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THE INTERFACE OF MENTAL AND EMOTIONAL HEALTH AND PREGNANCY IN URBAN INDIGENOUS WOMEN: RESEARCH IN PROGRESS BARBARA A. HAYES, ALISTAIR CAMPBELL, BERYL BUCKBY, LYNORE K. GEIA, AND MARGARET E. EGAN
James Cook University, Townsville, Australia Research among indigenous women in Australia has shown that a number of lifestyle factors are associated with poor obstetric outcomes; however, little evidence appears in the literature about the role of social stressors and mental health among indigenous women. The not-for-profit organization beyondblue established a “Depression Initiative” in Australia. As part of this they provided funding to the Townsville Aboriginal and Torres Strait Islander Health Service in the “Mums and Babies” clinic. The aim of this was to establish a project to (a) describe the mental health and level of social stressors among antenatal indigenous women and (b) assess the impact of social stressors and mental health on perinatal outcome. A purposive sample of 92 indigenous women was carried out. Culturally appropriate research instruments were developed through consultations with indigenous women’s reference groups. The participants reported a range of psychosocial stressors during the pregnancy or within the last 12 months. Significant, positive correlations emerged between the participants’ Edinburgh Postnatal Depression Scale (EPDS; J. Cox, J. Holden, & R. Sagovsky, 1987) score and the mothers’ history of child abuse and a history of exposure to domestic violence. A more conservative cutoff point for the EPDS (>9 vs. >12) led to 28 versus 17% of women being identified as “at risk” for depression. Maternal depression and stress during pregnancy and early parenthood are now recognized as having multiple negative sequelae for the fetus and infant, especially in early brain development and self-regulation of stress and emotions. Because of the cumulative cultural losses experienced by Australian indigenous women, there is a reduced buffer to psychosocial stressors during pregnancy; thus, it is important for health professionals to monitor the women’s emotional and mental well-being. ABSTRACT:
La investigaci´on llevada a cabo con mujeres ind´ıgenas en Australia ha demostrado que un n´umero de factores de estilo de vida est´an asociados con pobres resultados obst´etricos. Sin embargo, poca evidencia aparece en la literatura acerca del papel de los factores sociales de estr´es y la salud mental entre las mujeres ind´ıgenas. La organizaci´on sin fines lucrativos “beyondblue” estableci´o en Australia una
RESUMEN:
We acknowledge the beyondblue National Postnatal Depression Program as the source of funding; the Board and staff members of the Townsville Aboriginal and Islander Health Service (TAIHS); and Claudinia Daley as Aboriginal Research Assistant at TAIHS. We thank Dr. Kathryn Panaretto, Melvina Mitchell, and the TAIHS for their valuable contributions to this project. Direct correspondence to: Barbara A. Hayes, School of Nursing Sciences, James Cook University, Townsville, Australia; e-mail: [email protected]. INFANT MENTAL HEALTH JOURNAL, Vol. 31(3), 277–290 (2010) C 2010 Michigan Association for Infant Mental Health Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/imhj.20256
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“Iniciativa para la Depresi´on.” Como parte de tal iniciativa, la organizaci´on provey´o los fondos para el Servicio de Salud Townsville Aboriginal and Torres Strait Islander (TAIHS) en la cl´ınica para “Mam´as y Beb´es.” El prop´osito de la iniciativa fue de establecer un proyecto para (a) describir la salud mental y el nivel de factores sociales de estr´es entre mujeres ind´ıgenas antes de dar a luz y (b) evaluar el impacto de los factores sociales de estr´es y la salud mental sobre el resultado perinatal. El grupo muestra ‘a prop´osito’ de 92 mujeres ind´ıgenas fue puesto en pr´actica. Se desarrollaron instrumentos de investigaci´on culturalmente apropiados en consulta con los Grupos de Referencia de las Mujeres Ind´ıgenas. Las participantes reportaron un n´umero de factores sociales de estr´es durante el embarazo o dentro de los u´ ltimos 12 meses. Surgieron correlaciones significativas y positivas entre los puntajes de EPDS de las participantes y la historia de abuso infantil de las madres, as´ı como la historia de haber estado espuestas a la violencia dom´estica. Una m´as conservadora l´ınea l´ımite para los puntajes de EPDS (>9 vs >12) dio como resultado que un 28% vs 17% de las mujeres fueran identificadas ‘bajo riesgo’ de depresi´on. Se reconoce ahora que la depresi´on materna y el estr´es durante el embarazo y el principio de la crianza tienen secuelas negativas m´ultiples para el feto y para el infante, especialmente en la primera etapa de desarrollo del cerebro y la autorregulaci´on del estr´es y las emociones. A causa de las p´erdidas culturales acumuladas experimentadas por mujeres australianas ind´ıgenas, se produce un amortiguador para los factores sicol´ogicos de estr´es durante el embarazo, y por tanto es importante para los profesionales de la salud mantener en observaci´on el bienestar emocional y mental de las mujeres. ´ ´ RESUM E:
Les recherches chez les femmes aborig`enes d’Australie ont montr´e qu’un certain nombre de facteurs de style de vie sont li´es a` de faibles r´esultats obst´etriques. Cependant, on trouve peu de d’´evidence dans les recherches sur le rˆole de facteurs de stress sociaux et en mati`ere de sant´e mentale chez les femmes aborig`enes. L’organisation sans profit «audel`aducafard a e´ tabli une “Initiative de D´epression” en Australie. Entre autres, parmi leurs projets, cette organisation a donn´e des fonds pour le Service de Sant´e Aborig`ene de Townsville et de Torres Strait Islander dans la clinique “Mamans et B´eb´es.” Le but e´ tait d’´etablir un projet pour (a) d´ecrire la sant´e mentale et le niveau de stresseurs sociaux chez les femmes aborig`enes avant la naissance et (b) e´ valuer l’impact des stresseurs sociaux et de la sant´e mentale sur le r´esultat p´erinatal. 92 femmes aborig`enes ont e´ t´e s´electionn´ees pour l’´etude. Des intruments de recherche appropri´es a` la culture ont e´ t´e d´evelopp´e a` travers des consultations avec les Groupes de R´ef´erences des Femmes Aborig`enes. Les participantes ont fait e´ tat d’un e´ ventail de facteurs de stress psychosocial durant la grossesse ou durant les 12 derniers mois. Les liens importants et positifs ont e´ merg´e entre les scores EPDS des participantes et le pass´e de maltraitance en tant qu’enfant des m`eres et un pass´e d’exposition a` la violence conjugale. Un point de d´elimitation pour l’EPDS plus conservateur (>9 compar´e a` >12) a conduit a` 28% compar´e a` 17% de femmes e´ tant identifi´ees comme e´ tant “`a risque” de d´epression. La d´epression maternelle et le stress maternel durant la grossesse et le parentage pr´ecoce sont maintenant reconnus comme ayant de multiples s´equelles n´egatives pour le foetus et le nourrisson surtout pour ce qui concerne le d´eveloppement pr´ecoce du cerveau et l’auto-r´egulation du stress et des e´ motions. A cause des pertes cumulatives culturelles dont ont fait l’exp´erience les femmes aborig`enes il existe un tampon r´eduit aux facteurs de stress psychosociaux durant la grossesse, et donc il est important que les professionnels de la sant´e surveillent le bien-ˆetre e´ motionnel et mental des femmes. ZUSAMMENFASSUNG: Die Forschung u¨ ber Aboriginesfrauen in Australien zeigt, dass Faktoren des Lebensstils in Zusammenhang mit ung¨unstigen Geburtssituationen stehen. Trotzdem gibt es in der Literatur wenig Belege u¨ ber die Rolle von sozialen Stressoren und psychischer Gesundheit von Aboriginesfrauen. Eine bewusst gew¨ahlt Gruppe von 92 Aboriginesfrauen wurde ausgew¨ahlt. Kulturell abgestimmte Forschungsinstrumente wurden gemeinsam mit Bezugsgruppen von Aboriginesfrauen entwickelt. Die Teilnehmerinnen berichteten eine F¨ulle von psychosozialen Stressoren w¨ahrend der Schwangerschaft oder
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innerhalb der letzen 12 Monate. Signifikant positive Zusammenh¨ange zeigten sich zwischen EPDS Werten der Teilnehmerinnen und Kindesmisshandlungen der in der Geschichte der M¨utter sowie dem Ausgeliefert sein von h¨auslicher Gewalt. Eine zur¨uckhaltendere Bewertung von EPDS (>9 vs >12) zeigte 28% vs 17% der Frauen als “gef¨ahrdet f¨ur eine Depression. M¨utterliche Depression, Stress in der Schwangerschaft und jugendliche M¨utter wurden als Hinweise f¨ur multiple negative Sp¨atfolgen f¨ur den F¨otus und das Kleinkind speziell in der fr¨uhen Gehirnentwicklung und Selbstregulation von Stress und Emotionen identifiziert. Da Aborigiesfrauen einen massiven Werteverlust erlebt haben, haben sie weniger Puffer f¨ur psychosoziale Stressoren in der Schwangerschaft und demnach ist es f¨ur s¨amtliches Gesundheitspersonal wichtig, die Emotionen und das psychische Wohlbefinden mit zu ber¨ucksichtigen.
