1
BIRTH 40:1 March 2013
Who Is Well After Childbirth? Factors Related to Positive Outcome Jane Henderson, BSc, MSc and Maggie Redshaw, BA, PhD, C Psychol ABSTRACT: Background: Poor outcomes after childbirth are associated with physical ill
health and with an absence of a positive sense of well-being. Postnatally poor physical health is thought to be influenced by the care received, the nature of the birth, and associated complications. The aim of this study was to estimate the effects of a range of clinical and other factors on positive outcome and well-being 3 months after childbirth. Methods: This study used data on more than 5,000 women from a 2010 National Maternity Survey about their experiences of maternity care, and health and well-being 3 months after childbirth. Positive outcome was defined as women reporting no problems and feeling “very well” at the time of the survey. Results: In the univariate analysis, several variables were significantly associated with positive outcome, including sociodemographic, antenatal, intrapartum, and postnatal factors. In the final logistic regression model, young mothers, those without physical disability and those with no or few antenatal or early postnatal problems, were most likely to have positive outcomes. Other significant factors included a positive initial reaction to the pregnancy, not reporting antenatal depression, fewer worries about the labor and birth, and access to information about choices for care. Conclusions: This study shows how positive outcomes for women after childbirth may be influenced by health, social, and care factors. It is important for caregivers to bear these factors in mind so that extra support may be made available to those women who are likely to be susceptible to poor outcome. (BIRTH 40:1 March 2013) Key words: maternal well-being, maternity survey, positive outcome, postnatal health The literature relating to birth outcomes mostly focuses on risk factors associated with poor outcome rather than looking at factors related to a good outcome. However, positive outcome is not simply the absence of illness but requires a different paradigm; it cannot be assumed that the factors that contribute to good outcomes are simply the converse of those associated with negative or poor outcomes. The factors contributing to women having a satisfying experience of early motherhood, enjoying early parenting, and feeling positive
about their role as mothers have been found, not surprisingly, to be closely associated with current mood, health problems, and tiredness (1). Woman who have been empowered in their pregnancy and birth feel better and more confident about themselves and are better able to cope with the transition to motherhood than those who do not feel this way (2,3). However, positive well-being itself in the postnatal period has less often been a focus than poor health, emotional distress, and general unhappiness (4).
Jane Henderson is a Health Service Researcher at the Policy Research Unit in Maternal Health and Care, National Perinatal Epidemiology Unit, University of Oxford, and Maggie Redshaw is a Senior Research Fellow and Social Scientist at the Policy Research Unit in Maternal Health and Care, National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom.
Address correspondence to Maggie Redshaw, BA, PhD, National Perinatal Epidemiology Unit, University of Oxford, Old Road, Oxford OX3 7LF, UK
Accepted April 13, 2012 This paper reports on an independent study which is funded by the Policy Research Program in the Department of Health. The views expressed are not necessarily those of the Department of Health. The original survey was funded by the Department of Health in 2009 to 2010, London, United Kingdom.
© 2013, Copyright the Authors Journal compilation © 2013, Wiley Periodicals, Inc..
BIRTH 40:1 March 2013
2 The influences of pregnancy, labor, and childbirth on physical and emotional health postnatally have been explored in a wide range of studies. It has been estimated that approximately 20 percent of women suffer from poor physical health and 17 percent from poor emotional health at 2 months postpartum (5). These figures, although high, represent an improvement over women’s health in late pregnancy, when poor physical health has been reported by more than one-third of women, a commonly reported pattern (6,7). The main factors associated with functional limitations postnatally appear to be poor physical health and attendant pain (5,8–10), limited education (5), financial worries (5,7,8), cesarean delivery (5,11,12), and inadequate social or partner support (5,8,10,13,14). A systematic review of the literature on postnatal social support programs, including a variety of interventions such as nurse, midwife, or pediatrician visits or telephone contact; peer support; and debriefing, found no significant benefits to women’s physical or mental health or quality of life from untargeted support programs (15). Postnatal problems appear to manifest themselves most commonly as tiredness and fatigue, headache, sleep problems, musculoskeletal problems, and breastfeeding difficulties or early interruption of breastfeeding (5,13). Postnatal depression may also predispose women to early interruption of breastfeeding (16). The aim of this study was to use data from a large sample of women responding to a national maternity survey to estimate the effects of different antenatal, labor and delivery, and postnatal factors on positive outcome and well-being 3 months after childbirth.
