Esta dissertação é fruto de profundas inquietações a respeito da origem e da importância das primeiras relações entre mãe e bebê, bem como das forças atuantes na constituição do psiquismo infantil. Ao longo do estudo, surgiu a necessidade de pesquisar a depressão pós-parto como conseqüência do retorno a si mesma, fruto da regressão da mãe e do contato facilitado que toda mãe é levada a fazer ao dar à luz um bebê com conteúdos e conflitos inconscientes relativos a experiências e fantasias infantis e suas reverberações no desencontro da dupla. O estudo inicia-se pela visão de Freud, Klein e alguns de seus discípulos atuais sobre como a menina se torna mulher e qual o impacto da maternidade para o psiquismo feminino; discute a importância da complexa trama envolvida no cenário das primeiras relações; demonstra as competências do recém-nascido, seu uso dos cinco sentidos, e a noção de estados de consciência; trata das confirmações encontradas pela neurociência às questões da importância das relações iniciais que a psicanálise discute; aborda aspectos da interação mãe e bebê, inclusive a psicopatologia do bebê decorrente do desencontro entre a dupla e seus efeitos, com atenção especial à compreensão da depressão materna no período puerperal. Num segundo momento, discutem-se entrevistas que realizamos com pediatras profissionais que atendem no início a dupla mãe-bebê possuidores de experiência diversificada em clínica médica. Aborda-se o universo que apresentam, bem como se registram as reflexões advindas desses contatos produtivos, articulando-os com os conhecimentos teóricos oferecidos pela psicanálise. Assim, propõe-se verificar e observar a capacitação dos pediatras no diagnóstico da depressão puerperal; investigar a atenção que os pediatras dedicam aos aspectos da relação entre mãe e filho e seu impacto no desenvolvimento do bebê; e apontar de que forma a psicologia e a psicanálise podem fornecer subsídios à pediatria. / This essay is a result of profound concerns about the origins and the importance of the early relationship between mother and baby and of the active crosscurrents in the constitution of child psyche. Throughout the work, there came the necessity of researching the postpartum depression as a consequence of the return to the self, a product of mother regression and of the facilitated contact which every mother is supposed to undergo after child bearing with unconscious themes and conflicts related to child experiences and fantasies and their reverberations in the lack of mother-baby approximation. This study begins with the perspectives of Freud, Klein and some of their contemporary followers about how the girl becomes a woman and the impact of motherhood in women psyche; then, it discusses the importance of the complex web involved in the early relationships; it shows the skills of the newborn baby, its use of the five senses, and the concept of states of conscience; it addresses how neuroscience has confirmed the issues related to the centrality of the early relationships discussed by psychoanalysis; it approaches the aspects relating to the interactions between mother and baby and their effects, focusing specially in the understanding of motherhood depression in the puerperal period. In a second stance, our work discusses the interviews we have made with pediatricians professionals giving an early medical care to mother and baby who have a diverse experience in medical practice. Our work addresses the universe they present, and observes the reflections that come from these productive contacts, articulating them with the theoretical knowledge offered by psychoanalysis. By this light, we intend to examine and observe the ability pediatricians have in the diagnosis of puerperal depression; to investigate the attention they give to the aspects of mother-baby relationship and their impact on child development; and to show how psychology and psychoanalysis are able to furnish useful tools to pediatrics.

