Postpartum depression (PPD) refers to the onset of depressive symptoms anytime within first year following the birth of a child. PPD affects approximately 10-20% of new mothers and often goes underdiagnosed and untreated. Left untreated, PPD can predispose women to more severe and frequent future depressive episodes. Literature suggests depression in mothers may have long-term negative effects on infants’ and children’s psychosocial development. The American Academy of Pediatrics (AAP) has identified pediatric primary care as the ideal location to screen and refer mothers possibly suffering from depression. Routinely assessing PPD in mothers during well-child checks is not only recommended, it is increasingly being considered a best practice standard. The AAP calls for further research to improve the feasibility of assessing and treating PPD in mothers in pediatric primary care. This paper is part of a larger study that will be evaluating the effectiveness of screening new mothers for PPD in pediatric primary care settings and providing a brief same day interventions. The current aims of this portion of the study will be to evaluate 1) referral results, and 2) mothers’ level of satisfaction with the protocol. Research assistants (RA) will approach mothers of infants, birth to 6 months of age in the waiting rooms of ETSU Pediatrics in Johnson City, TN. Mothers will be given a brief description of PPD, the study and will be asked to participate by signing a voluntary informed consent document. As part of the visit, nurses will distribute and score the Edinburg Postpartum Depression Scale (EPDS). Mothers scoring 9 or above will receive a brief educational brochure about PPD, a brief intervention and a one week follow-up phone call with an onsite behavioral health consultant (BCH) or social worker (SW). At mothers’ discretion, an appropriate outside referral to preferred provider will be made, if necessary. Approximately two weeks postintervention, a satisfaction survey by phone will be administered by RAs. The survey will examine referral results (e.g., of high scores, what recommendations were made, did mothers follow through, treatments received, was there improvement in EPDS score) and the mothers’ level of satisfaction with the protocol (e.g., satisfaction with how protocol was handled by staff and how well mothers felt their needs were addressed). Satisfaction will be noted on a likert-scale ranging from 0 (no satisfaction) to 10 (very satisfied). Data is pending and collection will start during the first week of March showing EDPS uptake, referral results and mother satisfaction. Data is expected for approximately 60-100 new mothers.

The association between pain and depression is well documented across various populations, but not in puerperal women. This study examined the association of childbirth pain with postpartum depression (PPD) in a nationally representative sample of Canadian women. Data from the Canadian Maternity Experiences Survey (n=6421) was used. Multivariate logistic regressions and partial proportional odds models were fitted and included socio-demographic, obstetric, health, psychological, and psychosocial factors. Chronic pain sufferers at mean 7.3 months postpartum had adjusted odds of PPD of 2.4 (95% CI: 1.6, 3.6) compared to women without pain. Adjusted odds of PPD increased with the number of areas of chronic pain, reaching 4.2 (95% C.I.: 0.7, 25.0) for 3 or more areas. Immigration, obesity, cesarean section and social support increased the strength of the association while smoking and the use of pain relief were protective effect modifiers. Persistent postpartum pain is a major risk factor for PPD.

The association between pain and depression is well documented across various populations, but not in puerperal women. This study examined the association of childbirth pain with postpartum depression (PPD) in a nationally representative sample of Canadian women. Data from the Canadian Maternity Experiences Survey (n=6421) was used. Multivariate logistic regressions and partial proportional odds models were fitted and included socio-demographic, obstetric, health, psychological, and psychosocial factors. Chronic pain sufferers at mean 7.3 months postpartum had adjusted odds of PPD of 2.4 (95% CI: 1.6, 3.6) compared to women without pain. Adjusted odds of PPD increased with the number of areas of chronic pain, reaching 4.2 (95% C.I.: 0.7, 25.0) for 3 or more areas. Immigration, obesity, cesarean section and social support increased the strength of the association while smoking and the use of pain relief were protective effect modifiers. Persistent postpartum pain is a major risk factor for PPD.

The association between pain and depression is well documented across various populations, but not in puerperal women. This study examined the association of childbirth pain with postpartum depression (PPD) in a nationally representative sample of Canadian women. Data from the Canadian Maternity Experiences Survey (n=6421) was used. Multivariate logistic regressions and partial proportional odds models were fitted and included socio-demographic, obstetric, health, psychological, and psychosocial factors. Chronic pain sufferers at mean 7.3 months postpartum had adjusted odds of PPD of 2.4 (95% CI: 1.6, 3.6) compared to women without pain. Adjusted odds of PPD increased with the number of areas of chronic pain, reaching 4.2 (95% C.I.: 0.7, 25.0) for 3 or more areas. Immigration, obesity, cesarean section and social support increased the strength of the association while smoking and the use of pain relief were protective effect modifiers. Persistent postpartum pain is a major risk factor for PPD.

