This thesis aimed to explore whether self-management techniques, effective in essential hypertension, could be applied to women with hypertensive disorders of pregnancy postpartum (HDP). HDP affect one in ten pregnancies, remain a leading cause of maternal death worldwide and are associated with elevated long-term maternal cardiovascular risk. Hypertension often persists postpartum and complications can occur. During the puerperium, multiple stresses on new mothers and their healthcare professionals can distract from good quality blood pressure (BP) management. Transfer of responsibility, from secondary to primary care, increases scope for uncertainty. The primary objective was to develop and test the feasibility of a novel self-management intervention for postnatal antihypertensive treatment. A systematic literature review (39 studies), local audit (n=20) and regional survey (n=101) were conducted to evaluate existing evidence and clinical practice. A pilot randomised controlled trial compared self-management of postnatal antihypertensive medication with usual care (n=91). Taking patients' views of self-management into account is essential to successful implementation and these were captured through qualitative interviews (n=68). A sub-study to assess markers of vascular risk (n=16) was conducted to further evaluate the relationship between postnatal BP and elevated long-term cardiovascular risk. There is a lack of good quality evidence underpinning hypertension management postpartum and widespread inconsistencies in approaches to care. The pilot trial suggested that expanding the study would be feasible, and that self-management may be more effective than usual care in terms of BP control. Strikingly, the 4-5mmHg reduction in diastolic BP observed with self-management persisted to six months, despite the majority of women being off treatment by this stage, reinforcing the idea that BP control during the puerperium may influence cardiovascular remodelling. However, no differences were demonstrated in markers of cardiovascular risk between sub-study groups. Participants commonly preferred self-management to usual care, and reported feeling more in control through this approach.

SAMMANFATTNING Bakgrund: Förlossningsdepression är en depressiv sjukdom som varar i några veckor upp till ett år efter en förlossning och som drabbar 10 - 15 procent av nyblivna mammor. Förlossningsdepression påverkar mammans livskvalitet och ökar risken för att bli deprimerad igen senare i livet. Detta tydliggör hur viktigt det är för sjuksköterskor att identifiera kvinnor med symtom av förlossningsdepression och att ha vetskap kring vilka åtgärder som finns. Syftet: Syftet med litteraturstudien var att undersöka kvinnors upplevelser kring förlossningsdepression och vilka åtgärder det finns för att lindra symtomen av förlossningsdepression. Metodbeskrivning: En litteraturöversikt utfördes med 11 originalartiklar från olika länder som valdes från databasen PubMed. Artiklarna granskades och tre kategorier utformades. Katie Erikssons omvårdnadsteori användes som teoretisk referensram i studien. Resultat: Det finns en stor rädsla för att bli stigmatiserad på grund av sin förlossningsdepression. Många kvinnor hade svårt att erkänna att de hade ett problem, vilket i sin tur hindrade dem från att söka hjälp. Något som var mycket viktigt för dem var behovet av socialt och professionellt stöd. Olika åtgärder identifierades, exempelvis gruppsamtal, mindfulness, och yoga. Det fanns även olika utbildningsprogram samt program baserade på kognitiv beteendeterapi. Slutsats: Kvinnor med förlossningsdepression känner sig stigmatiserade vilket leder till att de inte söker hjälp. Gruppaktiviteter och utbildning kring förlossningsdepression hade en positiv inverkan på kvinnornas mående. Genom att aktivt normalisera förlossningsdepression och erbjuda olika åtgärder, kan sjuksköterskor bryta stigma och bemöta kvinnor med insikt och förståelse. / ABSTRACT Background: Postpartum depression is a depressive disorder which lasts for a few weeks up to a year after childbirth, and it affects 10 - 15 percent of new mothers. Postpartum depression affects the mother’s quality of life and increases the risk of becoming depressed later in life. This highlights the importance of nurses identifying women with symptoms of postpartum depression and having awareness of existing standards of care. Aim: The aim of this literature review was to examine women’s experiences concerning postpartum depression and which standards of care that exist to relieve symptoms of postpartum depression. Method: A literature review was conducted with 11 original articles from different countries, which were chosen from the PubMed database. The articles were audited and three categories were developed. The nursing theory of Katie Eriksson was used as theoretical framework in this study. Results: There existed a great fear towards becoming stigmatised because of postpartum depression. Many women had trouble acknowledging that they had a problem, which in turn hindered them from seeking help. One aspect which was very important to them was the need for social and professional support. Different standards of care were identified, for example group discussion, mindfulness and yoga. There were also varying educational programmes as well as programmes based on cognitive behavioural therapy. Conclusion: Women with postpartum depression feel stigmatised which leads to them not seeking help. Group activities and education concerning postpartum depression had a positive effect on women’s wellbeing. Through active normalisation of postpartum depression and by offering varying standards of care, nurses are able to break the stigma, and receive women with insight and understanding.