Bakgrund: Postpartumdepression drabbar mellan 8-15 procent av kvinnor som föder barn. Depressionen bryter oftast ut några veckor efter förlossningen och kan vara upp till ett år eller mer och innebär ett stort lidande för den som drabbas. Studier visar att en stor del av de som drabbas inte söker hjälp, vilket visar på behovet av att sjuksköterskan fångar upp dessa kvinnor för att tidigt erbjuda stöd och behandling. Syfte: Syftet med litteraturöversikten var att undersöka vilka barriärer kvinnor drabbade av postpartumdepression upplever för att söka hjälp. Metodbeskrivning: Allmän litteraturöversikt valdes som metod, tio kvalitativa studier valdes utifrån databaserna PubMed och CINAHL. Artiklarna kvalitetgranskades utifrån en kvalitetsmall. Tre kategorier utformades därefter av den analyserade datan. Resultat: De kategorier som identifierades som barriärer var; kvinnorna själva, familj och omgivning samt sjukvården. Det identifierades en stor okunskap om postpartumdepression bland de deltagande kvinnorna, vilket ledde till att de normaliserade sina symtom och avvaktade med att söka hjälp. Rädslan för att bli stigmatiserade och att uppfattas som dåliga mammor var ytterligare en barriär. Bristande stöd från sjukvården framkom som ytterligare barriärer. Slutsats: Kvinnor upplever ett stigma kopplat till psykisk ohälsa och moderskap, vilket leder till att de inte söker hjälp. En ofta upplevd oförståelse inför sina symtom leder till att kvinnor normaliserar dem. En stöttande sjukvård är av största vikt, sjuksköterskans arbete kan bidra till att bryta stigmat och skapa en trygg och fördomsfri miljö där kvinnor kan öppna upp sig. / Background: Postpartum depression affects around 8-15 percent of women who have given birth. Symptoms present within a few weeks and can last upwards of a year; and cause a great deal of suffering to the women experiencing it. Evidence suggests women do not seek help for their depressive symptoms, which highlights the need of nurses to identify symptoms and offer treatment and support. Aim: The aim of this literature review is to examine the experienced barriers among women to seek help for postpartum depression. Method: The studies analysed in this literature review were chosen from the databases PubMed and CINAHL. Ten studies were included. Quality of the articles was identified using a criteria and three categories were found within the findings. Results: The three categories concerned the women, their surrounding and the health care as barriers. Stigmatisations attached to mental healt issues and the ‘ideal’ image of motherhood created a major barrier to seek help. Women experienced a lack of knowledge and understanding of PPD, they often normalised the symptoms and explained them with external factors. A lack of support from health care also posed as barriers when seeking help. Conclusion: Women experience numerous stigmatisations related to mental health issues and the ‘ideal’ image of motherhood, which figured as a major barrier to seek help. This study reiterates the importance of having supportive health care; with the nurse playing an important role in breaking this stigma and creating a safe environment for women to share their experiences.

Foram realizados quatro trabalhos visando avaliar a substituição da fibra em detergente neutro (FDN) do feno de &#39:coastcross&#39: (Cynodon sp.) pela FDN da casca de soja (CS) sobre a digestibilidade dos nutrientes em cordeiros e sobre a produção e composição de leite, comportamento ingestivo e atividade ovariana pós-parto de ovelhas Santa Inês. Todas as rações experimentais foram isonitrogenadas, contendo teores semelhantes de FDN e balanceadas de acordo com o NRC (1985). O tratamento controle foi uma ração composta de 70% de feno na matéria seca (MS) da ração (CS0), sendo a FDN proveniente do feno substituída em 33% (CS33), 67% (CS67) e 100% (CS100) pela FDN proveniente da CS. No experimento de digestibilidade, 24 cordeiros Santa Inês (42,5 &#177; 3,6 kg PV e 6 meses de idade) foram arranjados em delineamento blocos completos casualizados definidos pelo peso vivo (PV). No experimento de produção, composição de leite, comportamento ingestivo e retorno da atividade ovariana pós-parto, 56 ovelhas (56 &#177; 0,5 kg PV) foram individualmente alojadas em baias cobertas e distribuídas em delineamento blocos completos