* * * Births to women of Aboriginal or Torres Strait Islander descent represent about 3% of confinements in Australia each year, with Queensland having the highest number of indigenous births among the Australian states (Laws & Sullivan, 2005; Queensland Council on Obstetric and Paediatric Morbidity and Mortality, 2005). The poor health of the indigenous community in Australia is well documented and is reflected in demoralizing indigenous perinatal statistics with rates of preterm birth, low birth weight, and perinatal mortality remaining more than twice that of the nonindigenous population over the past decade (Laws & Sullivan, 2005; Panaretto, Muller, Patole, Watson, & Whitehall, 2002; Queensland Council on Obstetric and Paediatric Morbidity and Mortality, 2005). Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
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Preterm birth continues to be comprehensively investigated with predictors including previous preterm birth, ethnicity, infection, and socioeconomic status (Main, 1988; Moutquin, 2003). Evidence for psychosocial stress is less well documented, but research has suggested that stressful events relating to family illness, disruption, violence, and financial distress may be related to an increased likelihood of preterm birth (Moutquin, 2003). There also is a body of opinion that accumulation of psychosocial stress over years also may add to adverse pregnancy outcome (Hogue & Bremmer, 2005; Rich-Edwards & Grizzard, 2005). Previous research among indigenous women in Australia has shown that late antenatal attendance, maternal malnutrition, and high rates of tobacco and alcohol use were associated with poor obstetric outcome (de Costa & Child, 1996; Humphrey & Keating, 2004; Panaretto et al., 2002). However, there is little evidence about the impact of social stressors and mental health among indigenous women or, indeed, the best way to gather that data for this population. Internationally, screening of postnatal women for depression has received considerable attention in the literature. Using the most widely accepted postnatal depression screening tool, the Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden, & Sagovsky, 1987), 10 to 15% of women will experience postnatal depression (O’Hara & Swain, 1996) with similar rates in Australia (Astbury, Brown, Lumley, & Small, 1994; Dennerstein, Lehart, & Riphagen, 1989; Milgrom, Ericksen, Negri, & Gemmill, 2005). More recently, the focus of postnatal depression research has broadened to include antenatal depression (Austin & Lumley, 2003; Cooper, Murray, Hooper, & West, 1996; Posner, Unterman, Williams, & Williams, 1997), with the term perinatal depression now describing the depressive disorders associated with pregnancy and early parenthood. There is a general consensus emerging that antenatal depression is a significant problem and that further research is necessary to ascertain its exact incidence and impact (Hayes, Muller, & Bradley, 2001; Hayes & Muller, 2005). More recently, there has been considerable research focus on postnatal depression in developing countries. Studies have considered the incidence of postnatal depression in impoverished and rural communities (Cooper et al., 1999; Patel, Rodrigues, & DeSouza, 2002; Rahman, Iqbal, & Harrington, 2003), and there has been particular interest in the effect of maternal depression on infant development (Patel, DeSouza, & Rodrigues, 2003; Patel, Rahman, Jacob, & Hughes, 2004; Surkan et al., 2008; Tomlinson, Cooper, Stein, Swartz, & Molteno, 2006). Findings have been somewhat mixed, although there is evidence that postnatal depression may have a relationship with infant growth and failure to thrive. These and other studies also have found that the incidence of postnatal depression is related to a range of sociocultural factors including poverty, negative life events, relationship factors, and exposure to violence (Surkan et al., 2008); however, Halbreich and Karkun (2006), in a recent review of the cross-cultural evidence, noted that there is considerable variability in the rate of postnatal depression and associated factors. There has been very little research in relation to postnatal depression within minority indigenous, or “First Nation,” cultures. One U.S. study found a much higher incidence of postnatal depression in a sample of American Indian (Lumbee Tribe) women (23%) than that in other populations (Baker et al., 2005). In a New Zealand study of 206 European and Maori women, Webster, Thompson, Mitchell, and Werry (1994) found that there was an increased risk of postnatal depression among Maori women. Webster et al. also found that marital status and satisfaction with the relationship were significant predictors along with mother’s age at the birth of her first child. The beyondblue National Postnatal Depression Program was established in 2001 with the aim to evaluate antenatal and postnatal screening for women’s emotional and mental health, to Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
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facilitate the linking of all services involved in the care of perinatal women, and to increase community and health professional awareness of perinatal depression. In this context, when the Townsville Aboriginal and Islanders Health Service (TAIHS) was approached by the beyondblue team from James Cook University to participate in a research project exploring the use of the EPDS with indigenous women, it was seen as an opportunity to further enhance the antenatal care services (ANC) offered to women attending the “Mums and Babies” program at the TAIHS (Panaretto et al., 2005) and explore the relationship between psychosocial factors and pregnancy outcome in indigenous women. The evaluation of the project reported in this article had two aims: to describe the mental health and level of social stressors among indigenous women who attended the TAIHS for antenatal care and to assess the impact of social stressors and mental health on perinatal outcome. METHODS Setting
Townsville, the second largest city in Queensland, is 1,200 km north of Brisbane and the tertiary medical-referral center for North Queensland. The Townsville region has a large indigenous population: 16,875 (Australian Bureau of Statistics, 2001 Census), comprising 5.2% of the population, with 70% being of Aboriginal descent and 30% being of Torres Strait Islander descent. The TAIHS is a community-controlled Aboriginal Medical Service, with a 10-member elected board and over 100 staff members. The participants in this study were not primarily living a traditional Aboriginal life style, and many were located in urban communities. However, note that most Aboriginal families in Northern Australia retain links with their traditional communities and frequently return to “country” (i.e., traditional homelands) for family and ceremonial reasons (e.g., births, deaths, land disputes). Study Design
This was a prospective study involving women who attended the TAIHS for ANC with the Mums and Babies program, in the 18 months between September 1, 2003 and February 28, 2005. The intention initially was to invite all women presenting for ANC at the TAIHS to participate in the beyondblue project. Due to budget constraints, perinatal women who attended the “Mums and Babies” clinic 2 days a week (Tuesday, Thursday) were administered adapted versions of the beyondblue screening tools by a trained community worker: the mainstream EPDS, an EPDS modified for indigenous participants, and a psychosocial survey derived from the beyondblue project (Buist & Bilstza, 2005). The Maternal and Child Health team was notified by the interviewer of any woman whose EPDS screening score was higher than 12. The screening tool—the modified EPDS—and resource package were developed by the research team working with a community focus group (Campbell, Hayes, & Buckby, 2008). These resource materials were based on materials already in use in the beyondblue National Postnatal Depression project: the EPDS and a resource booklet entitled Emotional Care in Pregnancy and Early Parenthood. The EPDS was modified by adapting the language of the questions to select common language usage within the Townsville indigenous community as previously described (Hayes, Geia, & Egan, 2006). Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
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The process for the development of the TAIHS translation of the EPDS followed the National Health and Medical Research Council Guidelines for research with Australian indigenous people (National Health & Medical Research Council, 2003). Iterative consultation was undertaken with each community to form a site-specific reference group of Aboriginal and Torres Strait Islander women. At the TAIHS, the non-Aboriginal Medical Officer of the Mums and Babies unit also was a member of the reference group. The research data package, including revised wording of the EPDS, was developed by iterative consultations first through focus groups and then with indigenous women’s reference groups appointed through the focus groups at each site. The package consisted of the following site-specific, culturally acceptable materials: (a) an information sheet, (b) a consent form, (c) a translated EPDS, (d) a standard EPDS, (e) a demographic–psychosocial assessment form, and (f) a translated educational booklet. These materials were the promised benefit by the researchers to the community members for participating in the research. Consultation with Aboriginal and Torres Strait Islander Health Workers, community people, and all levels of Queensland Health Board or Aboriginal Management Board was conducted prior to the initial education seminars; the Reference Groups were then able to provide the authoritative input for development of site-specific screening packages. Specific education of Aboriginal and Torres Strait Islander Health Workers, and other indigenous women selected by each community, regarding early recognition and appropriate referral of perinatal women who experienced emotional and mental health issues was an essential component. The whole screening package was scrutinized by the current Governing Board of the TAIHS, who gave it full approval, and by senior staff at the Child Health Centre and Yapatjarra in Mt Isa. The Aboriginal and Torres Strait Islander version was not translated into other languages; although this task would itself be valuable, it was beyond the scope of the study. As the common language of the study population was English, the English words used were adapted to reflect common usage and implicit meaning of English in these communities, much like a local dialect. Superficially, it will seem that some of the items were not altered much, and most changes involved an alteration in specific words or simplification of sentence structures, but the women recognized their “own” translation when used in screening. Management
Standard antenatal shared-care protocols, which are based on those developed by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, were used. All women unsure of their dates were referred for dating ultrasound. All deliveries occurred at the Townsville Hospital unless a patient relocated. Standard best treatment protocols were followed for pregnancy and obstetric complications. Patients with “high-risk” or complicated pregnancies were referred to the Townsville Hospital, as appropriate, by the attending medical staff. Women with an EPDS greater than 12 were managed at the discretion of the Maternal and Child Health team. Mental health services and early family intervention services were available to assist in management of these women through the TAIHS and Community Child Health and Mental Health Services. Ethics Approval
The project and evaluation had the full support of the community-elected board of the TAIHS. The coordinator of the program is an Aboriginal Health worker trained in maternal and child Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
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health. The program is overseen by a reference group that meets monthly and includes a consumer representative. The beyondblue project was approved by the Townsville Health Service District Ethics Committee and by the Human Subjects Subcommittee of the Experimental Ethics Committee of James Cook University. All participating women were provided with both printed and verbal information before written consent to participate in the project was obtained.
