The maternal health study: Study design update for a prospective cohort of first-time mothers and their firstborn children from birth to age ten.

BACKGROUND: Maternal health is critical to the health and well-being of children and families, but is rarely the primary focus of pregnancy and birth cohort studies. Globally, poor maternal health and the exposure of women and children to family violence contribute to the perpetuation and persistence of intergenerational health inequalities. OBJECTIVES: The Maternal Health Study was designed to investigate the contribution of social and obstetric risk factors to common maternal physical and psychological morbidities. Over time, our focus has expanded to include mother-child pairs and investigation of intergenerational trauma and family violence. POPULATION: A total of 1507 first-time mothers were recruited in early pregnancy from six public hospitals in Melbourne, Australia, in 2003-2005. METHODS: Women completed questionnaires or telephone interviews in early pregnancy (≤24 weeks); at 32 weeks' gestation; at three, six, nine, 12 and 18 months postpartum; and at four and ten years. At ten years, women and children were invited to participate in face-to-face interviews, which included direct assessment of children's cognitive and language development. A wide range of obstetric, social and contextual factors have been measured, including exposure to intimate partner violence (IPV) (1-year, 4-year and 10-year follow-up). RESULTS: 1507 eligible women were recruited at a mean gestation of 15 weeks. At one year, four years and ten years postpartum, 90.0%, 73.1% and 63.2% of the original cohort took part in follow-up. One in three women in the study (34.5%) reported exposure to IPV in the first ten years of motherhood: 19% in the first 12 months postpartum, 20% in the year prior to four-year follow-up and 18.3% in the year prior to ten-year follow-up. CONCLUSION: The study affords a unique opportunity to examine patterns of maternal and child health and health service use associated with exposure to IPV.

Maternal depressive symptoms at three months postpartum and breastfeeding rates at six months postpartum: Implications for primary care in a prospective cohort study of primiparous women in Australia.

BACKGROUND: The World Health Organisation recommends exclusive breastfeeding to six months postpartum, but most women in developed countries do not breastfeed this long. Prior studies exploring the relationship between breastfeeding duration and maternal depression show ambiguous findings. AIM: To explore associations between maternal depressive symptoms at three months postpartum, and breastfeeding status over the first six months postpartum. METHODS: Prospective pregnancy cohort study of nulliparous women. 1507 women were recruited from six public hospitals in early pregnancy, completing baseline data in early pregnancy (mean gestation 15 weeks). Follow-up questionnaires were completed at three and six months postpartum. Women reported how many months they breastfed for (breastfeeding refers to 'any' breastfeeding, including expressed breastmilk). Depressive symptoms were measured at three months postpartum with the Edinburgh Postnatal Depression Scale (scores ≥13 indicated probable major depression). FINDINGS: Of the almost 95% of women who initiated breastfeeding, 76% were still breastfeeding at three months postpartum, and by six months postpartum this dropped to 61%. Women who reported depressive symptoms at three months had significantly lower rates of breastfeeding at six months postpartum compared to women without depressive symptoms (49% vs. 61%; adjusted OR=0.55, 95% CI 0.34-0.90). Maternal social characteristics associated with not breastfeeding at six months postpartum were: young maternal age; lower education; and smoking in pregnancy. CONCLUSIONS: Women's decisions around infant-feeding are influenced by a range of psycho-social factors, and early postnatal depressive symptoms appear to be a significant part of this picture, as either a cause or consequence of decisions to cease breastfeeding.

Differentiating maternal fatigue and depressive symptoms at six months and four years post partum: Considerations for assessment, diagnosis and intervention.

OBJECTIVE: fatigue and depressive symptoms are common among women in the postpartum period, and it has been proposed that fatigue is a risk factor for later depression. To progress this research, there is a need to clarify the conceptual and measurement issue of whether these two sets of symptoms are distinct constructs. There is also a need to determine whether they are distinct constructs beyond the postnatal period. The aim of the study was to assess the construct and discriminant validity of fatigue and depressive symptoms as measured by the SF-36 Vitality subscale (SF-36) and the Edinburgh Postnatal Depression Scale (EPDS) at six months and at four years post partum. DESIGN, SETTING AND PARTICIPANTS: data from over 1000 women participating in the Maternal Health Study, a longitudinal study of women׳s physical and psychological health and recovery after childbirth were used. FINDINGS: confirmatory factor analysis revealed a two-factor model of fatigue and depressive symptoms represented as distinct but related constructs was a better fit to the data than a one-factor model of fatigue and depression sharing the same underlying construct at both six months and four years post partum. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: this study provides empirical evidence that maternal fatigue and depression in the first year after having a baby and at four years post partum are best understood as separate psychological constructs or experiences. The findings have important implications for clinical practice, in particular underlining the importance of differentiating tiredness from depression.

Physical health after childbirth and maternal depression in the first 12 months post partum: results of an Australian nulliparous pregnancy cohort study.

