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THE ASSOCIATION BETWEEN MATERNAL WEIGHT GAIN AND
POSTPARTUM DEPRESSIVE SYMPTOMATOLOGY, FUNCTIONAL STATUS,
AND FAMILY FUNCTIONING
By

AYMEE L. KAKUK

A THESIS
Submitted to
Michigan State University

in partial ﬁllﬁllment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1 999

Professor Rachel F. Schiﬂ'man

ABSTRACT

THE ASSOCIATION BETWEEN MATERNAL WEIGHT GAIN AND POSTPARTUM
DEPRESSIVE SYMPTOMATOLOGY,
FUNCTIONAL STATUS, AND FAMILY FUNCTIONING

By
Aymee L. Kakuk

Postpartum diﬁculties aﬂ‘ect up to 20 percent of childbearing women to some degree
(Aﬂ‘onso, 1992). The purpose'of this study was to explore the relationship of weight gain
in pregnancy to postpartum depressive symptomatology, family functioning, and
functional status. The conceptual model used to depict this relationship was Peck’s
Women’s Self-Deﬁnition Model. This study was a secondary analysis of data from 65 low
income women. Data was analyzed using descriptive and frequency statistics. Infomation
gained in this study will assist the nurse working in advanced practice with women during
and after pregnancy to assess for signs of depressive symptomatology, alterations in
functional status, and decreased satisfaction with family functioning related to weight
gained in pregnancy. In this study there were no signiﬁcant relationships between the
amount of weight gained in pregnancy and postpartum depressive symptomatology,
alterations in ﬁmctional status or decreased satisfaction with family functioning. However,
women, on average, had moderate levels of postpartum depressive symptomatology, low
functional status scores, and decreased satisfaction with family functioning at six weeks
postpartum. Implications for advanced nursing practice and further research include the

need to assess all women, regardless of weight gain for postpartum disturbances.

For my family, in particular my son, Stephen James Schuyler, for giving me the inspiration
to complete this academic pursuit, and my parents, John and Marie Kalcuk for their
support, encouragement, and unconditional love.

For my special friends, Chevon Norwood and Tim Tinldepaugh for supporting and
encouraging me in the absence of my family.

Above all, thanks to the Lord for providing me with spirituality and guidance to overcome
the many obstacles encountered while achieving this academic pursuit.

ACKNOWLEDGMENTS

To my thesis advisor Rachel F. Schiﬂinan RN, PhD. for her dedication to this
project during my Master’s preparation. To Mildred A. Omar, RNC, Ph.D. and Kathy
Dontje, RN, MSN, my other committee members, for their commitment, time, and

feedback needed to complete this project.

iv

TABLE OF CONTENTS

Page

LIST OF TABLES ................................................. vi i
LIST OF FIGURES ................................................ vi i i
INTRODUCTION ................................................... 1
Background of the problem. ...................................... 1
Statement of the problem. ........................................ 4
Conceptual Framework. ............................................. . . 6
The women’s Self Deﬁnition in Adulthood Model ...................... 6
Application of The Model to the Study ..... . ......................... 8

Social Historical Time. ............ . ............................. 10

Sphere of Inﬂuence. ............................................ 11
Self-Deﬁnition. ................................................ 12
Summary ..................................................... 16
Review of Literature. .................................................. 17
Critique of Literature. ........................................... 23
Methods. .......................................................... 25
Design. ..................................................... 25

Sample ..................................................... 26
Operational Deﬁnitions .......................................... 26
Instruments .................................................. 28
Protection on Human Rights ...................................... 30

Data Analysis ................................................ 31
Limitations ............ . ..................................... 31
Assumptions .................................................. 32
Results ............................................. . .............. 32
Sample ...................................................... 32
Answers to Research Questions ................................... 32
Discussion ......................................................... 36
Sample. ..................................................... 36
Implications. .................................................. . . . . . 42
Recommendations for Further Research. .............................. 48

