JOGNN
REVIEW
A Systematic Review of Psychosocial Interventions for Women with Postpartum Stress Ju-Eun Song, Tiffany Kim, and Jeong-Ah Ahn
Correspondence Jeong-Ah Ahn, PhD, RN, School of Nursing, Northeastern University, 360 Huntington Ave., Boston, MA 02115. [email protected] Keywords mothers postpartum period stress intervention studies review
ABSTRACT Objective: To analyze the effects of psychosocial interventions with the aim of reducing the intensity of stress in mothers during the postpartum period as compared with usual care. Data Sources: Eligible studies were identified by searching MEDLINE, EMBASE, CINAHL, and ProQuest dissertations and theses. Study Selection: Randomized controlled trials (RCTs) treating stress in postpartum mothers older than age 19 years were included. The suitability of the quality of articles was evaluated using Joanna Briggs Institute’s Critical Appraisal Checklist for Experimental Studies. Fourteen articles met the inclusion criteria for data analysis. Data Extraction: Authors, country, sample, setting, methods, time period, major content of the intervention, outcome measures, and salient findings were extracted and summarized in a data extraction form for further analysis and synthesis. Data Synthesis: Standardized mean differences with 95% confidence intervals were calculated for 13 suitable articles using Cochrane Review Manager. Results: Of 1,871 publications, 14 RCTs, conducted between 1994 and 2012, were evaluated in the systematic review and 13 studies were included in the meta-analysis. Studies were categorized into three major types by interventional methods. We found that psychosocial interventions in general (standard mean difference −1.66, 95% confidence interval [−2.74, −0.57], p = .003), and supportive stress management programs in particular (standard mean difference −0.59, 95% confidence interval [−0.94, −0.23], p = .001), were effective for women dealing with postpartum stress. Conclusions: This review indicated that psychosocial interventions including supportive stress management programs are effective for reducing postpartum stress in women, so those interventions should become an essential part of maternity care.
JOGNN, 44, 183-192; 2015. DOI: 10.1111/1552-6909.12541 Accepted November 2014
Ju-Eun Song, PhD, RN, is an associate professor in the College of Nursing, Ajou University, Suwon, Korea. Tiffany Kim, PhD, RN, WHCNP-BC, is an assistant professor in the School of Nursing, Bouv´e College of Health Sciences, Northeastern University, Boston, MA.
(Continued)
The authors report no conflict of interest or relevant financial relationships.
http://jognn.awhonn.org
he postpartum period represents one of the most important transitional times in a woman’s life. It is a time of biological, psychological, and social change that can contribute to personal enrichment, maturity, and happiness; at the same time it may also predispose a woman to psychological distress (Bener, Gerber, & Sheikh, 2012). After childbirth, women may experience a number of physical and psychological stressors. Physical stressors include perineal pain, backaches, urinary incontinence, hemorrhoids/constipation, fatigue/physical exhaustion, sleep difficulties, and breast problems. Psychological stressors include the pressure to return to prepregnancy weight, sexual changes, concerns about the maternal role, feeding the newborn, growth and develop-
T
ment of the newborn, unpredictable behaviors or sudden sickness of the newborn, relationships with partner and family, and the lack of social resources and support (Beck, Gable, Sakala, & Declercq, 2011; Cheng & Li, 2008; Hung, Lin, Stocker, & Yu, 2011). Although various distress reactions, including sadness, depression, fear, anxiety, and helplessness are considered normal after childbirth, significant and prolonged postpartum stress is a major clinical concern (Lefkowitz, Baxt, & Evans, 2010). The actual prevalence rate of postpartum stress among women is unclear, but studies report that approximately 10% to 15% of postpartum women are affected by maternal mental health problems
C 2015 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
183
REVIEW
Psychosocial Interventions for Women with Postpartum Stress
Maternity care to support new mothers should be focused on maternal role adjustment and postpartum stress in a coordinated manner.
including depression, anxiety, and stress (Glavin & Leahy-Warren, 2013). Several thousand women are affected by this condition each year, thus the World Health Organization – The United Nations Fund for Population Activities (WHO-UNFPA; 2013) declared maternal mental health as a fundamental and important aspect in achieving the Millennium Development Goals. Postpartum stress is defined as a constraining force, in other words, the condition of constriction or a distinct negative emotional state produced by postpartum stressors that occur within 6 weeks after delivery (Hung, 2001). Women in the postpartum period are vulnerable to stress because they have to face the new tasks associated with their maternal and familial roles as well as the tremendous changes to their minds and bodies (Zauderer, 2009). The maternal role must be learned; however, many new mothers find the adjustment to motherhood to be stressful due to all the changes in the family life and the new responsibilities. The stressors can have negative effects on the mother’s health, the newborn’s health, and the mother’s relationship with her partner and extended family (Glasheen, Richardson, & Fabio, 2010; Mec¸e, 2013).
