Understanding bereavement experiences of mothers facing the loss of newborn infants / Experiências de luto das mães frente à perda do filho neonato

Abstract Objective: to understand mothers' bereavement experiences regarding the loss of their newborn child in the Neonatal Intensive Care Unit of a Brazilian university hospital. Methods: the study was designed by the clinical-qualitative method to understand the meaning of the emerging relationships of health scenarios. Sample consisted of six mothers. The sufficiency of the sample was verified through the saturation of the data. The data collection instrument was a semistructured interview with script of open questions, the collected material was recorded and transcribed in full. Thematic analysis was performed by two independent authors. Results: feelings and perceptions of the grieving process gave rise to three categories: 1. Guilt and fantasy of bereavement related to the death and grief for their children; 2. Relationships and ambiguities - the relationship between internal concerns and perception of external relations; 3. Fear, disbelief, abandonment and loneliness - questions about perception of the external environment. Conclusions: mothers' bereavement experience is mainly permeated by loneliness and abandonment related to feelings of guilt for not being able to keep their children alive. The difficult and definitive separation in the postpartum period, caused by death, brings fantasies of reunion with their child. Women show the need to realize grief, especially by recognizing their baby's identity.

Resumo Objetivo: compreender experiências de luto das mães frente à perda do filho neonato na Unidade de Terapia Intensiva Neonatal de um hospital universitário brasileiro. Métodos: o estudo foi desenhado pelo método clínico-qualitativo que propõe a compreensão do sentido das relações emergentes nos cenários de saúde. A amostra foi composta por seis mães e sua suficiência foi verificada através da saturação de dados. O instrumento de coleta de dados foi uma entrevista semiestruturada com roteiro de questões abertas, o material coletado foi gravadoe transcrito na íntegra. A análise temática foi realizada por dois autores independentes. Resultados: os sentimentos e as percepções do processo de luto deram origem a três categorias: 1. Culpa e fantasia das mulheres enlutadas relacionadas com a morte e luto por seus filhos; 2. Relacionamentos e ambiguidades - a relação entre preocupações internas e a percepção de relações externas; 3. Medo, descrença, abandono e solidão - questões sobre a percepção do ambiente externo. Conclusões: a experiência de luto das mães é permeada sobretudo, por solidão e abandono relacionados com sentimento de culpa por não poder manter o filho vivo. A separação no período de puerpério, provocada pela morte, é difícil, definitiva e traz fantasias de reencontro com o filho. As mulheres mostram a necessidade de concretizar o luto especialmente através do reconhecimento da identidade de seu bebê.

Depressão como mediadora da relação entre violência por parceiro íntimo e dificuldades sexuais após o parto: uma análise estrutural / Depression as a mediator between intimate partner violence and postpartum sexual issues: a structural analysis

RESUMO: Introdução: Não foram encontrados estudos que avaliam associação entre violência por parceiro íntimo (VPI) anterior ao parto e dificuldades na esfera da sexualidade no período pós-parto. O presente estudo avalia se existe essa associação. Método: Estudo transversal com 700 mulheres que realizaram o pré-natal em Unidade Básica de Saúde (UBS), em São Paulo, entre 2006 e 2007. As dificuldades sexuais (DS) foram avaliadas por meio de questionário elaborado pelos autores e a VPI foi investigada por questionário estruturado elaborado pela Organização Mundial da Saúde (OMS). Já a depressão pós-parto (DPP) foi avaliada por meio do Self-Reporting Questionnaire (SRQ-20) e foi considerada variável mediadora. Para calcular os coeficientes de associação das vias diretas e indiretas foi utilizada a análise estrutural (path analysis). Resultados: As prevalências de DS, a VPI e a DPP foram, respectivamente, 30, 42,8 e 27,8%. A violência ocorrida antes do parto não mostrou associação direta - ED = 0,072 (-0,06 - 0,20; p = 0,060) - nem indireta - EI: 0,045 (-0,06 - 0,20; p = 0,123) - em relação ao desfecho estudado. Conclusão: Futuras investigações sobre a relação entre as três variáveis estudadas são recomendadas. Estudos longitudinais que incluam outros mediadores podem trazer melhor entendimento da cadeia causal e elucidação das variáveis que influenciam as questões da sexualidade no pós-parto.