LIST OF REFERENCES .............................................. 52

APPENDICES

Appendix A .............................................. 61
Appendix B .............................................. 63
Appendix C .............................................. .67
Appendix D ............................................... 69
Appendix E ............................................. 72

vi

Table 1:

Table 2:

Table 3:

Table 4:

Table 5:

Table 6:

Table 7:

LIST OF TABLES

Page

Frequency and Percent of Sample

Characteristics ............................................ 33
Means, Standard Deviations, and Ranges for Depressive

Symptomatology in the Postpartum Period by Weight

Gain Adequacy ................ . ......... . ................ 34
Analysis of the Variance for Depressive Symptomatology

in the Postpartum Period by Weight Gain Adequacy. . . . ............ 34
Means, Standard Deviations, and Ranges for Functional

Status by Weight Gain Adequacy ............ . ................ 35
Analysis of Variance for Functional Status

in the Postpartum Period by Weight Gain Adequacy ............... 35
Means, Standard Deviations, and Ranges

for Family Functioning by Weight Gain Adequacy ................. 36
Analysis of Variance for Family Functioning by

Weight Gain Adequacy .............. . ....... . .............. 36

vii

LIST OF FIGURES

Page
Figure 1: A Model of Women’s SelfDeﬁnition in
Adulthood ................................................ 7
Figure 2: An Adaptation of a Model of Women’s
Self-Deﬁnition using the concept’s of Weight Gain
Depressive Symptomatology, Functional Status, and
Family Functioning ......................................... 9

viii

INTRODUCTION

BackgroundnfthePLoblem

There is little information in the literature related to weight gain in pregnancy and
how it affects postpartum diﬁculties such as postpartum depressive symptomatology,
functional status and family ﬁrnctioning. A very revealing picture in Psychology Today’s
1997 body image survey (Garner, 1997) found that weight gain is a common cause for
negative feelings about the body and that pregnancy is increasingly being seen, not as a
normal body function, but as an encumbrance to well being. Some women claim that their
obsession with body image and weight gain are their sole reasons for deciding against
conception (Garner, 1997). After concern for their infant’s health and well being, an
almost universal anxiety among new mothers is whether or not they will lose the weight
they gained during pregnancy (Parker, 1994). Most women hope to return to their
pre-pregnancy weight within the ﬁrst few months; however, losing weight more slowly
after the initial ﬂuid readjustment is more common (Abrams & Berman, 1993; Lederrnan
1993). This imbalance between expectation and reality may cause new mothers to feel
depressed, as they are trapped inside a body that they thought and expected would look
diﬁ’erent aﬁer child bearing. Furthermore, hopelessness may be potentiated by the media
portraying unrealistic or enhanced photographs of models looking as though they were
never pregnant shortly after giving birth. Professional models, our most pervasive
standard of beauty, are now estimated to be 23% lighter than the average North American
woman (Wolf, 1990).

There is information in the literature describing the impact of obesity on a
woman’s self concept, and it is widely believed that childbearing is a cause of obesity in
American women (Lederrnan, 1993). Recent literature indicates that women with a prior
history of dieting are more likely to be concerned during pregnancy and obsess about
weight loss after childbirth (Garner, 1997) than women who are content with their weight

1

(F airburn & Welch, 1990) . It is estimated that approximately 89% of all women have
tried to diet during their childbearing years (Garner, 1997). Middleman, Vazquez, and
Durant (1998) found that in a study of 3,055 students with a mean age of 16, 61.5% of
females were trying to lose weight or had a negative body image, and Hall (1991)
determined that overall low self concept in adolescents was related to obesity of the
adolescent’s mother (Hall, 1991).