Ethnicity
Staff asked all women presenting for ANC whether they and their partner identified as Aboriginal, Torres Strait Islander, both Aboriginal and Torres Strait Islander, or other identities. A baby was identified as indigenous if either parent identified as such, comprising 93% of all births to women receiving antenatal care at the TAIHS during the study period.
Data Collection
A comprehensive, confidential record of each pregnancy is recorded at the TAIHS in a secure database, including demographic data, the number and timing of antenatal visits made, the gestation of the first visit, the number and timing of ultrasounds performed, and data relating to the completion and results of “cycle of care” activities such as clinical screening, performance of care-planning activities, pregnancy complications, and pregnancy outcomes. Definitions used for explanatory variables and perinatal outcomes. Preterm birth was defined as less than 37 weeks’ completed gestation, and low birth weight as less than 2,500 g. Harmful/ hazardous alcohol use was defined as more than two standard drinks a day. Inadequate antenatal care was defined as three antenatal care visits or fewer, and late presentation for antenatal care as a first visit at 24 weeks’ gestation or later. An unwanted pregnancy was defined as any birth where the mother had discussed termination with the TAIHS antenatal care team. “At risk” of depression was defined as an EPDS score of 12 or higher. Data quality. Two hundred seventy-five singleton births occurred in the study period. Ninetysix women completed the screening tools; of these, 92 were indigenous births. Given that the screening occurred on 2 clinic days only, participation may have been as high as 84% (92 women of 110 available women). Overall, mothers had at least one ultrasound in 92% of the births, with 63% having had a dating scan. Birth weight data were not available for 5 women (5.4%) of the sample. Data analysis. Data were analyzed using Statistica 6.0 (StatSoft & Inc, 2001) and EpiCalc 2000 (Gilman & Myatt, 1998). Due to the number of participants and the nature of data collected, the main approach to analysis was univariate, using nonparametric statistics as appropriate. Stepwise multivariate regression analysis also was used to identify significant predictors of risk for depression. As there were missing data for the EPDS scores, particularly the antenatal score, the main data analysis was carried out using the postnatal data, with missing values imputed from the antenatal score where available. Prevalence odds ratios and 95% confidence intervals are reported; a two-tailed p value below 0.05 was considered significant. Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
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TABLE 1. Prevalence of Women “At Risk” of Depression Using Two EPDS Cut-Off Scores in Pregnant and Postnatal Aboriginal and Torres Strait Islander Women Attending TAIHS for Antenatal Care Between 2003 and 2005 and Were Screened for Depression Women Not At Risk EPDS Cut-Off Score EPDS > 9
EPDS > 12
Antenatal (n = 37) Postnatal (n = 64) Imputed PN (n = 92) Antenatal (n = 37) Postnatal (n = 64) Imputed PN (n = 92)
Women At Risk
n
%
95% CI
n
%
95% CI
21 45 66 23 55 76
56.7 70.3 71.7 62.2 85.9 82.6
(39.6, 72.5) (57.4, 80.7) (61.2, 80.4) (44.8, 77.1) (74.5, 93.0) (73.0, 89.4)
16 19 26 14 9 16
43.2 29.7 28.3 37.8 14.6 17.4
(27.5, 60.4) (19.2, 42.6) (19.6, 38.8) (22.9, 55.2) (7.0, 25.5) (10.6, 27.0)
RESULTS
The women in the study group were compared to 183 women who attended the TAIHS for ANC during the study period but who did not participate in the EPDS screening. There were no differences between these two groups on most of the study variables; however, significantly more women who did not complete an EPDS reported using alcohol (31.15 vs. 18.75%), χ 2 = 4.292, p = .026, and significantly more had fewer than four antenatal care visits (49.45 vs. 21.88%), χ 2 = 19.93, p = .001. Table 1 presents the distribution of women who were screened as “at risk” of depression using two separate cutoffs: EPDS >9 and EPDS >12 for both the antenatal and the postnatal data, respectively. As can be seen, the numbers completing the antenatal measures were quite low.1 With the more conservative cutoff, some 17% of women were identified as being at risk for depression. The less conservative cutoff led to 10 more women being identified, leading to a proportion of 28%. Mothers
Demographic, psychosocial, pregnancy characteristics, and pregnancy outcomes are shown in Table 2 for those participants who completed the EPDS screening. The average age of the participants was 24.3 years (youngest = 15.3 years; oldest = 43.3 years). Thirteen (18.0%) participants were under 20 years, and 5 (5.5%) were over 35 years. At their first antenatal care visit, over 50% reported tobacco use, nearly 25% alcohol use, 10% an unwanted pregnancy, and 15% domestic violence. Thirty-seven (41%) reported a major life event in the past 12 months. Of these, 14 (37%) reported a single event whereas 24 (63%) reported multiple events. Nine women (24%) reported a miscarriage, 16 (42%) reported a death or serious illness in the family, 16 (42%) reported family problems, 15 (39%) reported job loss or financial problems, and 34 (89%) reported problems relating to their partner, including separation, problems with the previous partner, or partner being in jail. Nineteen women (21%) reported a history of childhood abuse; of these, 5 (26%) 1 The antenatal data were used to impute missing values in the postnatal data, leading to the imputed values in Table 1. Data referred to from this point are the imputed data.
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TABLE 2. Prevalence of Demographic and Pregnancy Characteristics and EPDS Score > 9 in Pregnant Aboriginal and Torres Strait Islander Women Attending TAIHS for Antenatal Care Between 2003 and 2005
Independent Variables Demographics Age Marital Status Tobacco Smoking Domestic Violence Drug Use Alcohol Use Psychosocial Confidence with Baby Expect Social Support Expect Partner Support Daily Hassles
24 weeks 12
N
%
n
%
OR (95% C.I.)
20 72 34 58 50 42 14 78 14 78 17 75
21.7 78.3 37.0 63.0 54.3 45.7 15.0 85.0 15.0 85.0 18.5 81.5
3 13 4 12 10 6 7 9 3 13 4 12
15.0 18.0 11.8 20.7 20.0 14.3 50.0 11.5 21.4 16.7 23.5 16.0
0.8 (0.20, 3.14) 0.51 [0.15, 1.73] 1.50 [0.50, 4.54] 7.67 [2.18, 26.95] 1.36 [0.33, 5.58] 1.62 [0.45, 5.81]
18 74 28 64 42 50 26 66 37 55 19 73
19.6 80.4 30.4 69.6 45.7 54.3 28.3 71.7 40.2 59.8 20.6 79.3
4 12 5 11 10 6 8 8 9 7 8 8
22.2 16.2 17.8 17.2 23.8 12.0 30.8 12.1 24.3 12.7 42.1 10.9
1.48 [0.41, 5.26] 1.05 [0.33, 3.36] 2.29 [0.76, 6.95] 3.22 [1.06, 9.81] 2.20 [0.74, 6.57] 5.91 [1.83, 19.04]
32 60 20 72 8 84 12 80 12 75 9 83
34.8 65.2 21.7 78.3 8.7 91.3 13.0 87.0 13.8 86.2 9.8 90.2
4 12 5 11 2 14 3 13 1 14 3 13
12.5 20.0 25.0 15.3 25.0 16.7 25.0 16.2 8.3 18.7 33.3 15.7
0.57 [0.17, 1.94] 1.85 [0.56, 6.13] 1.67 [0.30, 9.12] 1.72 [0.41, 7.22] 0.40 [0.05, 3.33] 2.69 [0.60, 12.15]
p
Correlation with EPDS∗ N = 92
p
0.988
−0.03
0.753
0.421
0.11
0.281
0.657
0.08
0.477
0.001
0.36
0.000
0.960
0.05
0.669
0.700
0.08
0.465
0.798
0.06
0.552
0.825
−0.01
0.939
0.225
−0.16
0.140
0.069
0.22
0.034
0.247
0.15
0.153
0.004
0.33
0.001
0.538
0.09
0.372
0.496
0.11
0.316
0.915
−0.06
0.557
0.736
0.08
0.461
0.639
−0.09
0.385
0.387
0.14
0.188
∗ Spearman
Rho correlations between categorical variables. Bold – statistically significant (p < 0.01). Underline – approaches significance (p < 0.10).