ABSTRACT: Introduction: No studies were found that evaluate the association between intimate partner violence (IPV) before childbirth and sexual issues in the postpartum period. Method: A cross-sectional study with 700 women who received prenatal care in a basic health unit in São Paulo, between 2006 and 2007. Sexual issues were assessed through a questionnaire created by the authors, and intimate partner violence was evaluated using a structured questionnaire developed by the WHO. Postpartum depression was evaluated using the SRQ-20 instrument, with a cut-off point of 7/8 considered to be the mediating variable. A path analysis was performed to determine the different pathways: the direct association between outcome and exposure, and the indirect pathways through the mediator. Results: The prevalence of sexual issues, intimate partner violence and postpartum depression were 30; 42.8; 27.8%, respectively. Violence occurring exclusively before childbirth did not show a direct association (ED = 0.072 (-0.06 - 0.20, p = 0.060)) or indirect (EI: 0.045 (-0.06 - 0.20, p = 0.123)), with sexual issues. Conclusion: Longitudinal studies that include other mediators may provide a better understanding of the causal chain and elucidate variables that influence postpartum sexuality issues.

Association between postpartum depression and the practice of exclusive breastfeeding in the first three months of life / Associação entre a depressão pós-parto e a prática do aleitamento materno exclusivo nos três primeiros meses de vida

Abstract Objective: To investigate the association between postpartum depression and the occurrence of exclusive breastfeeding. Method: This is a cross-sectional study conducted in the states of the Northeast region, during the vaccination campaign in 2010. The sample consisted of 2583 mother-child pairs, with children aged from 15 days to 3 months. The Edinburgh Postnatal Depression Scale was used to screen for postpartum depression. The outcome was lack of exclusive breastfeeding, defined as the occurrence of this practice in the 24 h preceding the interview. Postpartum depression was the explanatory variable of interest and the covariates were: socioeconomic and demographic conditions; maternal health care; prenatal, delivery, and postnatal care; and the child's biological factors. Multivariate logistic regression analysis was conducted to control for possible confounding factors. Results: Exclusive breastfeeding was observed in 50.8% of the infants and 11.8% of women had symptoms of postpartum depression. In the multivariate logistic regression analysis, a higher chance of exclusive breastfeeding absence was found among mothers with symptoms of postpartum depression (OR = 1.67; p < 0.001), among younger subjects (OR = 1.89; p < 0.001), those who reported receiving benefits from the Bolsa Família Program (OR = 1.25; p = 0.016), and those started antenatal care later during pregnancy (OR = 2.14; p = 0.032). Conclusions: Postpartum depression contributed to reducing the practice of exclusive breastfeeding. Therefore, this disorder should be included in the prenatal and early postpartum support guidelines for breastfeeding, especially in low socioeconomic status women.

Resumo Objetivo: Verificar a associação entre a depressão pós-parto e a ocorrência do aleitamento materno exclusivo. Método: Estudo de corte transversal feito nos estados da Região Nordeste, durante a campanha de vacinação de 2010. A amostra consistiu de 2.583 binômios mães-crianças entre 15 dias e três meses. Usou-se a Escala de Depressão Pós-Parto de Edimburgo para rastrear a depressão pós-parto. O desfecho consistiu da ausência de aleitamento materno exclusivo nas 24 horas que antecederam a entrevista. A depressão pós-parto foi variável explanatória de interesse e as covariáveis foram: condições socioeconômicas e demográficas, assistência pré-natal, ao parto e pós-natal e fatores da criança. Fez-se análise de regressão logística multivariada com o objetivo de controlar possíveis fatores de confusão. Resultados: A amamentação exclusiva foi observada em 50,8% das crianças e 11,8% das mulheres apresentaram sintomatologia indicativa de depressão pós-parto. Na análise de regressão logística multivariada foi verificada uma maior chance de ausência do aleitamento materno exclusivo entre as mães com sintomas de depressão pós-parto (OR = 1,67; p < 0,001). Conclusões: A depressão pós-parto contribuiu para redução da prática do aleitamento materno exclusivo. Assim, esse transtorno deveria ser incluído nas orientações de apoio desde o pré-natal e nos primeiros meses pós-parto, especialmente em mulheres de baixo nível socioeconômico.