Methods This study used data from a 2010 survey of new mothers aimed at evaluating women’s experience and views of maternity care. A random sample of 10,000 women aged 16 years and over who had their baby in a 2-week period in England at the end of 2009 were selected by the Office for National Statistics from birth registration. Mothers whose babies had died and women aged less than 16 years were excluded from the sample. Women were sent a questionnaire, invitation letter, information leaflet, and sheet detailing contact information in a range of languages when the babies were 3 months of age. Tailored reminder letters were sent to nonrespondents after 2 weeks, another questionnaire after 4 weeks, and a final reminder letter 4 weeks later (17). The survey collected self-report data on care in the antenatal, intrapartum, and postnatal periods, as well as sociodemographic factors and how women perceived their care. For the purposes of this analysis, positive
outcome was defined as women reporting no problems and feeling “very well” in the last few days before completing the survey. The problems that women could have identified relating to health and well-being at 10 days, 1 month, and for positive outcome, 3 months after birth were “the blues,” painful stitches, breastfeeding problems, depression, wound infection, stress incontinence, fatigue or severe tiredness, backache, anxiety, difficulties or pain during intercourse, sleep problems (not related to the baby), “flash backs” to the labor or birth, and difficulties in concentrating.
Data Analysis Based on the literature about the influence of largely negative factors, a list of variables hypothesized as being associated with positive outcome was constructed before undertaking the analysis. This list included demographic factors such as ethnicity (18) and age (19); clinical factors such as type of delivery (20); individual factors such as social and partner support and antenatal mental health (21); and experiential factors such as perceptions of quality of care (4,22,23). Responses to antenatal and postnatal problem, worry and perception checklists, and a range of structured question formats (24–27) were used (see Appendix). Univariate analyses were carried out using chisquared statistics; significance was set at p < 0.01 due to the number of variables and the size of the data set. Many variables overlap in their effect on positive outcome, for example, single mothers often also have no post-compulsory education. To adjust for these overlapping factors, binary logistic regression was used to determine the most important variables associated with positive outcome. An initial binary logistic regression was carried out using sociodemographic factors with positive outcome as the dependent variable. Additional variables that were significant in the univariate analyses were entered into a binary logistic regression in one of three separate analyses on antenatal, intrapartum, or postnatal factors. Significance here was set at p < 0.05. Those variables that were significant in these logistic regressions were entered into a final model with the sociodemographic variables to determine the main factors associated with a positive outcome following pregnancy and childbirth. Analyses were conducted using SPSSX version 20 (28).
Results The response rate to the survey was 55.1 percent, with 5,333 women returning usable responses. Using data from the Office for National Statistics sampling frame,
3
BIRTH 40:1 March 2013
it was possible to compare responders and nonresponders. Compared with responders, nonresponders were slightly more likely to live in London, be single parents, be born outside the United Kingdom, be younger, live in a deprived area, be a student, or not state their occupation (17). The definition of positive outcome used (women reporting no problems and feeling “very well” in the last few days before completing the surveys that were returned a median of 3.15 months after the birth) resulted in approximately one-third of women being categorized in this way. In the univariate analysis, a considerable number of variables were significantly associated with positive outcome (Tables 1–4), including sociodemographic, antenatal, intrapartum, and postnatal factors, those associated with the woman’s health, and those associated with care received and perceptions of that care. In the logistic regression using sociodemographic variables, outcome was significantly better in women who were multiparous, young, and white ethnicity; those who had not undertaken postcompulsory education; and those without long-standing physical or mental disability (Table 5). Data are not shown for the interim logistic regressions specific to the antenatal, intrapartum, and postnatal periods, but the following variables were significant: women and partner’s reaction to the pregnancy, long-term health problems complicating the pregnancy, worries about labor, type of birth, being able to hold the baby and to breastfeed the baby soon after birth, overall satisfaction with intrapartum care, being given information at the right time to decide about care, the kindness of postnatal staff, length of postnatal stay, and postnatal problems at 10 days and at 1 month. There was no effect from living in the most deprived areas