Anxiety in the perinatal period: antenatal and postnatal influences and women’s experience of care

Objective: To examine the characteristics of women with antenatal or postnatal anxiety and to investigate aspects of their care that may be associated with it. Background: Positive outcomes following childbirth are associated with good physical and mental health during pregnancy and following childbirth. Although a degree of anxiety is normal in pregnancy, for some women it can become a serious problem. Methods: This study used data on 5332 women from a 2010 national maternity survey which asked about antenatal and postnatal health and well-being three months after childbirth. Women self-identified as experiencing anxiety and other problems during pregnancy and the postnatal period. Results: Antenatal anxiety was reported by 14% of women and postnatal anxiety by 5% of women. Antenatal anxiety was associated with younger age, Black and Minority Ethnic status, single parenthood, living in a disadvantaged area, having an unwanted pregnancy and long-term health problems. Of these factors, only long-term mental health problems were associated with anxiety in the postnatal period. In the logistic regression models long-term mental health problems dominated the findings. Significant differences in the perceptions of the care experienced were evident in the responses from women with anxiety both antenatally and postnatally. Conclusions: This study shows that antenatal and postnatal anxiety are influenced by health and social factors. Asking women about their current physical and psychological health and past history during pregnancy and following up on their well-being in the postnatal period is an essential element in planning and providing care to meet their needs.     

Unauthorised pregnancies and use of maternity care in rural China

ABSTRACT

Objectives To describe the use of maternity care in rural China by the legal status of the pregnancy.

Methods Cross-sectional survey wherein information was obtained about 2576 women who gave birth in 2006. Logistic regression was used to compare women having an unauthorised pregnancy with those having an authorised second birth, adjusting for confounding factors.

Results Almost all respondents had antenatal care and most deliveries occurred in hospitals. Women with unauthorised pregnancies were significantly less likely to have had maternity care, particularly prenatal care, postnatal care, to have been hospitalised during pregnancy, and to have been reimbursed for hospital delivery costs than women with an authorised second birth. They were also more likely to have been hospitalised for seven or more days after delivery. Primiparous women used maternity care services and received financial support more often than women with an authorised second birth. Among the women with an unauthorised pregnancy an important reason for not using hospital care during pregnancy or delivery was financial constraint.

Conclusions Women with unauthorised pregnancies use less maternity care, although pregnancy in such circumstances may adversely impact their health. Primiparous women benefit from more financial support than multiparous women.     

The findings of the MBRRACE-UK confidential enquiry into Maternal Deaths and Morbidity

Reports from the UK Confidential Enquiries into Maternal Deaths and Morbidity are now published annually. In 2013–15, the maternal mortality rate was 8.8 per 100,000 maternities. Over two thirds of women died from medical and mental health causes and less than one third from obstetric causes. Cardiac disease remained the leading cause of maternal death in the UK. With the majority of women dying from pre-existing conditions, there remain multiple opportunities to reduce women's risk of complications in pregnancy through early and forward planning of the care of women with known pre-existing medical and mental health problems. Provision of appropriate advice and optimisation of medication prior to pregnancy, referral early in pregnancy for the appropriate specialist advice and planning of antenatal, intrapartum and postnatal care and effective postnatal provision of advice concerning risks and planning for future pregnancies are the key improvements needed to prevent women dying in the future.     

Opioid and Cannabis Use During Pregnancy and Breastfeeding in Relation to Sociodemographics and Mental Health Status: A Descriptive Study

ObjectiveThis study of Canadian women estimates the prevalence of opioid and cannabis use during pregnancy and cannabis use during the breastfeeding period and explores the sociodemographic and mental health characteristics associated with use.MethodsA total of 13 000 women who gave birth between January and June 2018 were invited to participate in the Survey on Maternal Health by Statistics Canada; 7111 women participated for a response rate of 54.7%. Participants were asked about their mental health, supports during pregnancy, and substance use. Multivariable logistic regression was used to describe the relationship between sociodemographic and mental health characteristics and substance use during pregnancy and while breastfeeding.ResultsThe prevalence of self-reported opioid use during pregnancy was 1.4% (95% confidence interval [CI] 1.1%–1.8%). A higher proportion of women reported using cannabis during pregnancy and while breastfeeding, at 3.1% (95% CI 2.5%–3.6%) and 2.6% (95% CI 2.1%–3.1%), respectively. Younger age, not being in a relationship, lower level of education, and thoughts of self-harm were significantly associated with cannabis use during pregnancy. Lower level of education and thoughts of self-harm were also significantly associated with cannabis use while breastfeeding, as were symptoms of postpartum depression and/or generalized anxiety. Lower level of education and symptoms of postpartum depression and/or generalized anxiety were also significantly associated with opioid use during pregnancy.ConclusionThe results of this survey show relatively low levels of opioid and cannabis use during pregnancy and cannabis use while breastfeeding in Canada. Different sociodemographic and mental health characteristics are associated with the use of these substances, and public health interventions and policies should take into account these factors.     