The association between pain and depression is well documented across various populations, but not in puerperal women. This study examined the association of childbirth pain with postpartum depression (PPD) in a nationally representative sample of Canadian women. Data from the Canadian Maternity Experiences Survey (n=6421) was used. Multivariate logistic regressions and partial proportional odds models were fitted and included socio-demographic, obstetric, health, psychological, and psychosocial factors. Chronic pain sufferers at mean 7.3 months postpartum had adjusted odds of PPD of 2.4 (95% CI: 1.6, 3.6) compared to women without pain. Adjusted odds of PPD increased with the number of areas of chronic pain, reaching 4.2 (95% C.I.: 0.7, 25.0) for 3 or more areas. Immigration, obesity, cesarean section and social support increased the strength of the association while smoking and the use of pain relief were protective effect modifiers. Persistent postpartum pain is a major risk factor for PPD.

A violência entre parceiros íntimos (VPI) e a depressão pós-parto (DPP) são as temáticas principais dessa Tese. Seu objetivo principal foi investigar se a violência física entre parceiros íntimos (VFPI) é um fator de risco para DPP. Adicionalmente, a estrutura dimensional da Edinburgh Postnatal Depression Scale (EPDS) foi reavaliada, e outro estudo estimou a prevalência de DPP entre mulheres usuárias de unidades básicas de saúde na cidade do Rio de Janeiro, Brazil. As informações que subjazem esses três artigos originaram-se de um inquérito realizado em cinco UABS no Rio de Janeiro, entre janeiro e junho de 2007. Foram selecionadas aleatoriamente mulheres com até cinco meses pós-parto que estivessem aguardando por consultas pediátricas, sendo consideradas inelegíveis aquelas que não haviam vivenciado ao menos um mês de relação íntima no ciclo grávido-puerperal, cujas gestações-índice foram gemelares, ou se houvesse contra-indicação absoluta para a amamentação. Dentre 852 mulheres selecionadas, 18 (2,1%) eram inelegíveis e 23 (2,8%) recusaram-se a participar, totalizando então 811 entrevistas completas. No artigo inicial a validade dimensional da EPDS foi reavaliada através de análise fatorial exploratória (AFE) e, em seguida, análise fatorial confirmatória (AFC). Os resultados da AFC apontaram que a EPDS é mais bem definida por uma solução fatorial que inclui três fatores de primeira ordem (―stress comum‖, ―ansiedade‖ e ―depressão‖) e um fator de segunda ordem, o qual parece representar o construto depressão pós-parto. O segundo artigo mostrou uma prevalência geral estimada de DPP na população estudada de 24,3%. Contudo, houve um pico de sintomas depressivos próximo ao terceiro mês pós-parto, quando a magnitude projetada de DPP atingiu 37,5%. Ainda neste período crítico, a prevalência estimada de DPP ultrapassou 50% entre mulheres com bebês prematuros ou cujos parceiros faziam uso excessivo de álcool. Quadro ainda mais grave foi observado entre mães sem parceiros fixos ou cujos companheiros usavam drogas ilícitas ou psicotrópicas, com mais de 70% delas apresentando-se provavelmente deprimidas. Em relação ao artigo principal dessa Tese, este revelou que a VFPI é um fator de risco para DPP mesmo após essa relação ser controlada para diversas covariadas. Foi também identificada uma interação significativa entre VFPI e o uso demasiado de álcool pelos companheiros (p-valor=0,026). Entre as mulheres cujos parceiros faziam mal uso de álcool, apenas um ato de VFPI não aumentou a probabilidade de DPP (OR=0,87, IC 95% 0,25-3,03), enquanto dois ou mais eventos foram significativamente associados à DPP (OR=3,62, IC 95% 1,64-7,99). Já entre aquelas cujos companheiros não faziam mal uso de álcool, o aumento na probabilidade de DPP deu-se especialmente com a ocorrência de um episódio de VFPI (OR=2,47, IC 95% 1,31-4,66), enquanto dois ou mais episódios mostraram uma menor associação com DPP (OR=1,66, IC 95% 1,00-2,75). Em síntese, vislumbra-se que os resultados dessa Tese possam colaborar para uma melhor saúde materno-infantil em nosso meio. Conforme já discutido por outros autores, a utilização da EPDS para uma abordagem inicial dos quadros depressivos pós-natais deve ser encorajada, especialmente em situações de elevado risco psicossocial. Adicionalmente, ações que visem à prevenção da DPP devem contemplar o enfrentamento da VPI. / The intimate partner violence (IPV) and the postpartum depression (PPD) are the main themes of this Thesis, whose main purpose was to investigate whether physical intimate partner violence (PIPV) is a risk factor for postpartum depression (PPD). Additionally, a methodological study reappraised the dimensional structure of the Edinburgh Postnatal Depression Scale (EPDS), and another descriptive study provided estimates of the