as evidenced by the area-based Index of Multiple Deprivation or single parenthood (Table 1), pregnancy planning, induction of labor, or length of labor (data not shown). In the final logistic regression, fewer variables were significantly associated with positive outcome: age less than 30 years; white ethnic group; primiparity; the woman having a positive reaction to the pregnancy (although not the partner’s reaction); not having antenatal health problems, specifically depression, or a physical disability; having fewer worries about labor and birth; having a normal delivery (specifically avoiding an instrumental delivery); describing care during labor and birth more positively; having a postnatal stay of less than 24 hours; few or no postnatal problems at 10 days and at 1 month; in general being given information at the right time to decide about care, and postnatally at home; seeing the midwife as much as wished (Table 6). The greatest benefits in terms of having a positive outcome at 3 months after childbirth were associated with
a woman being less than 30 years of age, having no physical disability, not having antenatal depression, and not having earlier postnatal health problems. Table 1. Characteristics of Women Who Had a Positive Outcome and Those Who Had One or More Problems 3 Months after Birth
Variable Age (yr)* < 20 (153) 20–24 (697) 25–29 (1,312) 30–34 (1,747) 35–39 (1,087) 40+ (272) Ethnicity White (4,487) BME (750) Age left full-time education* < 17 yr (1,150) 17 or 18 yr (1,398) 19+ yr (2,617) Still in full-time education (73) Index of Multiple Deprivation 1 (1,055) 2 (1,041) 3 (1,131) 4 (1,013) 5 (1,091) Parity Primiparous (2,610) Multiparous (2,603) Single parent Yes (605) Long-term health problem Physical problem or disability* (134) Mental health problem or learning disability* (119) Maternal health problem affecting pregnancy* (477)
No Problems and “Very Well” (%) (n = 1,771)
One or More Problems or Not “Very Well” (%) (n = 3,561)
3.2 15.2 26.7 31.1 19.2 4.6
2.7 12.3 24.0 34.2 21.3 5.5
88.8 11.2
84.1 15.9
26.3 29.7 43.0 1.0
19.8 25.2 53.5 1.6
18.9 19.8 21.7 19.3 20.4
20.2 19.4 21.0 18.9 20.5
48.7 51.3
50.7 49.3
11.5
11.5
1.3
3.2
1.0
2.9
6.2
10.5
Index of Multiple Deprivation: 1 minimum deprivation, 5 maximum deprivation; *Statistically significant differences (p < 0.01); BME = black and minority ethnic groups.
BIRTH 40:1 March 2013
4 Discussion The variables that were significantly associated with positive outcome in the final model fell into three groups: those associated with health, such as physical disability, antenatal and postnatal health problems; those associated with emotional or mental health issues, Table 2. Antenatal Factors Associated with Maternal Health and Well-Being at 3 Months Postpartum
Characteristic
One or More No Problems Problems or Not and “Very Well” “Very Well” (n = 1,771) (n = 3,561)
Reaction to pregnancy Overjoyed/pleased (4,155) 82.3 75.7 Not overjoyed/pleased 17.1 24.0 (1,156) Antenatal health problems 0–1 (1,788) 40.4 30.1 2–3 (2,000) 37.7 37.4 4 or more (1,544) 21.9 32.5 Antenatal health problem Affecting baby (1,228) 21.3 25.0 Anxiety (743) 8.4 16.7 Depression (475) 4.4 11.1 Number of worries about labor and birth 0–3 (1,677) 38.7 27.9 4–6 (1,683) 31.7 31.5 7 or more (1,972) 29.6 40.6 Antenatal interactions with midwives Talked to me in a 90.1 87.1 way I could understand (4,328) Treated me with 89.2 85.6 respect (4,269) Treated me with 89.2 85.3 kindness (4,186) Antenatal interactions with doctors Treated me with 91.6 88.5 respect (4,298) Treated me with 91.9 88.8 kindness (4,222) Overall satisfaction with antenatal care Satisfied (4,610) 92.3 85.0 Partner’s reaction to pregnancy Overjoyed/pleased (4,268) 85.8 80.9 Not overjoyed/pleased (903) 14.2 19.1 Partner’s rating of clinical communication antenatally Good (4,013) 85.2 78.6 All differences are statistically significant at p < 0.01.
Table 3. Labor and Birth Factors Associated with Maternal Health and Well-Being at 3 Months Postpartum
Characteristic
One or More No Problems Problems or Not and “Very Well” “Very Well” (n = 1,771) (n = 3,561)
Type of birth Normal vaginal (3,275)
66.6
60.4
Forceps/ventouse (661)
10.1
13.9
Planned cesarean (630)
12.1
12.0
Unplanned cesarean (675)
11.3
13.7
21.6
26.5
Not left alone by staff when worried (3,942)
81.6
72.5
Able to hold baby soon after birth (4,713)
92.7
87.4
Skin-to-skin contact after birth (4,361)
85.6
81.0
Breastfed soon after birth (3,817)
72.1
72.3
Staff communicated well (4,806)
94.5
89.7
Confidence and trust in staff (5,013)
97.6
94.6
0–3 (1,589)
24.9
32.2
4–5 (1,661)
31.1
31.2
6+ (2,082)
44.0
36.6
Episiotomy Yes (988) Care during labor
Interaction with staff
Adjective checklist count Positive terms
Negative terms 0 (3,779)
78.2
67.2
1 or more (1,553)
21.8
32.8
92.5
88.5
Midwives Talked to me in a way I could understand (4,404) Treated me with respect (4,281)
90.7
86.0
Treated me with kindness (4,238)
91.8
85.3
93.5
89.8
Doctors Talked to me in a way I could understand (3,826) Treated me with respect (3,787)
93.1
89.7
Treated me with kindness (3,763)
94.0
89.7
92.0
84.1
91.5
86.0
Overall satisfaction with labor and birth care Satisfied (4,555) Partner’s rating of staff communication during labor and birth Good (4,390)
All associations are statistically significant at p < 0.01.