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TABLE 3. Multivariate Logistic Regression: Independent Predictors of EPDS Score > 9 in 92 Indigenous Australian Women Attending the “Mums & Babies” Program for Antenatal Care at TAIHS March, 2003 to September 2005 and Screened for Depression Predictor Variable
POR
95% C.I.
p
Domestic Violence Low Birthweight Child Abuse Alcohol Use Marital Status
5.08 24 3.71 4.51 4.13
1.07-24.16 1.25-460.58 0.90-15.31 0.93-21.83 0.99-17.30
0.041 0.035 0.070 0.052 0.061
Cox & Snell R2 = 40.7.
reported a history of childhood sexual abuse, 3 (16%) reported emotional abuse, and 11 (58%) reported a combination of sexual, emotional, and physical abuse. Thirty-two (34.8%) women were primiparous, 50 (54.3%) were multiparous, and 10 (10.9%) were grand multiparous. Births
The average gestation at birth was 39 weeks (SD = ±2.4 weeks). There were 12 (13%) lowbirth-weight births, 10 births (11%) were of 12
The strongest independent predictors for an EPDS at-risk score are shown in Table 3. While low-birth-weight birth conferred greatly increased odds of an at-risk EPDS score, only having a history of domestic violence reached significance as an independent predictor of an at-risk EPDS score. A history of child abuse, alcohol abuse, and being single all trended toward significance. DISCUSSION
This study adds to the small body of research exploring social and emotional well-being in pregnant indigenous women in Australia. The data suggest that the prevalence of social stressors is high among indigenous women in Townsville, and a significant proportion of these women are at risk for depression and its sequelae. This study does have limitations. For practical reasons, it was a small, purposive sample of women derived from women attending the TAIHS Mums and Babies program for perinatal care, Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
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and thus were self-selected pregnant women in a regional/remote urban setting. The results, while being relevant to other indigenous pregnant women across Australia, especially in urban settings, perhaps should not be extrapolated to the general indigenous community. All data were self-report and subject to recall bias. The demographic data were fairly typical of Mums and Babies women for most demographic characteristics; however, the small numbers do make the regression estimates unstable. Despite these limitations, some findings are of interest. The most widely accepted postnatal depression screening tool is the EPDS (Cox et al., 1987). The EPDS, which has been validated in Australia (P. Boyce, Stubbs, & Todd, 1993), was developed because of the inadequacy of the tools available at the time, which used somatic symptoms in diagnosing depression, many of which can be “normal” in pregnancy and the postnatal period. Postnatally, a cutoff score of >9 (i.e., ≥10) has been used to indicate distress whereas a cutoff score of >12 (i.e., ≥13) is considered as being a closer correlate to a major depressive illness (Cox et al., 1987; D. Murray & Cox, 1990; L. Murray & Carothers, 1990). Note that the EPDS is not a predictive nor a diagnostic tool; it can only “detect” current emotional distress. National data from the beyondblue postnatal depression program (Buist & Bilstza, 2005) suggest that being indigenous significantly increases the risk of depression. Nationally, antenatally 8.9% of all women had an EPDS >12 compared with 19% of indigenous women, and 7.6% of all women had an EPDS >12 postnatally compared with 12% of indigenous women, with indigenous status conferring twice the risk of an EPDS >12 (Buist & Bilstza, 2005). In our study, the rates of distress for indigenous women were comparable, although somewhat higher, to these rates: 28 and 17%, respectively. This may well be related to an increased exposure to social stressors among indigenous pregnant women in Queensland; without a comparison group in this study, however, it is not possible to be certain. The elevated levels in our study could be due to the sensitivity of the screening tool in this population or an error related to the relatively small sample. A number of psychosocial factors have been found to be significant risks for depression during pregnancy and early parenthood: childhood abuse (Buist & Barnett, 1995; Buist & Janson, 2001), personality type, marital disharmony (Dennerstein et al., 1989; Goering, Lancee, & Freeman, 1992; Kumar & Robson, 1984), stressful life events (Dennerstein et al., 1989; O’Hara & Swain, 1996), and social support (Small, Astbury, Brown, & Lumley, 1994). The prevalence of most of the psychosocial stressors was high in this group of indigenous women: Nearly 1 in 2 (45.7%) of these women had a low expectation of partner support, 2 of 5 (40.2%) reported a major life event in the past 12 months, and nearly 1 in 3 (28.3%) rated their daily hassles as high (see Table 2). However, only a history of childhood abuse and domestic violence were significantly associated with high EPDS scores. This was consistent with the National beyondblue data for all Australian women which identified no partner, a past history of abuse, and emotional problems in pregnancy as being strong risk factors for an EPDS >12. The elevated risks in the Townsville group of women in relation to experiencing a major life stress in the previous 12 months, rating of daily hassles, and the expectation of no support from a partner may have reached significance in a larger study. The high prevalence of psychosocial stressors reported by these women is consistent with data from North America. Evidence from Canada and the United States has suggested the prevalence of stressful life events and stressors such as financial, physical abuse, and poor partner support is higher in Native American pregnant women than it is in non-Native American women (Walters & Simoni, 2002). However, evidence for a link between psychosocial stress and poor pregnancy outcome, preterm and low birth weight birth, has not been consistent in Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
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North American studies and studies in the developing world (W.T. Boyce et al., 1986; Cooper et al., 1999; Gennaro, 2005; Patel et al., 2003; Patel et al., 2004). The data presented in this study do suggest a link between low birth weight and perinatal stress, but the lack of power means that this must be interpreted cautiously. The broader implications of depression and psychosocial stress suggests the persistently high prevalence of these stressors in both Australia and North America among “First Nation” women remains a cause for concern and reinforces the need for intensive support of these women and their families. Perinatal depression is recognized as a significant contributor to difficulties with early childhood well-being (Wisner, Chambers, & Sit, 2006), with a wealth of evidence that has linked maternal perinatal depression and problems with cognitive and behavioral development in early childhood. In conclusion, poverty and ethnicity are not the sole contributors to pregnancy outcome. The data from this group of women suggest that the prevalence of psychosocial stressors may be high among urban indigenous pregnant women in Australia. In caring for pregnant indigenous women, health professionals need to monitor, with vigilance, social and emotional health and to structure a multidisciplinary approach to care to organize referrals and more timely support.
REFERENCES Astbury, J., Brown, S., Lumley, J., & Small, R. (1994). Birth events, birth experiences and social differences in postnatal depression. Australian Journal of Public Health, 18(2), 176–184. Austin, M., & Lumley, J. (2003). Antenatal screening for postnatal depression: A systematic review. Acta Psychiatrica Scandinavica, 107, 10–17. Australian Bureau of Statistics. (2001 Census). Population distribution, indigenous Australians. Canberra, Australia: Author. Baker, L., Cross, S., Greaver, L., Wei, G., Lewis, R., & Healthy Start Corps. (2005). Prevalence of postpartum depression in a Native American population. Maternal and Child Health Journal, 9(1), 21–25. Boyce, P., Stubbs, J., & Todd, A. (1993). The Edinburgh Postnatal Depression Scale: Validation for an Australian sample. Australian and New Zealand Journal of Psychiatry, 27, 472–476. Boyce, W.T., Schaefer, C., Harrison, H.R., Haffner, W.H.J., Lewis, M., & Wright, A.L. (1986). Social and cultural factors in pregnancy complications among Navajo women. American Journal of Epidemiology, 124(2), 242–253. Buist, A., & Barnett, B. (1995). Childhood sexual abuse: A risk factor for postpartum depression? Australian and New Zealand Journal of Psychiatry, 29(12), 604–608. Buist, A., & Bilstza, J. (2005). The beyondblue National Postnatal Depression Program. Prevention and early intervention 2001–2005, Final Report. Melbourne, Australia: beyondblue. Buist, A., & Janson, H. (2001). Childhood sexual abuse, parenting and postpartum depression—A 3-year follow-up study. Child Abuse and Neglect, 25(7), 909–921. Campbell, A., Hayes, B., & Buckby, B. (2008). Aboriginal and Torres Strait Islander women’s experience when interacting with the Edinburgh Postnatal Depression Scale: A brief note. Australian Journal of Rural Health, 16, 124–131. Cooper, P., Murray, L., Hooper, R., & West, A. (1996). The development and validation of a predictive index for postpartum depression. Psychological Medicine, 26, 627–634.
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Cooper, P., Tomlinson, M., Swartz, L., Woolgar, M., Murray, L., & Molteno, C. (1999). Post-partum depression and the mother–infant relationship in a South African peri-urban settlement. British Journal of Psychiatry, 175, 554–558. Cox, J., Holden, J., & Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150(June), 782–786. de Costa, C., & Child, A. (1996). Pregnancy outcomes in urban aboriginal women. Medical Journal of Australia, 164(9), 523–526. Dennerstein, L., Lehart, P., & Riphagen, F. (1989). Postpartum depression—Risk factors. Journal of Psychosomatic Obstetrics and Gynaecology, 10, 53–65. Gennaro, S. (2005). Overview of current state of research on pregnancy outcomes in minority populations American Journal of Obstetrics and Gynecology, 192(5), S3–S10. Gilman, J., & Myatt, M. (1998). Epicalc 2000 (Version 1.02). Brixton, UK: Brixton Health. Goering, P., Lancee, W., & Freeman, S. (1992). Marital support and recovery from depression. British Journal of Psychiatry, 160(1), 76–82. Halbreich, U., & Karkun, S. (2006). Cross-cultural and social diversity of prevalence of postpartum depression and depressive symptoms. Journal of Affective Disorders, 91, 97–111. Hayes, B., Muller, R., & Bradley, B.S. (2001). A randomized controlled trial of an antenatal education intervention for primiparas. Birth, 28(1), 28–35. Hayes, B.A., Geia, L.K., & Egan, M.E. (2006). Plenary Address. In Development and evaluation of the Edinburgh Postnatal Depression Scale for Aboriginal and Torres Strait Islander women in North Queensland. Paper presented at the 1st Australian Aboriginal and Torres Strait Islander Perinatal and Infant Mental Health Conference: Working With “Ghosts in the Nursery,” May 4–6, Sydney. Hayes, B.A., & Muller, R. (2005). Prenatal depression: A randomized controlled trial in the emotional health of primiparous women. In R. Williams & B. Hagerty (Eds.), Depression research in nursing: Global perspectives (pp. 41–58). New York: Springer. Hogue, C., & Bremmer, J. (2005). Stress model for research into preterm delivery among black women. American Journal of Obstetrics and Gynecology, 192(5), S47–55. Humphrey, M., & Keating, S. (2004). Lack of antenatal care in far north Queensland. Australian and New Zealand Journal of Obstetrics and Gynaecology, 44(1), 10–13. Kumar, R., & Robson, K. (1984). A prospective study of emotional disorders in childbearing women. British Journal of Psychiatry, 144(1), 35–47. Laws, P., & Sullivan, E. (2005). Australia’s mothers and babies 2003. Sydney: Australian Institute of Health and Welfare. Main, D. (1988). The epidemiology of preterm birth. Clinical Obstetrics and Gynecology, 31, 521– 532. Milgrom, J., Ericksen, J., Negri, L., & Gemmill, A. (2005). Screening for postnatal depression in routine primary care: Properties of the Edinburgh Postnatal Depression Scale in an Australian sample. Australian and New Zealand Journal of Psychiatry, 39(9), 833–839. Moutquin, J. (2003). Socio-economic and psychosocial factors in the management and prevention of preterm labour. British Journal of Obstetrics and Gynaecology, 110(Suppl. 20), 56–60. Murray, D., & Cox, J. (1990). Screening for depression during pregnancy with the Edinburgh Depression Scale (EPDS). Journal of Reproductive and Infant Psychology, 8, 99–107. Murray, L., & Carothers, A. (1990). The validation of the Edinburgh Post-natal Depression Scale on a community sample. British Journal of Psychiatry, 157, 288–290.
