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Derakhshanpour F, Kashani L, Taghavi S, Salimi Z, Shahini N. Effect of a Psychoeducation Intervention on Postpartum Health. jcbr 2020; 4 (4) :8-16
URL: http://jcbr.goums.ac.ir/article-1-281-en.html
1- Golestan Research Center of Psychiatry, Golestan University of Medical Sciences, Gorgan, Iran
2- Golestan Research Center of Psychiatry (GRCP), Golestan University of Medical Sciences, Gorgan, Iran
3- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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INTRODUCTION
  Pregnancy and postpartum period are important times in a woman’s life in terms of psychological problems (1). Approximately 10-15% of women experience one psychological disorder, such as depression, anxiety or stress, during pregnancy or postpartum period (1, 2). It has been shown that undiagnosed psychological disorders during pregnancy and postpartum are risk factors for malnutrition, poor self-care, drug abuse and self-harm or child abuse (2, 3). Due to the alterations in serum steroids and peptide hormones in pregnancy, depression in pregnancy is prevalent and costly to manage. Women experience high level of stress after delivery, especially in the puerperium period. Therefore, this period makes women prone to psychological disorders (4, 5). The most common postpartum disorders are postpartum blues and postpartum depression (4, 6). Nearly 10-15% of women experience mild to moderate depression within first or second months postpartum (7). Postpartum depression is reported in 30-75% of primiparous women and can affect child health in 10-15% of the cases (8, 9). Postpartum depression has been reported to increase stress, anxiety and depression in couples and negatively affects couple relationship (10). Children of women with severe postpartum depression are at a high risk of long-term complications including developmental delay disorganized or insecure attachment, behavioral problems and low academic performance (11, 12). Moreover, a link has been found between postpartum depression and depression in children during late adolescence (12). Therefore, there is a need for efficient screening of high risk women for postpartum depression.
  One of the hypotheses for the high prevalence of depression in the pregnancy and postpartum periods is lack of the ability to adapt with the maternal role (15). Being accompanied by spouse in the first 12 weeks postpartum and receiving psychological support and counselling were found to reduce the rate of depression in mothers
 
(16). It is important to assess psychological health and design interventions to prevent anxiety, depression and psychological disorders in pregnant women (17). Due to the importance of psychological well-being and family support in the prevention of mental health conditions in pregnancy and postpartum period, this study was aimed to assess the effects of an educational intervention including psychoeducation on postpartum health.
 
MATERIALS AND METHODS
Study subjects
  This randomized controlled trial was conducted on women who gave birth through either caesarean section or normal vaginal delivery in the Department of Obstetrics and Gynecology of Shahid Sayyad Shirazi hospital in Gorgan (Northeast of Iran) from December 2016 to January 2017. All women who gave birth to healthy, live, singleton children in the mentioned hospital were included in the study. Exclusion criteria were major depressive disorder, psychosis or taking psychiatric medications and history of mental disorders or addiction in spouse. Subjects were interviewed by the researchers and the required data were obtained directly from the subjects based on self-reporting. Similarly, history of mental disorders and addiction status was obtained from subjects’ spouses based on self-reporting.
 
Ethical approval
  The study was approved by the ethics committee of Golestan University of Medical Sciences, Gorgan, Iran. A written informed consent was obtained from all subjects and their spouses prior to participation.
 
Sample size calculation
  Sample size was calculated using the following equation considering 90% power and 95% confidence level:
 
 
.
  Considering 20% drop-out, the sample size in each group was determined as 40 subjects (80 subjects in total). Out of a total of 91 registered women, 80 were enrolled in the study.
 
Data collection tools
  Research instruments included a demographic questionnaire and the General Health Questionnaire-28 (GHQ-28), a widely used psychometry tool for screening and identifying psychological disorders in the general population (18). The GHQ-18 includes 28 questions under four subscales (seven items each): somatic, anxiety and insomnia, social dysfunction and severe depression subscales. The questionnaire items are scored based on a 4-point Likert scale (19). Scores higher than 23 indicate lack of general health. The severe depression subscale was included in the study assessments to determine the incidence of asymptomatic severe postpartum depression in the study population.
 