Postpartum depression är vanligast hos mödrar men även pappor kan drabbas. Studiens syfte var att identifiera riskfaktorer för pappan att drabbas av depression postpartum. Metoden var en strukturerad litteraturstudie med en integrativ ansats. Resultatet visade att sociodemografiska faktorer så som arbetslöshet, tillfällig anställning, oro över ekonomi och låg utbildning var riskfaktorer för depression postpartum hos pappor. Förändringar och försämring i relationen till partnern och upplevelsen av att ha ett besvärligt barn påverkade papporna. Barn med tillväxtproblematik, sjukdomsfall hos barnet och barn som sov dåligt var faktorer som spelade in. Att pappan känner ett utanförskap eller brist på sammanhang och brist på stöd kunde vara riskfaktorer men en del män ville trots tillgång till stöd inte nyttja detta. Konklusionen blev att distriktssköterskan bör vara medveten om riskfaktorer för pappan att drabbas av depression postpartum då en generell screening inte utförs i dagsläget. Mer forskning kring vad som kan leda till depression hos pappor samt vilket slags stöd pappor med depressiva symtom behöver av distriktssköterskan på barnavårdscentralen vore fördelaktigt. / To suffer from postpartum depression is most common in mothers but it can also happen to fathers. The aim of the study was to identify risk factors for fathers to suffer from postpartum depression. The method used was a structured literature study with an integrative approach. The results showed that socio-demographic factors such as unemployment, temporary employment, concern about economics and low education were risk factors for depression postpartum in fathers. Changes and deterioration in the relationship with the partner and the experience of having a difficult child affected the dads. Children with growth problems, illnesses in the child and children who slept poorly were factors that were shown. Feeling of isolation or lack of coherence and lack of support could be risk factors, but some men, despite access to support, would not use this. The conclusion was that the district nurse should be aware of the risk factors for the father to suffer from postpartum depression when screening for depression in fathers is not usually performed. More research on risk factors for depression in fathers and what kind of support depressed fathers needs from the nurse at the child welfare center would be beneficial.

Orientador: Olga Maria Piazentim Rolim Rodrigues / Banca: Patrícia Alvarenga / Banca: Bárbara Fernandes Carvalho Figueiredo / Resumo: Desde o nascimento a interação do recém-nascido com o mundo é facilitada pela mãe. Estudos indicam que a saúde mental materna pode afetar a qualidade desta interação e, por exemplo, mães deprimidas podem interagir pouco com seu bebê, podendo gerar déficits comportamentais e cognitivos, identificáveis ao longo do desenvolvimento. Este trabalho, composto por dois estudos, pretendeu descrever e relacionar o índice de depressão pós-parto apresentado por mães de bebês com as variáveis sociodemograficas e avaliar a relação entre a presença da depressão e a qualidade da interação mãe-bebê. Participaram mães e seus bebês, usuárias do Projeto de Extensão "Acompanhamento do desenvolvimento de bebês: avaliação e orientação aos pais". No primeiro estudo pretendeu-se identificar fatores de risco para a depressão pós-parto considerando variáveis sociodemograficas maternas, dos bebês e familiares. Uma amostra de 103 mães participou da primeira etapa em que responderam a uma entrevista inicial para a coleta de dados sociodemográficos e a "Escala de Depressão Pós-Parto de Edimburgo" (EDPE). Os resultados apontaram que 33% das mães apresentaram depressão pós-parto. Segundo o teste estatístico ρ de Pearson observou-se correlação linear negativa com a escolaridade materna (p=0,008), ou seja, quanto maior o índice de depressão, menor o número de anos de estudo. Além disso, houve uma correlação linear positiva entre a depressão e a condição socioeconômica (p=0,044), sendo que a variação da ABEP é ... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The newborn interaction with the world is facilitated by his mother. Studies indicates that maternal mental health can affect the quality of this interaction, for example, depressed mothers may interact less with their baby and it can cause behavioral and cognitive deficits throughout the development. This work, consisting on two studies which describe and relate the index of postpartum depression presented on the baby's mothers with socio-demographic variables and evaluate the relationship between the presence of depression and quality of mother-infant interaction. Participated mothers and their babies, Extension Project users "Monitoring the development of babies: evaluation and guidance for parents." In the first study aimed to identify risk factors for postpartum depression considering maternal, babies and family socio-demographic variables. A sample of 103 mothers participated in the first step in responding to an initial interview to collect demographic data and "Edinburgh Postpartum Depression Scale" (EPDS). The results showed that 33% of the mothers had postpartum depression. The average age of the infants was 4.4 months, the gestational age of 36.9 weeks, with respect to risk condition (prematurity, low birth weight and teen mom), 46% had some of these characteristics. The average age of the mothers was 27.2, about the type of family, 78% of the sample is nuclear family and the socioeconomic level of the sample is Class B (68%). In the second study was intended to de... (Complete abstract click electronic access below) / Mestre

Background: The Missed Opportunities for Maternal and Infant Health (MOMI) project, which aimed at upgrading maternal and infant postpartum care (PPC), implemented a package of interventions including the integration of maternal PPC in infant immunization services in 12 health facilities in Kaya Health district in Burkina Faso from 2013 to 2015. This paper assesses the coverage and the quality of combined mother-infant PPC in reproductive, maternal, newborn and child health services (RMNCH). Methods: We conducted a mixed methods study with cross-sectional surveys before and after the intervention in the Kaya health and demographic surveillance system. On the quantitative side, two household surveys were performed in 2012 ( N = 757) and in 2014 ( N = 754) among mothers within one year postpartum. The analysis examines the result of the intervention by the date of delivery at three key time points in the PPC schedule: the first 48 h, days 6 - 10 and during weeks 6 - 8 and beyond. On the qualitative side, in depth interviews, focus group discussions and observations were conducted in four health facilities in 2012 and 2015. They involved mothers in the postpartum period, facility and community health workers, and other stakeholders. We performed a descriptive analysis and a two-sample test of proportions of the quantitative data. The qualitative data were recorded, transcribed and analysed along the themes relevant for the intervention. Results: The findings show that the WHO guidelines, in terms of content and improvement of maternal PPC, were followed for physical examinations and consultations. They also show a significant increase in the coverage of maternal PPC services from 50% (372/752) before the intervention to 81% (544/672) one year after the start of the intervention. However, more women were assessed at days 6 - 10 than at later visits. Integration of maternal PPC was low, with little improvements in history taking and physical examination of mothers in immunization services. While health workers are polyvalent, difficulties in restructuring and organizing services hindered the integration. Conclusion: Unless a comprehensive strategy of integration within RMNCH services is implemented to address the primary health care challenges within the health system, integration will not yield the desired results.