The impact of migration on women's mental health in the postpartum period / O impacto da migração na saúde mental das mulheres no pós-parto

ABSTRACT OBJECTIVE To assess the influence of I mmigration on the psychological health of women after childbirth. METHODS In this cross-sectional study, immigrant and Portuguese-native women delivering in the four public hospitals of the metropolitan area of Porto, Portugal, were contacted by telephone between February and December 2012 during the first postpartum month to schedule a home visit and fill in a questionnaire. Most immigrant (76.1%) and Portuguese mothers (80.0%) agreed to participate and with the visits, thus a total of 89 immigrants and 188 Portuguese women were included in the study. The questionnaire included the application of four validated scales: Mental Health Inventory-5, Edinburgh Postpartum Depression Scale, Perceived Stress Scale, and Scale of Satisfaction with Social Support. Statistical analysis included t-test and Chi-square or Fisher's test, and logistic regression models. RESULTS Immigrants had an increased risk of postpartum depression (OR = 6.444, 95%CI 1.858-22.344), and of low satisfaction with social support (OR = 6.118, 95%CI 1.991-18.798). We did not perceive any associations between migrant state, perceived stress, and impoverished mental health. CONCLUSIONS Immigrant mothers have increased vulnerabilities in the postpartum period, resulting in an increased risk of postpartum depression and lesser satisfaction with the received social support.

RESUMO OBJETIVO Avaliar a influência da imigração na saúde psicológica da mulher após o parto. MÉTODOS Neste estudo transversal, mulheres imigrantes e portuguesas com partos nos quatro hospitais públicos da região metropolitana de Porto, Portugal, foram contatadas por telefone entre fevereiro e dezembro de 2012, durante o primeiro mês pós-parto, para agendar uma visita domiciliar e preencher um questionário. A maioria das mães imigrantes (76,1%) e das mães portuguesas (80,0%) aceitou participar e aceder a visitas domiciliares, totalizando 89 imigrantes e 188 mulheres portuguesas incluídas no estudo. O questionário incluiu a aplicação de quatro escalas validadas: Inventário de Saúde Mental-5, Escala de Depressão Pós-parto de Edimburgo, Escala de Stress Percebido e Escala de Satisfação com o Suporte Social. As análises estatísticas incluíram os testes t-student, Qui-quadrado ou teste de Fisher e o cálculo de modelos de regressão logística. RESULTADOS As imigrantes tiveram risco aumentado de depressão pós-parto (OR 6,444; IC95% 1,858-22,344) e de baixa satisfação com o suporte social (OR = 6,118; IC95% 1,991-18,798). Não houve associação entre migração, stress percebido e saúde mental empobrecida. CONCLUSÕES Mães imigrantes apresentam vulnerabilidades aumentadas no período pós-parto, aumentando o risco de depressão pós-parto e havendo menor satisfação com o apoio social recebido.

Is positive affect in pregnancy protective of postpartum depression?

OBJECTIVE: To investigate the predictive/protective role of negative affect/positive affect in late pregnancy on the outcome of postpartum depression. METHODS: A total of 491 pregnant women participated in the study. The participants were asked to fill out a series of questionnaires, which included the Profile of Mood States, the Beck Depression Inventory-II, psychosocial variables and socio-demographic characteristics and were asked to participate in a psychiatric interview. After delivery, 272 mothers participated again in the study and filled out a similar series of questionnaires. RESULTS: Negative affect was associated with more intense depressive symptomatology, more self-perceived stress, lower self-reported social support, lower quality of life and perception of having a more difficult infant. By contrast, positive affect was negatively associated with these variables. Negative affect in late pregnancy increased the likelihood of experiencing postpartum depression (DSM-IV/OR = 2.1, 95%CI = 1.3-3.4, p = .003; ICD-10/OR = 2.1, 95%CI = 1.5-3.0, p < .001), while positive affect increased the odds of not having this condition (DSM-IV/OR = 2.0, 95%CI = 1.5-2.7, p = .042). CONCLUSION: In pregnancy, negative affect was a predictor of postpartum depression, whereas positive affect showed a protective role. Future studies are required to explore whether psychotherapeutic strategies focusing on decreasing negative affect and enhancing positive affect in the last trimester of pregnancy can reduce the risk of postpartum depression.

Prevalence of suicide risk and comorbidities in postpartum women in Pelotas / Prevalência do risco de suicídio e de comorbidades em mulheres pós-parto em Pelotas

OBJECTIVES: To evaluate the prevalence of suicide risk and comorbidities in postpartum women. METHODS: This is a cross-sectional study of postpartum women. The sample comprised mothers who have received prenatal care from the Brazilian National System of Public Heath in the city of Pelotas. Suicide risk and other mental disorders were evaluated using the Mini International Neuropsychiatric Interview (MINI). A yes answer on one of the six interview questions was considered a sign of suicide risk. RESULTS: The sample consisted of 919 postpartum women. The 11.5% suicide prevalence was 4.62 (CI 2.45, 8.73) times higher in women with low educational levels. Women with comorbid depression or an anxiety disorder showed a 17.04 (CI 2.27; 19.96) times greater risk of suicide than those who did not suffer from any mood disorder. CONCLUSION: Lower education levels and psychiatric disorders are associated with suicide risk. Bipolar disorder is the psychiatric disorder with the highest impact on suicide risk.

OBJETIVOS: Avaliar a prevalência do risco de suicídio e de comorbidades em mulheres pós-parto. MÉTODOS: Este foi um estudo em corte transversal com mulheres pós-parto. A amostra foi constituída de mães que receberam cuidados pré-natais prestados pelo Sistema Nacional de Saúde Pública do Brasil na cidade de Pelotas. O risco de suicídio e outros transtornos mentais foram avaliados pela Mini International Neuropsychiatric Interview (MINI). Uma resposta afirmativa a qualquer das seis perguntas é considerada um risco de suicídio. RESULTADOS: A amostra consistiu de 919 mulheres pós-parto. A prevalência do risco de suicídio foi de 11,5%. Ela foi 4,62 vezes mais alta (IC de 95% 2,45; 8,73) em mulheres de baixo nível educacional. Mulheres apresentando qualquer comorbidade para depressão e transtornos ansiosos tiveram uma chance 17,04 vezes maior (IC 95% 2,27; 19,96) àquelas que não apresentaram nenhum transtorno afetivo. CONCLUSÃO: Um nível educacional mais baixo e a presença de um transtorno psiquiátrico se associam ao risco de suicídio. O transtorno bipolar é o diagnóstico psiquiátrico com maior impacto sobre o risco de suicídio.

Sociodemographic risk factors of perinatal depression: a cohort study in the public health care system / Fatores sociodemográficos de risco de depressão perinatal: um estudo populacional no sistema público de cuidados de saúde

OBJECTIVE: To assess the sociodemographic risk factors for the prevalence and incidence of relevant postpartum depressive symptoms. METHOD: We studied a cohort of women in their perinatal period with the assistance of the public health system in the city of Pelotas-RS, Brazil. We assessed depressive symptoms with the Edinburgh Postnatal Depression Scale (EPDS) in the prenatal and postnatal periods. RESULTS We interviewed 1,109 women. The prevalence of meaningful depressive symptoms during pregnancy was 20.5% and postpartum was 16.5%. Women with prenatal depression were at higher risk for postpartum depression. CONCLUSION: The mother's poverty level, psychiatric history, partner absence and stressful life events should be considered important risk factors for relevant postpartum depressive symptoms.

