ORIGINAL ARTICLE
Mental health trajectories and related factors among perinatal women Pei-Chao Lin and Chich-Hsiu Hung
Aims and objectives. To investigate Taiwanese women’s mental health trajectories from the third trimester of pregnancy to four weeks postpartum and the correlations of these trajectories with perceived social support and demographic characteristics. Background. Previous studies have reported differences between prenatal and postpartum mental health status. Design. A repeated design study was conducted in a medical hospital in Southern Taiwan. Methods. One-hundred and ninety-four Taiwanese women completed the Chinese Health Questionnaire and Social Support Scale at the 36th prenatal week and first and fourth week postpartum. Results. Three linear mental health trajectories for perinatal women were identified. Consistently poor perinatal mental health was reported by 160% of the participants. Less social support was associated with lower prenatal mental health scores. Younger age was a risk factor for consistently poor perinatal health. Vaginal delivery was associated with improved mental health after childbirth. Conclusions. Mental health was worse in the third trimester of pregnancy than postpartum. Less social support was associated with lower prenatal mental health scores, and this association was similarly distributed between women with consistently poor and improved mental health after birth. Relevance to clinical practice. Health care providers should assess women’s mental health status and provide timely interventions during the perinatal period. Social support should be provided for pregnant women, especially younger women or those with lower perceived social support.
What does this paper contribute to the wider global clinical community?
• The findings of this study indi-
•
cate that some women experience minor psychiatric morbidity during the perinatal period, and provide a preliminary understanding of mental health trajectories among perinatal women. Women with younger age and lower perceived social support were more likely to report consistently poor perinatal mental health.
Key words: mental health, perinatal, trajectory, women Accepted for publication: 3 December 2014
Introduction Perinatal mental health has become a global public health issue (Austin et al. 2012). Studies have found that 11–19% of women experience anxiety or depression during the Authors: Pei-Chao Lin, MSN, RN, Doctoral Candidate, School of Nursing, Kaohsiung Medical University, Kaohsiung; Chich-Hsiu Hung, PhD, RN, Professor, School of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1585–1593, doi: 10.1111/jocn.12759
perinatal period (Goedhart et al. 2010). Maternal mental health, including perinatal anxiety and depression, adversely affects women’s health and infant development (Ross et al. 2011), involving preterm birth, low birth weight, low Apgar score and child loss (Goedhart et al. Correspondence: Chich-Hsiu Hung, Professor, School of Nursing, Kaohsiung Medical University No. 100, Shih-Chuan 1st Rd., Kaohsiung City 80708, Taiwan. Telephone: +886 (7)3121101 ext. 2601. E-mail: [email protected]
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P-C Lin and C-H Hung
2010), as well as hampered cognitive and socio-emotional infant development (Kingston et al. 2012). Austin et al. (2012) have recently suggested that mental health status and detection of potential problems should be assessed early in pregnancy, and accordingly, adequate intervention should be provided for women during the perinatal period.
Background Previous studies regarding mental health among perinatal women have focused mainly on the prevalence of depression (Roomruangwong & Epperson 2010). However, it is too late to diagnose women with depression or other mental health issues late in the perinatal period. From the perspective of primary prevention in public health, the nursing practice should be more actively concerned with providing early intervention to women with potential mental health problems (Austin et al. 2012). Studies have examined women’s mental health status in the second and third trimesters of pregnancy and postpartum (Su et al. 2007, Witt et al. 2011). In addition, researchers found that over 50% of women with postpartum mental health problems previously demonstrated poor prenatal mental health (Witt et al. 2011) and that the vast majority (907%) of women without postpartum mental health problems had no history of prenatal mental health problems (Witt et al. 2011). Zelkowitz et al. (2008) also found that prenatal depression was an important predictor of postpartum depression. Thus, compared with postpartum mental health, women’s prenatal mental health status in the third trimester of pregnancy should be more carefully assessed by health care providers. Mental health status is associated with social support among perinatal women (Golbasi et al. 2010). Women with prenatal depression may experience lack of social support, especially support from their husbands (Tseng et al. 2008). Sawyer et al. (2010) also concluded that lack of social support during the postnatal period was closely associated with poor mental health. Besides social support, studies have also found that demographic characteristics may contribute to explaining the mental health status among perinatal women. Previous studies have yielded inconsistent findings on the correlation between age and perinatal mental health. Golbasi et al. (2010) reported a significant positive correlation between depression level and maternal age. However, a longitudinal study by Lau (2011) revealed that women 25 years old or younger had higher depression levels than older women in the third trimester. Westdahl et al. (2007) also reported a negative association between age and perinatal depression.