Study design
  The subjects were randomly divided into an intervention (n=40) and a control (n=40) group based on a method described previously (19). The control group did not receive any educational intervention regarding postpartum psychological care but only received routine maternal education based on the national protocols. Subjects in the intervention group and their spouses received educational intervention 24-48 hours before the estimated delivery date (EDD). Sessions were held separately for men and women. The psychoeducation sessions for women were held in the delivery unit, while the sessions for men were held in a designated room. Education topics for women included general information regarding the postpartum period and psychological symptoms commonly
 
 
experienced in this period as well as management strategies to cope with the symptoms. Education topics for men included information regarding common psychological symptoms in the postpartum period and empathy and support methods. The sessions were held in groups of 4-5 subjects for 40 minutes based on the findings of previous studies that indicated the effectiveness of psychoeducation of 15-90 minutes (20-22). Pregnant women with uterine pain were instructed to leave the class and return as soon as the pain subsided. All subjects were asked to return for follow up two and four weeks after delivery. All questionnaires were filled by the subjects at baseline and at each follow up visit. If a subject could not attend the follow up visits, the questionnaires were filled through phone call.
 
Statistical analysis
  Data were analyzed using the SPSS software (version 18). Mean, median and standard deviation (SD) were used to describe variables. The Kolmogorov-Smirnov test was used to assess the normal distribution of continuous variables. Continuous variables were compared between groups using independent t-test. Comparison of continuous variables between time points was performed using one-way repeated measures analysis of variance (ANOVA) and paired sample t-test for pairwise comparison. The chi-square or Fisher's exact test were used for the comparison of categorical variables between groups. Multivariate linear regression and correlation coefficient were also used. All statistical analyses were performed at significance of 0.05.
 
RESULTS
  The mean age of the subjects in the intervention and control groups was 25.7 ± 6.0 and 27.9 ± 5.1 years, respectively. There was no significant difference between the groups in terms of age (P=0.081), pregnancy order (P=0.148) and mean number of abortions (P=0.853). Overall, we found no significant difference between the groups in terms of baseline characteristics (Table 1).
 
  
Table 1. Baseline characteristics of the study subjects
Variable Intervention Control P-value
Frequency Percentage Frequency Percentage
Type of delivery Normal vaginal delivery 35 87.5 33 82.5 0.531
C-section 5 22.5 7 27.5
 
Positive history of addiction in spouses 8 20.0 9 22.5 0.785
Positive history of addiction in mothers 4 10.0 6 15.0 0.737†
Comparisons were made using chi-square.
† The Fisher's exact test was used for the comparison.
 
 
 
  The prevalence of abnormal GHQ-28 scores was significantly higher in mothers with history of addiction compared to non-addict mothers (48.8% vs. 33.2% respectively, P=0.001). Changes in the GHQ-28 scores over time are presented in table 2. In both groups, there was a significant difference in GHQ-28 scores at 4th week postpartum compared to baseline (P=0.001). Comparison of GHQ-28 subscale scores showed a significant difference between the anxiety subscale
 
 
and other subscales at baseline (P=0.001) and between the depression subscale and other subscales at 4th week postpartum (P=0.007). Mean depression, anxiety and somatic and social dysfunction scores significantly changed from baseline to 4th week postpartum in both groups, but the depression score change was not significant in the study groups (Table 2). The power ranged from 0.52 to 0.61 for the chi-square test and from 0.50 to 0.91 for repeated measures ANOVA.
 
 
 
  
Table 2. Comparison of GHQ-28 subscale scores between groups over time
Variable Time point Intervention group Control group P-value
General psychological health Baseline 33.95 ± 4.39 34.52 ± 8.36 0.560
2nd week postpartum 33.47 ± 4.21 33.34 v 8.30 0.550
4th week postpartum 25.2 ± 5.38 25.24 ± 7.90 0.590
Somatic dysfunction Baseline 8.15 ± 2.88 8.62 ± 3.48 0.450
2nd week postpartum 7.15 ± 2.88 7.65 ± 3.43 0.550
4th week postpartum 6.10 ± 2.77 6.65 ± 5.12 0.540
Social dysfunction Baseline 4.32 ± 1.50 5.12 ± 3.00 0.340
2nd week postpartum 3.77 ± 1.73 4.55 ± 2.90 0.320
4th week postpartum 2.40 ± 1.21 3.00 ± 2.50 0.580
Depression Baseline 6.42 ± 2.10 6.80 ± 2.80 0.560
2nd week postpartum 8.42 9.47 ± 2.20 0.310
4th week postpartum 12.50 13.10 ± 3.20 0.28
Anxiety Baseline 15.05 14.80 ± 3.10 0.230
2nd week postpartum 15.00 14.30 ± 3.50 0.300
4th week postpartum 5.25 5.00 ± 4.80 0.360
Total GHQ-28 score Baseline 33.95 ± 4.39a 34.52 ± 8.36 b 0.001*
2nd week postpartum 33.47 ± 4.21 33.34 ± 8.30
4th week postpartum 25.2 ± 5.38a 25.24 ± 7.90b
Results are presented as mean ± SD.
Comparisons were made using one-way ANOVA and paired sample t-test for pairwise comparison. 
* Statistically significant difference. a P=0.001, b P=0.001.
 