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National Health & Medical Research Council. (2003). Values and ethics: Guidelines for Ethical Conduct in Aboriginal and Torres Strait Islander Health Research (p. 27). Commonwealth of Australia, Canberra, ACT. O’Hara, M., & Swain, A. (1996). Rates and risk of postpartum depression—A meta-analysis. International Review of Psychiatry, 8, 37–54. Panaretto, K., Muller, R., Patole, S., Watson, D., & Whitehall, J. (2002). Is being Aboriginal or Torres Strait Islander a risk factor for poor neonatal outcome in a tertiary referral unit in North Queensland? Journal of Paediatric Child Health, 38(1), 16–22. Panaretto, K.S., Lee, H.M., Mitchell, M.R., Larkins, S.L., Manessis, V., Buettner, P.G., et al. (2005). Impact of a collaborative shared antenatal care program for urban indigenous women: A prospective cohort study. Medical Journal of Australia, 182(10), 514–519. Patel, V., DeSouza, N., & Rodrigues, M. (2003). Postnatal depression and infant growth and development in low income countries: A cohort study from Goa, India. Archives of Diseases of Childhood, 88, 34–37. Patel, V., Rahman, A., Jacob, K.S., & Hughes, M. (2004). Effect of maternal mental health on infant growth in low income countries: New evidence from South Asia. British Medical Journal, 328, 820–823. Patel, V., Rodrigues, M., & DeSouza, N. (2002). Gender, poverty, and postnatal depression: A study of mothers in Goa, India. American Journal of Psychiatry, 159, 43–47. Posner, N., Unterman, R., Williams, K., & Williams, G. (1997). Screening for postpartum depression. An antepartum questionnaire. Journal of Reproductive Medicine, 42(4), 207–215. Queensland Council on Obstetric and Paediatric Morbidity and Mortality. (2005). Maternal, perinatal and paediatric mortality and morbidity in Queensland, 2000–2004, Brisbane: QCOPMM. Rahman, A., Iqbal, Z., & Harrington, R. (2003). Life events, social support and depression in childbirth: Perspectives from a rural community in the developing world. Psychological Medicine, 33, 1161– 1167. Rich-Edwards, J., & Grizzard, T. (2005). Psychosocial stress and neuroendocrine mechanisms in preterm delivery. American Journal of Obstetrics and Gynecology, 192(5), S30–S35. Small, R., Astbury, J., Brown, S., & Lumley, J. (1994). Depression after childbirth: Does social context matter? Medical Journal of Australia, 161, 473–477. Surkan, P.J., Kawachi, I., Ryan, L.M., Berkman, L.F., Vieira, L.M.C., & Peterson, K.E. (2008). Maternal depressive symptoms, parenting self-efficacy, and child growth. American Journal of Public Health, 98(1), 125–132. Tomlinson, M., Cooper, P.J., Stein, A., Swartz, L., & Molteno, C. (2006). Post-partum depression and infant growth in a South African peri-urban settlement. Child: Care, Health & Development, 32(1), 81–86. Walters, K.L., & Simoni, J.M. (2002). Reconceptualizing Native Women’s health: An “indigenist” stresscoping model. American Journal of Public Health, 92(4), 520–524. Webster, M.L., Thompson, J.M.D., Mitchell, E.A., & Werry, J.S. (1994). Postnatal depression in a community cohort. Australian and New Zealand Journal of Psychiatry, 28(1), 42–49. Wisner, K.L., Chambers, C., & Sit, D.K.Y. (2006). Postpartum depression: A major public health problem. Journal of the American Medical Association, 296(21), 2616–2618.
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THE INTERFACE OF MENTAL AND EMOTIONAL HEALTH AND PREGNANCY IN URBAN INDIGENOUS WOMEN: RESEARCH IN PROGRESS BARBARA A. HAYES, ALISTAIR CAMPBELL, BERYL BUCKBY, LYNORE K. GEIA, AND MARGARET E. EGAN
James Cook University, Townsville, Australia Research among indigenous women in Australia has shown that a number of lifestyle factors are associated with poor obstetric outcomes; however, little evidence appears in the literature about the role of social stressors and mental health among indigenous women. The not-for-profit organization beyondblue established a “Depression Initiative” in Australia. As part of this they provided funding to the Townsville Aboriginal and Torres Strait Islander Health Service in the “Mums and Babies” clinic. The aim of this was to establish a project to (a) describe the mental health and level of social stressors among antenatal indigenous women and (b) assess the impact of social stressors and mental health on perinatal outcome. A purposive sample of 92 indigenous women was carried out. Culturally appropriate research instruments were developed through consultations with indigenous women’s reference groups. The participants reported a range of psychosocial stressors during the pregnancy or within the last 12 months. Significant, positive correlations emerged between the participants’ Edinburgh Postnatal Depression Scale (EPDS; J. Cox, J. Holden, & R. Sagovsky, 1987) score and the mothers’ history of child abuse and a history of exposure to domestic violence. A more conservative cutoff point for the EPDS (>9 vs. >12) led to 28 versus 17% of women being identified as “at risk” for depression. Maternal depression and stress during pregnancy and early parenthood are now recognized as having multiple negative sequelae for the fetus and infant, especially in early brain development and self-regulation of stress and emotions. Because of the cumulative cultural losses experienced by Australian indigenous women, there is a reduced buffer to psychosocial stressors during pregnancy; thus, it is important for health professionals to monitor the women’s emotional and mental well-being. ABSTRACT:
La investigaci´on llevada a cabo con mujeres ind´ıgenas en Australia ha demostrado que un n´umero de factores de estilo de vida est´an asociados con pobres resultados obst´etricos. Sin embargo, poca evidencia aparece en la literatura acerca del papel de los factores sociales de estr´es y la salud mental entre las mujeres ind´ıgenas. La organizaci´on sin fines lucrativos “beyondblue” estableci´o en Australia una
RESUMEN:
We acknowledge the beyondblue National Postnatal Depression Program as the source of funding; the Board and staff members of the Townsville Aboriginal and Islander Health Service (TAIHS); and Claudinia Daley as Aboriginal Research Assistant at TAIHS. We thank Dr. Kathryn Panaretto, Melvina Mitchell, and the TAIHS for their valuable contributions to this project. Direct correspondence to: Barbara A. Hayes, School of Nursing Sciences, James Cook University, Townsville, Australia; e-mail: [email protected]. INFANT MENTAL HEALTH JOURNAL, Vol. 31(3), 277–290 (2010) C 2010 Michigan Association for Infant Mental Health Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/imhj.20256
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“Iniciativa para la Depresi´on.” Como parte de tal iniciativa, la organizaci´on provey´o los fondos para el Servicio de Salud Townsville Aboriginal and Torres Strait Islander (TAIHS) en la cl´ınica para “Mam´as y Beb´es.” El prop´osito de la iniciativa fue de establecer un proyecto para (a) describir la salud mental y el nivel de factores sociales de estr´es entre mujeres ind´ıgenas antes de dar a luz y (b) evaluar el impacto de los factores sociales de estr´es y la salud mental sobre el resultado perinatal. El grupo muestra ‘a prop´osito’ de 92 mujeres ind´ıgenas fue puesto en pr´actica. Se desarrollaron instrumentos de investigaci´on culturalmente apropiados en consulta con los Grupos de Referencia de las Mujeres Ind´ıgenas. Las participantes reportaron un n´umero de factores sociales de estr´es durante el embarazo o dentro de los u´ ltimos 12 meses. Surgieron correlaciones significativas y positivas entre los puntajes de EPDS de las participantes y la historia de abuso infantil de las madres, as´ı como la historia de haber estado espuestas a la violencia dom´estica. Una m´as conservadora l´ınea l´ımite para los puntajes de EPDS (>9 vs >12) dio como resultado que un 28% vs 17% de las mujeres fueran identificadas ‘bajo riesgo’ de depresi´on. Se reconoce ahora que la depresi´on materna y el estr´es durante el embarazo y el principio de la crianza tienen secuelas negativas m´ultiples para el feto y para el infante, especialmente en la primera etapa de desarrollo del cerebro y la autorregulaci´on del estr´es y las emociones. A causa de las p´erdidas culturales acumuladas experimentadas por mujeres australianas ind´ıgenas, se produce un amortiguador para los factores sicol´ogicos de estr´es durante el embarazo, y por tanto es importante para los profesionales de la salud mantener en observaci´on el bienestar emocional y mental de las mujeres. ´ ´ RESUM E:
Les recherches chez les femmes aborig`enes d’Australie ont montr´e qu’un certain nombre de facteurs de style de vie sont li´es a` de faibles r´esultats obst´etriques. Cependant, on trouve peu de d’´evidence dans les recherches sur le rˆole de facteurs de stress sociaux et en mati`ere de sant´e mentale chez les femmes aborig`enes. L’organisation sans profit «audel`aducafard a e´ tabli une “Initiative de D´epression” en Australie. Entre autres, parmi leurs projets, cette organisation a donn´e des fonds pour le Service de Sant´e Aborig`ene de Townsville et de Torres Strait Islander dans la clinique “Mamans et B´eb´es.” Le but e´ tait d’´etablir un projet pour (a) d´ecrire la sant´e mentale et le niveau de stresseurs sociaux chez les femmes aborig`enes avant la naissance et (b) e´ valuer l’impact des stresseurs sociaux et de la sant´e mentale sur le r´esultat p´erinatal. 92 femmes aborig`enes ont e´ t´e s´electionn´ees pour l’´etude. Des intruments de recherche appropri´es a` la culture ont e´ t´e d´evelopp´e a` travers des consultations avec les Groupes de R´ef´erences des Femmes Aborig`enes. Les participantes ont fait e´ tat d’un e´ ventail de facteurs de stress psychosocial durant la grossesse ou durant les 12 derniers mois. Les liens importants et positifs ont e´ merg´e entre les scores EPDS des participantes et le pass´e de maltraitance en tant qu’enfant des m`eres et un pass´e d’exposition a` la violence conjugale. Un point de d´elimitation pour l’EPDS plus conservateur (>9 compar´e a` >12) a conduit a` 28% compar´e a` 17% de femmes e´ tant identifi´ees comme e´ tant “`a risque” de d´epression. La d´epression maternelle et le stress maternel durant la grossesse et le parentage pr´ecoce sont maintenant reconnus comme ayant de multiples s´equelles n´egatives pour le foetus et le nourrisson surtout pour ce qui concerne le d´eveloppement pr´ecoce du cerveau et l’auto-r´egulation du stress et des e´ motions. A cause des pertes cumulatives culturelles dont ont fait l’exp´erience les femmes aborig`enes il existe un tampon r´eduit aux facteurs de stress psychosociaux durant la grossesse, et donc il est important que les professionnels de la sant´e surveillent le bien-ˆetre e´ motionnel et mental des femmes. ZUSAMMENFASSUNG: Die Forschung u¨ ber Aboriginesfrauen in Australien zeigt, dass Faktoren des Lebensstils in Zusammenhang mit ung¨unstigen Geburtssituationen stehen. Trotzdem gibt es in der Literatur wenig Belege u¨ ber die Rolle von sozialen Stressoren und psychischer Gesundheit von Aboriginesfrauen. Eine bewusst gew¨ahlt Gruppe von 92 Aboriginesfrauen wurde ausgew¨ahlt. Kulturell abgestimmte Forschungsinstrumente wurden gemeinsam mit Bezugsgruppen von Aboriginesfrauen entwickelt. Die Teilnehmerinnen berichteten eine F¨ulle von psychosozialen Stressoren w¨ahrend der Schwangerschaft oder