A depressão pós-parto é um transtorno mental de alta prevalência que surge nas primeiras semanas, após o parto, e provoca alterações emocionais, cognitivas comportamentais e físicas. Mães adolescentes apresentam risco aumentado para a depressão pós-parto. Estudos mostram que a prática do aleitamento materno não se dá de forma efetiva nos casos em que a nutriz apresenta alterações emocionais. Diante do exposto, buscamos compreender quais as representações sociais sobre amamentação na perspectiva de mães adolescentes com sintomas de depressão pós-parto. Trata-se de uma pesquisa qualitativa, desenvolvida com 14 mulheres, mães de crianças com até um ano de idade e usuárias de um serviço público de saúde de Ribeirão Preto-SP. A primeira etapa consistiu na aplicação da Escala de Depressão Pós-natal de Edimburgo para rastrear as mães adolescentes que apresentavam sintomas de depressão, no puerpério. As mães que apresentavam pontuação de 12 ou mais pontos eram convidadas a continuar a participar do estudo. Para as mulheres que aceitavam ser incluídas na pesquisa, foram aplicados questionário sociodemográfico e a entrevista semiestruturada que foram gravados e transcritos na íntegra e realizados no local de escolha da participante. Para a análise dos dados, utilizamos o Método de Interpretação dos Sentidos à luz das representações sociais na perspectiva socioantropológica. Emergiram três categorias temáticas: 1) \"Ser mãe na adolescência com sintomas de depressão no pós-parto\"; 2) \"Amamentando na adolescência com sintomas de depressão no pós-parto\"; 3) \"A rede de apoio: eu e a amamentação\". A gravidez é considerada indesejada no contexto investigado, pois é vista como empecilho para se dar continuidade à vida. E isto se reflete negativamente na amamentação, visto que, há dificuldades para se desempenhar papéis maternos, nesse momento da vida. Com relação à amamentação, observamos que os conhecimentos se restringem aos aspectos nutricionais e imunológicos, sendo desconsiderados os aspectos relacionais e de construção de vínculo da prática de amamentar. Este pensamento se justifica quando fazemos um olhar para o modo como as participantes se sentem somado ao contexto cultural em que vivem, um meio que trata a amamentação como mera prática de alimentação infantil. Há a ideia de que o leite materno é fraco, sendo a mamadeira vista como uma aliada, pois além de proporcionar sensação de saciedade do bebê por mais tempo, ainda impede que ele chore e incomode principalmente no período noturno, já no período diurno evita constrangimentos por ter de amamentar em locais públicos e pode ser oferecida por outra pessoa. A mamadeira é algo que proporciona sensação de liberdade, ocasionando a independência do bebê em relação à mãe. A mulher tem como maior fonte de influência e apoio sua mãe, o parceiro ainda permanece distante à realidade da amamentação e o profissional de saúde oferece orientações pontuais, nas quais desconsideram os contextos de vida nas quais as adolescentes estão inseridas. A internet é usada para se ter conhecimento, sendo considerada veículo de forte influência. Mesmo com apoio materno, a mulher ainda permanece sozinha, com dificuldades para falar sobre sua real situação emocional e sobre suas limitações para amamentar / Postpartum depression is a mental disorder of high prevalence that arises in the first weeks after childbirth and causes emotional, cognitive, behavioral and physical changes. Adolescent mothers present an increased risk for postpartum depression. Studies show that the practice of breastfeeding does not occur effectively in cases where the mother presents emotional changes. In view of the above, we aimed to understand which are the social representations regarding breastfeeding, in the perspective of adolescent mothers with symptoms of postpartum depression. This is a qualitative research conducted with 14 women, mothers of children up to one year of age and users of a public health service in Ribeirão Preto - SP. The first phase consisted in the application of the Edinburgh Postnatal Depression Scale for screening adolescent mothers with symptoms of depression in the puerperal period. Mothers who achieved a score of 12 or more were invited to proceed participating in the research. For those who accepted to be included, socio demographic questionnaires were applied and, semi- structured interviews were conducted and recorded in a participant\'s choice location and then, fully transcribed. For the data analysis, we used the Interpretation of the Meaning Method, in accordance with the social representations in a socio anthropological approach. Three thematic categories emerged: 1) \"Being a mother in adolescence with symptoms of postpartum depression\"; 2) \"Breastfeeding in adolescence with symptoms of postpartum depression\"; 3) \"The network support: the breastfeeding and I.