Jeong-Ah Ahn, PhD, RN, is a visiting scholar in the School of Nursing, Bouv´e College of Health Sciences, Northeastern University, Boston, MA.
184
It is necessary to provide appropriate, effective, and evidence-based nursing intervention programs to reduce postpartum stress. By using effective interventions, nurses can work with new mothers to maintain and enhance the mother’s physical and mental health, promote effective adaptation, enrich newborn health, and strengthen the relationships among family members. In recent years, clinical scholars have emphasized the importance of using postpartumspecific interventions to manage maternal mental health during the postpartum period, rather than using general maternal health care as a part of routine patient discharge instructions (Alderdice, McNeill, & Lynn, 2013; Bernard et al., 2011; Gamble & Creedy, 2009). However, to our knowledge, there is currently no available systematic review focused on postpartum stress interventions.
meta-analysis to identify the effectiveness of interventions. Using this method, our aim was to explore the effectiveness of psychosocial interventions in the reduction of stress intensity in mothers during the postpartum period. The specific research questions were: 1. What elements of psychosocial interventions have been applied to reduce postpartum stress? 2. Are psychosocial interventions to reduce postpartum stress more effective than usual care, such as routine hospital discharge care with general maternal and infant care instructions?
Methods Inclusion Criteria To select eligible studies for this review, Population, Intervention, Comparator, Outcomes, and types of Studies (PICOS) were first defined. Studies written in English and published between 1994 and 2012 were included if they met the following criteria: (a) population was primiparous or multiparous women at least age 19 years, during the postpartum period, (b) intervention included any form of psychosocial intervention to reduce postpartum stress in a variety of settings compared with any form of usual postpartum care, (c) stress was measured as one of the major outcome variables in relation to postpartum care, and (d) the study design was a RCT. Articles were excluded from the review if (a) the studies were reported only in abstract form; (b) the studies used a non-RCT design including cohort, case study, observational, and qualitative design; or (c) pharmacological stress treatment was a part of the intervention.
Search Strategy
In this study, we selected and analyzed randomized controlled trials (RCTs) for reducing postpartum stress in the systematic review and
We searched for articles through the MEDLINE, EMBASE, CINAHL, and ProQuest electronic databases. We did not limit the year of publication because we intended to conduct a comprehensive literature search. The first article that met the criteria was published in 1994, so the publication year of all selected studies was between 1994 and 2012. We searched the literature using various combinations of Medical Subject Headings (MeSH) terms and/or keywords covering the main search topic/area of psychosocial interventions for postpartum stress. MeSH terms or keywords included mothers, stress, postpartum stress, maternal stress, childcare stress, parenting stress, perceived stress, mental health, psychological health, postpartum care, intervention, and clinical trial.
JOGNN, 44, 183-192; 2015. DOI: 10.1111/1552-6909.12541
http://jognn.awhonn.org
REVIEW
Song, J.-E., Kim, T., and Ahn, J.-A.
Data Selection Two review authors independently screened titles and abstracts of all studies obtained from the literature searches for inclusion in the review. A short list of potentially relevant papers was created. The full text was retrieved if there was any doubt about whether a study should be included in the review. The methodological quality of the articles was first evaluated independently using Joanna Briggs Institute’s Critical Appraisal Checklist for Experimental Studies by two of the authors (Pearson, Field, & Jordan, 2007). After discussion, there was complete agreement between the two review authors on the methodological quality of each study.
Data Extraction To summarize the results of the selected studies, we designed a data extraction form, which included all major components of each study. For eligible studies, two review authors independently extracted the data using the data extraction form. Author(s), country, sample, setting, methods, time period, major content of the intervention, outcome measures, and the salient findings were extracted and summarized in the form for further analysis and synthesis. Statistical data for meta-analysis, for example, the number of participants of each group, mean, and standard deviation were entered into Cochrane Review Manager (RevMan 5.2).