 
 
DISCUSSION
  This study was conducted to assess the effectiveness of a psychoeducation intervention on general health of mothers after delivery based on the GHQ-28 questionnaire. The results indicated that the psychoeducation intervention in the first 24-48 hours postpartum did not have a significant effect on general health of mothers. However, we found that the general health of mothers with history of
 
 
 
addiction was significantly higher than that of non-addict counterparts. This finding might negatively affect the intervention outcome in the mothers with a history of addiction. Therefore, it is recommended to offer social support instead of psychoeducation for female addicts in order to reduce anxiety.
   Previous studies have reported that life skills education has a role in maternal mental health and reducing postpartum depression. In all studies, educational interventions were offered either during pregnancy or in the first weeks of postpartum. A study conducted on 60 newly delivered mothers in Iran reported that an eight-week self-presentation educational intervention for 60-90 minutes twice weekly at 4-8 weeks postpartum significantly reduced depression scores (23). In another study on 54 women in Iran, six sessions (45-90 minutes) of problem solving skills education for nine weeks significantly reduced depression scores, based on the Beck’s depression inventory (24). Similarly, another study reported that 20 sessions (60-90 minutes) of life skills education significantly improved GHQ-28 scores (3). Unlike the previous studies, the present study consisted of one session of psychoeducation 24-48 hours before delivery. Lack of significant findings in our study might indicate that psychoeducation for duration of 40 minutes near EDD might not have a significant effect on postpartum depression.
  In our study, the depression subscale scores significantly increased in the 4th week postpartum in both groups, while more than 30% of the subjects had abnormal GHQ-28 scores. The scores were significantly higher in women with a positive history of addiction compared to non-addicts. Inconsistent with our findings, a previous study in Iran found that 15.5% of women experienced postpartum depression and no significant association between personal characteristics and postpartum depression (25). In another study, the prevalence of postpartum depression was reported to be 20% and no relationship was reported between postpartum depression and age, educational level and birth order (24). The prevalence of postpartum depression was reported to range from 30 to 75% among primiparous women (26). Unlike most previous studies that were population studies with the aim of assessing the prevalence and risk factors of postpartum depression, the present study was a clinical trial with the aim to assess the effect of psychoeducation on postpartum depression; therefore, the sample size was calculated based on the effect size not prevalence. It is also noteworthy to mention that due to the high prevalence of postpartum depression, the results might not be inferable to the whole population as the study population was not representative of the general population. These findings should be confirmed in studies with a larger sample size or in multicenter studies.
  We observed a significant reduction in anxiety subscale scores at 4th week postpartum in both groups. This finding might indicate that 4th week postpartum is an ideal time for educational interventions. However, given the high incidence of postpartum depression during the first and second months postpartum, preventive interventions might be more effective if conducted during pregnancy. Therefore, it is recommended that these interventions be performed either few months before delivery or four weeks after delivery.
  In our study, the power analysis revealed that most ANOVA tests including the comparison of total GHQ-28 scores between groups was of high power (>0.80), while the chi-square test had low power. This implies that regardless of the matching, the findings of this study did not have the required power to be generalized to the whole population, while the significant change in GHQ-28 could be generalized to the whole population. This might also justify the lack of significant change in the GHQ-28 subscale scores in the groups. Another limitation of this study was the short follow up duration and not considering confounding factors for postpartum depression, including maternal education, occupation and socioeconomic status. Therefore, it is recommended to conduct future studies on larger populations while assessing the effects of confounding factors on the outcome of psychoeducation intervention on postpartum depression.
CONCLUSION
  The findings of this study indicate that short-term educational intervention, 24-48 hours before delivery, is not effective in improving mental health in the postpartum period. Therefore, educational interventions should be conducted either weeks before or after delivery. We found that the depression scores in both groups significantly reduce at 4th week postpartum.
 
ACKNOWLEDGMENTS
  The results of this study was extracted from a thesis supported by the Golestan University of Medical Sciences, Iran.
 
DECLARATIONS
Funding
Not applicable.
 
Ethics approvals and consent to participate
  The study was approved by the ethics committee of Golestan University of Medical Sciences, Gorgan, Iran. A written informed consent was obtained from all subjects and their spouses prior to participation.
 
Conflict of interest
  The author declares that there is no conflict of interest regarding publication of this article.
 
