Is mode of delivery associated with postpartum depression at 6 weeks: a prospective cohort study.

OBJECTIVE: To examine the relationship between delivery mode and postpartum depression at 6 weeks following hospital discharge. DESIGN: A prospective cohort study. SETTING: Eleven hospitals in Ontario, Canada. SAMPLE: A total of 2560 women ≥16 years of age who delivered singleton, live infants at term. METHODS: Women completed a questionnaire in hospital and 74% (n = 1897) participated in a structured telephone interview 6 weeks after discharge. Additional data were extracted from labour and delivery records. Generalised estimating equations (GEEs) were used to investigate factors associated with postpartum depression. MAIN OUTCOME MEASURE: Women were screened for depression at 6 weeks following hospital discharge using the Edinburgh Postnatal Depression Scale (EPDS). A score of ≥12 on the EPDS was used as a measure of the primary outcome, depression. RESULTS: Mode of delivery was not independently associated with postpartum depression, and did not factor into the main-effects model. The multivariable analysis identified 11 predictor variables for depression: young maternal age (OR 5.27; 95% CI 2.73-10.15); maternal hospital readmission (OR 3.02; 95% CI 1.46-6.24); non-initiation of breastfeeding (OR 2.02; 95% CI 0.99-4.11); good, fair, or poor self-reported postpartum health (OR 1.82; 95% CI 1.19-2.80); urinary incontinence (OR 1.79; 95% CI 1.06-3.03); multiparity (OR 1.59; 95% CI 1.22-2.08); low mental health functioning (OR 1.20; 95% CI 1.15-1.25); low subjective social status (OR 1.16; 95% CI 1.02-1.33); high number of unmet learning needs in hospital (OR 1.12; 95% CI 1.03-1.22); low social support (OR 1.06; 95% CI 1.03-1.09); and low physical health functioning (OR 1.03; 95% CI 1.003-1.055). An exploratory interaction model revealed that caesarean section was associated with higher odds of becoming depressed in Canadian-born women, but that in women born outside of Canada it was associated with a lower risk of becoming depressed. CONCLUSIONS: Delivery mode had no significant impact on the development of postpartum depression in the main-effects model. However, it may interact with place of birth and other unmeasured factors to create a risk for depression.

Understanding newborn infant readmission: findings of the Ontario Mother and Infant Survey.

The Ontario Mother and Infant Survey examined health and social service utilization of postpartum women and newborn infants from five hospital sites. A cross-sectional multilanguage survey design with longitudinal follow-up was used: 1,250 eligible, consenting women completed a self-report questionnaire in hospital and 875 women participated in a structured telephone interview at four weeks post-discharge. Rates of newborn infant readmission ranged from 2.4% to 6.7%. The best predictors of readmission were: main source of household income was other than employment; maternal self-rating of health was poor; mother anticipated inadequate help and support at home following discharge; mother received help from friends/neighbours following discharge; and mother had concern about infant care and behaviour. Readmission was not associated with length of postpartum hospital stay. The study findings suggest that there is a complex relationship between infant health care needs, family resources and provider practices that produces clinically important, site-specific readmission patterns.

Costs of postpartum care: examining associations from the Ontario mother and infant survey.

A cross-sectional survey of 1,250 mothers of "normal" newborn infants was conducted to assess mother and infant characteristics as well as the costs of health and social services used in the first 4 weeks after discharge from hospital in the province of Ontario, Canada. Each mother was asked to recall use of services for herself and her infant. This utilization was multiplied by the unit cost of each service and summed to arrive at the total cost of services used. Although re-admission rates were low (1% for mothers, 4% for infants), costs associated with hospital and emergency room care ($194 on average per mother/infant dyad) accounted for the greatest proportion of total health-care costs. Physician or midwife visits, which were received by almost all mothers, were the next most costly service ($128 on average per dyad). Mothers with incomes under $20,000 had more medical costs than those with higher incomes. Costs of community nursing care ($86 on average per dyad) were higher for mothers with more than 5 self-identified learning needs (e.g., infant feeding, infant care and behaviour, emotional changes in self, signs of illness in infant); perception of their own health as poor; perception of inadequate help and support at home; many signs and symptoms of depression; and postpartum hospital stay of 48 hours or less. Costs for social work visits were higher for mothers with depression and mothers with low incomes. Total health and social service costs were double for mothers with family incomes under $20,000 ($788 vs. $399 on average per dyad) and for mothers with clinical depression ($845 vs. $413). Specifically, nursing care costs were greater for mothers with high depression scores ($135 vs. $81).