\" Pregnancy is considered undesirable in the context investigated, as it is seen as an impediment to give continuity to life. And this reflects negatively on breastfeeding, since there are difficulties to play maternal roles at this moment of life. Regarding breastfeeding, we observed that adolescent mother\'s knowledge is restricted to nutritional and immunological aspects, and the relational and building link aspects of breastfeeding practice are not considered. This thought is justified when observed how the participants feel in their cultural context, in which they deal with breastfeeding as a simple infant feeding practice. There is the idea that breast milk is weak, and the bottle is seen as an allied, since, as well as providing baby satiety feeling for longer, still prevents him to cry and bother, especially at night. Even during the day, the bottle avoids embarrassments when breastfeeding in public places and it can be offered by someone else. It is something that gives sense of freedom, causing the baby\'s independence from the mother. The woman has the greatest source of influence and support in her mother, while her partner remains distant to the reality of breastfeeding and the health professional provides specific guidelines in which disregards the life contexts in which the adolescents live. Internet is used in order to acquire knowledge, being considered vehicle of strong influence. Even with maternal support, the woman remains alone, struggling to talk about her real emotional situation and limitations to breastfeed. Thus, the social representations that support the breastfeeding practice, for these adolescents, bring with them the ambiguity of willing to give the best for your child - the breast milk, but also the will to be free and independent in life

Background: Despite postpartum depression (PPD) being the most common medical complication surrounding childbirth affecting 10-20% of new mothers, it is often underdiagnosed and undertreated, especially in primary care. Universal screening with a validated tool is recommended for all postpartum women as evidence shows that formal screening is superior to non-formal screening in detecting women with PPD. Unfortunately, most primary care providers do not formally screen. In southern Maricopa, low income minority women were found to have a higher than average prevalence of PPD. Thus, it is important for providers in this area to screen. Purpose: The purpose of this quality improvement project was to determine provider knowledge, practice behaviors, and perceived facilitators and barriers to PPD screening at an urban Federally Qualified Health Center in the Southwestern United States. This needs assessment was then used to make site-specific recommendations for PPD screening to enhance early identification of women with PPD. Design: A quality improvement project using a quantitative descriptive design. A quantitative survey assessed provider knowledge, practice behaviors, perceived barriers, and perceived facilitators regarding PPD screening. Setting: Wesley Health Center, a primary care clinic in Phoenix, Arizona. Participants: Five primary care providers in family practice. Results: Universal screening with validated screening tools was common. More than half of providers (60%) universally screen all postpartum women for depression with a formal screening tool up to one year postpartum. Providers were correctly using validated screening tools for PPD such as the Patient Health Questionnaire-2 (PHQ-2), PHQ-9 and Edinburgh Postnatal Depression Scale (EPDS), but only one provider (20%) was aware that the PHQ-2 and PHQ-9 are validated for that specific purpose. Wesley is already attempting to universally screen for depression with a two-step process using the PHQ-2 and PHQ-9 for all patients, but participants report that support staff sometimes forget to provide patients with the screening tool before the provider visit, patients sometimes decline to be screened, and providers either forget to catch the opportunity or do not have time. Identified facilitators to screening are support staff (80%) and the electronic health record (20%). Conclusion: One major strength of the clinic is that it already has a policy of universally screening for depression that is validated for use for PPD. The findings from the study indicate that this policy is not always followed due to barriers such as lack of time, support staff not providing screening tools before the provider encounter with the patient, and providers forgetting to screen. The screening process could be enhanced by taking the time to ensure that tools are readily accessible, gathering the input from support staff on the barriers they face to screening patients, and utilizing the electronic health record to make the process more automated. Enhancing the policy already in place would be enhancing screening practices for PPD and improve early detection of this condition. Findings will be disseminated via an executive summary and PowerPoint presentation to the staff.

