Social and Behavioral Problems in School-Aged Children After Maternal Postpartum Depression: A Secondary Analysis of Future of Families and Child Wellbeing Study.

OBJECTIVES: To examine the relation between perinatal depression at child age 1 year and behavioral issues and altered social functioning at school age. METHODS: The Future of Families (formerly Fragile Families) and Child Wellbeing Study longitudinal cohort age 9 nationally representative urban sample was used to examine associations between maternal depression at child age 1 and child behavior and social functioning at age 9 (n = 2,305 children and their mothers). Measures included the Composite International Diagnostics Interview (depression), Child Behavior Checklist total score (child behavior problems) and social function subscale. Clinical significance of child behavior problems and social function problems were determined by normed T-scores. Analyses included chi square, t-tests, and linear regression using SAS 9.4 Survey procedures. RESULTS: Higher household income was associated with lower behavior problem scores (F = 8.76, p < 0.0001, R2 = 0.07. School-aged children whose mothers had major depression at child age 1 (10.8%) were more than twice as likely to have clinically significant behavior problems (OR 2.46, p < 0.0001) than children whose mothers did not have depression (4.1%). Further, children with depressed mothers were more than twice as likely to have clinically significant social function problems than children whose mothers were not depressed (OR = 2.09, p < 0.0001). CONCLUSIONS FOR PRACTICE: Children whose mothers were depressed at child age 1 have higher risk of having behavior problems and poor social functioning at age 9. Early and repeated maternal depression screening is needed to treat the disease sooner and attempt to avoid these outcomes.

The impact of anencephaly on parents: A mixed-methods study.

This study used a convergent parallel mixed-method design to explore the impact of an anencephalic pregnancy on parents. Twenty women and four men between 18-59 years old participated. Interview transcripts were analyzed using interpretive phenomenology and synthesized with Perinatal Grief Intensity Scale scores using a Pearson's correlation. Overall, 75% of parents scored intense grief. Qualitative patterns included overwhelming trauma, patient-centeredness as critical, stigmatizing perinatal loss, embracing personhood, and reframing reality. Control over care was associated with decreased grief (p =.019). Health care professionals are ideally positioned to reduce the risk of intense grief in parents experiencing an anencephalic pregnancy.

Arab Muslims' Perceptions of Perinatal Loss Care in the United States of America.

One in four American women will experience a miscarriage, stillbirth or neonatal death each time she becomes pregnant. These perinatal losses occur even more frequently in women who are immigrants from developing countries. Care of Muslim families after perinatal loss is based primarily on expert opinion as opposed to research evidence, as few, if any, studies exist on this topic. It is critically important to know what parent's preferences for care actually are, since care that is incongruent with the desires of the bereaved parents may intensify their grief. The purpose of this study was to examine the perceptions and attitudes of immigrant Arab Muslims regarding psychosocial bereavement practices common in the United States after perinatal loss and to pilot test an investigator-developed instrument for collecting data regarding culturally relevant psychosocial bereavement practices of immigrant Arab Muslims after perinatal loss. The study employed a cross-sectional survey design using an investigator-developed instrument entitled the Arab Muslim Perceptions of Perinatal Loss Care (AMPPLC). The AMPPLC, available in both English and Arabic, was used to collect data on perinatal loss care from a convenience sample of 79 immigrant Arab Muslim adults (male n = 43 [54.4%]; female n = 36 [45.6%]). The study opened in June 2017 and closed in August 2019. The AMPPLC instrument demonstrated good reliability (α = 0.89) in measuring participants' responses. Responses by survey participants did not always agree with prior published literature on Muslim preferences after a loss. Optimal care for Arab Muslim immigrants involves offering all options that are typically part of Western bereavement care as well as options that may be more specifically associated with Islam. This information will enable healthcare providers to provide more culturally sensitive and compassionate care to Middle Eastern Muslim parents during this difficult and tragic experience.

The Role of Helplessness in the Appraisal of Illness Uncertainty in Women With Fibromyalgia.

Fibromyalgia is a chronic pain disorder characterized by uncertainty in etiology, symptomatology, diagnosis, treatment, and outcome. The high level of illness uncertainty that results from fibromyalgia is a risk factor for maladjustment to illness. A cross-sectional survey design was used to examine the relationships among illness uncertainty, helplessness, and subjective well-being in 138 women with fibromyalgia. Multiple regression analyses were conducted to examine a predictive model for mediation. We found illness uncertainty is negatively associated with subjective well-being and that helplessness strongly influences the impact of illness uncertainty on subjective well-being in women with fibromyalgia.