The Ontario Mother and Infant Survey: breastfeeding outcomes.

A cross-sectional survey of postpartum women following discharge from five hospitals in Ontario, Canada, examined breatfeeding patterns and risk factors for early discontinuation. Consenting mothers completed self-administered questionnaires prior to discharge (n = 1250) and telephone interviews at 4 weeks postdischarge (n = 875). Breastfeeding initiation rates for women completing the interview varied from 82% to 96% across the sites. Continuation rates rapidly declined, with 13% to 24% of women who had initiated breastfeeding switching to formula by 4 weeks postpartum. Perceived inadequate milk supply, difficulty with breastfeeding techniques, and sore nipples were the main reasons reported. Risk factors for breastfeeding cessation included not completing high school; intention to breastfeed less than 4 months; not anticipating the use of a "mom's group" or "drop-in center"; one or more maternal visits to a family physician; length of postpartum stay greater than 48 hours; unmet need for care or help with breastfeeding; and received advice, information, or support about formula feeding.

A socio-ecological approach to understanding barriers to prenatal care for women of low income.

This paper critically examines the notion of barriers as conceptualized in the literature and suggests an expanded orientation to more fully appreciate its complexity. This alternative approach not only takes into account factors and processes relevant to the individual that create constraints to utilization, but also acknowledges influences on the design and delivery of health care. These latter considerations determine the availability and characteristics of programmes and services that may or may not encourage or enable participation by persons of low income. A socio-ecological model is proposed that compels health care practitioners and researchers to acknowledge the many influences on utilization behaviour. The literature on barriers to prenatal care is subsequently reviewed and evaluated, with consideration given to the range of behavioural determinants suggested by the model. Finally, a case is made for qualitative methods for inquiry to further enhance knowledge about factors and processes influencing use of the health care system, including prenatal care. It is argued that these approaches lead to enhanced appreciation of behaviour as a social product and are consistent with the ideology of health promotion.

Breastfeeding outcomes of women following uncomplicated birth in Hamilton-Wentworth.

OBJECTIVE: To examine infant feeding practices up to 8 weeks postpartum in Hamilton-Wentworth. METHODS: A cross-sectional survey of 227 women using a pre-discharge, self-administered questionnaire, medical record review and follow-up telephone interview. RESULTS: Breastfeeding initiation rate was 85%. By 6-8 weeks postpartum, 30% of women had stopped breastfeeding; 55% had switched to formula within the first 14 days. Infants who did not receive supplementation in hospital were 2.49 times more likely than infants who received supplementation to breastfeed for at least 6 weeks. Although 54% of mothers who initiated breastfeeding reported receiving formula gift packs, no association was found. CONCLUSIONS: The breastfeeding initiation rate appears to have increased in Hamilton-Wentworth since 1995. However, this study reinforces the need to address early cessation and infant supplementation, and raises concern about violation of the WHO/UNICEF International Code of Marketing of Breastmilk Substitutes through mailing of formula coupons.

Examination of student learning about dimensions of health and illness using Stewart's conceptual framework for primary health care.

In view of the increasing emphasis on community-based primary health care, nursing education programs need to identify creative learning strategies to prepare nurses capable of promoting, maintaining and restoring health in diverse populations. The purpose of this descriptive study was to identify the learning outcomes acknowledged by junior baccalaureate nursing students in non-traditional community settings. Data were gathered through semi-structured interviews with the students, through journals kept daily by the students, and from the faculty tutor's anecdotal notes. Analysis of data illustrated concepts from Stewart's conceptual framework for primary health care. Students gained an appreciation of the influence of the social-cultural-political and physical environments on health. They also came to understand the significance of collaborative modes of interaction with recipients of nursing care. Thus, non-traditional community experiences demonstrated effectiveness in enhancing students' understanding of the multiple dimensions of health as well as the necessity for mutuality in nurse-person interactions. Providing varied learning environments in undergraduate nursing programs will produce practitioners who are more responsive to present and future primary health care issues.

Enhancing students' perspectives of health through non-traditional community experiences.

The shift in emphasis to community-based health care necessitates that opportunities be provided for nursing students to acquire an understanding of the complex nature of health. A qualitative study was used to demonstrate the benefits accrued by junior baccalaureate nursing students in non-traditional community settings. Key themes that emerged from data analysis included definitions of health and illness as context specific, and environmental factors influencing health. The study demonstrated that learning experiences with diverse communities can broaden students' perspectives and understanding of health behaviours. Students gained an appreciation of the sociocultural variation in meanings of health and illness as well as of the social and political dimensions of health.