Data Analysis We performed a narrative synthesis of selected studies’ findings to improve our understanding of the elements of interventions used to reduce postpartum stress. For the meta-analysis, we first investigated possible publication (reporting) bias using funnel plots and visually assessed them for obvious asymmetry. There was no publication bias under this evaluation method; the funnel plots appeared symmetrical. In addition, we assessed the statistical heterogeneity in each meta-analysis using the I2 , which is a useful statistic for quantifying inconsistency; I2 values between 75% and 100% represent considerable heterogeneity (Higgins & Green, 2009). There was a large heterogeneity across studies overall (I2 = 93%), so we used a random-effect model for controlling the heterogeneity among the studies to provide an estimate of the average treatment effect (Higgins & Green, 2009). Nevertheless, as there was heterogeneity across studies in sample size, type of intervention components, delivery format, and outcome measures, the results of the meta-analysis should be interpreted with caution. We calculated the stan-
JOGNN 2015; Vol. 44, Issue 2
dardized mean difference with 95% confidence intervals to combine trials that examined the same outcome and to identify the intervention effects. We also performed subgroup analyses to determine the effects of three different psychosocial interventions categorized by their major content.
Results Description of Studies Among 1,871 publications, 14 RCTs published between 1994 and 2012 met the inclusion criteria and were selected for the systematic review. After excluding one study that did not provide the necessary statistical data, including mean and standard deviation, 13 studies were included in the metaanalysis (Figure 1). The mean sample size calculated for all 14 studies in this review was 121.07 with a standard deviation of 68.41 and range of 30 to 250. Sample size of each group (intervention and control group) was more than 30 in the 11 studies. Participants in the studies were mothers with preterm infants (n = 7, 50.0%); vulnerable mothers including drug-abusing women, low-income women, and highly distressed women (n = 6, 42.9%); and general postpartum women (n = 1, 7.1%). Interventions were provided at the hospital including the neonatal intensive care units (NICU) (n = 6, 42.9%), in the home setting (n = 6, 42.9%), or in both (n = 2, 14.3%). Psychosocial interventions to reduce postpartum stress were categorized into three major types: supportive postpartum stress management programs (n = 5, 35.7%), education programs on infant care (n = 5, 35.7%), and interaction promoting programs between the infant and parents (n = 7, 50.0%) (Table 1). Four studies were conducted in Australia, three in the United States, two each in Norway and Taiwan, and one each in the United Kingdom, Canada, and The Netherlands. All studies that included postpartum stress as an outcome also reported on other psychosocial variables including depression, anxiety, self-esteem, parenting attitude, maternal behavior, family (home) environment, parent and family function, couple relationship satisfaction, interpersonal support, and perceived social support. In eight studies (57.1%), postpartum stress was measured by the Parenting Stress Index (Abidin, 1990, 1995), including the short-form version (Reitman, Currier, & Stickle, 2002). Three studies (21.4%) used the Parental Stress Scale (Miles, Funk, & Carlson, 1993; Miles, Funk, & Kasper, 1991), and three other studies
185
REVIEW
Psychosocial Interventions for Women with Postpartum Stress
Citations identified for review by electronic databases literature search (n = 1,871) Excluded not relevant (n = 1,813) Abstracts reviewed for content relevancy and inclusion criteria (n = 58) Excluded not relevant (n = 36) Full text articles reviewed for detailed examination (n = 22) Excluded not relevant (n = 4) Selected articles for critical appraisal assessed for methodological quality (n = 18) Excluded not suitable (n = 4) Selected articles for data analyses (n = 14) Excluded not suitable (n = 1) Selected articles for meta-analyses (n = 13) Figure 1. Flow chart of study selection.
Fourteen studies were included in the narrative synthesis to understand the elements and the effectiveness of individual interventions on postpartum stress. Summaries of the studies
are presented in Table 2 as supplemental information to the online version of this article (http://jognn.awhonn.org). In terms of supportive postpartum stress management programs, supportive group sessions that included discussions concerning the transition to motherhood, postnatal stress management, communication skills, and life planning had significant effects on decreasing women’s perceived stress after childbirth (Chen, Tseng, Chou, & Wang, 2000). A couple
JOGNN, 44, 183-192; 2015. DOI: 10.1111/1552-6909.12541
http://jognn.awhonn.org
(21.4%) used the Perceived Stress Scale (Cohen, Kamarch, & Mermelstein, 1983) to measure postpartum women’s stress (Tables 1 & 2).