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   13.Sharma M. Trends and prospects in public health education: A commentary. Social Behavior Research & Health. 2017;1(2):67-72.
 
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  17.Leger J, Letourneau N. New mothers and postpartum depression: a narrative review of peer support intervention studies. Health & social care in the community. 2015;23(4):337-48.
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  19.Saghaei M. Random allocation software for parallel group randomized trials. BMC medical research methodology. 2004;4(1):1-6.
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  20.Shorey S, Chan SWC, Chong YS, He HG. A randomized controlled trial of the effectiveness of a postnatal psychoeducation programme on self‐efficacy, social support and postnatal depression among primiparas. Journal of advanced nursing. 2015;71(6):1260-73.
https://doi.org/10.1111/jan.12590
 
  21.ChuPL. AnEvidence-based guideline (Doctoral dissertation, University of Hong Kong).
 
  22.Posmontier B, Neugebauer R, Stuart S, Chittams J, Shaughnessy R. Telephone‐administered interpersonal psychotherapy by Nurse‐Midwives for postpartum depression. Journal of midwifery & women's health. 2016;61(4):456-66.
https://doi.org/10.1111/jmwh.12411
 
  23.Heidari H, Mardani Hamooleh M. The effect of assertiveness on postpartum
 
depression. ANNALS OF MILITARY AND HEALTH SCIENCES RESEARCH. 2011;8.
 
  24.Kordi M, Nasiri S, Modaresgharavi M, Ebrahimzade S. The effect of problem solving skills training on severity of depression symptoms in postpartum period. J Fundament Mental Health. 2012;14:26-35.
 
  25.Bagherzadeh R, Zahmatkeshan N, Moatamed N, Khorramroudi R, Ganjoo M. Prevalence of maternal blues, postpartum depression and their correlation with premenstrual syndrome in women refferred to health centers affiliated to Bushehr University of Medical Sciences. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2009;12(3):9-15.
 
  26.Yamashita H, Yoshida K. Screening and intervention for depressive mothers of new-born infants. Seishin shinkeigaku zasshi= Psychiatria et neurologia Japonica. 2003;105(9):1129-35.
 
 
  
How to Cite: Derakhshanpour F, Taghavi S, Salimi Z, Shahini N. Effect of a Psychoeducation Intervention on Postpartum Health. jcbr. 2020; 4 (4)