OBJETIVO: Avaliar os fatores sociodemográficos de risco quanto à prevalência e à incidência de sintomas depressivos pós-parto relevantes. MÉTODO: Estudou-se um grupo de mulheres em seu período perinatal sendo assistidas pelo sistema público de saúde na cidade de Pelotas, RS, Brasil. Foram avaliados os sintomas depressivos com o uso da Edinburgh Postnatal Depression Scale (EDPS) nos períodos pré-natal e pós-natal. RESULTADOS: Foram entrevistadas 1.019 mulheres. A prevalência de sintomas depressivos significativos durante a gravidez foi de 20,5% e no período pós-parto de 16,5%. As mulheres com depressão pré-natal apresentaram um risco maior de depressão pós-parto. CONCLUSÃO: O nível de pobreza, a história psiquiátrica, a ausência do parceiro e eventos vitais estressantes devem ser considerados fatores de risco importantes para sintomas depressivos pós-parto relevantes.

Factores de riesgo asociados a síntomas depresivos post parto en mujeres de bajo riesgo obstétrico atendidas en el sistema público / Risk factors for post partum depression

Background: Postpartum depression (PPD) is a public health problem with high prevalence in Chile. Many factors are associated with PPD. Aim: To analyze the factors associated with the incidence of depressive symptoms (SD) in women with low obstetric risk. Material and Methods: Cross-sectional analytical study on a sample of 105 postpartum women with low obstetric risk assessed by the Edinburgh Depression Scale at the eighth week postpartum. Results: A 37% prevalence of depressive symptoms was found. Univariate analysis showed that the perception of family functioning, overcrowding and number of siblings, were significantly associated with postpartum depressive symptoms. A multiple regression model only accepted family functioning as a predictor of depression. Conclusions: Perception of family functioning was the only variable that explained in part the presence of depressive symptoms in women with low obstetric risk.

Caracterización de madres deprimidas en el posparto / Characterization of depressed mothers in the postpartum

Background: Postpartum depression (PPD) is a mood disorder that occurs during a specific period of women's lifetime: puerperium. The prevalence of PPD ranges from 8 percent to 30 percent, and a three-fold increase is seen in emerging as compared to developed countries. Aim: To characterize women consulting in primary care facilities for PPD. Material and Methods: Social and demographic features, obstetrical history, clinical symptoms and puerperal care of 440 postpartum women that sought help in primary care and were diagnosed as depressed, are described. Results: These women had no paid employment (82.7 percent), had unplanned pregnancies (62.5 percent) and lacked adequate social support (59.4 percent). From the clinical viewpoint, most of these puerperal women had a family history of depression (64.2 percent) and 31 percent had suffered from previous depressive episodes. The clinical symptoms of these patients consisted of depressed mood (93.2 percent), anhedonia (87.9 percent) and fatigue (87 percent). Conclusions: Women depressed postpartum form a group that requires more clinical attention due to its great biological vulnerability, active depressive symptoms, and enormous psychosocial risk. The mother and child program, which benefits them, needs to be combined with a mental health component that can offer them a treatment adapted to their psychosocial context.

Prevalencia y factores de riesgo asociados a la depresión posparto en puérperas de un Centro de Atención Primaria en el Sur de Chile / Prevalence and risk factors associated with postpartum depression in puerperal women consulting in primary care

Background: Mood disorders are common in Chile. Among these, post partum depression (PPD) deranges the maternal and family relationships. Aim: To determine the prevalence and risk factors associated with PPD in puerperal women in Temuco, Chile. Material and methods: The Edinburgh Postnatal Depression Scale was administered to 73 puerperal women aged 15 to 32 years, between 40 to 45 days after delivery. To detect risk factors, 20 women with and 20 women without post partum depression (PPD) were interviewed and their clinical records were reviewed to assess their perinatal care. Results: The prevalence of PPD in the whole sample was 50.7 percent. The individual psychological risk factors detected were a feeling of discomfort with their body after giving birth, a personal history of mental health problems and a high level of overload associated to child care. An individual physical risk factor was alcohol consumption during pregnancy. Family risk factors were a poor relationship with the father of the child during pregnancy, a history of mental health problems in close family members, a history of family violence and a poor realtionship with parents during puerpurium. Having more children was a sociodemographic risk factor. Conclusions: Pospartum depression is common. The characterization of risk factors should lead to the implementation of preventive strategies.