5
BIRTH 40:1 March 2013
Table 4. Postnatal Factors Associated with Maternal Health and Well-Being at 3 Months Postpartum
Characteristic
One or More Problems No Problems or Not and “Very Well” “Very Well” (n = 1,771) (n = 3,561)
Length of stay 24 hr (2,077) 49.1 38.9 Mother’s view of length of stay Too long (755) 14.8 16.4 About right (3,436) 76.8 69.8 Too short (572) 8.4 13.9 Felt treated as an individual Yes (4,388) 92.6 87.7 Put baby to breast at least once Yes (4,354) 79.4 85.8 Infant feeding during first few days At least some breastmilk 60.9 63.8 (3,304) Would have preferred to see midwife More often (1,247) 16.2 27.9 Less often (224) 3.8 4.6 Saw them as much 80.1 67.5 as I wanted (3,737) During first 6 wk Postnatal support from health care professionals with settling baby to sleep Enough (1,230) 25.5 22.5 Some but not enough (618) 8.6 13.4 None (1,631) 24.6 34.4 Did not need any (1,761) 41.3 29.7 Postnatal support from health care professionals with feeding Enough (2,983) 58.7 56.1 Some but not enough (937) 11.4 21.2 None (360) 6.4 7.1 Did not need any (954) 23.6 15.5 Postnatal support from health care professionals with baby’s crying Enough (1,268) 27.0 22.9 Some but not enough (663) 9.0 14.6 None (1,464) 22.2 31.0 Did not need any (1,819) 41.7 31.4 Overall satisfaction with postnatal care Satisfied or very 84.4 72.1 Satisfied (4,007) Partner’s rating of clinical communication postnatally Very well or well (3,711) 81.4 71.3 Not very well or not 18.6 28.7 at all (1,259) (continued)
Table 4 (continued)
Characteristic
One or More Problems No Problems or Not and “Very Well” “Very Well” (n = 1,771) (n = 3,561)
Partner postnatal involvement score > Median (2,423) 51.3 44.8 Postnatal problem count at 10 days 0 (1,026) 28.6 14.6 1+ (4,306) 71.4 85.4 Postnatal problem count at 1 mo 0 (2,018) 58.4 27.6 1+ (3,314) 41.6 72.4 Met postnatal midwives antenatally All (1,195) 25.2 21.8 Some (2,314) 44.8 44.2 None (1,702) 30.1 34.0 Had confidence and trust in midwives seen after going home Always/sometimes (5,001) 97.7 94.9 Postnatally have talked to health care professional about labor Yes (125) 42.3 46.3 Overall given enough information about choices regarding care Yes (3,120) 69.3 54.8 To some extent (1,692) 24.2 36.5 No (417) 6.5 8.7 Overall given enough information to help decide about care Yes (3,307) 72.1 58.9 To some extent (1,467) 21.6 31.4 No (449) 6.3 9.8 Given information at right time Yes (3,225) 72.3 56.8 To some extent (1,499) 21.1 32.7 No (478) 6.7 10.5 Postnatal staff interaction Staff talked so could 90.1 84.9 understand (3,991) Staff respectful (3,618) 83.7 76.9 Staff kind (3,588) 85.5 76.5 All associations are statistically significant at p < 0.01.