Due to these factors it is reasonable to consider that those women with concerns
related to weight gain prior to and during pregnancy, may be at risk for exhibiting signs of
post partum depressive symptomatology, alterations in functional status and decreased
family functional status. Research indicates signiﬁcant increases in marital satisfaction,
sexual functioning, and improvement in body image in women who have lost weight
(Stunka, 1992; Werlin, 1997), and more psychological and behavioral problems in those
who are overweight with body image anomalies (O’Neil, 1992). This indicates that
psychological disturbances related to being overweight impact intimate relationships and
personal well being. Major motivators identiﬁed to lose weight in the overweight
population are: appearance, self esteem, health, and fear of loss of functional status (Brink
& Ferguson, 1998). Overweight women report their health and ﬁmctional ability to be
poorer than those not overweight and report less positive mood states, and increased
anxiety and depression (Sullivan, Bouchard, Dahlgren, Jonsson, Larsson, & Lindstedt,
1993). For many women, obesity becomes an obsession that leads to physiologic,
psychological and social problems (Vicker, 1993).

Postpartum emotional problems have received increasing attention in the literature
recently; however, the nature of diﬁculties surrounding childbirth remain clouded and
overlooked (Horowitz, Darnato, Solon, Von Metsch, & Gill, 1995). In the literature,
postpartum depression has been studied much more in depth than {women’s functional
status and family functioning. Studies indicate that the prevalence of postpartum
depression ranges ﬁ'om 9 to 15 percent of women who have recently given birth (Beck,

2

1995), and that depressive symptomatology can aﬁ‘ect up to 20 percent of the childbearing
population to some extent (Aﬂ’onso, 1992). Theories about the causes of postpartum
depressive symptomatology fall into three general categories: biological (involving age
and hormonal, neurotransmitter, and genetic theories); psychological (including
psychoanalytic, personality, and attributional style theories); and environmental or cultural
(including social support, socioeconomic status, and preparation for childbearing)
(Hansen, 1991). The devastating eﬁ’ects of PPD are not only felt by mothers, but may
also have adverse consequences on young children’s general behavioral and developmental
functioning (Beck, 1995). The presence of postpartum diﬁculties has been shown to
aﬂ'ect future reproductive plans (Peindl, Zolnik, VVrsner, & Hanusa, 1995). This makes it
imperative for the Advanced Practice Nurse (APN) working in primary care to be able to
identify those mothers most at risk for developing PPD, changes in functional status, and
alterations in family ﬁmctioning. It is estimated that 30 percent of women with an episode
of postpartum depression are likely to develop a repeat episode after a subsequent birth
(Peindl et al., 1995).

The primary concern of those involved with postpartum care while in the hospital
is generally focused on the physical well being of the mother and child, while the
psychological well-being of the mother is often viewed as secondary in importance, if it is
viewed at all. In most situations women having a normal spontaneous vaginal delivery are
sent home from the hospital within 24 to 48 hours after delivery. This makes it diﬁcult, if
not impossible for the health care team to assess the presence of postpartum depressive
symptomatology, ﬁinctional status, and family functioning as studies suggest that the great
majority of postpartum diﬁculties have an onset of a few weeks, or more commonly,
three months postpartum (Kumar, 1991). Therefore, a vast majority of cases are the
responsibility of primary care providers to identify, as this is where women in the
postpartum period would most likely seek help for depression, diﬁculties in functional
capabilities and concerns with family functioning.

3

Primary care providers as a whole are better at identifying more depressed women
than any other professional group; however, it is estimated that approximately half of all
those with depressive symptomatology will be missed by their primary care provider
(Hearn et al., 1998). Identiﬁcation of those at a higher risk of developing postpartum
depressive symptomatology, altered functional status and altered family ﬁmctioning
would allow more comprehensive care for mothers, and enhance the relationships they
share with their new babies and other family members while promoting self esteem and
increased self efﬁcacy.

Advanced practice nurses working with mothers in the childbearing phase of life
are in a key position to incorporate women’s psychosocial context into counseling about
weight management during pregnancy and after childbirth. Through assessment, APNs
would also identify those women most at risk for developing postpartum depressive
symptomatology, and alterations in family and functional status related to negative feelings
about weight gain in pregnancy. The purpose of this secondary analysis was to explore
the relationship of weight gain during pregnancy to postpartum depressive symptoms,
functional status, and family functioning.