casualizados definidos pelo número, tipo e data do parto, além do sexo das crias. As ovelhas foram ordenhadas manualmente, uma vez por semana, da segunda até a oitava semana de lactação (data do desmame). A produção diária foi estimada pelo cálculo do total de gramas obtido durante o intervalo de 3h. As observações de comportamento foram feitas a cada cinco minutos durante 24h. A colheita de sangue foi feita pela veia jugular, duas vezes por semana, da segunda até a décima segunda semana pós-parto. O retorno da atividade ovariana pós-parto foi definido quando a concentração sérica de P4 foi &#8805; 1 ng/mL. As digestibilidades da matéria orgânica (P < 0,05), da FDN (P < 0,05) e da fibra em detergente ácido (P < 0,01) apresentaram efeito quadrático com a inclusão de CS, enquanto a digestibilidade da proteína bruta (PB) apresentou decréscimo linear (P < 0,0001). Efeito quadrático (P < 0,01) foi observado na produção de leite em 3h (142,4; 179,8; 212,6; 202,9 g) e no consumo de MS (2,27; 2,69; 3,25; 3,00 kg/dia). Os teores de gordura (7,59; 7,86; 7,59; 7,74%), de proteína (4,53; 4,43; 4,40; 4,55%) e sólidos totais (18,24; 18,54; 18,39; 18,64%) foram similares (P > 0,10). Houve efeito linear decrescente (P < 0,001) com a inclusão de CS no tempo de ingestão (min/dia, min/g MS e min/g FDN) e no tempo de ruminação e de mastigação (min/g MS e min/g FDN). Não houve diferença (P > 0,10) no número de dias necessários ao retorno da atividade ovariana. Em média, 34,5 dias foram necessários para a primeira ovulação. A CS é um interessante substituto à forragem na ração de ovinos Santa Inês e pode ser usada em altos teores na MS da ração. A utilização de intervalo entre partos menor do que oito meses é viável para ovelhas Santa Inês. / Four trials were conducted to evaluate the effects of replacing coastcross hay neutral detergent fiber (NDF) by soybean hulls (SH) NDF on nutrient digestibility of lambs and milk yield, milk composition, ingestive behavior and postpartum ovarian activity of Santa Inês ewes. Experimental diets were formulated to meet NRC (1985) requirements and to provide a similar amount of NDF and crude protein (CP). Hay NDF from a 70% roughage-based diet (SH0) was replaced with SH NDF by 33% (SH33), 67% (SH67) and 100% (SH100). In the digestibility trial, 24 Santa Inês ram lambs (42.5 &#177; 3.6 kg of BW and 6 months old) assigned in a complete randomized block design defined by body weight (BW) were allotted in suspended metabolism crates. In the milk yield, milk composition, ingestive behavior and postpartum ovarian activity trials, 56 lactating ewes (initial BW 56.0 &#177; 0.5) were penned individually and used in a complete randomized block design according to parity, type of rearing (single or twin), offspring gender and lambing date. Ewes were milked by hand once a week, from second to eighth week of lactation (weaning time). Milk production was recorded in a 3h-interval. Behavior observations were visually recorded in a five-min interval during 24h. Blood samples were collected by venipuncture two times a week, from the first to the twelfth week after lambing. Ovarian activity resumption was defined when P4 concentration was &#8805; 1 ng/mL. Organic matter digestibility showed a quadratic effect (P < 0.05) with SH inclusion while CP digestibility showed a linear decrease (P < 0.0001). Quadratic effect was also observed for NDF digestibility (P < 0.05) and acid detergent fiber digestibility (P < 0.01). A quadratic effect (P < 0.01) for 3-h milk production (142.4, 179.8, 212.6, 202.9 g) and dry matter intake (2.27, 2.69, 3.25, 3.00 kg/day) was observed as SH level increased from 0 to 85%. Milk fat (7.59, 7.86, 7.59 and 7.74%), protein (4.53, 4.43, 4.40 and 4.55%) and total solids (18.24, 18.54, 18.39 and 18.64%) were similar (P > 0.10) for SH0, SH33, SH67 and SH100, respectively. Ingestion time (min/day, min/g DM and min/g NDF) and time expended in rumination and chewing activities (min/g DM and min/g NDF) showed a linear decrease (P < 0.001) with addition of SH in the diets. There was no treatment effect (P > 0.10) on ovarian activity resumption. The mean value for the first ovulation was 34.5 days. SH are an interesting forage replacer for sheep diets and may be used in high levels of inclusion. A lambing interval shorter than eight months is possible for Santa Inês ewes.