Effects of Interventions
186
REVIEW
Song, J.-E., Kim, T., and Ahn, J.-A.
relationship and coparenting program for highly distressed parents with their first child was found to be effective at lessening parenting stress (Petch, Halford, Creedy, & Gamble, 2012). In terms of education programs on infant care, an individualized family-based intervention dealing with problems, including infant behaviors and characteristics during the hospitalization and the transition to home, was successful in reducing parental stress in the mothers of preterm infants (Meyer et al., 1994). Routine hospital discharge care plus follow-up phone calls from a nurse practitioner to discuss infant care concerns for the first 2 months significantly reduced low-income firsttime mothers’ perceived stress (Hannan, 2012). In studies combining education and mother/infant interaction promotion programs, a series of educational home visits for vulnerable families with infants by a child health nurse combined with subgroup dynamic therapy by a social worker showed positive effects on parenting stress (Armstrong, Fraser, Dadds, & Morris, 2000), and a mother/infant transaction program focusing on low-birth-weight infants’ characteristics and the interaction between the infant and the parents lowered parenting stress significantly (Kaaresen, Ronning, Ulvund, & Dahl, 2006).
A meta-analytic approach provided new information on the effectiveness of psychosocial interventions, including supportive stress management programs for women to reduce their postpartum stress.
Thirteen studies were included in the metaanalysis because one study did not provide the necessary statistical data for the analysis. The results are presented in Figures 2 and 3. In the overall comparison of all psychosocial interventions versus usual care, there was an overall beneficial effect of all types of interventions on postpartum stress (standard mean difference −1.66, 95% confidence interval [CI] [−2.74, −0.57], p = .003, I2 = 93%) (Figure 2). In the subgroup analysis of supportive stress management programs versus usual care, there was also a significant beneficial effect on postpartum stress (standard mean difference −0.59, 95% CI [−0.94, −0.23], p = .001, I2 = 64%) (Figure 3). There were, however, no significant beneficial effects in both educational programs and interaction promoting programs on postpartum stress.
Table 1: General Characteristics and Research Methodology Variables
Categories
Publication year
1994 1999
2 (14.3)
2000 2012
12 (85.7)
Type of study
RCT
14 (100)
Sample size of each group
REVIEW
A Systematic Review of Psychosocial Interventions for Women with Postpartum Stress Ju-Eun Song, Tiffany Kim, and Jeong-Ah Ahn
Correspondence Jeong-Ah Ahn, PhD, RN, School of Nursing, Northeastern University, 360 Huntington Ave., Boston, MA 02115. [email protected] Keywords mothers postpartum period stress intervention studies review
ABSTRACT Objective: To analyze the effects of psychosocial interventions with the aim of reducing the intensity of stress in mothers during the postpartum period as compared with usual care. Data Sources: Eligible studies were identified by searching MEDLINE, EMBASE, CINAHL, and ProQuest dissertations and theses. Study Selection: Randomized controlled trials (RCTs) treating stress in postpartum mothers older than age 19 years were included. The suitability of the quality of articles was evaluated using Joanna Briggs Institute’s Critical Appraisal Checklist for Experimental Studies. Fourteen articles met the inclusion criteria for data analysis. Data Extraction: Authors, country, sample, setting, methods, time period, major content of the intervention, outcome measures, and salient findings were extracted and summarized in a data extraction form for further analysis and synthesis. Data Synthesis: Standardized mean differences with 95% confidence intervals were calculated for 13 suitable articles using Cochrane Review Manager. Results: Of 1,871 publications, 14 RCTs, conducted between 1994 and 2012, were evaluated in the systematic review and 13 studies were included in the meta-analysis. Studies were categorized into three major types by interventional methods. We found that psychosocial interventions in general (standard mean difference −1.66, 95% confidence interval [−2.74, −0.57], p = .003), and supportive stress management programs in particular (standard mean difference −0.59, 95% confidence interval [−0.94, −0.23], p = .001), were effective for women dealing with postpartum stress. Conclusions: This review indicated that psychosocial interventions including supportive stress management programs are effective for reducing postpartum stress in women, so those interventions should become an essential part of maternity care.
JOGNN, 44, 183-192; 2015. DOI: 10.1111/1552-6909.12541 Accepted November 2014
Ju-Eun Song, PhD, RN, is an associate professor in the College of Nursing, Ajou University, Suwon, Korea. Tiffany Kim, PhD, RN, WHCNP-BC, is an assistant professor in the School of Nursing, Bouv´e College of Health Sciences, Northeastern University, Boston, MA.