Spousal violence and receipt of skilled maternity care during and after pregnancy in Nepal

Objectivesa substantial number of Nepali women experience spousal violence, which affects their health in many ways, including during and after pregnancy. This study aimed to examine associations between women's experiences of spousal violence and their receipt of skilled maternity care, using two indicators: (1) receiving skilled maternity care across a continuum from pregnancy to the early postnatal period and (2) receiving any skilled maternity care in pregnancy, childbirth, or postpartum.Methodsdata were analysed for married women aged 15–49 from the 2011 Nepal Demographic and Health Survey. Data were included on women who completed an interview on spousal violence as part of the survey and had given birth within the five years preceding the survey (weighted n=1375). Logistic regression models were developed for analyses.Resultsthe proportion of women who received skilled maternity care across the pregnancy continuum and those who received any skilled maternity care was 24.1% and 53.7%, respectively. Logistic regression analyses showed that spousal violence was statistically significantly associated with receiving low levels of skilled maternity care, after adjusting for accessibility of health care. However, after controlling for women's sociodemographic backgrounds (age, number of children born, educational level, husband's education level, husband's occupation, region of residence, urban/rural residence, wealth index), these significant associations disappeared. Better-educated women, women whose husbands were professionals or skilled workers and women from well-off households were more likely to receive skilled maternity care either across the pregnancy continuum or at recommended points during or after pregnancy.Conclusionspousal violence and low uptake of skilled maternity care are deeply embedded in a society in which gender inequality prevails. Factors affecting the receipt of skilled maternity care are multidimensional; simply expanding geographical access to maternity services may not be sufficient to ensure that all women receive skilled maternity care.     

Maternal depressive symptoms have a negative impact on prenatal attachment – findings from a Swedish community sample

Objective: The objective of this study was to evaluate attachment and its association to obstetric and demographic factors as well as emotional well-being using a standard measure of prenatal attachment during pregnancy. Background: The strength of the mothers’ relationship with her baby has important implications in the postnatal period, influencing the relationship she develops with her child, and the quality of the care she provides. Methods: This was a population-based longitudinal survey comprising a consecutive sample from a one-year cohort in a Swedish county. In this study the three subscales of PAI-R (Prenatal Attachment Inventory – Revised) were used for evaluation of attachment. In total, 718 pregnant women participated in this study. Results: Women with elevated levels of depression (HADS-D > 8) recorded lower attachment scores across all three PAI-R subscales. Lack of perceived support from partner was associated with lower scores on Interaction. Lack of support from own mother and own father were also associated with lower scores on all subscales. Attachment was also associated with feelings about the approaching birth and about the first weeks with the newborn, with women who reported less than positive feelings recording lower scores on each of the PAI-R subscales. Conclusion: A focus on attachment during antenatal care and the use of PAI-R during pregnancy provides a means of identifying those women who show lower levels of attachment and possible emotional problems that may impact on emotional health and the birth process.     

Not identifying with postnatal depression: a qualitative study of women’s postnatal symptoms of distress and need for support

Abstract

Introduction: Diagnoses and symptoms of postnatal mental health problems are associated with adverse outcomes for women and their families. Current classification and assessment of postnatal mental health problems may not adequately address the range or combination of emotional distress experienced by mothers. This study aims to explore symptoms of mental health problems reported by new mothers and their experiences of being assessed for these.

Methods: In-depth interviews with 17 women in southeast England with a baby under 1-year old who experienced a postnatal mental health problem. Data were analyzed using inductive thematic analysis.