INTRODUÇÃO: Manter hábitos alimentares saudáveis durante a gravidez evita a retenção de peso pós-parto, desfecho que contribui para a elevação da prevalência de obesidade em mulheres. OBJETIVO: Estudar, em coorte de grávidas clientes de serviço público de pré-natal: o consumo alimentar e fatores sócio-econômicos associados; e a influência do consumo alimentar sobre a retenção de peso pós-parto. MÉTODOS: Em estudo de coorte realizado em 5 Unidades Básicas de Saúde do Município de São Paulo, foram acompanhadas 88 gestantes entrevistadas nas consultas de pré-natal e em visita domiciliar 15 dias pós-parto. Para avaliação do consumo alimentar utilizou-se o inquérito Recordatório de 24h, aplicado no 2º trimestre de gestação. Foram calculados o consumo energético e de frutas, verduras e legumes (FLVs), fibras, gordura saturada, açúcar adicionado, alimentos processados e a densidade energética da dieta por meio de tabelas de composição de alimentos. O consumo alimentar foi comparado com as metas de ingestão da OMS. Avaliou-se a retenção de peso pós-parto pela diferença entre a medida de peso 15 dias pós-parto e a realizada no início da gestação. A influência das variáveis sócio-econômicas (renda familiar per capita, escolaridade, estado marital e idade) sobre a adequação do consumo alimentar foi avaliada utilizando-se análise de regressão logística múltipla. Estudou-se a associação entre as variáveis de consumo alimentar (divididas em terços) e a retenção de peso pós-parto mediante análise de regressão linear múltipla. RESULTADOS: Mais de 30 por cento das mulheres apresentaram consumo excessivo de açúcar adicionado e gordura saturada, 64 por cento não atingiram a ingestão mínima de FLVs e nenhuma consumiu a quantidade de fibra alimentar recomendada. O aumento da renda reduziu o Odds Ratio de consumo insuficiente de FLVs (p=0,007). O Odds Ratio de consumo excessivo de açúcar adicionado elevou-se nas mulheres com companheiro (p=0,011) e com maior escolaridade (p=0,008). Maior consumo de gordura saturada elevou a retenção de peso pós-parto de forma estatisticamente significativa no modelo ajustado (p de tendência=0,033). Não foi encontrada relação significativa entre retenção de peso pós-parto e as demais variáveis de consumo alimentar. CONCLUSÃO: O padrão alimentar das gestantes não se mostrou adequado diante as recomendações da OMS, principalmente quanto à ingestão de alimentos saudáveis. O aumento da renda foi um fator de proteção para o consumo inadequado de FLVs na gestação. Houve aumento da retenção de peso pós-parto com a elevação do consumo de gordura saturada nas mulheres estudadas. / Introduction: Healthy food habits during pregnancy prevent postpartum weight retention, which contributes for increasing obesity prevalence among women. Objectives: To study in a cohort of pregnant women: dietary intake and related socioeconomic factors; and the influence of dietary intake on postpartum weight retention. Methods: In this cohort study, 88 pregnant women were interviewed during prenatal appointments in five Primary Units of Public Health and during a domiciliary visit 15 days after delivery, in the city of São Paulo, Brazil. For dietary intake evaluation, the 24-Hour Dietary Recall method was performed at the 2nd trimester of gestation. Energy, fruits and vegetables (FV), dietary fiber, added sugar, processed foods and saturated fat consumption and dietary energy density were calculated using food composition tables and adjusted by energy intake when necessary. Dietary intake variables were compared with WHO recommendations. Postpartum weight retention was calculated by the difference between the weight measured at the beginning of gestation and the same measure 15 days after delivery. The influence of socioeconomic variables (per capita familiar income, education, marital status and age) on dietary intake adequacy was analyzed by multiple logistic regression analysis. The association between dietary intake variables (divided in tertiles) and postpartum weight retention was assessed by multiple linear regression analysis. Results: More than 30 per cent of the women had inadequate added sugar and saturated fat consumption, 64 per cent didnt reach the minimum FV ingestion and none consumed the minimum recommendation for dietary fiber. Income increases reduced the odds ratio for insufficient FV consumption (p=0,007). The odds ratio for excessive added sugar consumption increased among women who lived with a partner (p=0,011) and who had higher educational levels (p=0,008). Postpartum weight retention was significantly higher with elevated ingestion of saturated fat in the adjusted model (p for trend=0,033). No significant relation was found between weight retention and the other dietary indicators. Conclusion: The dietary pattern of the pregnant women assessed in this study was not entirely adequate with regard to WHO recommendations, mainly because of the lack of healthy food ingestion. Income influenced positively the consumption of FV during gestation. Higher consumption of saturated fat increased postpartum weight retention among the studied women.

