Alexandra Sawyer

Pre- and postnatal psychological wellbeing in Africa: A systematic review

BACKGROUND Perinatal mental health disorders are recognised as an important public health issue in low-income countries as well as in developed countries. This paper reviews evidence on the prevalence and risk factors of maternal mental health disorders in African women living in Africa. METHODS A systematic review of the literature was conducted. Studies were mainly located through computerised databases, and additionally through hand searching references of identified articles and reviews. Thirty-five studies, with a total of 10,880 participants, were identified that reported prevalence rates of maternal psychological health in eight African countries. RESULTS Depression was the most commonly assessed disorder with a weighted mean prevalence of 11.3% (95% CI 9.5%-13.1%) during pregnancy and 18.3% (95% CI 17.6%-19.1%) after birth. Only a small number of studies assessed other psychological disorders. Prevalence rates of pre- and postnatal anxiety were 14.8% (95% CI 12.3%-17.4%) and 14.0% (95% CI 12.9%-15.2%), respectively; and one study reported the prevalence of PTSD as 5.9% (95% CI 4.4%-7.4%) following childbirth. Lack of support and marital/family conflict were associated with poorer mental health. Evidence relating sociodemographic and obstetric variables to mental health was inconclusive. LIMITATIONS Most studies included in this review were cross-sectional and measures of mental health varied considerably. CONCLUSIONS This paper demonstrates that maternal mental health disorders are prevalent in African women, and highlights the importance of maternal mental health care being integrated into future maternal and infant health policies in African countries.

Posttraumatic growth and adjustment among individuals with cancer or HIV/AIDS: A meta-analysis

Abstract There is increasing research on posttraumatic growth after life-threatening illnesses such as cancer and HIV/AIDS, although it is unclear whether growth confers any psychological or physical benefits in such samples. Consequently, this meta-analysis explored the relationship between posttraumatic growth and psychological and physical wellbeing in adults diagnosed with cancer or HIV/AIDS and examined potential moderators of these relationships. Analysis of 38 studies (N =7927) of posttraumatic growth after cancer or HIV/AIDS revealed that growth was related to increased positive mental health, reduced negative mental health and better subjective physical health. Moderators of these relationships included time since the event, age, ethnicity, and type of negative mental health outcome. It is hoped that this synthesis will encourage further examination of the potentially complex relationship between posttraumatic growth and adjustment in individuals living with life-threatening medical conditions.

Posttraumatic stress disorder after childbirth: Analysis of symptom presentation and sampling

BACKGROUND There is converging evidence that approximately 2% of women fulfill PTSD criteria following childbirth. This study examined the presentation and symptom structure of PTSD after birth and key risk factors in women from internet and community samples. METHODS PTSD was measured in 1423 women after birth recruited via the community (n=502) or internet (n=921). Demographic, obstetric, and trauma history variables were also measured. RESULTS Full PTSD diagnostic criteria were endorsed by 2.5% of women from the community and 21% of women on the internet. Many more endorsed individual PTSD symptom criteria, suggesting this might be inflated by postnatal factors. Samples differed on demographic and obstetric characteristics. Factor analysis found two PTSD symptom clusters of re-experiencing and avoidance (RA) and numbing and arousal (NA). PTSD cases were predicted by parity, delivery type, NA and RA symptoms, and the interaction between sexual trauma and delivery type. This correctly identified 60% of PTSD cases. LIMITATIONS Questionnaire measurement of PTSD means prevalence rates may be over-estimated. Differences between samples suggest that internet samples over represent symptomatic women. CONCLUSIONS Results emphasise the importance of measuring full diagnostic criteria in postnatal samples, as reports of symptoms may be inflated. In addition a few risk factors are identified that could be used to screen for women at risk.