Using Theory to Inform and Guide Perinatal Bereavement Care.

Providing nursing care to perinatally bereaved women and their families is difficult, emotionally demanding, and complicated. Here we demonstrate how, through understanding the theoretical underpinnings of Guided Participation and perinatal grief intensity, nurses can significantly expand their competence and confidence in their ability to provide highly individualized, supportive, relationship-based perinatal bereavement care. The way that parents respond to a perinatal loss may range from little response to highly intense, long-lasting grief. Grief after such losses may be intensified when the loss experience is highly incongruent with a parent's expectations, and the parent is unable to act to reduce this incongruence. The Hutti Perinatal Grief Intensity theoretical framework and the Perinatal Grief Intensity Scale may be used to help identify parents who are likely to experience highly intense grief and need for professional follow-up after perinatal loss. However, many parents who experience intense grief have little experience in coping with such feelings. Guided Participation is a middle-range theory of teaching and learning. It is used in the context of perinatal bereavement to help bereaved parents navigate the feelings and numerous grief-related issues that occur as a consequence of the loss, with the nurse serving as the expert guide. This combined theoretical approach to care assists nurses to assess grief intensity and to provide highly effective, relationship-driven care.

Predicting Need for Follow-Up Due to Severe Anxiety and Depression Symptoms After Perinatal Loss.

OBJECTIVE: To evaluate the ability of the Perinatal Grief Intensity Scale (PGIS) when used within 8 weeks of perinatal loss to predict intense anxiety and severe depression symptoms in women 3 months later (Time 2 [T2]). DESIGN: Prospective survey. SETTING: Participants were recruited from hospitals in Louisville, KY and via the Internet. PARTICIPANTS: Women (N = 103) who experienced perinatal loss. METHODS: Data were collected using the PGIS, Beck Anxiety Inventory, and the Center for Epidemiologic Studies Depression Scale. We used logistic regression, odds ratios, and receiver operating characteristic curve analysis. RESULTS: The PGIS had 97.9% sensitivity and 29.6% specificity to predict severe depression symptoms and 95.2% sensitivity and 56.2% specificity to predict intense anxiety at T2. A baseline PGIS score greater than or equal to 3.53 predicted severe depression symptoms (odds ratio = 1.82, 95% confidence interval [CI] [1.46, 2.18], p = .014) and intense anxiety (odds ratio = 1.43, 95% CI [1.07, 1.82], p = .029) at T2. The receiver operating characteristic curves of the PGIS suggest the PGIS performs well at predicting (screening positive) for severe depression symptoms (area under the curve = 0.86, 95% CI [0.79, 0.94], p < .001) and intense anxiety (area under the curve = 0.86, 95% CI [0.78, 0.93], p < .001) after perinatal loss. CONCLUSION: The PGIS accurately predicted intense anxiety and severe depression symptoms 3 to 5 months after perinatal loss. This instrument may help health care providers identify women who need further mental health evaluation after perinatal loss.

Predicting grief intensity after recent perinatal loss.

OBJECTIVE: The Perinatal Grief Intensity Scale (PGIS) was developed for clinical use to identify and predict intense grief and need for follow-up after perinatal loss. This study evaluates the validity of the PGIS via its ability to predict future intense grief based on a PGIS score obtained early after a loss. METHODS: A prospective observational study was conducted with 103 international, English-speaking women recruited at hospital discharge or via the internet who experienced a miscarriage, stillbirth, or neonatal death within the previous 8weeks. Survey data were collected at baseline using the PGIS and the Perinatal Grief Scale (PGS). Follow-up data on the PGS were obtained 3months later. Data analysis included descriptive statistics, Cronbach's alpha, receiver operating characteristic curve analysis, and confirmatory factor analysis. RESULTS: Cronbach's alphas were ≥0.70 for both instruments. PGIS factor analysis yielded three factors as predicted, explaining 57.7% of the variance. The optimal cutoff identified for the PGIS was 3.535. No difference was found when the ability of the PGIS to identify intense grief was compared to the PGS (p=0.754). The PGIS was not inferior to the PGS (AUC=0.78, 95% CI 0.68-0.88, p<0.001) in predicting intense grief at the follow-up. A PGIS score≥3.53 at baseline was associated with increased grief intensity at Time 2 (PGS: OR=1.97, 95% CI 1.59-2.34, p<0.001). CONCLUSIONS: The PGIS is comparable to the PGS, has a lower response burden, and can reliably and validly predict women who may experience future intense grief associated with perinatal loss.