Statementnikmblem

The phenomenon of postpartum depression has increased over the last three
decades. Three to six percent of childbearing women were reported to experience
postpartum depression in the 1960’s whereas current prevalence rates estimate as many as
20 percent are aﬁ’ected to some degree by symptoms of depression (Gitlin & Pasnau,
1989; Gotlib, Wrﬁ’en, Mount, Milner, & Gordy, 1989). The literature tends to imply that
role mastery occurs simultaneously with recovery in the postpartum period at about 6
weeks (McVeigh, 1998). However, ﬁndings of a retrospective study indicated resumption
of some role activities did not occur until 6 months postpartum (Tulrnan & Fawcett,
1988). Individual psychosocial variables such as conﬁdence in one’s ability to cope with

motherhood and satisfaction with motherhood rival with physical energy in the postpartum

4

period (Tulman, Fawcett, Groblewski, & Silverrnan, 1990) as important determinants of
functional status. Weight gain over the recommended guidelines could be a factor which
interferes with the physical energy and psychological well being required to adjust to
motherhood, yet the link between weight gain and functional status remains understudied.
Likewise, emotional support from one’s spouse is also linked to maternal role attainment
(Mercer, 1986), and psychosocial well being (Beck, 1995). Women who are happy with
their weight report better relationships with their signiﬁcant others (Garner, 1997),
possibly indicating that excessive weight gain in pregnancy could likely aﬂ’ect family
ﬁrnctional status in the postpartum period. The link between weight gain in pregnancy and
family functional status is not addressed in the literature. While this secondary analysis
does not address etiology speciﬁcally, variables that may be affected by weight gain in
pregnancy, such as postpartum depressive symptomatology, ﬁrnctional status and family
functioning were explored.

Despite the increased prevalence of PPD and other postpartum diﬁculties, we are
not much closer to identifying and deﬁning variables that would predict depressive
symptoms, alterations in ﬁrnctional status and alterations in family functioning in the
postpartum period. There is limited research on the effect of maternal weight gain in
relation to depressive symptoms, ﬁmctional status, and family functioning in the postnatal
period. Identifying weight gain as a variable that affects depressive symptomatology,
functional status, and family functioning would allow future research to focus on
interventions to promote well being in the childbearing woman, and healthy acceptance of
inevitable weight gain. The research questions in this study were:

1) Is there an association between weight gain in pregnancy as recommended by the

Institute of Medicine (10M) and postpartum depressive symptomatology?

2) Is there an association between weight gain in pregnancy as recommended by IOM
guidelines and ﬁrnctional status after childbirth?

3) Is there a relationship between weight gain in pregnancy as recommended by the

IOM guidelines and family functioning after childbirth?

Conceptual Framework
W

The conceptual model used in this study is The Women’s Self-Deﬁnition in
Adulthood Model developed by Peck (1986). The model is appropriate as it is based on
research which emphasizes the importance of relationships in women’s adult experiences.
This is important because a woman’s self deﬁnition, or the way she sees herself, aﬂ‘ects the
relationships she has with others in her life.

Peck’s model consists of three main components: Social-historical time dimension,
sphere of inﬂuence, and self—deﬁnition (see Figure 1). The model is cylinder-like and
encompasses several layers. The ﬂexible outer layer represents the social-historical time
dimension within which a woman lives her adult life. This outer layer is perceived as the
social, emotional, and political context within which a woman is allowed to deﬁne herself
at any given point in time (Peck, 1986). The impact of a woman’s social background is
therefore directly related to her development of self knowledge and self worth. The outer
layer represents the way a woman sees herself.

