et al, 1996) in 3 important ways. First, diagnostic caseness data was obtained on antenatal and postnatal depression, rather than self report data alone. Second, the stress and coping model was applied to both the antenatal and the postpartum stages to investigate depression across the transition to motherhood. Third, the stress and coping model was extended to include appraisal of motherhood as a predictor of postnatal depression. Coping resources and stress were assessed at Times 1 and 2, while coping strategies, depressive symptomatology and appraisal were assessed at Times 1, 2 and 3.

DOES EARLY DISCHARGE OF MOTHERS FROM HOSPITAL AFTER CHILDBIRTH INFLUENCE THE RISK OF POSTNATAL DEPRESSION?

Jane Thompson, S Ellwood, J Cubis, C Roberts
Dept of Obstetrics & Gynaecology, The Canberra Hospital, ACT

Background: Research on a possible association between early discharge from hospital after childbirth and the risk of subsequent postnatal depression has produced equivocal findings. A randomised controlled trial (RCT) is one way of investigating such an association.

Aim: To conduct a pilot study of all aspects of a proposed RCT of very early postnatal discharge.

Methods: 50 antenatal clinic clients were randomly allocated to either very early discharge (VED) within 36 hours of delivery or early discharge (ED) 37-72 hours after delivery. The primary outcome measure was postnatal depression at 6 weeks, 3 and 6 months using the EPDS and the Beck Depression Inventory (Short Form). Secondary outcome measures were breastfeeding success, maternal satisfaction with care and length of stay, confidence in caring for infant, health service use and experience of motherhood. Sociodemographic details, and variables known to be associated with postnatal depression were also assessed.

Results: 75% of eligible women agreed to participate. 3 women subsequently withdrew; 18 of the remaining 47 (38%) did not meet the criteria for early discharge. Of the remaining 29, 15 (52%) complied with the randomisation (27% compliance in VED, 67% in ED). Preference for the non-allocated treatment was the primary reason for non-compliance.

Conclusion: The pilot study demonstrated difficulties in proceeding with the trial, most importantly, a high rate of postpartum exclusions and a high rate of non-compliance. Further, the importance of timing of a trial and the difficulties when participants have preferences for one treatment over another were highlighted. RCTs may be the gold standard for medical research but are neither universally applicable nor always realistically possible, particularly in evaluating social interventions and where outcome measures are psychological. A non-experimental study design may be more appropriate to answer concerns about the psychosocial outcomes of early postnatal discharge.

THE TRAUMA OF CHILDBIRTH

Debra Creedy, School of Nursing, Griffith University, QLD

Critics of contemporary maternity services have raised concerns that childbirth practices are fragmented, mechanistic and unresponsive to the emotional needs of women. Giving birth is a critical life event, yet there is little understanding of the impact of childbirth on the woman's psychological development. During the postpartum. memories of labour and delivery may produce feelings of anxiety and negatively influence the mother-infant relationship. Despite the paucity of literature on the psychological sequelae of birthing, there is an emerging connection between birthing experiences and the development of stress responses. This paper presents the findings of an exploratory descriptive study that investigated the birthing experiences of women in a hospital and/or home environment. The women were interviewed in depth about their birthing experiences. Typed transcripts of the recorded interviews were returned to each woman and consensus reached on the interpreted themes which emerged. While a number of theories were generated from the data, this paper will focus on the experiences of trauma. During labour, women described unique feelings of vulnerability to environmental influences. In some cases this vulnerability was associated with being traumatised by modern obstetric care which adversely affected their perceptions of self-competence. Feeling in control and being part of the decision making process were important in shaping the mother's feelings of achievement and fulfilment. This study emphasises the psychosocial environment in which labour takes place and examines changes necessary for best practice.