Factors associated with perinatal depression among Jordanian women by Khitam Mohammad

1. 0 Factors associated with perinatal depression among Jordanian women by Khitam Mohammad Assistant Professor at Faculty of Nursing, Jordan University of Science & Technology, Jordan, Dr Jenny Gamble & Professor Debra Creedy, Griffith Health, Griffith University, Australia

2. 0 Overview of the study • Background about perinatal depression and maternity care in Jordan • Research problem • Literature review • Objectives and hypothesis • Methods • Results • Discussion and conclusion • Implications for midwifery and maternity care

3. 0 Background Depression in general, and in new mothers, has been extensively studied during the last few decades in western countries. Studies from non-industrialisedcountries beginning to emerge (Abiodun, 2006; Andajani-Sutjahjo et al., 2007). A 22% prevalence of PND in United Arab Emirates (Green et al., 2006) Few studies related to pregnancy, childbirth and postpartum experiences of women from Middle Eastern countries. Given the status of women in Middle Eastern countries, there is a need to investigate psychological well-being following childbirth.

4. 0 Jordanian maternal health care • Primary health care services now reach up to 90% of the population (Abushaikha & Oweis, 2004). • Maternity services are currently focused on screening and treating complications of childbearing. • Most of the births in both public or private hospitals are performed by resident doctors or obstetricians. The midwives role is to take women’s vital signs, apply cardiotocographs and assist doctors in conductingdeliveries.

5. 0 • Labour and birth medicalised with frequent interventions such as vaginal examinations and episiotomy. • The care givers are not regarded as supportive and helpful during pregnancy, birth, or postpartum and health practitioners rarely provide emotional care, or antenatal/ postpartum education. • Health professionals, not women, are the primary decision-makers about procedures during pregnancy, birth, and postpartum. • Women are often constrained by a range of social and cultural norms that may make it unacceptable for them to express negative emotions associated with pregnancy and childbirth.

6. 0 Research problem • High levels of medical intervention in combination with a lack of continuity of care, emphasis on medical procedures, lack of privacy, poor client-provider relationship, and absence of emotional care may contribute to emotional distress in the postpartum period. • The present study investigated the factors associated with perinatal depression in Jordanian women.

7. Literature Review: Birth experience and obstetric complications • Pregnancy or labour complications have been inconsistently related to perinatal depression. Some studies report more frequent mood disturbances in women with more stress, pregnancy or labour complications (Agoub et al., 2005; Alami et al., 2006; Saisto et al., 2001). For example, Yoshida et al. (1997) found an association between perinatal depression and operative birth, difficult labour, and long labour (longer than 12 hours). • Other studies reported that obstetric factors, such as induction or augmentation of labour, episiotomy, or being referred during pregnancy or labour for complications were not associated with perinatal depression (Feinman, 1997, Forman et al., 2001; Josefsson et al., 2001). • Negative birth experiences, including absence of a support person and perceived unhelpfulness of staff are seen to be at increased risk of perinatal depression (Willinck & cotton, 2004).

8. Literature review: Dissatisfaction with intrapartum care • Factors related to the dissatisfaction with intrapartum care as reported by Brown and Lumley (1994) were: insufficient information given to the women, perception that health care providers were unhelpful, lack of involvement in decision-making, and higher score of obstetric intervention. • Brown and Lumley (1998b) reported in another study that factors related to women’s dissatisfaction with their care during labour were unhelpful care givers (midwives and doctors) and not having an active say in decisions. • Women’s dissatisfaction with their labour and birth experience is associated with depressed mood postpartum and in subsequent pregnancies, a request for caesarean section in a subsequent pregnancy, and unwillingness to have another baby (Waldenstrom et al., 2004).

9. 0 Research Objectives To identify factors associated with the development of perinatal depression. Research hypotheses 1. Increased obstetric interventions during labour and birth are positively related to the development of perinatal depression. 2. Women’s perception of care received during labour and birth is negatively related to the development of PND

10. 0 Method • A longitudinal prospective design. • Conducted with 353 Jordanian women • aged between 18 and 45 years old • low-risk pregnancy • third trimester • recruited from selected maternity health care centres and hospital in Irbid city, Jordan. • Women were followed up at six to eight weeks postpartum and six months postpartum.

11. 0 Main outcomes measures 1. Edinburgh Postnatal Depression Scale (EPDS) - cut-off of >12 2. Maternity Social Support Scale (MSSS) - grouped into three categories: lowsupport (<19), medium support (19-24), & adequate support (>24). 3. Labour and Postnatal Care Questionnaire • Data was collected between November 2005 and August 2006. • Ethical clearance was obtained prior to data collection. • This study is a part of PhD thesis which was funded by Jordan University of Science & Technology, Jordan

12. Results Percentage of women who scored >12 in EPDS and <19 in MSSS during pregnancy, six to eight weeks and six months postpartum Measure During 6-8 weeks 6 months pregnancy postpartum postpartum EPDS >12 19% 22.1% 21.2% MSSS <19 39.1% 42.5% 40.5%

13. 0 Perinatal variables associated with perinatal depression at six to eight week postpartum Variable 2 df Significance Labour >11 hours 5.063 1 0.024* No of vaginal examinations >8 18.063 1 < 0.001* Lithotomy position 42.250 1 < 0.001* Episiotomy 15.034 2 0.001* Required sutures 19.600 1 < 0.001* Labour more painful than expected 61.906 2 < 0.001* Overall poor quality of care 8.667 1 0.003* Worried, frightened or anxious when labour first began 5.063 1 0.024* Not confident in labour 10.051 1 0.002 Feeling out of control 16.615 1 < 0.001* * = Statistically significant association

14. 0 Perinatal variables associated with perinatal depression at six months postpartum Variable 2 df Significance Labour >11 hours 73.385 4 < 0.001* No of vaginal examinations >8 6.785 1 0.009* Lithotomy position 36.938 1 < 0.001* Episiotomy 16.421 2 < 0.001* Required sutures 16.941 1 < 0.001* Labour more painful than expected 50.262 3 < 0.001* Overall poor quality of care 5.880 1 0.015* Worried, frightened or anxious when labour first began 38.800 2 < 0.001 * Not confident in labour 8.333 1 0.004* Feeling out of control 22.413 1 < 0.001* * = Statistically significant association

15. 0 • There were 21.2% of respondants who scored 13 or above on the EPDS. • Results showed that poor social support, stressful childbirth experiences, obstetric events, dissatisfaction with overall care during labour and birth, and feelings whilst in labour were all associated with perinatal depression.

16. Conclusion • The results confirm that dissatisfaction with support and care women received during their labour and birth, and feelings associated with lack of control and fear during labour and birth increased women’s risk of developing perinatal depression. Implications • Improving antenatal education • Closing the evidence- practice gap • Ensuring that health care providers are more supportive • Involving women in decision making regarding their care & respecting their choices. • Implementing culturally appropriate practices such as involvement of women’s female relatives in maternity care

17. 0 Thank You