Abstract A longitudinal follow-up study of postnatal depression was performed in the years 1995-2000 in the University of Oulu. A volunteer, ramdomly selected group of 187 mothers from maternal wards of the University Hospital of Oulu were studied with different questionnaires in the first postpartum week. Depressive symptoms were re-assessed with Edinburgh Postnatal Depression Scale four months postpartum when paternal depression was evaluated with Beck Depression Inventory. 16.2% of the women were immediately after delivery screened as being depressed. Four months postpartum 13.0% of the mothers were depressed whereas 5.1 % of the fathers were having depressive symptoms. The cumulative incidence of maternal postnatal depression within the first four months was 22.2%. These mothers who immediately showed depressive symptoms were at a higher risk to be depressed later. Maternal age 30 years or less predicted postnatal depression. The occurrence of maternal postnatal depression varied slightly during different seasons; during dark time immediate depressive symptoms increased and the spring seemed to protect from later postnatal depression. Analgesia during vaginal delivery, e.g. nitrous oxide, epidural analgesia or paracervical blockade, protected from postnatal depression as well. Caesarean section, either elective or emergency, did not predict postpartum mental well-being. Scores from the GHQ and the EPDS were strongly interrelated. Seven (5%) fathers were depressed four moths postpartum. They all were men whose partners also scored high in the EPDS. Those mothers who were depressed interpreted infant facial signals differently, seeing less joy, disgust and anger, but more sadness in the infant facial pictures. Cultural variability was found in complex blended facial features of emotions, e.g. distress, in the Infant Facial Expression from Looking at Picture scale, although remarkable agreement was achieved and reinforced. In the videotaped early mother-infant interaction small, but essential, changes were observed at 10 months postpartum. Overall, mothers who had had persistent depressive symptoms showed less negative expressions and had less anger and anxiety in their interaction. Their children were slightly less impulsive and seemed to have less visual and communicative contact with their mothers. The dyad was characterised by short periods of uninvolvement between the mother and the infant; e.g. the moments of reciprocity were less frequent than in the non-depressed mothers. At 42 months postpartum, the children of the persistently depressed mothers scored lower on the Expressive language scale than the children of the mothers who were depressed in one measurement or never.

Magister Psychologiae - MPsych / Adolescent pregnancy has been of longstanding societal concern primarily because of the inability of most young mothers to provide adequately for their infants. Depression often results in disengagement from mother-child interaction. Adolescent mothers identified as depressed are at increased risk of future psychopathology, with additional deleterious effects on their infants’ lives. The purpose of this study was to explore adolescent mothers’ experiences of motherhood and memories of feeling depressed during or after the birth of their babies. The first aim was to explore the young women’s experiences of mothering, by focusing upon the practice of being a mother. The second aim was to explore the young women’s experiences of depression, by focusing on their physical behaviour and emotional experiences. The third aim was to explore their perceptions of the causes of their depression. The rationale for this study was that these issues will further enhance the body of knowledge available to practitioners working with adolescent mothers. It will also provide a source of insights and hypotheses for preventive intervention research. The study was located within a feminist standpoint framework that begins from the perspective of women with the aim to explore women’s accounts of their experiences in relation to depression as an important source of knowledge. A qualitative research design and methodology was employed in the region of the Western Cape. Eight adolescent mothers between the ages of 16 and 19 were recruited and interviewed. The interviews were semi-structured and consisted out of open-ended questions. Interviews were recorded, transcribed verbatim and thematic analysis of data was carried out. The findings of this research yielded some interesting areas for future research and implications for treatment and intervention with first-time adolescent mothers. The adolescent mothers in this study experienced similar depressive symptoms to adult mothers in previous research. All the participants revealed that they feared their parents’ disappointment in them for being pregnant. This factor contributed to their depression, because they received very little (if any) support from their parents or the father of their baby. The participants discussed that their pregnancy or giving birth was linked to various aspects of themselves that they had lost as an adolescent. Before they received counselling, none of the participants understood why they experienced depressive symptoms or what was happening to them at the time after their pregnancies. / South Africa

In order to investigate the coping styles used by HIV-positive pregnant women over the first two years after diagnosis, structured interviews were conducted with 224 women at antenatal clinics in Tshwane, South Africa. The baseline interview was conducted four weeks after diagnosis during pregnancy, and three follow-up interviews were conducted postpartum. Coping was measured with an adapted version of the Brief COPE (Carver, 1997). Differences between each assessment period with regard to the different coping strategies were assessed by means of paired t-tests. Variables associated with coping were identified with mixed linear analysis. It was found that active coping was used more often than avoidant coping throughout the two-year period. The most frequently used coping strategies included acceptance, direct action, positive reframing, religion and distraction. Self-blame and out-of-control decreased substantially over time, whereas helping others increased markedly over time. Active coping was associated with low internalised stigma, low depression, high self-esteem, high positive social support, knowing someone who is HIV-positive, living above the poverty line and not receiving antiretroviral treatment. Avoidant coping was associated with low HIV-knowledge, low self-esteem, high internalised stigma, high depression as well as education below tertiary level. Recommendations for psychological support services, policy and further research are made. / Dissertation (Master of Arts)--University of Pretoria, 2012. / Psychology / unrestricted