such as the woman’s reaction to the pregnancy and the number of worries she had antenatally about labor and birth; and care factors such as seeing the midwife as much as she wanted postnatally at home and getting information at the right time. Many of the variables that were associated with positive outcome at 3 months were clearly related, at least in part, to the women’s health, including both direct
BIRTH 40:1 March 2013
6 indicators of health and indirect markers such as age, parity, type of delivery, and length of postnatal stay. The effect of age was clear with older women being nearly half as likely as younger women to have a positive outcome at 3 months, which is consistent with a similar pattern in other studies (19). The effect of parity was less clear: Multiparous women were more likely to have a positive outcome than primiparous women before adjustment, but less likely after adjusting for type of delivery and early postnatal health problems. This finding may be due to the effect of having to look after an older child or children as well as a newborn, and therefore, although perhaps having fewer direct
Table 5. Binary Logistic Regression: The Influence of Sociodemographic Factors and Individual Characteristics on Positive Outcome
Variable Age (yr)
BIRTH 40:1 March 2013
Who Is Well After Childbirth? Factors Related to Positive Outcome Jane Henderson, BSc, MSc and Maggie Redshaw, BA, PhD, C Psychol ABSTRACT: Background: Poor outcomes after childbirth are associated with physical ill
health and with an absence of a positive sense of well-being. Postnatally poor physical health is thought to be influenced by the care received, the nature of the birth, and associated complications. The aim of this study was to estimate the effects of a range of clinical and other factors on positive outcome and well-being 3 months after childbirth. Methods: This study used data on more than 5,000 women from a 2010 National Maternity Survey about their experiences of maternity care, and health and well-being 3 months after childbirth. Positive outcome was defined as women reporting no problems and feeling “very well” at the time of the survey. Results: In the univariate analysis, several variables were significantly associated with positive outcome, including sociodemographic, antenatal, intrapartum, and postnatal factors. In the final logistic regression model, young mothers, those without physical disability and those with no or few antenatal or early postnatal problems, were most likely to have positive outcomes. Other significant factors included a positive initial reaction to the pregnancy, not reporting antenatal depression, fewer worries about the labor and birth, and access to information about choices for care. Conclusions: This study shows how positive outcomes for women after childbirth may be influenced by health, social, and care factors. It is important for caregivers to bear these factors in mind so that extra support may be made available to those women who are likely to be susceptible to poor outcome. (BIRTH 40:1 March 2013) Key words: maternal well-being, maternity survey, positive outcome, postnatal health The literature relating to birth outcomes mostly focuses on risk factors associated with poor outcome rather than looking at factors related to a good outcome. However, positive outcome is not simply the absence of illness but requires a different paradigm; it cannot be assumed that the factors that contribute to good outcomes are simply the converse of those associated with negative or poor outcomes. The factors contributing to women having a satisfying experience of early motherhood, enjoying early parenting, and feeling positive
about their role as mothers have been found, not surprisingly, to be closely associated with current mood, health problems, and tiredness (1). Woman who have been empowered in their pregnancy and birth feel better and more confident about themselves and are better able to cope with the transition to motherhood than those who do not feel this way (2,3). However, positive well-being itself in the postnatal period has less often been a focus than poor health, emotional distress, and general unhappiness (4).
Jane Henderson is a Health Service Researcher at the Policy Research Unit in Maternal Health and Care, National Perinatal Epidemiology Unit, University of Oxford, and Maggie Redshaw is a Senior Research Fellow and Social Scientist at the Policy Research Unit in Maternal Health and Care, National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom.
Address correspondence to Maggie Redshaw, BA, PhD, National Perinatal Epidemiology Unit, University of Oxford, Old Road, Oxford OX3 7LF, UK
Accepted April 13, 2012 This paper reports on an independent study which is funded by the Policy Research Program in the Department of Health. The views expressed are not necessarily those of the Department of Health. The original survey was funded by the Department of Health in 2009 to 2010, London, United Kingdom.
© 2013, Copyright the Authors Journal compilation © 2013, Wiley Periodicals, Inc..
BIRTH 40:1 March 2013
2 The influences of pregnancy, labor, and childbirth on physical and emotional health postnatally have been explored in a wide range of studies. It has been estimated that approximately 20 percent of women suffer from poor physical health and 17 percent from poor emotional health at 2 months postpartum (5). These figures, although high, represent an improvement over women’s health in late pregnancy, when poor physical health has been reported by more than one-third of women, a commonly reported pattern (6,7). The main factors associated with functional limitations postnatally appear to be poor physical health and attendant pain (5,8–10), limited education (5), financial worries (5,7,8), cesarean delivery (5,11,12), and inadequate social or partner support (5,8,10,13,14). A systematic review of the literature on postnatal social support programs, including a variety of interventions such as nurse, midwife, or pediatrician visits or telephone contact; peer support; and debriefing, found no significant benefits to women’s physical or mental health or quality of life from untargeted support programs (15). Postnatal problems appear to manifest themselves most commonly as tiredness and fatigue, headache, sleep problems, musculoskeletal problems, and breastfeeding difficulties or early interruption of breastfeeding (5,13). Postnatal depression may also predispose women to early interruption of breastfeeding (16). The aim of this study was to use data from a large sample of women responding to a national maternity survey to estimate the effects of different antenatal, labor and delivery, and postnatal factors on positive outcome and well-being 3 months after childbirth.