The next layer of the model, the sphere of inﬂuence, consists of the sum of the
relationships in which a woman is involved (Peck, 1986). The sphere of inﬂuence includes
relationships of varying degrees of closeness, with signiﬁcant others, children, family,
friends, and work relationships. The degree of satisfaction and sense of competence a
woman receives from her interactions are the focus, rather than any particular state of
being. A woman’s interaction with groups outside of work and home also play a central
part of her self deﬁnition.

Flexibility and elasticity are two central characteristics of the sphere of inﬂuence.
Flexibility means that the sphere can expand to include new relationships and, conversely,

it can contract to prevent new relationships (Peck, 1986). A woman may seek support

6

 

 

f.

 

    

 

 

 

Soclal - Hlstorlcal Tlme u-..)

 

 

Figure 1. A model of women’s self-deﬁnition in adulthood (Peck, 1986).

outside of her primary relationship for validation and self worth. The external support that
a woman gets would then take up a larger part of the sphere than normal.

Elasticity refers to the degree to which particular relationships in the sphere are
responsive to the woman’s changing needs, motivations, and self-deﬁnition (Peck, 1986).
Through elasticity, a woman can see the effects of her inﬂuence on the relationships close
to her and also see herself as having some control over the extent to which others’ needs
and expectations aﬁ’ect her behavior and her ability to diﬂ’erentiate others’ concerns from
her own.

A sphere of inﬂuence that is ﬂexible and contains key elastic interactions provides
a woman with a strong sense of self worth and accomplishment. If a woman has a sphere
consisting of inelastic relationships, an inﬂexible sphere can cause self doubt and possible
emotional diﬁculties. An inelastic sphere of inﬂuence can then impact the relationship
that a woman has with herselfas well.

Emerging through the center of the sphere of inﬂuence is the woman’s self
deﬁnition. Self deﬁnition is directly related to the sum of the social-historical forces and
on the elasticity and ﬂexibility of the sphere of inﬂuence. The sphere of inﬂuence,
therefore, is representative of the woman’s self concept or self esteem.

! l' . E! I l l S l

The concepts of this study were deﬁned within the original model, and adapted as
appropriate (see Figure 2). The concept of weight gain during pregnancy falls within the
social-historical time dimension within which a woman lives her adult life. This outer layer
of social historical time subsumes a measure of the impact of the woman’s social
background upon her development of self-knowledge. The outcome variable of family
functioning is encompassed within the sphere of inﬂuence, or the sum of the relationships
in which a woman is involved. Functional status and depressive symptomatology, both

measured at the six week postpartum checkup, fall within the woman’s self deﬁnition.

 

 

 

/ ﬂ... \
Functional Status

’ SelfDeﬁnition
‘5

Postpartum Depressive
Symptomatology

 

 

 

Social Historical Time
1

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E
.5
B
.5
c3
3
is”
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Family Functioning

 

 

Eigurez. An adaptation of a model of women’s self-deﬁnition in adulthood, using the

concepts of weight gain, depressive symptomatology, ﬁrnctional status and family
ﬁrnctioning (Peclg 1986).

Win—Gain

A social-historical time dimension can be described as constraining and rigid or
wide and more ﬂexible. Timing of events has a direct impact on social development. The
concept of weight gain in pregnancy during a period in history when the emphasis on
physical ﬁtness is so prominent portrays a more constraining, rigid layer, whereas in the
past when there was less emphasis on aesthetic beauty and thinness a woman would have a
wider, more ﬂexible layer surrounding her self deﬁnition. Researchers indicate that body
dissatisfaction is soaring among women (Garner, 1997; Walker, 1997). Body image is
inﬂuenced by many factors such as mood and physical factors like body weight (Garner,
1997). The social-historical dimension subsumes chronological time, and thereby reﬂects
Neugarten’s ideas concerning the impact that the psychological experiencing of time in a
social context has on development (Neugarten, 1968). Current weight gain standards as
set by the IOM (1990) during pregnancy are classiