Effects of an interpersonal-psychotherapy-oriented postnatal programme for Chinese first-time mothers: A randomized controlled trial

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Abstract

Objective

This study aimed to investigate the effects of an interpersonal-psychotherapy-oriented postnatal psychoeducation programme on postpartum depressive symptoms, social support and maternal role competence in Chinese first-time mothers.

Method

A randomized, controlled trial was conducted in the postnatal unit of a regional hospital in China. The intervention consisted of a 1-h education session before discharge and one telephone follow-up within the 2 weeks after discharge from the hospital. One hundred and eighty first-time Chinese mothers were randomly assigned to the study group (n = 90) or the control group (n = 90). Outcomes of the study included symptoms of postpartum depression, social support and maternal role competence which were measured by the Edinburgh Postnatal Depression Scale, the Perceived Social Support Scale and the Parenting Sense of Competence Scale-Efficacy subscale, respectively.

Results

Women receiving the postnatal psychoeducation programme had significantly fewer depressive symptoms (Mean [SD] = 7.61 [3.43] versus 8.96 [4.55]; t = −2.24; p = 0.026), higher level of social support (Mean [SD] = 65.44 [8.43] versus 61.82 [9.99]; t = 2.63; p = 0.009) and better maternal role competence (Mean [SD] = 35.87 [4.41] versus 32.79 [6.86]; t = 3.59; p < 0.001) at 6 weeks postpartum as compared with those who received routine postnatal care.

Conclusion

An interpersonal-psychotherapy-oriented postnatal psychoeducation programme may have the potential to facilitate the Chinese first-time mothers’ transition to motherhood. A larger trial is needed to test for therapist effects, a full economic evaluation, and whether the intervention is acceptable to staff and feasible to use in current practice.

Introduction

Transition to motherhood is an important developmental stage in a woman's life. A woman needs to make physical and psychosocial changes while integrating her sense of self as a mother and in relationship to her new infant (Emmanuel et al., 2008). Achieving maternal role competence and developing a sense of well-being are regarded as critical components of maternal adaptation (Gao et al., 2012). A positive transition period is known to impact on the quality of parenting behaviour and, ultimately on the child's psychosocial development (Jones and Prinz, 2005).

However, the reality of fatigue, the demanding responsibility of caring for a newborn, and the profound changes in roles and relationships may come as a shock for most women during the postpartum period (Nyström and öhrling, 2004). Women were often found to express feelings of inadequacy in the mothering role (Nelson, 2003). Some women might have difficulties in adapting to motherhood and develop depression (Chan et al., 2002).

Globally, in women of child-bearing age, depression accounts for the largest proportion of the burden associated with mental or neurological disorders (Vos et al., 2012). Postpartum depression (PPD) is a major unipolar depressive disorder occurring within 4–6 weeks after giving birth and lasting for at least 2 consecutive weeks (American Psychiatric Association, 2000). PPD is a significant public health concern. PPD was found to affect 19.2% of women in a meta-analysis of 28 studies across diverse countries and cultures (Gavin et al., 2005). In mainland China, PPD affect about 5.45% ∼ 17% postpartum women (Gao et al., 2009, Shi et al., 2003). PPD is an important marker of the mother's risk for subsequent depression (Dennis et al., 2012); a risk factor for depression in partners (Gao et al., 2009); and also has adverse effects on the cognitive, social and emotional development in infants (Chun and Panos, 2004).

Social support can facilitate women's transition to motherhood (Gao et al., 2009, Gao et al., 2012, Warren et al., 2012). Social support is defined as the interpersonal resources accessed and mobilized when individuals attempt to deal with the everyday stresses and strains of life. Social support consists of the availability and perceptions of social support (Gao et al., 2009). As a buffer, social support can protect an individual from the potentially adverse effects of stressful events and enhance health outcomes (Taylor, 2003). Women with higher social support tend to report less depressive symptoms (Gao et al., 2012, Ngai et al., 2010). Lack of social support has been consistently indicated as a significant predictor of PPD (Gao et al., 2009, Heh et al., 2004).

Social support also has a positive effect on maternal role competence (Gao et al., 2012, Warren, 2005). According to Bandura (1997), social support may influence maternal role competence through processes involving opportunities to observe significant others’ parenting and verbal persuasion and encouragement. Bandura (1997) comments that watching others function successfully in their parenting role may shape expectations for women's own performance, and maintaining maternal role competence beliefs is easier for an individual when their significant others believe in their capacities and say so. Women who perceived themselves as being well supported are more likely to report higher level of maternal role competence (Gao et al., 2012, Ngai et al., 2010).

Family members are the most important sources for the new mothers to get social support. At present in mainland China postpartum practices “doing the month” are still common, in which the new mother is accompanied by her mother-in-law or mother. The mother-in-law or mother helps the new mother in household chores and baby care.

However, because of the ensuing modernization and ingress of Western values, the younger women and their mothers-in-law or mothers may have different values and belief systems (Gao et al., 2010b). These differences are manifested explicitly in postpartum customs, baby care and the preference for a male baby, which may cause deterioration of the relationship between the women and their old generations or husbands during the postpartum period (Gao et al., 2010a, Gao et al., 2010b, Gao et al., 2012). Many studies revealed that “doing the month” was not always perceived as supportive to Chinese women or meeting their true needs (Gao et al., 2013, Wong and Fisher, 2009).

In addition to family members, most women feel a need for psychosocial support during their transition to motherhood from health professionals such as midwives (Darvill et al., 2010, Teeffelen et al., 2011, Wilkins, 2006). Besides information, the new mothers want their midwives’ appraisal and emotional support as well, such as reassurance, more contact with their midwives (Teeffelen et al., 2011). It is recommended that psychosocial support should be integrated into routine midwifery care, giving all women access to support during the transition to motherhood (International Confederation of Midwives, 2013).

Facilitating women's transition to motherhood is an important concern for nurses and midwives. Nurses and midwives could be a source of social support for new mothers. They could also provide knowledge and skills to help new mothers to acquire social support from families and friends (Gao et al., 2013).

Parenting in the early postpartum period is a time of maternal learning and adaptation. A recent meta-analysis indicated that one of the effective interventions with a clear effect on decreasing depressive symptomatology was intensive postpartum support by a health professional, and exclusively postpartum interventions were more successful than interventions that also incorporated a prenatal component (Dennis and Dowswell, 2013).

Now in mainland China, women in the cities usually give birth in the hospitals. After delivery, they generally stay in the hospital for 2–3 days. It is good timing for nurses to initiate psychoeducation programme to new mothers. However, the present nursing care in the postnatal ward centres on women's physical recovery and breastfeeding skills. There is very little content on psychosocial issues related to transition to motherhood, such as new role adaptation, communication skills and skills in maintaining satisfied interpersonal relationships (Li et al., 2008).

Evidence suggested that the interpersonal psychotherapy (IPT) might work as a potential framework for developing postnatal psychoeducation programme for Chinese new mothers (Gao et al., 2010a, Gao et al., 2012). IPT is a manual-based, time-limited psychotherapeutic approach. It is based on the hypothesis that depression, regardless of aetiology, is initiated and maintained within an interpersonal context (Klerman et al., 1984, Stuart and Franzcp, 2003). Target depressive clients’ social functioning problems are conceptualized as one or more of four areas: interpersonal disputes, role transitions, grief, and interpersonal deficits. IPT is primarily concerned with interpersonal relationships and has a specific focus on social interactions, communication, social supports, and interpersonal functioning.

Previous studies also demonstrated that the IPT oriented intervention was effective in enhancing social support, maternal role competence and reducing depressive symptoms (Gao et al., 2012, Zlotnick et al., 2001, Zlotnick et al., 2006). However, postnatal intervention based on the principles of IPT has not been examined in mainland China. Therefore, it is significant to evaluate an IPT oriented postnatal psychoeducation programme for Chinese first-time mothers.

Section snippets

Aims

The primary aim of this study was to examine the impact of an IPT-oriented postnatal psychoeducation programme on postpartum depressive symptoms, social support and maternal role competence in Chinese first-time mothers at 6 weeks postpartum. The secondary aim of this study was to explore the relationship among social support, maternal role competence and postpartum depressive symptoms.

The primary hypotheses of this study were: at 6 weeks postpartum when compared with women received the routine

Design and setting

A randomized, controlled trial was conducted from September 2012 to February 2013 at a regional teaching hospital in Guangzhou where the birth rate was more than 5000 babies per year.

Participants, recruitment and randomization

The inclusion criteria were: first-time mother who had given birth with single full-term health baby (gestation age 37–40 weeks, body weight over 2500 g and Apgar score equal or above 8), married and living with their husband. Women with past or family psychiatric history and major postnatal complications, such as

Results

Fig. 1 shows the flow of the participants through the trial. Three hundred and sixty-eight first-time mothers were screened and 180 agreed to participate in the study. All the mothers in the study group received the education session before discharge and 86 mothers received the telephone follow-up within 2 weeks after delivery. One hundred and sixty-six women (92.2%) had responded to the post-test measurement at 6 weeks postpartum. A comparison of the baseline characteristics for the

Discussion

This study demonstrated an initiation to apply the principles of IPT into postnatal care in Chinese first-time mothers. The findings of this study indicated that the IPT-oriented postnatal psychoeducation programme was effective in decreasing depressive symptoms and promoting social support and maternal role competence in Chinese first-time mothers. This study provided preliminary support for the effectiveness of the IPT-oriented postnatal psychoeducation programme in facilitating Chinese

Acknowledgements

This study was supported by Department of Health of Guangdong Province, China. The authors would like to thank the women who participated in our study and pay tribute to the experts and hospitals for supporting this project.

Conflict of interest. None declared.

Funding. Medical Scientific Research Foundation of Guangdong Province, China supported this research and governed the progress and review of this study. (No. A2012164)

Ethical approval. None declared.

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