Methods This study used data from a 2010 survey of new mothers aimed at evaluating women’s experience and views of maternity care. A random sample of 10,000 women aged 16 years and over who had their baby in a 2-week period in England at the end of 2009 were selected by the Office for National Statistics from birth registration. Mothers whose babies had died and women aged less than 16 years were excluded from the sample. Women were sent a questionnaire, invitation letter, information leaflet, and sheet detailing contact information in a range of languages when the babies were 3 months of age. Tailored reminder letters were sent to nonrespondents after 2 weeks, another questionnaire after 4 weeks, and a final reminder letter 4 weeks later (17). The survey collected self-report data on care in the antenatal, intrapartum, and postnatal periods, as well as sociodemographic factors and how women perceived their care. For the purposes of this analysis, positive
outcome was defined as women reporting no problems and feeling “very well” in the last few days before completing the survey. The problems that women could have identified relating to health and well-being at 10 days, 1 month, and for positive outcome, 3 months after birth were “the blues,” painful stitches, breastfeeding problems, depression, wound infection, stress incontinence, fatigue or severe tiredness, backache, anxiety, difficulties or pain during intercourse, sleep problems (not related to the baby), “flash backs” to the labor or birth, and difficulties in concentrating.
Data Analysis Based on the literature about the influence of largely negative factors, a list of variables hypothesized as being associated with positive outcome was constructed before undertaking the analysis. This list included demographic factors such as ethnicity (18) and age (19); clinical factors such as type of delivery (20); individual factors such as social and partner support and antenatal mental health (21); and experiential factors such as perceptions of quality of care (4,22,23). Responses to antenatal and postnatal problem, worry and perception checklists, and a range of structured question formats (24–27) were used (see Appendix). Univariate analyses were carried out using chisquared statistics; significance was set at p < 0.01 due to the number of variables and the size of the data set. Many variables overlap in their effect on positive outcome, for example, single mothers often also have no post-compulsory education. To adjust for these overlapping factors, binary logistic regression was used to determine the most important variables associated with positive outcome. An initial binary logistic regression was carried out using sociodemographic factors with positive outcome as the dependent variable. Additional variables that were significant in the univariate analyses were entered into a binary logistic regression in one of three separate analyses on antenatal, intrapartum, or postnatal factors. Significance here was set at p < 0.05. Those variables that were significant in these logistic regressions were entered into a final model with the sociodemographic variables to determine the main factors associated with a positive outcome following pregnancy and childbirth. Analyses were conducted using SPSSX version 20 (28).
Results The response rate to the survey was 55.1 percent, with 5,333 women returning usable responses. Using data from the Office for National Statistics sampling frame,
3
BIRTH 40:1 March 2013
it was possible to compare responders and nonresponders. Compared with responders, nonresponders were slightly more likely to live in London, be single parents, be born outside the United Kingdom, be younger, live in a deprived area, be a student, or not state their occupation (17). The definition of positive outcome used (women reporting no problems and feeling “very well” in the last few days before completing the surveys that were returned a median of 3.15 months after the birth) resulted in approximately one-third of women being categorized in this way. In the univariate analysis, a considerable number of variables were significantly associated with positive outcome (Tables 1–4), including sociodemographic, antenatal, intrapartum, and postnatal factors, those associated with the woman’s health, and those associated with care received and perceptions of that care. In the logistic regression using sociodemographic variables, outcome was significantly better in women who were multiparous, young, and white ethnicity; those who had not undertaken postcompulsory education; and those without long-standing physical or mental disability (Table 5). Data are not shown for the interim logistic regressions specific to the antenatal, intrapartum, and postnatal periods, but the following variables were significant: women and partner’s reaction to the pregnancy, long-term health problems complicating the pregnancy, worries about labor, type of birth, being able to hold the baby and to breastfeed the baby soon after birth, overall satisfaction with intrapartum care, being given information at the right time to decide about care, the kindness of postnatal staff, length of postnatal stay, and postnatal problems at 10 days and at 1 month. There was no effect from living in the most deprived areas