OBJECTIVE: to investigate the relationship between maternal physical health problems and depressive symptoms in the first year after childbirth. DESIGN: prospective pregnancy cohort study. SETTING: Melbourne, Victoria, Australia. POPULATION: 1507 nulliparous women. METHODS: women were recruited from six public hospitals between six and 24 weeks gestation. Written questionnaires were completed at recruitment and at three, six and 12 months post partum. OUTCOME MEASURES: Edinburgh Postnatal Depression Scale (EPDS); standardised measures of urinary and faecal incontinence, a checklist of symptoms for other physical health problems. RESULTS: overall, 16.1% of women reported depressive symptoms during the first 12 months post partum, with point prevalence at three, six and 12 months post partum of 6.9%, 8.8% and 7.8% respectively. The most commonly reported physical health problems in the first three months were tiredness (67%), back pain (47%), breast problems (37%), painful perineum (30%), and urinary incontinence (29%). Compared with women reporting 0-2 health problems in the first three months post partum, women reporting 5 or more health problems had a six-fold increase in likelihood of reporting concurrent depressive symptoms at three months post partum (Adjusted OR=6.69, 95% CI=3.0-15.0) and a three-fold increase in likelihood of reporting subsequent depressive symptoms at 6-12 months post partum (Adjusted OR=3.43, 95% CI 2.1-5.5). CONCLUSIONS: poor physical health in the early postnatal period is associated with poorer mental health throughout the first 12 months post partum. Early intervention to promote maternal mental health should incorporate assessment and intervention to address common postnatal physical health problems.

Maternal depression and physical health problems in early pregnancy: findings of an Australian nulliparous pregnancy cohort study.

OBJECTIVE: to investigate the relationship between physical health problems and depressive symptoms in early pregnancy. DESIGN: baseline questionnaire, prospective pregnancy cohort study. SETTING: six metropolitan public maternity hospitals in Victoria, Australia. PARTICIPANTS: 1507 nulliparous women recruited in early pregnancy. FINDINGS: nine per cent of women (131/1500) scored ≥ 13 on the EPDS indicating probable clinical depression in early pregnancy (mean gestation=15 weeks). The five most commonly reported physical health problems were as follows: exhaustion (86.9%), morning sickness (64.3%), back pain (45.6%), constipation (43.5%) and severe headaches or migraines (29.5%). Women scoring ≥ 13 on the EPDS reported a mean of six physical health problems compared with a mean of 3.5 among women scoring <13 on the EPDS. Women reporting five or more physical health problems had a three-fold increase in likelihood of reporting depressive symptoms (Adj OR=3.13, 95% CI 2.14-4.58) after adjusting for socio-demographic factors, including maternal age. CONCLUSIONS: the findings from this large multi-centre study show that women experiencing a greater number of physical health problems are at increased risk of reporting depressive symptoms in early pregnancy. IMPLICATIONS FOR PRACTICE: early detection and support for women experiencing physical and psychological health problems in pregnancy is an important aspect of antenatal care. The extent of co-morbid physical and psychological health problems underlines the need for comprehensive primary health care as an integral component of antenatal care.

Physical health and recovery in the first 18 months postpartum: does cesarean section reduce long-term morbidity?

BACKGROUND: Research examining long-term health outcomes for women after childbirth has been limited. The objective of this study was to investigate the natural history of common morbidities in the 18 months after the birth of a first child, and to explore the hypothesis that women who have a cesarean section for a first birth experience less overall morbidity in the postnatal period. METHODS: A prospective nulliparous pregnancy cohort study was conducted of 1,507 women recruited in early pregnancy from six public hospitals in Melbourne, Australia (mean gestation 15 weeks). Follow-up questionnaires at 3, 6, 12, and 18 months postpartum included standardized measures of urinary and fecal incontinence, and a symptom checklist asking about common physical health problems. RESULTS: At 6, 12, and 18 months postpartum, no statistically significant differences were found in the proportion of women reporting three or more health problems by method of birth. Compared with women who had a spontaneous vaginal birth, women who had a cesarean section were more likely to report extreme tiredness at 6 months postpartum (adjusted OR: 1.39; 95% CI: 1.07-1.82) and at 12 months postpartum (adjusted OR: 1.40; 95% CI: 1.05-1.85), and were more likely to report back pain at 6 months postpartum (adjusted OR: 1.37; 95% CI: 1.06-1.77) and at 12 months postpartum (adjusted OR: 1.41; 95% CI: 1.06-1.87). Women who had a cesarean section were less likely to report urinary incontinence at 3, 6, and 12 months postpartum, respectively (adjusted OR: 0.26; 95% CI: 0.19-0.36; adjusted OR: 0.36; 95% CI: 0.25-0.52; adjusted OR: 0.48; 95% CI: 0.33-0.68). For all other physical health problems the pattern of morbidity did not differ between cesarean section and spontaneous vaginal birth. CONCLUSIONS: Physical health problems commonly persist or recur throughout the first 18 months postpartum, with potential long-term consequences for women's health. Cesarean section does not result in women experiencing less overall morbidity in the postpartum period compared with women who have a spontaneous vaginal birth.

Seeking help for anxiety and depression after childbirth: results of the Maternal Health Study.

Access to treatment for postnatal anxiety and depression is dependant on women seeking help for psychological symptoms. The aim of this paper was to investigate what women themselves say about seeking help for emotional difficulties after childbirth. The Maternal Health Study is a prospective pregnancy cohort study investigating the physical and psychological health of 1,507 nulliparous women during pregnancy and after birth. One thousand, three hundred eighty-five women completed a computer-assisted telephone interview at 9 months postpartum; 8.5% of women reported intense anxiety or panic attacks occasionally or often, and 9.5% reported depressed mood, between 6 and 9 months postpartum. Of those experiencing anxiety symptoms alone 44.4% had spoken to a health professional, compared with 65.5% of women experiencing depressive symptoms alone (RR = 0.68, 95% CI-0.5 to 0.9). Measures of anxiety and depressive symptoms at 9 months postpartum were not validated against diagnostic criteria. Anxiety is a common experience in the perinatal period. More research is needed into this area to determine what levels of anxiety are 'normal' and acceptable to women during this period. Public health campaigns may have been more effective in encouraging women to seek help for depression than anxiety.