 
Article Type: Research | Subject: Basic medical sciences

References
1. 1.McLeish J, Redshaw M. Mothers' accounts of the impact on emotional wellbeing of organised peer support in pregnancy and early parenthood: a qualitative study. BMC pregnancy and childbirth. 2017;17(1):28. [View at Publisher] [DOI] [pubmed] [google scholar]
2. Fujiwara T, Yamaoka Y, Kawachi I. Neighborhood social capital and infant physical abuse: a population-based study in Japan. International journal of mental health systems. 2016;10(1):1-7. https://doi.org/10.1186/s13033-016-0047-9 [View at Publisher] [DOI] [pubmed] [google scholar]
3. Golshani F, Gholmohammad Nejad Gr, Aghdasi An. The Effectiveness Of Teaching Life Skills During Pregnancy On Pregnant Mothers' Mental Health. (Journal Of Instruction And Evaluation) Journal Of Educational Sciences. 2014;7(26):89-101. [View at Publisher] [google scholar]
4. Polachek IS, Fung K, Putnam K, Meltzer-Brody S, Vigod SN. A latent class analysis of brief postpartum psychiatric hospital admissions. Psychiatry research. 2018;262:452-8. [View at Publisher] [DOI] [pubmed] [google scholar]
5. MacKinnon AL, Yang L, Feeley N, Gold I, Hayton B, Zelkowitz P. Birth setting, labour experience, and postpartum psychological distress. Midwifery. 2017;50:110-6. [View at Publisher] [DOI] [pubmed] [google scholar]
6. Black KA, MacDonald I, Chambers T, Ospina MB. Postpartum Mental Health Disorders in Indigenous Women: A Systematic Review and Meta-Analysis. Journal of Obstetrics and Gynaecology Canada. 2019;41(10):1470-8. [View at Publisher] [DOI] [pubmed] [google scholar]
7. Beck CT. Predictors of postpartum depression: an update. Nursing research. 2001;50(5):275-85. [View at Publisher] [DOI] [pubmed] [google scholar]
8. Skoog M, Hallström I, Berggren V. 'There's something in their eyes'-Child Health Services nurses' experiences of identifying signs of postpartum depression in non‐Swedish‐speaking immigrant mothers. Scandinavian Journal of Caring Sciences.2017;31(4):739-47. [View at Publisher] [DOI] [pubmed] [google scholar]
9. Yeaton-Massey A, Herrero T. Recognizing maternal mental health disorders: beyond postpartum depression. Current Opinion in Obstetrics and Gynecology. 2019;31(2):116-9. [View at Publisher] [DOI] [PubMed] [Google Scholar]
10. Moore Simas TA, Huang M-Y, Patton C, Reinhart M, Chawla AJ, Clemson C, et al. The humanistic burden of postpartum depression: a systematic literature review. Current medical research and opinion. 2019;35(3):383-93. [View at Publisher] [DOI] [PubMed] [Google Scholar]
11. Eimen PL. An Examinationof Postpartum Depression and its' Effects on Children. 2020. [View at Publisher] [Google Scholar]
12. Netsi E, Pearson RM, Murray L, Cooper P, Craske MG, Stein A. Association of persistent and severe postnatal depression with child outcomes. JAMA psychiatry. 2018;75(3):247-53. [View at Publisher] [DOI] [PubMed] [Google Scholar]
13. Sharma M. Trends and prospects in public health education: A commentary. Social Behavior Research & Health. 2017;1(2):67-72. [View at Publisher] [Google Scholar]
14. Biello S, Yoss S, Walker ER, Druss B, Lang DL. Addressing Public Mental Health Challenges: A Mixed-Methods Evaluation of Problem-Based Learning. Pedagogy in Health Promotion. 2020:2373379920944963. [View at Publisher] [DOI] [Google Scholar]
15. Mortazavi F, Mousavi SA, Chaman R, Khosravi A. Maternal quality of life during the transition to motherhood. Iranian Red Crescent medical journal. 2014;16(5). [View at Publisher] [DOI] [PubMed] [Google Scholar]
16. Kamalifard M, Yavarikia P, Kheiroddin JB, Pourmehr HS, Iranagh RI. The effect of peers support on postpartum depression: a single-blind randomized clinical trial. Journal of caring sciences. 2013;2(3):237. [View at Publisher] [PubMed] [Google Scholar]
17. Leger J, Letourneau N. New mothers and postpartum depression: a narrative review of peer support intervention studies. Health & social care in the community. 2015;23(4):337-48. [View at Publisher] [DOI] [PubMed] [Google Scholar]
18. Sterling M. General health questionnaire-28 (GHQ-28). Journal of physiotherapy. 2011;57(4):259. [View at Publisher] [DOI] [PubMed] [Google Scholar]
19. Saghaei M. Random allocation software for parallel group randomized trials. BMC medical research methodology. 2004;4(1):1-6. [View at Publisher] [DOI] [PubMed] [Google Scholar]
20. Shorey S, Chan SWC, Chong YS, He HG. A randomized controlled trial of the effectiveness of a postnatal psychoeducation programme on self‐efficacy, social support and postnatal depression among primiparas. Journal of advanced nursing. 2015;71(6):1260-73. [View at Publisher] [DOI] [PubMed] [Google Scholar]
21. ChuPL. AnEvidence-based guideline (Doctoral dissertation, University of Hong Kong).
22. Posmontier B, Neugebauer R, Stuart S, Chittams J, Shaughnessy R. Telephone‐administered interpersonal psychotherapy by Nurse‐Midwives for postpartum depression. Journal of midwifery & women's health. 2016;61(4):456-66. [View at Publisher] [DOI] [PubMed] [Google Scholar]
23. Heidari H, Mardani Hamooleh M. The effect of assertiveness on postpartum depression. ANNALS OF MILITARY AND HEALTH SCIENCES RESEARCH. 2011;8. [View at Publisher] [Google Scholar]
24. Kordi M, Nasiri S, Modaresgharavi M, Ebrahimzade S. The effect of problem solving skills training on severity of depression symptoms in postpartum period. J Fundament Mental Health. 2012;14:26-35. [View at Publisher] [Google Scholar]
25. Bagherzadeh R, Zahmatkeshan N, Moatamed N, Khorramroudi R, Ganjoo M. Prevalence of maternal blues, postpartum depression and their correlation with premenstrual syndrome in women refferred to health centers affiliated to Bushehr University of Medical Sciences. The Iranian Journal of Obstetrics, Gynecology and Infertility. 2009;12(3):9-15. [View at Publisher] [Google Scholar]
26. Yamashita H, Yoshida K. Screening and intervention for depressive mothers of new-born infants. Seishin shinkeigaku zasshi= Psychiatria et neurologia Japonica. 2003;105(9):1129-35. [View at Publisher] [PubMed] [Google Scholar]

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