Results: Women described a lack of identification with the concept of postnatal depression and felt that other forms of emotional distress were not recognized by the healthcare system. Women felt that support seeking for postnatal mental health problems needed to be normalized and that support should be available whether or not women were diagnosed. Assessment needs to be well timed and caringly implemented.

Discussion: Identification and recognition of symptoms and disorders other than postnatal depression need to be improved. Awareness of multiple types of distress needs to be raised both for women experiencing such distress, and for healthcare professionals, to enable them to support women at this time. Different approaches to assessment that include the range of symptoms reported should be piloted.     

Women's views and experiences of postnatal hospital care in the Victorian Survey of Recent Mothers 2000

OBJECTIVE: To investigate the views and experiences of postnatal hospital care of a representative sample of Victorian women who gave birth in Victoria, Australia, in 1999. DESIGN: Postal survey sent to women 5-6 months after giving birth. SETTING: Victoria, Australia. PARTICIPANTS: 1616 women who gave birth in Victoria in a 2-week period in September 1999. FINDINGS: 50.8% of women described their postnatal care in hospital as 'very good'. After adjusting for parity, method of birth, length of stay, model of care and socio-demographic characteristics, specific aspects of care with the greatest negative impact on the overall rating of postnatal care were as follows: midwives perceived as rushed and too busy (adjusted OR = 4.59 [95% CI 3.4-6.1]), doctors and midwives perceived as not 'always' sensitive and understanding (adjusted OR = 3.88 [2.8-5.5]), support and advice about going home not 'very helpful' (adjusted OR = 3.18 [2.3-4.5]), help and advice about baby feeding not 'extremely helpful' (adjusted OR = 3.27 [2.1-5.1]), not being given advice about baby feeding (adjusted OR = 2.84 [1.2-6.9]). Staying in hospital only 1-2 days (adjusted OR=2.00 [1.2-3.4]), and not knowing any of the midwives in the postnatal ward (adjusted OR = 1.80 [1.3-2.4]) were also associated with less positive ratings of postnatal hospital care. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The 2000 Survey shows that women rate early postnatal care in hospital far less favourably than care in pregnancy, labour and birth. The findings indicate that interactions with caregivers are a major influence on women's overall rating of postnatal hospital care. Acting on these findings requires a greater focus on communication and listening skills, attention to staffing levels, and leadership promoting more women-centred care in postnatal wards.     

Enhancing early postnatal care: findings from a major reform of maternity care in three Australian hospitals

Background

four hospitals comprising a health network in Melbourne, Australia, implemented a range of initiatives aimed at enhancing women's experiences of postnatal maternity care.

Objective

to compare women's views and experiences of early postnatal care before and after implementation of maternity enhancement initiatives.

Design

‘before and after’ study design incorporating two postal surveys of recent mothers (baseline and post-implementation).

Setting

four hospitals in Melbourne, Australia. Analysis of postnatal outcomes was confined to three hospitals where the initiatives were fully operational.

Participants

1256 women participated in the baseline survey in 1999 (before implementing the initiative) and 1050 women responded to the post-implementation survey in 2001.

Findings

the response to the 1999 baseline survey was 65.3% (1256/1922) and to the 2001 post-implementation survey 57.4% (1050/1829). Comparative analysis revealed a statistically significant improvement in overall ratings of hospital postnatal care; the level of advice and support received in relation to discharge and going home; the sensitivity of caregivers; and the proportion of women receiving domiciliary care after discharge. There was little change in the time women spent in hospital after birth between the two survey time-points. Over 90% of women reported one or more health problems in the first 3 months postpartum. The proportion of women reporting physical or emotional health problems between the two surveys did not change.

Key conclusion

mainstream maternity care can be restructured to improve women's experiences of early postnatal care.

Implications for practice

maternity service providers should consider a multi-faceted approach to reorientating postnatal services and improving women's experiences of care. Approaches worthy of consideration include attempts to ensure consistency and continuity of care through staffing arrangements, guidelines and protocols; an emphasis on planning for postnatal care during pregnancy; the use of evidence to inform both consumer information and advice and in the practice of caring; and skill-enhancement opportunities for care providers in managing postnatal issues and in effective communication.     