prevalence of PPD among women seeking care in primary health care (PHC) settings. The information underlying these manuscripts were derived from a survey performed in five PHC units in Rio de Janeiro, between January and June 2007. The participants were randomly selected among women whose children were under five months of age and were waiting for pediatric care. Women were considered ineligible if they have not experienced at least one month of intimate relationship during pregnancy or postpartum period, whether their index pregnancies were twins, or there was an absolute contraindication for breastfeeding. Among 853 women invited to participate, 18 (2.1%) were ineligible and 23 (2.7%) refused to participate, then totalizing 811 completed interviews. In the first study the dimensional validity of the EPDS was reevaluated through exploratory factorial analysis (EFA) and, subsequently, confirmatory factor analysis (CFA). The CFA results disclosed that the EPDS is better defined by a factorial solution that includes three first-order factors (―general distress‖, ―anxiety‖ and ―depression‖) and a second-order factor, which can be interpreted as a synthesis of the construct ―postpartum depression‖. The second article shows that the estimated overall prevalence of PPD in the study population was 24.3%. However, there was a peak of depressive symptoms around the third postnatal month, when the magnitude of women probably depressed reached 37.5%. Moreover, in this critical period, the estimated prevalence of PPD was more than 50% among women with premature babies or whose partners misused alcohol. Situation even more serious was observed among mothers without steady partners or whose partners used illicit or psychotropic substances, with more than 70% of them presenting probable PPD. Finally, the principal article of this thesis showed that the PIPV is a risk factor for PPD, even after this relationship is controlled for several covariates. It was also identified a significant interaction between PIPV and misuse of alcohol by partners (p-valor=0.026). Among women whose partners misused alcohol, only one act of PIPV did not increase the likelihood of PPD (OR=0.87, IC 95% 0.25-3.03), whereas two or more events were significantly associated with PPD (OR=3.62, IC 95% 1.64-7.99). In contrast, among those women whose partners did not misuse alcohol, the likelihood of PPD increased principally after a single episode of VFPI, whereas two or more episodes showed a lower association with PPD (OR=1.66, IC 95% 1.00-2.75). As a synthesis, the results of this Thesis can contribute to improve the maternal and child health. As already discussed by other authors, the EPDS should be used in a first approach of depressive disorders after birth, especially among people presenting a high-risk psicossocial profile. In addition, actions directed to the prevention of PPD should address IPV.

A violência entre parceiros íntimos (VPI) e a depressão pós-parto (DPP) são as temáticas principais dessa Tese. Seu objetivo principal foi investigar se a violência física entre parceiros íntimos (VFPI) é um fator de risco para DPP. Adicionalmente, a estrutura dimensional da Edinburgh Postnatal Depression Scale (EPDS) foi reavaliada, e outro estudo estimou a prevalência de DPP entre mulheres usuárias de unidades básicas de saúde na cidade do Rio de Janeiro, Brazil. As informações que subjazem esses três artigos originaram-se de um inquérito realizado em cinco UABS no Rio de Janeiro, entre janeiro e junho de 2007. Foram selecionadas aleatoriamente mulheres com até cinco meses pós-parto que estivessem aguardando por consultas pediátricas, sendo consideradas inelegíveis aquelas que não haviam vivenciado ao menos um mês de relação íntima no ciclo grávido-puerperal, cujas gestações-índice foram gemelares, ou se houvesse contra-indicação absoluta para a amamentação. Dentre 852 mulheres selecionadas, 18 (2,1%) eram inelegíveis e 23 (2,8%) recusaram-se a participar, totalizando então 811 entrevistas completas. No artigo inicial a validade dimensional da EPDS foi reavaliada através de análise fatorial exploratória (AFE) e, em seguida, análise fatorial confirmatória (AFC). Os resultados da AFC apontaram que a EPDS é mais bem definida por uma solução fatorial que inclui três fatores de primeira ordem (―stress comum‖, ―ansiedade‖ e ―depressão‖) e um fator de segunda ordem, o qual parece representar o construto depressão pós-parto. O segundo artigo mostrou uma prevalência geral estimada de DPP na população estudada de 24,3%. Contudo, houve um pico de sintomas depressivos próximo ao terceiro mês pós-parto, quando a magnitude projetada de DPP atingiu 37,5%. Ainda neste período crítico, a prevalência estimada de DPP ultrapassou 50% entre mulheres com bebês prematuros ou cujos parceiros