(Continued)
The authors report no conflict of interest or relevant financial relationships.
http://jognn.awhonn.org
he postpartum period represents one of the most important transitional times in a woman’s life. It is a time of biological, psychological, and social change that can contribute to personal enrichment, maturity, and happiness; at the same time it may also predispose a woman to psychological distress (Bener, Gerber, & Sheikh, 2012). After childbirth, women may experience a number of physical and psychological stressors. Physical stressors include perineal pain, backaches, urinary incontinence, hemorrhoids/constipation, fatigue/physical exhaustion, sleep difficulties, and breast problems. Psychological stressors include the pressure to return to prepregnancy weight, sexual changes, concerns about the maternal role, feeding the newborn, growth and develop-
T
ment of the newborn, unpredictable behaviors or sudden sickness of the newborn, relationships with partner and family, and the lack of social resources and support (Beck, Gable, Sakala, & Declercq, 2011; Cheng & Li, 2008; Hung, Lin, Stocker, & Yu, 2011). Although various distress reactions, including sadness, depression, fear, anxiety, and helplessness are considered normal after childbirth, significant and prolonged postpartum stress is a major clinical concern (Lefkowitz, Baxt, & Evans, 2010). The actual prevalence rate of postpartum stress among women is unclear, but studies report that approximately 10% to 15% of postpartum women are affected by maternal mental health problems
C 2015 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
183
REVIEW
Psychosocial Interventions for Women with Postpartum Stress
Maternity care to support new mothers should be focused on maternal role adjustment and postpartum stress in a coordinated manner.
including depression, anxiety, and stress (Glavin & Leahy-Warren, 2013). Several thousand women are affected by this condition each year, thus the World Health Organization – The United Nations Fund for Population Activities (WHO-UNFPA; 2013) declared maternal mental health as a fundamental and important aspect in achieving the Millennium Development Goals. Postpartum stress is defined as a constraining force, in other words, the condition of constriction or a distinct negative emotional state produced by postpartum stressors that occur within 6 weeks after delivery (Hung, 2001). Women in the postpartum period are vulnerable to stress because they have to face the new tasks associated with their maternal and familial roles as well as the tremendous changes to their minds and bodies (Zauderer, 2009). The maternal role must be learned; however, many new mothers find the adjustment to motherhood to be stressful due to all the changes in the family life and the new responsibilities. The stressors can have negative effects on the mother’s health, the newborn’s health, and the mother’s relationship with her partner and extended family (Glasheen, Richardson, & Fabio, 2010; Mec¸e, 2013).
Jeong-Ah Ahn, PhD, RN, is a visiting scholar in the School of Nursing, Bouv´e College of Health Sciences, Northeastern University, Boston, MA.
184
It is necessary to provide appropriate, effective, and evidence-based nursing intervention programs to reduce postpartum stress. By using effective interventions, nurses can work with new mothers to maintain and enhance the mother’s physical and mental health, promote effective adaptation, enrich newborn health, and strengthen the relationships among family members. In recent years, clinical scholars have emphasized the importance of using postpartumspecific interventions to manage maternal mental health during the postpartum period, rather than using general maternal health care as a part of routine patient discharge instructions (Alderdice, McNeill, & Lynn, 2013; Bernard et al., 2011; Gamble & Creedy, 2009). However, to our knowledge, there is currently no available systematic review focused on postpartum stress interventions.
meta-analysis to identify the effectiveness of interventions. Using this method, our aim was to explore the effectiveness of psychosocial interventions in the reduction of stress intensity in mothers during the postpartum period. The specific research questions were: 1. What elements of psychosocial interventions have been applied to reduce postpartum stress? 2. Are psychosocial interventions to reduce postpartum stress more effective than usual care, such as routine hospital discharge care with general maternal and infant care instructions?
Methods Inclusion Criteria To select eligible studies for this review, Population, Intervention, Comparator, Outcomes, and types of Studies (PICOS) were first defined. Studies written in English and published between 1994 and 2012 were included if they met the following criteria: (a) population was primiparous or multiparous women at least age 19 years, during the postpartum period, (b) intervention included any form of psychosocial intervention to reduce postpartum stress in a variety of settings compared with any form of usual postpartum care, (c) stress was measured as one of the major outcome variables in relation to postpartum care, and (d) the study design was a RCT. Articles were excluded from the review if (a) the studies were reported only in abstract form; (b) the studies used a non-RCT design including cohort, case study, observational, and qualitative design; or (c) pharmacological stress treatment was a part of the intervention.