The Association of Inadequate and Intensive Prenatal Care With Maternal,Fetal, and Infant Outcomes: A Population-Based Study in Manitoba,Canada

ObjectiveLittle is known about how prenatal care influences health outcomes in Canada. The objective of this study was to examine the association of prenatal care utilization with maternal, fetal, and infant outcomes in Manitoba.MethodsThis retrospective cohort study conducted at the Manitoba Centre for Health Policy investigated all deliveries of singleton births from 2004-2005 to 2008-2009 (N = 67 076). The proportion of women receiving inadequate, intermediate/adequate, and intensive prenatal care was calculated. Multivariable logistic regression was used to examine the association of inadequate and intensive prenatal care with maternal and fetal-infant health outcomes, health care use, and maternal health-related behaviours.ResultsThe distribution of prenatal care utilization was 11.6% inadequate, 84.4% intermediate/adequate, and 4.0% intensive. After adjusting for sociodemographic factors and maternal health conditions, inadequate prenatal care was associated with increased odds of stillbirth, preterm birth, low birth weight, small for gestational age (SGA), admission to the NICU, postpartum depressive/anxiety disorders, and short interpregnancy interval to next birth. Women with inadequate prenatal care had reduced odds of initiating breastfeeding or having their infant immunized. Intensive prenatal care was associated with reduced odds of stillbirth, preterm birth, and low birth weight and increased odds of postpartum depressive/anxiety disorders, initiation of breastfeeding, and infant immunization.ConclusionInadequate prenatal care was associated with increased odds of several adverse pregnancy outcomes and lower likelihood of health-related behaviours, whereas intensive prenatal care was associated with reduced odds of some adverse pregnancy outcomes and higher likelihood of health-related behaviours. Ensuring women receive adequate prenatal care may improve pregnancy outcomes.     

The emotional process from diagnosis to birth following a prenatal diagnosis of fetal anomaly: A qualitative study of messages in online discussion boards

Objectiveto explore written statements found in online discussion boards where parents currently expecting, or with previous experience of expecting, a child with a prenatally diagnosed congenital anomaly communicate about their emotional process from diagnosis to birth.Designcross-sectional qualitative study of messages in public online discussion boards.SettingSwedish public discussion boards about reproductive subjects.Sampleten pregnant women and eight parents (of children with prenatal diagnoses) who had written 852 messages in five threads in Swedish online discussion boards identified via systematic searches.Measurements and findingsthree phases were identified in the process of moving from the diagnosis to the birth: shock, existential crisis, and life remodeling. The people posting message (‘posters’) moved from initial shock to existential crisis and, lastly, a phase of remodeling life later in the pregnancy. During the pregnancy, considerable worries about both antenatal and postnatal aspects were expressed. To cope with their situation, the posters distanced themselves from the diagnoses, vented their feelings, sought control, and obtained practical support from friends and relatives.Key conclusionsexpectant parents faced with a prenatal diagnosis move from initial shock to a phase of life remodeling and acceptance. Burdened with considerable worries, expectant parents cope with their situation through informational, emotional, and instrumental support from health professionals, family, friends, and peers.Implications for practicehealth professionals should make sure that expectant parents feel involved in planning their children's postnatal care, that they are offered sufficient information, and that they have access to emotional and instrumental support structures.     

Embarrassment and modesty feelings during pregnancy,childbirth and follow-up care: A qualitative approach

Objective: Pregnancy and childbirth require several medical examinations which can awaken feelings of modesty in women. Although little research has been done on this specific question, previous research indicates that feelings of modesty and embarrassment could surface during medical examinations, particularly those requiring patient nudity. The aim of the present study was to explore women’s feelings of modesty and embarrassment during medical examinations during pregnancy, childbirth and postnatal care. Method: Qualitative with phenomenological approach. Data were collected by tape-recorded open-ended interviews during the early postnatal period at Paule de Viguier Hospital Maternity Unit, Toulouse (southern France). Twenty women were interviewed during their maternity stay. The interviews explored feelings of modesty during prenatal medical care, childbirth and postnatal care. Results: Results show that feelings of modesty and embarrassment are involved in women’s experience of medical care during pregnancy and childbirth. Nevertheless, all of these women accepted the necessity of medical examinations, citing that their and their baby’s health were more important than personal comfort. Conclusion: Some factors such as ensuring a professional and respectful attitude from the medical staff as well as having procedures explained could reduce feelings of modesty. This study offers an insight of an area that has, as yet, been little explored.     