Measures of satisfaction with care during labour and birth: a comparative review

BackgroundSatisfaction is the one of the most frequently reported outcome measures for quality of care. Assessment of satisfaction with maternity services is crucial, and psychometrically sound measures are needed if this is to inform health practices. This paper comparatively reviews current measures of satisfaction with care during labour and birth.MethodsA review of the literature was conducted. Studies were located through computerised databases and hand searching references of identified articles and reviews. Inclusion criteria were that the questionnaire was a multi-item scale of satisfaction with care during labour and birth, and some form of psychometric information (either information about questionnaire construction, or reliability, or validity) had to be reported.ResultsNine questionnaires of satisfaction with care during labour and birth were identified. Instruments varied in psychometric properties and dimensions. Most described questionnaire construction and tested some form of reliability and validity. Measures were generally not based on the main theoretical models of satisfaction and varied in scope and application to different types of samples (e.g. satisfaction following caesarean section). For an in-depth measure of satisfaction with intrapartum care, the Intrapartal-Specific Quality from the Patient’s Perspective questionnaire (QPP-I) is recommended. Brief measures with good reliability and validity are provided by the Six Simple Questions (SSQ) or Perceptions of Care Adjective Checklist (PCACL-R).ConclusionsDespite the interest in measures of satisfaction there are only a small number of validated measures of satisfaction with care during labour and birth. It is important that brief, reliable and valid measures are available for use in general and specific populations in order to assist research and inform practice.

Post-traumatic growth in women after childbirth.

Childbirth is a complex event that leads to a variety of psychological outcomes. This cross-sectional study examined post-traumatic growth in women following childbirth (N = 219) using an online questionnaire, and explored associations between growth, support and control during birth, coping after birth and symptoms of post-traumatic stress disorder (PTSD). At least moderate degrees of growth were reported by 50.2% of women and average levels of growth were similar to those reported following accidents and assaults. Growth was positively related to approach coping and the avoidant strategy of seeking alternative rewards, but was unrelated to support and control during birth, other avoidant coping strategies after birth, and PTSD symptoms. It is concluded that growth does occur following childbirth. Further research is needed to clarify factors associated with growth in women following childbirth and to determine if growth is associated with psychological benefits in this population.

Post-traumatic stress disorder following childbirth: an update of current issues and recommendations for future research

Objective: This paper aimed to report the current status of research in the field of post-traumatic stress disorder following childbirth (PTSD FC), and to update the findings of an earlier 2008 paper. Background: A group of international researchers, clinicians and service users met in 2006 to establish the state of clinical and academic knowledge relating to PTSD FC. A paper identified four key areas of research knowledge at that time. Methods: Fourteen clinicians and researchers met in Oxford, UK to update the previously published paper relating to PTSD FC. The first part of the meeting focused on updating the four key areas identified previously, and the second part on discussing new and emerging areas of research within the field. Results: A number of advances have been made in research within the area of PTSD FC. Prevalence is well established within mothers, several intervention studies have been published, and there is growing interest in new areas: staff and pathways; prevention and early intervention; impact on families and children; special populations; and post-traumatic growth. Conclusion: Despite progress, significant gaps remain within the PTSD FC knowledge base. Further research continues to be needed across all areas identified in 2006, and five areas were identified which can be seen as ‘new and emerging’. All of these new areas require further extensive research. Relatively little is still known about PTSD FC.

Posttraumatic growth after childbirth: a prospective study

A growing body of research has examined the potential for positive change following challenging and traumatic events, this is known as posttraumatic growth (PTG). Childbirth is a valuable opportunity to extend previous work on PTG as it allows the role of different variables to be considered prospectively. The aim of this study was to prospectively examine correlates of PTG after birth, including sociodemographic and obstetric variables, social support and psychological distress, using a prospective, longitudinal design. A total of 125 women completed questionnaires during their third trimester of pregnancy and 8 weeks after birth. At least a small degree of positive change following childbirth was reported by 47.9% of women; however, average levels of growth were lower than generally reported in other studies. A regression model of age, type of delivery, posttraumatic stress symptoms during pregnancy and general distress after birth significantly predicted 32% of the variance in growth after childbirth. The strongest predictors of growth were operative delivery (β 0.23–0.30) and posttraumatic stress symptoms in pregnancy (β 0.32). These findings emphasise the importance of assessing pre-event characteristics when considering the development of PTG after a challenging event.