Search Strategy
In this study, we selected and analyzed randomized controlled trials (RCTs) for reducing postpartum stress in the systematic review and
We searched for articles through the MEDLINE, EMBASE, CINAHL, and ProQuest electronic databases. We did not limit the year of publication because we intended to conduct a comprehensive literature search. The first article that met the criteria was published in 1994, so the publication year of all selected studies was between 1994 and 2012. We searched the literature using various combinations of Medical Subject Headings (MeSH) terms and/or keywords covering the main search topic/area of psychosocial interventions for postpartum stress. MeSH terms or keywords included mothers, stress, postpartum stress, maternal stress, childcare stress, parenting stress, perceived stress, mental health, psychological health, postpartum care, intervention, and clinical trial.
JOGNN, 44, 183-192; 2015. DOI: 10.1111/1552-6909.12541
http://jognn.awhonn.org
REVIEW
Song, J.-E., Kim, T., and Ahn, J.-A.
Data Selection Two review authors independently screened titles and abstracts of all studies obtained from the literature searches for inclusion in the review. A short list of potentially relevant papers was created. The full text was retrieved if there was any doubt about whether a study should be included in the review. The methodological quality of the articles was first evaluated independently using Joanna Briggs Institute’s Critical Appraisal Checklist for Experimental Studies by two of the authors (Pearson, Field, & Jordan, 2007). After discussion, there was complete agreement between the two review authors on the methodological quality of each study.
Data Extraction To summarize the results of the selected studies, we designed a data extraction form, which included all major components of each study. For eligible studies, two review authors independently extracted the data using the data extraction form. Author(s), country, sample, setting, methods, time period, major content of the intervention, outcome measures, and the salient findings were extracted and summarized in the form for further analysis and synthesis. Statistical data for meta-analysis, for example, the number of participants of each group, mean, and standard deviation were entered into Cochrane Review Manager (RevMan 5.2).
Data Analysis We performed a narrative synthesis of selected studies’ findings to improve our understanding of the elements of interventions used to reduce postpartum stress. For the meta-analysis, we first investigated possible publication (reporting) bias using funnel plots and visually assessed them for obvious asymmetry. There was no publication bias under this evaluation method; the funnel plots appeared symmetrical. In addition, we assessed the statistical heterogeneity in each meta-analysis using the I2 , which is a useful statistic for quantifying inconsistency; I2 values between 75% and 100% represent considerable heterogeneity (Higgins & Green, 2009). There was a large heterogeneity across studies overall (I2 = 93%), so we used a random-effect model for controlling the heterogeneity among the studies to provide an estimate of the average treatment effect (Higgins & Green, 2009). Nevertheless, as there was heterogeneity across studies in sample size, type of intervention components, delivery format, and outcome measures, the results of the meta-analysis should be interpreted with caution. We calculated the stan-
JOGNN 2015; Vol. 44, Issue 2
dardized mean difference with 95% confidence intervals to combine trials that examined the same outcome and to identify the intervention effects. We also performed subgroup analyses to determine the effects of three different psychosocial interventions categorized by their major content.