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Furthermore, women experiencing economic adversity are more likely to present with perinatal mental health problems than those not experiencing economic adversity (Prady et al. 2013). Women not currently working or enrolled as full-time students had a higher prevalence of perinatal mental health problems than those working fulltime or part-time (Prady et al. 2013). Women with lower education levels were also more likely to experience perinatal mental health problems than those receiving higher education (Prady et al. 2013). Buddhism is the dominant religion in Taiwan and other Asian countries. Limlomwongse and Liabsuetrakul (2006) further demonstrated that non-Buddhist Thai women were at increased risk for postpartum depression compared with Buddhist women. Undergoing a caesarean section has also been associated with increased risk for postpartum depression compared with undergoing vaginal delivery (Barbadoro et al. 2012). Because mental health is dynamic, perinatal mental health should be examined longitudinally from the prenatal to postpartum period. Health care providers should have knowledge of the factors associated with the perinatal mental health trajectory before offering an effective intervention; however, few studies have explored such factors. Thus, the purpose of the present study was to explore the trajectories of change in mental health from the third trimester of pregnancy to four weeks postpartum among Taiwanese women, and to investigate the correlations of different trajectories with women’s perceived social support and demographic characteristics. Previous studies have reported differences between prenatal and postpartum mental health status and found that the prenatal mental health status may be a predictor of postpartum mental health status (Witt et al. 2011). Therefore, the current study hypothesised that perinatal women present with distinct patterns of change in mental health over time.
Methods Design and participants A prospective and repeated-measure study was conducted over a three-year study period. A least 10 participants per independent variable is required for logistic regression (Hosmer & Lemeshow 2000). For preferred participantto-variable ratios, we adopted 20 to 1 for multinomial logistic regression. Thus, the minimum number of participants was 140 based on the ratio of seven independent variables. A total of 217 pregnant women with a © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1585–1593
Original article
gestational age of
Mental health trajectories and related factors among perinatal women Pei-Chao Lin and Chich-Hsiu Hung
Aims and objectives. To investigate Taiwanese women’s mental health trajectories from the third trimester of pregnancy to four weeks postpartum and the correlations of these trajectories with perceived social support and demographic characteristics. Background. Previous studies have reported differences between prenatal and postpartum mental health status. Design. A repeated design study was conducted in a medical hospital in Southern Taiwan. Methods. One-hundred and ninety-four Taiwanese women completed the Chinese Health Questionnaire and Social Support Scale at the 36th prenatal week and first and fourth week postpartum. Results. Three linear mental health trajectories for perinatal women were identified. Consistently poor perinatal mental health was reported by 160% of the participants. Less social support was associated with lower prenatal mental health scores. Younger age was a risk factor for consistently poor perinatal health. Vaginal delivery was associated with improved mental health after childbirth. Conclusions. Mental health was worse in the third trimester of pregnancy than postpartum. Less social support was associated with lower prenatal mental health scores, and this association was similarly distributed between women with consistently poor and improved mental health after birth. Relevance to clinical practice. Health care providers should assess women’s mental health status and provide timely interventions during the perinatal period. Social support should be provided for pregnant women, especially younger women or those with lower perceived social support.
What does this paper contribute to the wider global clinical community?
• The findings of this study indi-
•
cate that some women experience minor psychiatric morbidity during the perinatal period, and provide a preliminary understanding of mental health trajectories among perinatal women. Women with younger age and lower perceived social support were more likely to report consistently poor perinatal mental health.