Parents’ first moments with their very preterm babies: a qualitative study

Objectives To assess parents’ first experiences of their very preterm babies and the neonatal intensive care unit (NICU). Design Qualitative study using semistructured interviews. Participants 32 mothers and 7 fathers of very preterm babies (<32 weeks gestation). Setting Three neonatal units in tertiary care hospitals in South East England. Results Five themes were identified. The first describes parents’ blurred recall of the birth. The second shows the anticipation of seeing and touching their baby for the first time was characterised by contrasting emotions, with some parents feeling scared and others excited about the event. The third theme describes parents’ first sight and touch of their babies and their ‘rollercoaster’ of emotions during this time. It also highlights the importance of touch to trigger and strengthen the parent–baby bond. However, some parents were worried that touching or holding the baby might transmit infection or interfere with care. The fourth theme captures parents’ impressions of NICU and how overwhelming this was particularly for parents who had not toured NICU beforehand or whose first sight of their baby was on NICU. The final theme captures unique experiences of fathers, in particular that many felt excluded and confused about their role. Conclusions This study informs family-centred care by providing insight into the experiences of parents of very preterm infants at a time when they are most in need of support. Clinical implications include the importance of offering parents preparatory tours of the NICU and including fathers.

Parents’ views on care of their very premature babies in neonatal intensive care units: a qualitative study

BackgroundThe admission of a very premature infant to the neonatal intensive care unit (NICU) is often a difficult time for parents. This paper explores parents’ views and experiences of the care for their very premature baby on NICU.MethodsParents were eligible if they had a baby born before 32 weeks gestation and cared for in a NICU, and spoke English well. 32 mothers and 7 fathers were interviewed to explore their experiences of preterm birth. Although parents’ evaluation of care in the NICU was not the aim of these interviews, all parents spoke spontaneously and at length on this topic. Results were analysed using thematic analysis.ResultsOverall, parents were satisfied with the care on the neonatal unit. Three major themes determining satisfaction with neonatal care emerged: 1) parents’ involvement; including looking after their own baby, the challenges of expressing breast milk, and easy access to their baby; 2) staff competence and efficiency; including communication, experience and confidence, information and explanation; and 3) interpersonal relationships with staff; including sensitive and emotional support, reassurance and encouragement, feeling like an individual.ConclusionsDeterminants of positive experiences of care were generally consistent with previous research. Specifically, provision of information, support for parents and increasing their involvement in the care of their baby were highlighted by parents as important in their experience of care.

Neurodevelopmental Outcomes at 2 and 3.5 Years for Very Preterm Babies Enrolled in a Randomized Trial of Milking the Umbilical Cord versus Delayed Cord Clamping

Background: Guidelines published by the International Liaison Committee for Resuscitation and by the World Health Organization recommend delaying cord clamping at birth as part of routine care for infants. Objective: To study the use of milking of the cord 4 times as an alternative to enhance the redistribution of placental blood into the baby. Methods: This is a prospective cohort study of neurodevelopmental assessment by the Bayley III method of very preterm infants who had participated in a trial of delayed cord clamping versus cord milking at birth that was conducted in a neonatal tertiary care hospital. The primary outcomes were differences in cognitive, motor and language development at 2 and 3.5 years. Two-tailed analyses were performed with the χ2 test, Fishers exact test, t test, Mann-Whitney U test and ANCOVA. Results: Out of the 58 infants enrolled in the original study, 39 infants (67%) were assessed at 2 years and 29 (50%) at 3.5 years of age. Neurodevelopmental outcomes at 2 and 3.5 years did not significantly differ between the two groups for the three Bayley III composite scores. At 3.5 years there was a trend towards higher scores for girls in the language composite scores (girls: mean = 121.6, SD = 15.22; boys: mean = 101.07, SD = 19.84) and on the motor scale (girls: mean = 124.60, SD = 18.15; boys: mean = 97.86, SD = 17.23). Conclusions: In this small number of participants followed up at 2 and 3.5 years of age, milking of the cord 4 times did not have any long-term adverse effect on neurodevelopmental outcome, suggesting that cord milking could be used as an alternative to delayed cord clamping.