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innerhalb der letzen 12 Monate. Signifikant positive Zusammenh¨ange zeigten sich zwischen EPDS Werten der Teilnehmerinnen und Kindesmisshandlungen der in der Geschichte der M¨utter sowie dem Ausgeliefert sein von h¨auslicher Gewalt. Eine zur¨uckhaltendere Bewertung von EPDS (>9 vs >12) zeigte 28% vs 17% der Frauen als “gef¨ahrdet f¨ur eine Depression. M¨utterliche Depression, Stress in der Schwangerschaft und jugendliche M¨utter wurden als Hinweise f¨ur multiple negative Sp¨atfolgen f¨ur den F¨otus und das Kleinkind speziell in der fr¨uhen Gehirnentwicklung und Selbstregulation von Stress und Emotionen identifiziert. Da Aborigiesfrauen einen massiven Werteverlust erlebt haben, haben sie weniger Puffer f¨ur psychosoziale Stressoren in der Schwangerschaft und demnach ist es f¨ur s¨amtliches Gesundheitspersonal wichtig, die Emotionen und das psychische Wohlbefinden mit zu ber¨ucksichtigen.
* * * Births to women of Aboriginal or Torres Strait Islander descent represent about 3% of confinements in Australia each year, with Queensland having the highest number of indigenous births among the Australian states (Laws & Sullivan, 2005; Queensland Council on Obstetric and Paediatric Morbidity and Mortality, 2005). The poor health of the indigenous community in Australia is well documented and is reflected in demoralizing indigenous perinatal statistics with rates of preterm birth, low birth weight, and perinatal mortality remaining more than twice that of the nonindigenous population over the past decade (Laws & Sullivan, 2005; Panaretto, Muller, Patole, Watson, & Whitehall, 2002; Queensland Council on Obstetric and Paediatric Morbidity and Mortality, 2005). Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
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Preterm birth continues to be comprehensively investigated with predictors including previous preterm birth, ethnicity, infection, and socioeconomic status (Main, 1988; Moutquin, 2003). Evidence for psychosocial stress is less well documented, but research has suggested that stressful events relating to family illness, disruption, violence, and financial distress may be related to an increased likelihood of preterm birth (Moutquin, 2003). There also is a body of opinion that accumulation of psychosocial stress over years also may add to adverse pregnancy outcome (Hogue & Bremmer, 2005; Rich-Edwards & Grizzard, 2005). Previous research among indigenous women in Australia has shown that late antenatal attendance, maternal malnutrition, and high rates of tobacco and alcohol use were associated with poor obstetric outcome (de Costa & Child, 1996; Humphrey & Keating, 2004; Panaretto et al., 2002). However, there is little evidence about the impact of social stressors and mental health among indigenous women or, indeed, the best way to gather that data for this population. Internationally, screening of postnatal women for depression has received considerable attention in the literature. Using the most widely accepted postnatal depression screening tool, the Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden, & Sagovsky, 1987), 10 to 15% of women will experience postnatal depression (O’Hara & Swain, 1996) with similar rates in Australia (Astbury, Brown, Lumley, & Small, 1994; Dennerstein, Lehart, & Riphagen, 1989; Milgrom, Ericksen, Negri, & Gemmill, 2005). More recently, the focus of postnatal depression research has broadened to include antenatal depression (Austin & Lumley, 2003; Cooper, Murray, Hooper, & West, 1996; Posner, Unterman, Williams, & Williams, 1997), with the term perinatal depression now describing the depressive disorders associated with pregnancy and early parenthood. There is a general consensus emerging that antenatal depression is a significant problem and that further research is necessary to ascertain its exact incidence and impact (Hayes, Muller, & Bradley, 2001; Hayes & Muller, 2005). More recently, there has been considerable research focus on postnatal depression in developing countries. Studies have considered the incidence of postnatal depression in impoverished and rural communities (Cooper et al., 1999; Patel, Rodrigues, & DeSouza, 2002; Rahman, Iqbal, & Harrington, 2003), and there has been particular interest in the effect of maternal depression on infant development (Patel, DeSouza, & Rodrigues, 2003; Patel, Rahman, Jacob, & Hughes, 2004; Surkan et al., 2008; Tomlinson, Cooper, Stein, Swartz, & Molteno, 2006). Findings have been somewhat mixed, although there is evidence that postnatal depression may have a relationship with infant growth and failure to thrive. These and other studies also have found that the incidence of postnatal depression is related to a range of sociocultural factors including poverty, negative life events, relationship factors, and exposure to violence (Surkan et al., 2008); however, Halbreich and Karkun (2006), in a recent review of the cross-cultural evidence, noted that there is considerable variability in the rate of postnatal depression and associated factors. There has been very little research in relation to postnatal depression within minority indigenous, or “First Nation,” cultures. One U.S. study found a much higher incidence of postnatal depression in a sample of American Indian (Lumbee Tribe) women (23%) than that in other populations (Baker et al., 2005). In a New Zealand study of 206 European and Maori women, Webster, Thompson, Mitchell, and Werry (1994) found that there was an increased risk of postnatal depression among Maori women. Webster et al. also found that marital status and satisfaction with the relationship were significant predictors along with mother’s age at the birth of her first child. The beyondblue National Postnatal Depression Program was established in 2001 with the aim to evaluate antenatal and postnatal screening for women’s emotional and mental health, to Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
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facilitate the linking of all services involved in the care of perinatal women, and to increase community and health professional awareness of perinatal depression. In this context, when the Townsville Aboriginal and Islanders Health Service (TAIHS) was approached by the beyondblue team from James Cook University to participate in a research project exploring the use of the EPDS with indigenous women, it was seen as an opportunity to further enhance the antenatal care services (ANC) offered to women attending the “Mums and Babies” program at the TAIHS (Panaretto et al., 2005) and explore the relationship between psychosocial factors and pregnancy outcome in indigenous women. The evaluation of the project reported in this article had two aims: to describe the mental health and level of social stressors among indigenous women who attended the TAIHS for antenatal care and to assess the impact of social stressors and mental health on perinatal outcome. METHODS Setting
Townsville, the second largest city in Queensland, is 1,200 km north of Brisbane and the tertiary medical-referral center for North Queensland. The Townsville region has a large indigenous population: 16,875 (Australian Bureau of Statistics, 2001 Census), comprising 5.2% of the population, with 70% being of Aboriginal descent and 30% being of Torres Strait Islander descent. The TAIHS is a community-controlled Aboriginal Medical Service, with a 10-member elected board and over 100 staff members. The participants in this study were not primarily living a traditional Aboriginal life style, and many were located in urban communities. However, note that most Aboriginal families in Northern Australia retain links with their traditional communities and frequently return to “country” (i.e., traditional homelands) for family and ceremonial reasons (e.g., births, deaths, land disputes). Study Design
This was a prospective study involving women who attended the TAIHS for ANC with the Mums and Babies program, in the 18 months between September 1, 2003 and February 28, 2005. The intention initially was to invite all women presenting for ANC at the TAIHS to participate in the beyondblue project. Due to budget constraints, perinatal women who attended the “Mums and Babies” clinic 2 days a week (Tuesday, Thursday) were administered adapted versions of the beyondblue screening tools by a trained community worker: the mainstream EPDS, an EPDS modified for indigenous participants, and a psychosocial survey derived from the beyondblue project (Buist & Bilstza, 2005). The Maternal and Child Health team was notified by the interviewer of any woman whose EPDS screening score was higher than 12. The screening tool—the modified EPDS—and resource package were developed by the research team working with a community focus group (Campbell, Hayes, & Buckby, 2008). These resource materials were based on materials already in use in the beyondblue National Postnatal Depression project: the EPDS and a resource booklet entitled Emotional Care in Pregnancy and Early Parenthood. The EPDS was modified by adapting the language of the questions to select common language usage within the Townsville indigenous community as previously described (Hayes, Geia, & Egan, 2006). Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