Results Description of Studies Among 1,871 publications, 14 RCTs published between 1994 and 2012 met the inclusion criteria and were selected for the systematic review. After excluding one study that did not provide the necessary statistical data, including mean and standard deviation, 13 studies were included in the metaanalysis (Figure 1). The mean sample size calculated for all 14 studies in this review was 121.07 with a standard deviation of 68.41 and range of 30 to 250. Sample size of each group (intervention and control group) was more than 30 in the 11 studies. Participants in the studies were mothers with preterm infants (n = 7, 50.0%); vulnerable mothers including drug-abusing women, low-income women, and highly distressed women (n = 6, 42.9%); and general postpartum women (n = 1, 7.1%). Interventions were provided at the hospital including the neonatal intensive care units (NICU) (n = 6, 42.9%), in the home setting (n = 6, 42.9%), or in both (n = 2, 14.3%). Psychosocial interventions to reduce postpartum stress were categorized into three major types: supportive postpartum stress management programs (n = 5, 35.7%), education programs on infant care (n = 5, 35.7%), and interaction promoting programs between the infant and parents (n = 7, 50.0%) (Table 1). Four studies were conducted in Australia, three in the United States, two each in Norway and Taiwan, and one each in the United Kingdom, Canada, and The Netherlands. All studies that included postpartum stress as an outcome also reported on other psychosocial variables including depression, anxiety, self-esteem, parenting attitude, maternal behavior, family (home) environment, parent and family function, couple relationship satisfaction, interpersonal support, and perceived social support. In eight studies (57.1%), postpartum stress was measured by the Parenting Stress Index (Abidin, 1990, 1995), including the short-form version (Reitman, Currier, & Stickle, 2002). Three studies (21.4%) used the Parental Stress Scale (Miles, Funk, & Carlson, 1993; Miles, Funk, & Kasper, 1991), and three other studies
185
REVIEW
Psychosocial Interventions for Women with Postpartum Stress
Citations identified for review by electronic databases literature search (n = 1,871) Excluded not relevant (n = 1,813) Abstracts reviewed for content relevancy and inclusion criteria (n = 58) Excluded not relevant (n = 36) Full text articles reviewed for detailed examination (n = 22) Excluded not relevant (n = 4) Selected articles for critical appraisal assessed for methodological quality (n = 18) Excluded not suitable (n = 4) Selected articles for data analyses (n = 14) Excluded not suitable (n = 1) Selected articles for meta-analyses (n = 13) Figure 1. Flow chart of study selection.
Fourteen studies were included in the narrative synthesis to understand the elements and the effectiveness of individual interventions on postpartum stress. Summaries of the studies
are presented in Table 2 as supplemental information to the online version of this article (http://jognn.awhonn.org). In terms of supportive postpartum stress management programs, supportive group sessions that included discussions concerning the transition to motherhood, postnatal stress management, communication skills, and life planning had significant effects on decreasing women’s perceived stress after childbirth (Chen, Tseng, Chou, & Wang, 2000). A couple
JOGNN, 44, 183-192; 2015. DOI: 10.1111/1552-6909.12541
http://jognn.awhonn.org
(21.4%) used the Perceived Stress Scale (Cohen, Kamarch, & Mermelstein, 1983) to measure postpartum women’s stress (Tables 1 & 2).
Effects of Interventions
186
REVIEW
Song, J.-E., Kim, T., and Ahn, J.-A.
relationship and coparenting program for highly distressed parents with their first child was found to be effective at lessening parenting stress (Petch, Halford, Creedy, & Gamble, 2012). In terms of education programs on infant care, an individualized family-based intervention dealing with problems, including infant behaviors and characteristics during the hospitalization and the transition to home, was successful in reducing parental stress in the mothers of preterm infants (Meyer et al., 1994). Routine hospital discharge care plus follow-up phone calls from a nurse practitioner to discuss infant care concerns for the first 2 months significantly reduced low-income firsttime mothers’ perceived stress (Hannan, 2012). In studies combining education and mother/infant interaction promotion programs, a series of educational home visits for vulnerable families with infants by a child health nurse combined with subgroup dynamic therapy by a social worker showed positive effects on parenting stress (Armstrong, Fraser, Dadds, & Morris, 2000), and a mother/infant transaction program focusing on low-birth-weight infants’ characteristics and the interaction between the infant and the parents lowered parenting stress significantly (Kaaresen, Ronning, Ulvund, & Dahl, 2006).
A meta-analytic approach provided new information on the effectiveness of psychosocial interventions, including supportive stress management programs for women to reduce their postpartum stress.
Thirteen studies were included in the metaanalysis because one study did not provide the necessary statistical data for the analysis. The results are presented in Figures 2 and 3. In the overall comparison of all psychosocial interventions versus usual care, there was an overall beneficial effect of all types of interventions on postpartum stress (standard mean difference −1.66, 95% confidence interval [CI] [−2.74, −0.57], p = .003, I2 = 93%) (Figure 2). In the subgroup analysis of supportive stress management programs versus usual care, there was also a significant beneficial effect on postpartum stress (standard mean difference −0.59, 95% CI [−0.94, −0.23], p = .001, I2 = 64%) (Figure 3). There were, however, no significant beneficial effects in both educational programs and interaction promoting programs on postpartum stress.
Table 1: General Characteristics and Research Methodology Variables
Categories
Publication year
1994 1999
2 (14.3)
2000 2012
12 (85.7)
Type of study
RCT
14 (100)
Sample size of each group