as evidenced by the area-based Index of Multiple Deprivation or single parenthood (Table 1), pregnancy planning, induction of labor, or length of labor (data not shown). In the final logistic regression, fewer variables were significantly associated with positive outcome: age less than 30 years; white ethnic group; primiparity; the woman having a positive reaction to the pregnancy (although not the partner’s reaction); not having antenatal health problems, specifically depression, or a physical disability; having fewer worries about labor and birth; having a normal delivery (specifically avoiding an instrumental delivery); describing care during labor and birth more positively; having a postnatal stay of less than 24 hours; few or no postnatal problems at 10 days and at 1 month; in general being given information at the right time to decide about care, and postnatally at home; seeing the midwife as much as wished (Table 6). The greatest benefits in terms of having a positive outcome at 3 months after childbirth were associated with
a woman being less than 30 years of age, having no physical disability, not having antenatal depression, and not having earlier postnatal health problems. Table 1. Characteristics of Women Who Had a Positive Outcome and Those Who Had One or More Problems 3 Months after Birth
Variable Age (yr)* < 20 (153) 20–24 (697) 25–29 (1,312) 30–34 (1,747) 35–39 (1,087) 40+ (272) Ethnicity White (4,487) BME (750) Age left full-time education* < 17 yr (1,150) 17 or 18 yr (1,398) 19+ yr (2,617) Still in full-time education (73) Index of Multiple Deprivation 1 (1,055) 2 (1,041) 3 (1,131) 4 (1,013) 5 (1,091) Parity Primiparous (2,610) Multiparous (2,603) Single parent Yes (605) Long-term health problem Physical problem or disability* (134) Mental health problem or learning disability* (119) Maternal health problem affecting pregnancy* (477)
No Problems and “Very Well” (%) (n = 1,771)
One or More Problems or Not “Very Well” (%) (n = 3,561)
3.2 15.2 26.7 31.1 19.2 4.6
2.7 12.3 24.0 34.2 21.3 5.5
88.8 11.2
84.1 15.9
26.3 29.7 43.0 1.0
19.8 25.2 53.5 1.6
18.9 19.8 21.7 19.3 20.4
20.2 19.4 21.0 18.9 20.5
48.7 51.3
50.7 49.3
11.5
11.5
1.3
3.2
1.0
2.9
6.2
10.5
Index of Multiple Deprivation: 1 minimum deprivation, 5 maximum deprivation; *Statistically significant differences (p < 0.01); BME = black and minority ethnic groups.
BIRTH 40:1 March 2013
4 Discussion The variables that were significantly associated with positive outcome in the final model fell into three groups: those associated with health, such as physical disability, antenatal and postnatal health problems; those associated with emotional or mental health issues, Table 2. Antenatal Factors Associated with Maternal Health and Well-Being at 3 Months Postpartum
Characteristic
One or More No Problems Problems or Not and “Very Well” “Very Well” (n = 1,771) (n = 3,561)
Reaction to pregnancy Overjoyed/pleased (4,155) 82.3 75.7 Not overjoyed/pleased 17.1 24.0 (1,156) Antenatal health problems 0–1 (1,788) 40.4 30.1 2–3 (2,000) 37.7 37.4 4 or more (1,544) 21.9 32.5 Antenatal health problem Affecting baby (1,228) 21.3 25.0 Anxiety (743) 8.4 16.7 Depression (475) 4.4 11.1 Number of worries about labor and birth 0–3 (1,677) 38.7 27.9 4–6 (1,683) 31.7 31.5 7 or more (1,972) 29.6 40.6 Antenatal interactions with midwives Talked to me in a 90.1 87.1 way I could understand (4,328) Treated me with 89.2 85.6 respect (4,269) Treated me with 89.2 85.3 kindness (4,186) Antenatal interactions with doctors Treated me with 91.6 88.5 respect (4,298) Treated me with 91.9 88.8 kindness (4,222) Overall satisfaction with antenatal care Satisfied (4,610) 92.3 85.0 Partner’s reaction to pregnancy Overjoyed/pleased (4,268) 85.8 80.9 Not overjoyed/pleased (903) 14.2 19.1 Partner’s rating of clinical communication antenatally Good (4,013) 85.2 78.6 All differences are statistically significant at p < 0.01.
Table 3. Labor and Birth Factors Associated with Maternal Health and Well-Being at 3 Months Postpartum
Characteristic
One or More No Problems Problems or Not and “Very Well” “Very Well” (n = 1,771) (n = 3,561)
Type of birth Normal vaginal (3,275)
66.6
60.4
Forceps/ventouse (661)
10.1
13.9
Planned cesarean (630)
12.1
12.0
Unplanned cesarean (675)
11.3
13.7
21.6
26.5
Not left alone by staff when worried (3,942)
81.6
72.5
Able to hold baby soon after birth (4,713)
92.7
87.4
Skin-to-skin contact after birth (4,361)
85.6
81.0
Breastfed soon after birth (3,817)
72.1
72.3
Staff communicated well (4,806)
94.5
89.7
Confidence and trust in staff (5,013)
97.6
94.6
0–3 (1,589)
24.9
32.2
4–5 (1,661)
31.1
31.2
6+ (2,082)
44.0
36.6
Episiotomy Yes (988) Care during labor
Interaction with staff
Adjective checklist count Positive terms
Negative terms 0 (3,779)
78.2
67.2
1 or more (1,553)
21.8
32.8
92.5
88.5
Midwives Talked to me in a way I could understand (4,404) Treated me with respect (4,281)
90.7
86.0
Treated me with kindness (4,238)
91.8
85.3
93.5
89.8
Doctors Talked to me in a way I could understand (3,826) Treated me with respect (3,787)
93.1
89.7
Treated me with kindness (3,763)
94.0
89.7
92.0
84.1
91.5
86.0
Overall satisfaction with labor and birth care Satisfied (4,555) Partner’s rating of staff communication during labor and birth Good (4,390)
All associations are statistically significant at p < 0.01.