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The process for the development of the TAIHS translation of the EPDS followed the National Health and Medical Research Council Guidelines for research with Australian indigenous people (National Health & Medical Research Council, 2003). Iterative consultation was undertaken with each community to form a site-specific reference group of Aboriginal and Torres Strait Islander women. At the TAIHS, the non-Aboriginal Medical Officer of the Mums and Babies unit also was a member of the reference group. The research data package, including revised wording of the EPDS, was developed by iterative consultations first through focus groups and then with indigenous women’s reference groups appointed through the focus groups at each site. The package consisted of the following site-specific, culturally acceptable materials: (a) an information sheet, (b) a consent form, (c) a translated EPDS, (d) a standard EPDS, (e) a demographic–psychosocial assessment form, and (f) a translated educational booklet. These materials were the promised benefit by the researchers to the community members for participating in the research. Consultation with Aboriginal and Torres Strait Islander Health Workers, community people, and all levels of Queensland Health Board or Aboriginal Management Board was conducted prior to the initial education seminars; the Reference Groups were then able to provide the authoritative input for development of site-specific screening packages. Specific education of Aboriginal and Torres Strait Islander Health Workers, and other indigenous women selected by each community, regarding early recognition and appropriate referral of perinatal women who experienced emotional and mental health issues was an essential component. The whole screening package was scrutinized by the current Governing Board of the TAIHS, who gave it full approval, and by senior staff at the Child Health Centre and Yapatjarra in Mt Isa. The Aboriginal and Torres Strait Islander version was not translated into other languages; although this task would itself be valuable, it was beyond the scope of the study. As the common language of the study population was English, the English words used were adapted to reflect common usage and implicit meaning of English in these communities, much like a local dialect. Superficially, it will seem that some of the items were not altered much, and most changes involved an alteration in specific words or simplification of sentence structures, but the women recognized their “own” translation when used in screening. Management
Standard antenatal shared-care protocols, which are based on those developed by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, were used. All women unsure of their dates were referred for dating ultrasound. All deliveries occurred at the Townsville Hospital unless a patient relocated. Standard best treatment protocols were followed for pregnancy and obstetric complications. Patients with “high-risk” or complicated pregnancies were referred to the Townsville Hospital, as appropriate, by the attending medical staff. Women with an EPDS greater than 12 were managed at the discretion of the Maternal and Child Health team. Mental health services and early family intervention services were available to assist in management of these women through the TAIHS and Community Child Health and Mental Health Services. Ethics Approval
The project and evaluation had the full support of the community-elected board of the TAIHS. The coordinator of the program is an Aboriginal Health worker trained in maternal and child Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
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health. The program is overseen by a reference group that meets monthly and includes a consumer representative. The beyondblue project was approved by the Townsville Health Service District Ethics Committee and by the Human Subjects Subcommittee of the Experimental Ethics Committee of James Cook University. All participating women were provided with both printed and verbal information before written consent to participate in the project was obtained.
Ethnicity
Staff asked all women presenting for ANC whether they and their partner identified as Aboriginal, Torres Strait Islander, both Aboriginal and Torres Strait Islander, or other identities. A baby was identified as indigenous if either parent identified as such, comprising 93% of all births to women receiving antenatal care at the TAIHS during the study period.
Data Collection
A comprehensive, confidential record of each pregnancy is recorded at the TAIHS in a secure database, including demographic data, the number and timing of antenatal visits made, the gestation of the first visit, the number and timing of ultrasounds performed, and data relating to the completion and results of “cycle of care” activities such as clinical screening, performance of care-planning activities, pregnancy complications, and pregnancy outcomes. Definitions used for explanatory variables and perinatal outcomes. Preterm birth was defined as less than 37 weeks’ completed gestation, and low birth weight as less than 2,500 g. Harmful/ hazardous alcohol use was defined as more than two standard drinks a day. Inadequate antenatal care was defined as three antenatal care visits or fewer, and late presentation for antenatal care as a first visit at 24 weeks’ gestation or later. An unwanted pregnancy was defined as any birth where the mother had discussed termination with the TAIHS antenatal care team. “At risk” of depression was defined as an EPDS score of 12 or higher. Data quality. Two hundred seventy-five singleton births occurred in the study period. Ninetysix women completed the screening tools; of these, 92 were indigenous births. Given that the screening occurred on 2 clinic days only, participation may have been as high as 84% (92 women of 110 available women). Overall, mothers had at least one ultrasound in 92% of the births, with 63% having had a dating scan. Birth weight data were not available for 5 women (5.4%) of the sample. Data analysis. Data were analyzed using Statistica 6.0 (StatSoft & Inc, 2001) and EpiCalc 2000 (Gilman & Myatt, 1998). Due to the number of participants and the nature of data collected, the main approach to analysis was univariate, using nonparametric statistics as appropriate. Stepwise multivariate regression analysis also was used to identify significant predictors of risk for depression. As there were missing data for the EPDS scores, particularly the antenatal score, the main data analysis was carried out using the postnatal data, with missing values imputed from the antenatal score where available. Prevalence odds ratios and 95% confidence intervals are reported; a two-tailed p value below 0.05 was considered significant. Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
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TABLE 1. Prevalence of Women “At Risk” of Depression Using Two EPDS Cut-Off Scores in Pregnant and Postnatal Aboriginal and Torres Strait Islander Women Attending TAIHS for Antenatal Care Between 2003 and 2005 and Were Screened for Depression Women Not At Risk EPDS Cut-Off Score EPDS > 9
EPDS > 12
Antenatal (n = 37) Postnatal (n = 64) Imputed PN (n = 92) Antenatal (n = 37) Postnatal (n = 64) Imputed PN (n = 92)
Women At Risk
n
%
95% CI
n
%
95% CI
21 45 66 23 55 76
56.7 70.3 71.7 62.2 85.9 82.6
(39.6, 72.5) (57.4, 80.7) (61.2, 80.4) (44.8, 77.1) (74.5, 93.0) (73.0, 89.4)
16 19 26 14 9 16
43.2 29.7 28.3 37.8 14.6 17.4
(27.5, 60.4) (19.2, 42.6) (19.6, 38.8) (22.9, 55.2) (7.0, 25.5) (10.6, 27.0)
RESULTS
The women in the study group were compared to 183 women who attended the TAIHS for ANC during the study period but who did not participate in the EPDS screening. There were no differences between these two groups on most of the study variables; however, significantly more women who did not complete an EPDS reported using alcohol (31.15 vs. 18.75%), χ 2 = 4.292, p = .026, and significantly more had fewer than four antenatal care visits (49.45 vs. 21.88%), χ 2 = 19.93, p = .001. Table 1 presents the distribution of women who were screened as “at risk” of depression using two separate cutoffs: EPDS >9 and EPDS >12 for both the antenatal and the postnatal data, respectively. As can be seen, the numbers completing the antenatal measures were quite low.1 With the more conservative cutoff, some 17% of women were identified as being at risk for depression. The less conservative cutoff led to 10 more women being identified, leading to a proportion of 28%. Mothers
Demographic, psychosocial, pregnancy characteristics, and pregnancy outcomes are shown in Table 2 for those participants who completed the EPDS screening. The average age of the participants was 24.3 years (youngest = 15.3 years; oldest = 43.3 years). Thirteen (18.0%) participants were under 20 years, and 5 (5.5%) were over 35 years. At their first antenatal care visit, over 50% reported tobacco use, nearly 25% alcohol use, 10% an unwanted pregnancy, and 15% domestic violence. Thirty-seven (41%) reported a major life event in the past 12 months. Of these, 14 (37%) reported a single event whereas 24 (63%) reported multiple events. Nine women (24%) reported a miscarriage, 16 (42%) reported a death or serious illness in the family, 16 (42%) reported family problems, 15 (39%) reported job loss or financial problems, and 34 (89%) reported problems relating to their partner, including separation, problems with the previous partner, or partner being in jail. Nineteen women (21%) reported a history of childhood abuse; of these, 5 (26%) 1 The antenatal data were used to impute missing values in the postnatal data, leading to the imputed values in Table 1. Data referred to from this point are the imputed data.