Postpartum Depression (PPD) occurs in 10-20% of new mothers. PPD can lead to serious health risks to both the mother and infant, increase the risk of complications during birth, and cause lasting effects on the development and wellbeing of the child. Many mothers suffering from PPD do not receive treatment due to fear of being stigmatized, lack of education, or not being able to access mental health services. High prevalence of PPD, along with the negative and lasting effects it can cause point to the importance of developing an effective and feasible method of assessing and treating this disorder. A pediatric primary care office may be an opportune setting to screen for PPD since mothers often accompany their children to regularly scheduled well child visits. While some studies have examined PPD screening within the pediatric primary care setting, few have explored the addition of an on-site Behavioral Health Consultant to provide brief interventions for depressed mothers as part of a stepped care model. The primary aim of the current study is assess the feasibility of implementing a stepped care protocol that assesses PPD and provides brief interventions and referrals for depressed mothers within a pediatric primary care clinic. The protocol consists of several phases including: 1) distribution of the Edinburgh Postpartum Depression Screener to every mother arriving for a well child visit during the first six months of their child’s life; 2) appropriate documentation in the clinic’s electronic health record (EHR) of the Edinburgh score and resulting plan of action; 3) a brief same day intervention by the on-site Behavioral Health Consultant and referral to outside provider, if applicable; and 4) phone call follow up with the mother and referred provider, if applicable. Research assistants will monitor the EHR to determine the clinic’s fidelity to the protocol (e.g., if the Edinburgh is being administered properly). Data will also be collected from the EHR to determine if a correlation exists between Edinburgh scores and number of Emergency Room visits made by the child, immunizations administered to the child, and number of well child checks the child attended. Data collected throughout the month of March showing the Edinburgh uptake, consistency with protocol, and any correlation between Edinburgh scores and other variables will be presented.

Postpartum Depression (PPD) affects 15% of women after childbirth. Its etiology includes psychoneuroimmunologic factors with long-lasting postpartum stressors that lead to allostatic overload. Using mindfulness-based stress reduction (MBSR) for PPD has not yet been studied. Addressing this literature gap, the potential benefits of including an 8-week MBSR component based on Beck's theory of PPD at support groups were examined in this phenomenological study based on a sample of 10 women and 2 group facilitators. Purposes of the study included describing the experience of PPD and the MBSR program, identifying the stage of behavioral change of the participants, and describing the population of women attending the PPD support groups. These assessments were carried out using coding and constant comparison, guided by the tenets of the transtheoretical model. Data triangulation safeguarded study validity and rigor. Results pointed to the value of utilizing the MBSR program in PPD support groups. Data analysis concluded in the identification of 9 stages and 5 themes of the PPD experience of which 2 constructs, unexpected experience and feeling dismissed, emerged as original contributions of the study. Positive impact on social change was evidenced at the individual level by women's report of high satisfaction with the support groups and the MBSR program; improved problem-solving and coping with anxiety, panic, and intrusive thoughts; and by positive behavioral change at Week 8. The updated knowledge about these women's experiences, along with the availability of a new tool for professionals to treat PPD, contribute to positive social change at a societal level by improving mothers' health and children's development.

Incentive-based education has a clear purpose and vision for the populations served. It is important for these organizations to demonstrate that their impact is positive, and that resources from the community are utilized efficiently. The purpose of this study is to identify the impacts of incentive-based education on the understanding and preparedness of a mother’s prenatal and postpartum experiences. Baby Steps, a non-profit incentive-based education program, was used as the research site. Clients of Baby Steps who have been involved in the program since a time during their pregnancy and who have had their baby between 3-12 months ago participated in this study. The mothers who participated in this survey reported needing financial, emotional, and/or educational support during and following their pregnancy. Survey participants’ ages ranged from 18 years to 34 years old, and came from a variety of ethnic backgrounds and countries of origin. The educational background of participants ranged from elementary school being the highest grade finished, to the completion a college degree. The findings of this study were able support the research hypothesis as these mothers were able to find at least some of the support they needed by participating in the Baby Steps program, thus yielding positive prenatal and postpartum outcomes.