What Somali women say about giving birth in Canada

It is estimated that about 130 million women worldwide have been circumcised and that 2 million or more girls experience this procedure each year. Women with previous female genital mutilation/circumcision are immigrating, with increasing frequency, to countries where this practice is uncommon. Many health care providers in these countries lack experience in assisting women with female genital mutilation during pregnancy and birth and are usually untrained in this aspect of care. In this study, Somali women (who customarily practise the most extensive form of female mutilation), who were resident in Ontario and who had recently given birth to a baby in Canada, were asked about their experiences in an attempt to explore the situation faced by women in Canada. A total of 432 Somali women with previous female genital mutilation who had given birth to a baby in Canada in the past 5 years were interviewed at home by a Somali interviewer.Women's comments are reported. Findings suggest that women are frequently treated in ways that are perceived to be harsh and even offensive to cultural values. Women are, however, also appreciative of the clinical care they receive. There is a need to modify knowledge about female genital mutilation as well as attitudes towards women who have experienced this practice during perinatal care. Less interventionist clinical care, and increased sensitivity for cross-cultural practices together with more respectful treatment, are needed.     

Preconception lifestyle changes in women with planned pregnancies

Objectives(1) to study preconception lifestyle changes and associated factors in women with planned pregnancies; (2) to assess the prevalence of risk factors for adverse pregnancy outcomes in women not reporting any preconception lifestyle changes; and (3) to explore the need for and use of preconception-related advice.Designsecondary data analysis of a cross-sectional study about pregnancy planning.Settingsix Flemish Hospitals (Belgium).Participantsfour hundred and thirty women with a planned pregnancy ending in birth.Measurementspreconception lifestyle changes were measured during the first 5 days postpartum using the validated London Measure of Unplanned Pregnancy. The following changes were assessed: folic acid or multivitamin intake, smoking reduction or cessation, alcohol reduction or cessation, caffeine reduction or cessation, eating more healthily, achieving a healthier weight, obtaining medical or health advice, or another self-reported preconception lifestyle change.Findingsmost women (83%) that planned their pregnancy reported ≥1 lifestyle change in preparation for pregnancy. Overall, nulliparous women (OR 2.18, 95% CI 1.23–3.87) and women with a previous miscarriage (OR 2.44, 95% CI 1.14–5.21) were more likely to prepare for pregnancy, while experiencing financial difficulties (OR 0.20, 95% CI 0.04–0.97) or having a lower educational level (OR 0.56, 95% CI 0.32–0.99) decreased the likelihood of preparing for pregnancy. Half of the women (48%) obtained advice about preconception health, and 86% of these women received their advice from a professional caregiver. Three-quarters (77%) of the women who did not improve their lifestyle before conceiving reported one or more risk factors for adverse pregnancy outcomes.Key Conclusions and implications for practicemultiparous women and women of lower socio-economic status were less likely to change their lifestyle before conception. Strategies to promote preconception health in these women need to be tailored to their needs and characteristics to overcome barriers to change. It may be advantageous to reach these women through non-medical channels, such as schools or other community organizations.     

Assessing mental health during pregnancy: An exploratory qualitative study of midwives’ perceptions

BackgroundMental health disorders are estimated to affect between 10% and 20% of women who access maternity services and can be defined as a public health issue due to the potential consequences for women, children and families. Detecting problems early in pregnancy can significantly improve outcomes for women and their families. However, mental health problems are not being consistently identified in routine midwifery practice and little is known from current literature about midwives’ practice in relation to current national guidelines or the impact models of care have on assessing maternal mental health.ObjectiveTo identify midwives’ views about barriers and facilitators to screening for mental health in pregnancy using current UK guidelines.DesignNine community midwives from a single district general hospital in the south of England were recruited to take part in focus groups. Thematic analysis was used to extract key themes from the data.FindingsThree key themes were identified from the focus groups and included system factors, social factors and trust. Barriers and facilitators to screening maternal mental health were associated with the initial ‘booking’ appointment’ and differences in models of care. Barriers to screening were defined as high workload, poor continuity, and a lack of trust between women and midwives.ConclusionsThis study highlights key barriers and facilitators associated with mental health screening during pregnancy, including issues of trust and uncertainty about women's willingness to disclose mental health conditions. Further research is required to evaluate the relationship between women and midwives in contemporary practice and the influence this may have on maternal mental health.