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TABLE 2. Prevalence of Demographic and Pregnancy Characteristics and EPDS Score > 9 in Pregnant Aboriginal and Torres Strait Islander Women Attending TAIHS for Antenatal Care Between 2003 and 2005
Independent Variables Demographics Age Marital Status Tobacco Smoking Domestic Violence Drug Use Alcohol Use Psychosocial Confidence with Baby Expect Social Support Expect Partner Support Daily Hassles
24 weeks 12
N
%
n
%
OR (95% C.I.)
20 72 34 58 50 42 14 78 14 78 17 75
21.7 78.3 37.0 63.0 54.3 45.7 15.0 85.0 15.0 85.0 18.5 81.5
3 13 4 12 10 6 7 9 3 13 4 12
15.0 18.0 11.8 20.7 20.0 14.3 50.0 11.5 21.4 16.7 23.5 16.0
0.8 (0.20, 3.14) 0.51 [0.15, 1.73] 1.50 [0.50, 4.54] 7.67 [2.18, 26.95] 1.36 [0.33, 5.58] 1.62 [0.45, 5.81]
18 74 28 64 42 50 26 66 37 55 19 73
19.6 80.4 30.4 69.6 45.7 54.3 28.3 71.7 40.2 59.8 20.6 79.3
4 12 5 11 10 6 8 8 9 7 8 8
22.2 16.2 17.8 17.2 23.8 12.0 30.8 12.1 24.3 12.7 42.1 10.9
1.48 [0.41, 5.26] 1.05 [0.33, 3.36] 2.29 [0.76, 6.95] 3.22 [1.06, 9.81] 2.20 [0.74, 6.57] 5.91 [1.83, 19.04]
32 60 20 72 8 84 12 80 12 75 9 83
34.8 65.2 21.7 78.3 8.7 91.3 13.0 87.0 13.8 86.2 9.8 90.2
4 12 5 11 2 14 3 13 1 14 3 13
12.5 20.0 25.0 15.3 25.0 16.7 25.0 16.2 8.3 18.7 33.3 15.7
0.57 [0.17, 1.94] 1.85 [0.56, 6.13] 1.67 [0.30, 9.12] 1.72 [0.41, 7.22] 0.40 [0.05, 3.33] 2.69 [0.60, 12.15]
p
Correlation with EPDS∗ N = 92
p
0.988
−0.03
0.753
0.421
0.11
0.281
0.657
0.08
0.477
0.001
0.36
0.000
0.960
0.05
0.669
0.700
0.08
0.465
0.798
0.06
0.552
0.825
−0.01
0.939
0.225
−0.16
0.140
0.069
0.22
0.034
0.247
0.15
0.153
0.004
0.33
0.001
0.538
0.09
0.372
0.496
0.11
0.316
0.915
−0.06
0.557
0.736
0.08
0.461
0.639
−0.09
0.385
0.387
0.14
0.188
∗ Spearman
Rho correlations between categorical variables. Bold – statistically significant (p < 0.01). Underline – approaches significance (p < 0.10).
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TABLE 3. Multivariate Logistic Regression: Independent Predictors of EPDS Score > 9 in 92 Indigenous Australian Women Attending the “Mums & Babies” Program for Antenatal Care at TAIHS March, 2003 to September 2005 and Screened for Depression Predictor Variable
POR
95% C.I.
p
Domestic Violence Low Birthweight Child Abuse Alcohol Use Marital Status
5.08 24 3.71 4.51 4.13
1.07-24.16 1.25-460.58 0.90-15.31 0.93-21.83 0.99-17.30
0.041 0.035 0.070 0.052 0.061
Cox & Snell R2 = 40.7.
reported a history of childhood sexual abuse, 3 (16%) reported emotional abuse, and 11 (58%) reported a combination of sexual, emotional, and physical abuse. Thirty-two (34.8%) women were primiparous, 50 (54.3%) were multiparous, and 10 (10.9%) were grand multiparous. Births
The average gestation at birth was 39 weeks (SD = ±2.4 weeks). There were 12 (13%) lowbirth-weight births, 10 births (11%) were of 12
The strongest independent predictors for an EPDS at-risk score are shown in Table 3. While low-birth-weight birth conferred greatly increased odds of an at-risk EPDS score, only having a history of domestic violence reached significance as an independent predictor of an at-risk EPDS score. A history of child abuse, alcohol abuse, and being single all trended toward significance. DISCUSSION
This study adds to the small body of research exploring social and emotional well-being in pregnant indigenous women in Australia. The data suggest that the prevalence of social stressors is high among indigenous women in Townsville, and a significant proportion of these women are at risk for depression and its sequelae. This study does have limitations. For practical reasons, it was a small, purposive sample of women derived from women attending the TAIHS Mums and Babies program for perinatal care, Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
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and thus were self-selected pregnant women in a regional/remote urban setting. The results, while being relevant to other indigenous pregnant women across Australia, especially in urban settings, perhaps should not be extrapolated to the general indigenous community. All data were self-report and subject to recall bias. The demographic data were fairly typical of Mums and Babies women for most demographic characteristics; however, the small numbers do make the regression estimates unstable. Despite these limitations, some findings are of interest. The most widely accepted postnatal depression screening tool is the EPDS (Cox et al., 1987). The EPDS, which has been validated in Australia (P. Boyce, Stubbs, & Todd, 1993), was developed because of the inadequacy of the tools available at the time, which used somatic symptoms in diagnosing depression, many of which can be “normal” in pregnancy and the postnatal period. Postnatally, a cutoff score of >9 (i.e., ≥10) has been used to indicate distress whereas a cutoff score of >12 (i.e., ≥13) is considered as being a closer correlate to a major depressive illness (Cox et al., 1987; D. Murray & Cox, 1990; L. Murray & Carothers, 1990). Note that the EPDS is not a predictive nor a diagnostic tool; it can only “detect” current emotional distress. National data from the beyondblue postnatal depression program (Buist & Bilstza, 2005) suggest that being indigenous significantly increases the risk of depression. Nationally, antenatally 8.9% of all women had an EPDS >12 compared with 19% of indigenous women, and 7.6% of all women had an EPDS >12 postnatally compared with 12% of indigenous women, with indigenous status conferring twice the risk of an EPDS >12 (Buist & Bilstza, 2005). In our study, the rates of distress for indigenous women were comparable, although somewhat higher, to these rates: 28 and 17%, respectively. This may well be related to an increased exposure to social stressors among indigenous pregnant women in Queensland; without a comparison group in this study, however, it is not possible to be certain. The elevated levels in our study could be due to the sensitivity of the screening tool in this population or an error related to the relatively small sample. A number of psychosocial factors have been found to be significant risks for depression during pregnancy and early parenthood: childhood abuse (Buist & Barnett, 1995; Buist & Janson, 2001), personality type, marital disharmony (Dennerstein et al., 1989; Goering, Lancee, & Freeman, 1992; Kumar & Robson, 1984), stressful life events (Dennerstein et al., 1989; O’Hara & Swain, 1996), and social support (Small, Astbury, Brown, & Lumley, 1994). The prevalence of most of the psychosocial stressors was high in this group of indigenous women: Nearly 1 in 2 (45.7%) of these women had a low expectation of partner support, 2 of 5 (40.2%) reported a major life event in the past 12 months, and nearly 1 in 3 (28.3%) rated their daily hassles as high (see Table 2). However, only a history of childhood abuse and domestic violence were significantly associated with high EPDS scores. This was consistent with the National beyondblue data for all Australian women which identified no partner, a past history of abuse, and emotional problems in pregnancy as being strong risk factors for an EPDS >12. The elevated risks in the Townsville group of women in relation to experiencing a major life stress in the previous 12 months, rating of daily hassles, and the expectation of no support from a partner may have reached significance in a larger study. The high prevalence of psychosocial stressors reported by these women is consistent with data from North America. Evidence from Canada and the United States has suggested the prevalence of stressful life events and stressors such as financial, physical abuse, and poor partner support is higher in Native American pregnant women than it is in non-Native American women (Walters & Simoni, 2002). However, evidence for a link between psychosocial stress and poor pregnancy outcome, preterm and low birth weight birth, has not been consistent in Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
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North American studies and studies in the developing world (W.T. Boyce et al., 1986; Cooper et al., 1999; Gennaro, 2005; Patel et al., 2003; Patel et al., 2004). The data presented in this study do suggest a link between low birth weight and perinatal stress, but the lack of power means that this must be interpreted cautiously. The broader implications of depression and psychosocial stress suggests the persistently high prevalence of these stressors in both Australia and North America among “First Nation” women remains a cause for concern and reinforces the need for intensive support of these women and their families. Perinatal depression is recognized as a significant contributor to difficulties with early childhood well-being (Wisner, Chambers, & Sit, 2006), with a wealth of evidence that has linked maternal perinatal depression and problems with cognitive and behavioral development in early childhood. In conclusion, poverty and ethnicity are not the sole contributors to pregnancy outcome. The data from this group of women suggest that the prevalence of psychosocial stressors may be high among urban indigenous pregnant women in Australia. In caring for pregnant indigenous women, health professionals need to monitor, with vigilance, social and emotional health and to structure a multidisciplinary approach to care to organize referrals and more timely support.
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Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.
