Gustavo Lobato

Revisiting the dimensional structure of the Edinburgh Postnatal Depression Scale (EPDS): empirical evidence for a general factor

BackgroundThe Edinburgh Postnatal Depression Scale (EPDS) has been proposed as a one-dimensional instrument and used as a single 10-item scale. This might be considered questionable since repeated psychometric studies have shown multi-dimensionality, which would entail using separate component subscales. This study reappraised the dimensional structure of the EPDS, with a focus on the extent of factor correlations and related factor-based discriminant validity as a foundation for deciding how to effectively scale the component items.MethodsThe sample comprised 811 randomly selected mothers of children up to 5 months attending primary health services of Rio de Janeiro, Brazil. Strict Confirmatory Factor Analysis (CFA) and Exploratory Factor Analysis modeled within a CFA framework (E/CFA) were sequentially used to identify best fitting and parsimonious model(s), including a bifactor analysis to evaluate the existence of a general factor. Properties concerning the related 10-item raw-score scale were also investigated using non-parametric items response theory methods (scalability and monotonicity).ResultsAn initial CFA rejected the one-dimensional structure, while an E/CFA subscribed a three-dimensional solution. Yet, factors were highly correlated (0.66, 0.75 and 0.82). The ensuing CFA showed poor discriminant validity (some square-roots of average variance extracted below the factor correlations). A general bifactor CFA was then fit. Results suggested that, although still weakly encompassing three specific factors, the EPDS might be better described by a model encompassing a general factor (loadings ranging from 0.51 to 0.81). The related 10-item raw score showed adequate scalability (Loevingers H coefficient = 0.4208), monotonicity e partial double monotonicity (nonintersections of Item Step Response Functions).ConclusionAlthough the EPDS indicated the presence of specific factors, they do not qualify as independent dimensions if used separately and should therefore not be used empirically as sub-scales (raw scores). An all-encompassing scale seems better suited and continuing its use in clinical practice and applied research should be encouraged.

Severe physical violence between intimate partners during pregnancy: a risk factor for early cessation of exclusive breast-feeding

OBJECTIVE To investigate the role of severe physical violence during pregnancy (SPVP) between intimate partners in early cessation of exclusive breast-feeding (EBF). DESIGN A health services survey. The revised Conflict Tactics Scale was used to characterize SPVP; premature breast-feeding cessation was identified using a current status data approach, which was based on the information reported from food recall during the preceding 7 d. The cumulative hazard function was estimated by complementary log-log transformation models, which allowed the ensuing estimation of early breast-feeding cessation rates in different age groups and the ratio of rates of weaning between women exposed and not exposed to violence. SETTING Five large public primary health-care facilities of Rio de Janeiro, Brazil. SUBJECTS The sample comprised 811 randomly selected mothers of children under 5 months of age who were waiting to be consulted. RESULTS SPVP is an independent risk factor of cessation of EBF since, after controlling for socio-economic, demographic, reproductive and lifestyle variables, women exposed to violence presented an incidence density that was 31% higher than those who were not exposed (hazard ratio = 1·30, 95% CI 1·01, 1·69). CONCLUSIONS The findings corroborate the hypothesis that SPVP is an important risk factor for EBF. This indicates the need for incentives to adequately train health-care personnel in dealing with lactating women in order to gain a broader view of breast-feeding beyond the biological aspects of lactation, including the maternal psychological dimension.

Magnitude da depressão pós-parto no Brasil: uma revisão sistemática

Objectives: to carry out a systematic review of studies of the extent of post-partum depression (PPD) in Brazil. Methods: articles were searched for and selected from national and international periodicals included in the Lilacs, SciELO and Medline electronic data-bases. Results: fourteen studies were selected, thirteen of which reported the prevalence of PPD and one, which followed up a limited number of cases (n=21) estimated the incidence of the disorder at 42.8%. The wide range of different populations studied, diag-nostic methods used, and post-partum period moni-tored made it difficult to obtain an aggregate estimate for the prevalence of PPD in Brazil. Nevertheless, studies conducted at Family Health Program basic health units and among underprivileged populations suggest a prevalence of around 30 to 40%, although studies that are based on population-wide samples and tertiary hospital units reveal a prevalence of around 20%. Conclusions: although further studies are needed to characterize the specific features of the extent of PPD in Brazil, the available evidence provides suffi-cient justification for prioritizing treatment of mental health disorders in mothers attending the public health services.