faziam uso excessivo de álcool. Quadro ainda mais grave foi observado entre mães sem parceiros fixos ou cujos companheiros usavam drogas ilícitas ou psicotrópicas, com mais de 70% delas apresentando-se provavelmente deprimidas. Em relação ao artigo principal dessa Tese, este revelou que a VFPI é um fator de risco para DPP mesmo após essa relação ser controlada para diversas covariadas. Foi também identificada uma interação significativa entre VFPI e o uso demasiado de álcool pelos companheiros (p-valor=0,026). Entre as mulheres cujos parceiros faziam mal uso de álcool, apenas um ato de VFPI não aumentou a probabilidade de DPP (OR=0,87, IC 95% 0,25-3,03), enquanto dois ou mais eventos foram significativamente associados à DPP (OR=3,62, IC 95% 1,64-7,99). Já entre aquelas cujos companheiros não faziam mal uso de álcool, o aumento na probabilidade de DPP deu-se especialmente com a ocorrência de um episódio de VFPI (OR=2,47, IC 95% 1,31-4,66), enquanto dois ou mais episódios mostraram uma menor associação com DPP (OR=1,66, IC 95% 1,00-2,75). Em síntese, vislumbra-se que os resultados dessa Tese possam colaborar para uma melhor saúde materno-infantil em nosso meio. Conforme já discutido por outros autores, a utilização da EPDS para uma abordagem inicial dos quadros depressivos pós-natais deve ser encorajada, especialmente em situações de elevado risco psicossocial. Adicionalmente, ações que visem à prevenção da DPP devem contemplar o enfrentamento da VPI. / The intimate partner violence (IPV) and the postpartum depression (PPD) are the main themes of this Thesis, whose main purpose was to investigate whether physical intimate partner violence (PIPV) is a risk factor for postpartum depression (PPD). Additionally, a methodological study reappraised the dimensional structure of the Edinburgh Postnatal Depression Scale (EPDS), and another descriptive study provided estimates of the prevalence of PPD among women seeking care in primary health care (PHC) settings. The information underlying these manuscripts were derived from a survey performed in five PHC units in Rio de Janeiro, between January and June 2007. The participants were randomly selected among women whose children were under five months of age and were waiting for pediatric care. Women were considered ineligible if they have not experienced at least one month of intimate relationship during pregnancy or postpartum period, whether their index pregnancies were twins, or there was an absolute contraindication for breastfeeding. Among 853 women invited to participate, 18 (2.1%) were ineligible and 23 (2.7%) refused to participate, then totalizing 811 completed interviews. In the first study the dimensional validity of the EPDS was reevaluated through exploratory factorial analysis (EFA) and, subsequently, confirmatory factor analysis (CFA). The CFA results disclosed that the EPDS is better defined by a factorial solution that includes three first-order factors (―general distress‖, ―anxiety‖ and ―depression‖) and a second-order factor, which can be interpreted as a synthesis of the construct ―postpartum depression‖. The second article shows that the estimated overall prevalence of PPD in the study population was 24.3%. However, there was a peak of depressive symptoms around the third postnatal month, when the magnitude of women probably depressed reached 37.5%. Moreover, in this critical period, the estimated prevalence of PPD was more than 50% among women with premature babies or whose partners misused alcohol. Situation even more serious was observed among mothers without steady partners or whose partners used illicit or psychotropic substances, with more than 70% of them presenting probable PPD. Finally, the principal article of this thesis showed that the PIPV is a risk factor for PPD, even after this relationship is controlled for several covariates. It was also identified a significant interaction between PIPV and misuse of alcohol by partners (p-valor=0.026). Among women whose partners misused alcohol, only one act of PIPV did not increase the likelihood of PPD (OR=0.87, IC 95% 0.25-3.03), whereas two or more events were significantly associated with PPD (OR=3.62, IC 95% 1.64-7.99). In contrast, among those women whose partners did not misuse alcohol, the likelihood of PPD increased principally after a single episode of VFPI, whereas two or more episodes showed a lower association with PPD (OR=1.66, IC 95% 1.00-2.75). As a synthesis, the results of this Thesis can contribute to improve the maternal and child health. As already discussed by other authors, the EPDS should be used in a first approach of depressive disorders after birth, especially among people presenting a high-risk psicossocial profile. In addition, actions directed to the prevention of PPD should address IPV.