Experiences of Nurses Who Care for Women After Fetal Loss.

OBJECTIVE: To examine the experiences of, meaning for, and personal consequences for obstetric, emergency, and surgical nurses caring for women after fetal death and to determine how these nurses use Swanson's caring processes in providing such care. DESIGN: Four focus groups. SETTING: Two hospitals within the same health care system. PARTICIPANTS: Registered nurses (N = 24) working in the obstetric, surgery, or emergency departments. METHODS: Swanson's Theory of Caring guided focus group questions that were audiotaped and transcribed verbatim. Data were analyzed using a continuously emergent process of data collection, data reduction, data display, and interpretation. RESULTS: All participants demonstrated all of Swanson's caring processes but used them preferentially according to situational exigencies and level of rapport with each woman. Nurses had positive and negative feelings associated with caring for women after fetal loss. CONCLUSIONS: Obstetric nurses provided relatively equal focus on all processes in the Theory of Caring except Maintaining Belief. Surgical and emergency department nurses focused primarily on the caring processes of Knowing and Doing For. The negative feelings reported by nurses mirror some emotions commonly associated with compassion fatigue. More research is needed to determine whether nurses caring for mothers experiencing fetal loss are at risk for compassion fatigue. Research is also needed to identify strategies and interventions to help nurses so they may continue to give the best care possible to these very vulnerable families without detriment to themselves.

Evaluation of the perinatal grief intensity scale in the subsequent pregnancy after perinatal loss.

OBJECTIVES: To evaluate the reliability and validity of the Perinatal Grief Intensity Scale (PGIS) for identifying a woman's grief intensity in the immediate subsequent pregnancy after a miscarriage, stillbirth, or neonatal death. DESIGN/SETTING/PARTICIPANTS: A web-based approach was used to collect data from 227 pregnant women after each woman had experienced a perinatal loss in her previous pregnancy. METHODS: Participants completed a demographic information form and the 14-item PGIS. RESULTS: Cronbach's alphas for the PGIS total scale and subscales were high: 0.75 (PGIS total), 0.80 (Reality), 0.82 (Confront Others), and 0.80 (Congruence), which indicated good internal consistency reliability. Validity was supported by factor analysis of the PGIS, which accounted for 66.94% of the total variance. Mothers in the neonatal death group experienced more intense grief, as measured by the PGIS, when compared with mothers in the miscarriage or stillbirth groups. CONCLUSIONS: Data from this study provided initial support for the reliability and validity of the PGIS in women in their immediate subsequent pregnancies after perinatal loss as well as the concepts of the grief intensity theoretical framework.

Healthcare utilization in the pregnancy following a perinatal loss.

PURPOSE: To evaluate the influence of previous perinatal loss, anxiety, depressive symptoms, impact of the previous loss, and maternal investment in the baby on mothers' healthcare utilization (HCU) during the subsequent pregnancy and postpartum periods. STUDY DESIGN AND METHODS: A longitudinal, cohort study design gathered telephone interview data from 36 mothers with a history of prior perinatal loss, 32 mothers with no loss history, and 38 first-time mothers. These data were collected during the third trimester of pregnancy until 8 months postpartum. MEASURES: Centers for Epidemiologic Studies-Depression Scale, Spielberger State-Trait Anxiety Scale, Pregnancy Outcome Questionnaire, Impact of Events Scale, Maternal Attitude Questionnaire, and a questionnaire regarding HCU. RESULTS: Mothers with a history of prior perinatal loss utilized more healthcare resources in the subsequent pregnancy when compared with non-loss controls. Increased HCU during pregnancy was associated with increased maternal anxiety and depressive symptoms after birth. CLINICAL IMPLICATIONS: Mothers with a history of prior perinatal loss may attempt to cope with their anxiety in pregnancy and depression in early postpartum with requests for additional healthcare resources. Nurses need to listen with compassion, providing appropriate education and information, and make referrals to mental healthcare providers and support groups as indicated. These nursing interventions during the subsequent pregnancy may be a better use of healthcare resources than providing extra, but medically unnecessary, laboratory and ultrasound testing for the sole purpose of fleeting reassurance.

Advice given by health-care professionals to mothers concerning subsequent pregnancy after stillbirth.