The purpose of this study was to identify barriers to receiving services for women suffering with Postpartum Depression (PPD) in the San Bernardino and Riverside County areas. 11 - 20% of mothers experience symptoms of PPD, which if left untreated can negatively impact the mother-infant relationship, ultimately affecting the entire family unit. Past studies have identified a variety of barriers to receiving treatment for PPD. However, research has not focused specifically on the obstacles mothers face in these two neighboring counties. The study utilized an online self-administered questionnaire developed by the researchers to identify barriers to treatment for PPD. There were 41 participants from San Bernardino and Riverside Counties. The questionnaire was intended to be distributed to service providers that come into contact with this vulnerable population; primarily social workers, licensed therapists, masters of social work (MSW) students student interns, physicians, registered nurses, and midwives. However, because a snowball sampling technique was used, it was possibly sent to other professionals who come into contact with this population. Our study found that most of the barriers identified in previous studies also applied to our participants. The barriers rated highest in terms of limiting access to PPD services were a physician’s lack of time with patients, knowledge of PDD symptoms, the patient’s relationship to physician, and limits in coverage, as well as knowledge of services covered, lack of emotional support from significant other and/or family members, and transportation challenges including distance from providers. Additional barriers that were recognized in the literature and in our research, were education barriers, cultural barriers, stigma associated with postpartum depression, fear of child welfare officials, lack of culturally sensitive screening tools, and fears surrounding the use of medication. The results from this study may help practitioners and researchers better understand the barriers women with PPD face in accessing services, and may help service providers tailor their treatments and services accordingly. Additionally, the knowledge gained from the research may also inspire policy changes to improve women’s access to PPD services.

Introduction: Financial incentives increase smoking abstinence among pregnant and postpartum women. They have also been reported to reduce psychological symptoms using the Beck Depression Inventory (BDI) and Brief Symptom Inventory (BSI) in women at risk for perinatal depression. This prospective study aims to replicate and extend these findings using the BDI and Edinburgh Postpartum Depression Scale (EPDS). Methods: Participants were 169 pregnant cigarette smokers who were assigned to one of two treatment conditions: Best Practices only (n=88), which entails brief counseling and a referral to a pregnancy-specific quit-line, or Best Practices + Incentives (n=81). Participants were categorized as at increased risk (Dep+; n= 91) or lower risk (Dep-; n= 76) for depression based on history of depressive symptoms and baseline symptom scores. Treatment effects on smoking status and BDI/EPDS scores were examined across nine perinatal assessments using repeated measures analyses of covariance. Results: Financial incentives increased rates of biochemically-verified abstinence through 12-weeks postpartum independent of depression risk (ps ≤ .01) but did not differentially decrease BDI or EPDS scores (ps > .05). Scores decreased with both interventions for the Dep+ women (p = .001). Conclusions: These results replicate earlier evidence that financial incentives increase perinatal smoking abstinence in Dep+ women but not their efficacy in differentially reducing depressive symptoms at levels greater than Best Practices. The failure to replicate effects on depressive symptoms may be due to use of different control conditions in the current and prior study or increased screening and intervention for perinatal mental health during routine obstetrical care.

Prior research on maternal postpartum care, the transition to motherhood, pelvic floor dysfunction, and pelvic floor muscle training (PFMT) has revealed that postpartum women are often denied the basic information, instruction, and preventive strategies necessary for optimal postbirth rehabilitation and psychological well-being. Employing a dual framework of self-determination theory and personal growth initiative (PGI) theory, this quantitative study utilized a cross-sectional design to investigate if autonomy, competence, and relatedness satisfaction predicted PGI in postpartum women. Differences in autonomy, competence, relatedness, and PGI between PFMT practicing and nonpracticing postpartum women were also examined. A web-based survey method was employed to collect data from 229 postpartum women, which consisted of 121 women not practicing PFMT and 108 women practicing PFMT. The Basic Psychological Need Satisfaction and Frustration Scale measured autonomy, competence, and relatedness. The PGI Scale-II measured PGI. Standard multiple regression and 4 independent-samples t tests were used to analyze the data. Results indicated that autonomy, competence, and relatedness predicted PGI. There were no significant mean differences between PFMT practicing and nonpracticing women. These findings have implications for positive social change such that the medical community and policy makers can utilize the fulfillment of postpartum women's needs for autonomy, competence, and relatedness to improve women's odds for optimal adjustment and adaptation to life after childbirth.