5
BIRTH 40:1 March 2013
Table 4. Postnatal Factors Associated with Maternal Health and Well-Being at 3 Months Postpartum
Characteristic
One or More Problems No Problems or Not and “Very Well” “Very Well” (n = 1,771) (n = 3,561)
Length of stay 24 hr (2,077) 49.1 38.9 Mother’s view of length of stay Too long (755) 14.8 16.4 About right (3,436) 76.8 69.8 Too short (572) 8.4 13.9 Felt treated as an individual Yes (4,388) 92.6 87.7 Put baby to breast at least once Yes (4,354) 79.4 85.8 Infant feeding during first few days At least some breastmilk 60.9 63.8 (3,304) Would have preferred to see midwife More often (1,247) 16.2 27.9 Less often (224) 3.8 4.6 Saw them as much 80.1 67.5 as I wanted (3,737) During first 6 wk Postnatal support from health care professionals with settling baby to sleep Enough (1,230) 25.5 22.5 Some but not enough (618) 8.6 13.4 None (1,631) 24.6 34.4 Did not need any (1,761) 41.3 29.7 Postnatal support from health care professionals with feeding Enough (2,983) 58.7 56.1 Some but not enough (937) 11.4 21.2 None (360) 6.4 7.1 Did not need any (954) 23.6 15.5 Postnatal support from health care professionals with baby’s crying Enough (1,268) 27.0 22.9 Some but not enough (663) 9.0 14.6 None (1,464) 22.2 31.0 Did not need any (1,819) 41.7 31.4 Overall satisfaction with postnatal care Satisfied or very 84.4 72.1 Satisfied (4,007) Partner’s rating of clinical communication postnatally Very well or well (3,711) 81.4 71.3 Not very well or not 18.6 28.7 at all (1,259) (continued)
Table 4 (continued)
Characteristic
One or More Problems No Problems or Not and “Very Well” “Very Well” (n = 1,771) (n = 3,561)
Partner postnatal involvement score > Median (2,423) 51.3 44.8 Postnatal problem count at 10 days 0 (1,026) 28.6 14.6 1+ (4,306) 71.4 85.4 Postnatal problem count at 1 mo 0 (2,018) 58.4 27.6 1+ (3,314) 41.6 72.4 Met postnatal midwives antenatally All (1,195) 25.2 21.8 Some (2,314) 44.8 44.2 None (1,702) 30.1 34.0 Had confidence and trust in midwives seen after going home Always/sometimes (5,001) 97.7 94.9 Postnatally have talked to health care professional about labor Yes (125) 42.3 46.3 Overall given enough information about choices regarding care Yes (3,120) 69.3 54.8 To some extent (1,692) 24.2 36.5 No (417) 6.5 8.7 Overall given enough information to help decide about care Yes (3,307) 72.1 58.9 To some extent (1,467) 21.6 31.4 No (449) 6.3 9.8 Given information at right time Yes (3,225) 72.3 56.8 To some extent (1,499) 21.1 32.7 No (478) 6.7 10.5 Postnatal staff interaction Staff talked so could 90.1 84.9 understand (3,991) Staff respectful (3,618) 83.7 76.9 Staff kind (3,588) 85.5 76.5 All associations are statistically significant at p < 0.01.
such as the woman’s reaction to the pregnancy and the number of worries she had antenatally about labor and birth; and care factors such as seeing the midwife as much as she wanted postnatally at home and getting information at the right time. Many of the variables that were associated with positive outcome at 3 months were clearly related, at least in part, to the women’s health, including both direct
BIRTH 40:1 March 2013
6 indicators of health and indirect markers such as age, parity, type of delivery, and length of postnatal stay. The effect of age was clear with older women being nearly half as likely as younger women to have a positive outcome at 3 months, which is consistent with a similar pattern in other studies (19). The effect of parity was less clear: Multiparous women were more likely to have a positive outcome than primiparous women before adjustment, but less likely after adjusting for type of delivery and early postnatal health problems. This finding may be due to the effect of having to look after an older child or children as well as a newborn, and therefore, although perhaps having fewer direct
Table 5. Binary Logistic Regression: The Influence of Sociodemographic Factors and Individual Characteristics on Positive Outcome
Variable Age (yr)