We studied the advice mothers with stillbirths were given concerning a suitable time to become pregnant. A questionnaire was sent in 2001 to mothers with a stillbirth at one of five hospitals in the Stockholm region in Sweden. At three months follow-up, 33 mothers participated and at 12 months 31. The advices varied from waiting one to 12 months. Eleven mothers were advised to trust their own feelings of readiness and six were advised to wait until they had dealt with their grief before becoming pregnant. At one year post-loss, most of the mothers felt that a suitable time for a subsequent pregnancy was as soon as the mother herself wanted. Mothers whose baby had died in utero were given radically different kinds of advice concerning a suitable time for a subsequent pregnancy. The best advice seems to be that the mother should wait until she, herself, feels ready.

The influence of prior perinatal loss on parents' psychological distress after the birth of a subsequent healthy infant.

OBJECTIVE: To evaluate the long-term influence of a previous perinatal loss on parents' psychological distress during a subsequent childbearing experience. DESIGN AND SAMPLE: A cohort design was used to examine 36 couples with a history of prior perinatal loss. Data were collected during the third trimester of pregnancy, 3 months postpartum, and again 8 months after birth. MEASURES: Outcome measures included posttraumatic stress (The Impact of Event Scale), depressive symptoms (Center for Epidemiologic Studies-Depression Scale), anxiety (Spielberger State-Trait Anxiety Inventory), and parental concerns and attitudes (Maternal/Paternal Attitudes Questionnaire). RESULTS: Levels of depressive symptoms (p<.001), anxiety (p<.001), and posttraumatic stress (p=.046) significantly decreased over time in this population. However, levels of posttraumatic stress remained in the moderate range even at 8 months after birth. Depression was significantly correlated with posttraumatic stress at each time point. In addition, depression was significantly related to posttraumatic stress, anxiety, and concerns parents had about their infant's well-being at T3. CONCLUSION: While levels of anxiety and depressive symptoms decreased for parents who have experienced a previous perinatal loss, posttraumatic stress levels remained moderately high. It is unclear how this compares to parents without losses. These may be the unique symptoms and concerns these parents have about their new infant. Parents with a history of prior loss should have assessments carefully tailored to their experiences to anticipate continued psychological distress.

Readability: an important issue impacting healthcare for women with postpartum depression.

PURPOSE: To evaluate the reading level of depression-screening instruments commonly used in postpartum depression (PPD) and evaluate the reading level of prevalent consumer pamphlets and books on PPD. DESIGN AND METHODS: Descriptive study evaluating the reading level of four PPD instruments (the Edinburgh Postnatal Depression Scale, The Center for Epidemiologic Symptoms of Depression, the Postpartum Depression Screening Scale, and the Beck Depression Inventory-II), five pamphlets from grassroots organizations, and seven consumer books using the Fry Readability Graph. RESULTS: The readability of the postpartum screening instruments varied, but all were at or below the recommended 6th grade reading level. CES-D had the lowest reading level (grade 2). The readability of the consumer publications also varied, but all had a higher reading level than the recommended 6th grade level, some at the college reading level. CLINICAL IMPLICATIONS: Readability is an important consideration in the choice of depression-screening instruments and written materials for consumers. Nurses using any of the four postpartum screening instruments studied can feel confident that women who can read will be able to read them. The readability of a book, pamphlet, or instrument should be of concern to nurses who work with women during the postpartum period.

Social and professional support needs of families after perinatal loss.

Perinatal loss has been associated with depression, anxiety, obsessive-compulsive disorder, suicide, marital conflict, and post-traumatic stress disorder. Nurses may provide professional support through teaching, role modeling, encouragement, counseling, problem solving, and other interventions. Nurses also may encourage more effective social support by helping significant others to provide willing, well-intentioned action that will produce a positive response in the bereaved couple. Interventions to increase professional and social support after perinatal loss are described.

Nursing telephonic case management and pregnancy outcomes of mothers and infants.

Limited success has been achieved in identifying high-risk pregnant women via prenatal risk identification tools. The purposes of this study were to examine a risk assessment and nursing telephonic case management protocol used to identify high-risk mothers and infants, and to evaluate the costs and benefits of the protocol. This study involved a retrospective review of insurance data held by a large managed care organization (MCO). Analyzed data included information about current and past medical problems, and current lifestyle risk factors. Data analysis included frequencies, chi2, t tests, and logistic regression analysis. Pregnant MCO members experienced fewer high-risk conditions versus nonmembers. The overall pregnancy cost for a member was 1,818 dollars versus 4,587 dollars for a nonmember. Members experienced 2.5 times fewer babies hospitalized in the NICU, and significantly fewer mothers with high-risk conditions. The MCO program reduces costs and promotes better maternal and infant outcomes.