Reappraising the relationship between maternal age and postpartum depression according to the evolutionary theory: Empirical evidence from a survey in primary health services

BACKGROUND Postpartum depression (PPD) is a widespread worldwide phenomenon, but its etiology remains unclear. This study reappraised how evolutionary theory could explain PPD as an adaptation through investigating the relationship between maternal age and PPD, and if this relationship is modified according to the number of children at home. METHODS A cross-sectional study carried out in five primary health care units included 811 participants randomly selected among mothers of children up to five postpartum months in Rio de Janeiro, Brazil. Postpartum depression was defined by scores above 11 on Edinburgh Postnatal Depression Scale (EPDS), and statistical analysis was based on multivariate logistic regression models. RESULTS One hundred and ninety-seven (24.3%, CI 95% 21.3-27.2) participants were classified as PPD positives. Maternal age was significantly associated to PPD (OR=0.96, p-value=0.019) independently of socioeconomic and reproductive characteristics, conjugal status or substance consumption by the couple. Thus, for each additional year, a reduction of 4% in the chance of developing PPD could be anticipated, effect which was not modified by the number of children at home (p-value=0.602). LIMITATIONS Information on social support was not included in this analysis since its relationship with maternal mental health would be better evaluated in a prospective fashion. CONCLUSIONS These findings suggest that adaptive mechanisms shaped through human generations persist contributing to the development of PPD in contemporary societies. According to this evolutionary approach, as maternal age advances the reproductive potential diminishes and, consequently, mothers are less prone to develop PPD and reduce investment in new offspring.

Caesarean rates in Brazil: what is involved?

Statistical data indicate that rates of caesarean births are increasing worldwide, being particularly high in some countries, including Brazil; however, consensus ends here. This is a controversial subject, particularly with regard to what would be the ideal caesarean rate and what are the determinants of high caesarean rates in some countries.

Sistema de informações hospitalares do sistema único de saúde (SIH-SUS): uma avaliação preliminar do seu desempenho no monitoramento da doença hemolítica perinatal Rh(D)

Considerando a utilizacao de bases administrativas na vigilância epidemiologica, propoe-se aqui avaliar a adequacao do Sistema de Informacoes Hospitalares do Sistema Unico de Saude (SIH-SUS) na identificacao dos casos de doenca hemolitica perinatal ocorridos no Instituto Fernandes Figueira, Fundacao Oswaldo Cruz (IFF/FIOCRUZ), entre 1998 e 2003. Foram analisadas informacoes disponibilizadas pelo Servico Neonatal, pelo Arquivo Medico e os dados da Autorizacao de Internacao Hospitalar (AIH) consolidados no SIH-SUS. A identificacao dos casos de doenca hemolitica perinatal se deu atraves dos campos Diagnostico Primario, Diagnostico Secundario e Procedimento Realizado. Nesse periodo, 194 neonatos foram diagnosticados com doenca hemolitica perinatal. No Arquivo Medico, 148 casos foram registrados, porem apenas 147 AIHs foram emitidas e 145 consolidadas no SIH-SUS. Entre essas, 84 AIHs arrolavam a doenca hemolitica perinatal como Diagnostico Primario; considerando tambem o Diagnostico Secundario, mais 38 casos foram identificados; e nenhum caso adicional foi recuperado pelo Procedimento Realizado. Assim, o SIH-SUS identificou apenas 122 (62,9%) dos 194 neonatos com doenca hemolitica perinatal assistidos no IFF/FIOCRUZ. Mesmo que ainda requerendo uma reavaliacao em outros hospitais, a utilizacao do SIH-SUS no monitoramento da doenca hemolitica perinatal nao parece recomendavel. Estudos ancilares sao necessarios quando do emprego de dados secundarios nesse contexto.This study aimed to evaluate the adequacy of the Hospital Information System of the National Unified Health System (SIH-SUS) in identifying cases of RhD hemolytic disease of the newborn (HDN) at the Fernandes Figueira Institute (IFF/FIOCRUZ) from 1998 to 2003. Neonatal records, data from the Medical Archives, and AIH (Hospital Admissions Authorization Form) data consolidated in the SIH-SUS were analyzed. Cases were identified according to the following fields: principal diagnosis, secondary diagnosis, and procedure performed. During the period studied, 194 cases of HDN were diagnosed. The Medical Archives registered 148 newborns with HDN, however only 147 AIHs were issued and 145 consolidated in the SIH-SUS. Among these 145 cases, 84 cited HDN as the principal diagnosis, while secondary diagnosis identified 38 additional cases and the procedures performed failed to identify any further cases. Thus, the SIH-SUS identified only 122 (62.9%) of the 194 cases of HDN treated at the IFF/FIOCRUZ. Although it is necessary to evaluate other units, the SIH-SUS does not appear to be reliable for monitoring HDN. Additional studies are essential for employing secondary administrative data in the context of epidemiological surveillance.

Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH-SUS): uma avaliação do seu desempenho para a identificação do near miss materno

Este estudo avaliou o desempenho do Sistema de Informacoes Hospitalares do Sistema Unico de Saude (SIH-SUS) na identificacao de casos de near miss materno ocorridos em hospital do Rio de Janeiro, em 2008. Os casos foram captados pela revisao de todos os prontuarios medicos de gestantes ou puerperas internadas na unidade, e a busca por potenciais eventos de near miss na base do SIH-SUS valeu-se de uma lista de procedimentos e codigos da Classificacao Internacional de Doencas, 10a revisao (CID-10), que fossem compativeis com esse diagnostico. A revisao de prontuarios identificou 27 casos, enquanto na base do SIH-SUS encontrou-se 70 possiveis ocorrencias de near miss. Porem, dessas 70 apenas cinco efetivamente eram casos near miss conforme os prontuarios, correspondendo entao a sensibilidade de 18,5% (IC95%: 6,3-38,1), especificidade de 94,3% (IC95%: 92,8-95,6), area sob a curva ROC de 0,56 (IC95%: 0,48-0,63) e valor preditivo positivo de 10,1% (IC95%: 4,7-20,3). Esses achados sugerem que o SIH-SUS nao e adequado para o monitoramento dos casos de near miss materno.

Reversion of the Ballantyne syndrome despite fetal hydrops persistence.

Introduction: The Ballantyne syndrome (or mirror syndrome) is a gestational proteinuric hypertension associated with fetal hydrops. This report describes a case in which Ballantyne syndrome reversion occurred despite fetal hydrops persistence. Case Report: A 24-year-old woman showed fetoplacental hydrops at 28 2/7 gestational weeks. Severe Rh(D) alloimmunization and fetal hemolytic anemia (fetal hematocrit 15.4%) were confirmed by cordocentesis, and an intrauterine transfusion was performed. She also revealed hypertension (160/100 mm Hg), edema and proteinuria (845 mg/day). After four intrauterine transfusions, blood pressure was normalized; urinary proteinuria was not significant, and the edema vanished completely. Fetal hydrops persisted until delivery at 32 gestational weeks, but a partial reduction of placental hydrops was noted. Discussion: Total or partial reduction of the placental edema may be responsible for the reversal of the Ballantyne syndrome despite the fetal hydrops persistence.

The role of intimate partner violence and other health-related social factors on postpartum common mental disorders: a survey-based structural equation modeling analysis

BackgroundAlthough studies suggest the relevance of intimate partner violence (IPV) and other health-related social characteristics as risk factors for postpartum mental health, literature lacks evidence about how these are effectively connected. This study thus aims to explore how socio-economic position, maternal age, household and marital arrangements, general stressors, alcohol misuse and illicit drug abuse, and especially psychological and physical IPV relate in a framework leading to postpartum common mental disorder (CMD).MethodsThe study was carried out in five primary health care units of Rio de Janeiro, Brazil, and included 810 randomly selected mothers of children up to five postpartum months waiting for pediatric visits. The postulated pathways between exposures and outcome were based on literature evidence and were further examined using structural equation models.ResultsDirect pathways to postpartum CMD arose from a latent variable depicting socio-economic position, a general stressors score, and both IPV variables. Notably, the effect of psychological IPV on postpartum CMD ran partly through physical IPV. The effect of teenage pregnancy, conjugal instability and maternal burden apparently happens solely through substance use, be it alcohol misuse, illicit drug abuse or both in tandem. Moreover, the effect of the latter on CMD seems to be entirely mediated through both types of IPV.ConclusionAlthough the theoretical model underlying the analysis still requires in-depth detailing, results of this study may have shed some light on the role of both psychological and physical IPV as part of an intricate network of events leading to postpartum CMD. Health initiatives may want to make use of this knowledge when designing preventive and intervention approaches.

Higher rates of postpartum depression among women lacking care after childbirth: clinical and epidemiological importance of missed postnatal visits

Although postpartum depression is recognised as a public health issue, the authors suggest that it is not clear just how prevalent it is and that the generally acceped figures could be affected by a number of personal, cross-cultural and methodological factors.