Key words: mental health, perinatal, trajectory, women Accepted for publication: 3 December 2014
Introduction Perinatal mental health has become a global public health issue (Austin et al. 2012). Studies have found that 11–19% of women experience anxiety or depression during the Authors: Pei-Chao Lin, MSN, RN, Doctoral Candidate, School of Nursing, Kaohsiung Medical University, Kaohsiung; Chich-Hsiu Hung, PhD, RN, Professor, School of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1585–1593, doi: 10.1111/jocn.12759
perinatal period (Goedhart et al. 2010). Maternal mental health, including perinatal anxiety and depression, adversely affects women’s health and infant development (Ross et al. 2011), involving preterm birth, low birth weight, low Apgar score and child loss (Goedhart et al. Correspondence: Chich-Hsiu Hung, Professor, School of Nursing, Kaohsiung Medical University No. 100, Shih-Chuan 1st Rd., Kaohsiung City 80708, Taiwan. Telephone: +886 (7)3121101 ext. 2601. E-mail: [email protected]
1585
P-C Lin and C-H Hung
2010), as well as hampered cognitive and socio-emotional infant development (Kingston et al. 2012). Austin et al. (2012) have recently suggested that mental health status and detection of potential problems should be assessed early in pregnancy, and accordingly, adequate intervention should be provided for women during the perinatal period.
Background Previous studies regarding mental health among perinatal women have focused mainly on the prevalence of depression (Roomruangwong & Epperson 2010). However, it is too late to diagnose women with depression or other mental health issues late in the perinatal period. From the perspective of primary prevention in public health, the nursing practice should be more actively concerned with providing early intervention to women with potential mental health problems (Austin et al. 2012). Studies have examined women’s mental health status in the second and third trimesters of pregnancy and postpartum (Su et al. 2007, Witt et al. 2011). In addition, researchers found that over 50% of women with postpartum mental health problems previously demonstrated poor prenatal mental health (Witt et al. 2011) and that the vast majority (907%) of women without postpartum mental health problems had no history of prenatal mental health problems (Witt et al. 2011). Zelkowitz et al. (2008) also found that prenatal depression was an important predictor of postpartum depression. Thus, compared with postpartum mental health, women’s prenatal mental health status in the third trimester of pregnancy should be more carefully assessed by health care providers. Mental health status is associated with social support among perinatal women (Golbasi et al. 2010). Women with prenatal depression may experience lack of social support, especially support from their husbands (Tseng et al. 2008). Sawyer et al. (2010) also concluded that lack of social support during the postnatal period was closely associated with poor mental health. Besides social support, studies have also found that demographic characteristics may contribute to explaining the mental health status among perinatal women. Previous studies have yielded inconsistent findings on the correlation between age and perinatal mental health. Golbasi et al. (2010) reported a significant positive correlation between depression level and maternal age. However, a longitudinal study by Lau (2011) revealed that women 25 years old or younger had higher depression levels than older women in the third trimester. Westdahl et al. (2007) also reported a negative association between age and perinatal depression.
1586
Furthermore, women experiencing economic adversity are more likely to present with perinatal mental health problems than those not experiencing economic adversity (Prady et al. 2013). Women not currently working or enrolled as full-time students had a higher prevalence of perinatal mental health problems than those working fulltime or part-time (Prady et al. 2013). Women with lower education levels were also more likely to experience perinatal mental health problems than those receiving higher education (Prady et al. 2013). Buddhism is the dominant religion in Taiwan and other Asian countries. Limlomwongse and Liabsuetrakul (2006) further demonstrated that non-Buddhist Thai women were at increased risk for postpartum depression compared with Buddhist women. Undergoing a caesarean section has also been associated with increased risk for postpartum depression compared with undergoing vaginal delivery (Barbadoro et al. 2012). Because mental health is dynamic, perinatal mental health should be examined longitudinally from the prenatal to postpartum period. Health care providers should have knowledge of the factors associated with the perinatal mental health trajectory before offering an effective intervention; however, few studies have explored such factors. Thus, the purpose of the present study was to explore the trajectories of change in mental health from the third trimester of pregnancy to four weeks postpartum among Taiwanese women, and to investigate the correlations of different trajectories with women’s perceived social support and demographic characteristics. Previous studies have reported differences between prenatal and postpartum mental health status and found that the prenatal mental health status may be a predictor of postpartum mental health status (Witt et al. 2011). Therefore, the current study hypothesised that perinatal women present with distinct patterns of change in mental health over time.
Methods Design and participants A prospective and repeated-measure study was conducted over a three-year study period. A least 10 participants per independent variable is required for logistic regression (Hosmer & Lemeshow 2000). For preferred participantto-variable ratios, we adopted 20 to 1 for multinomial logistic regression. Thus, the minimum number of participants was 140 based on the ratio of seven independent variables. A total of 217 pregnant women with a © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 1585–1593
Original article
gestational age of
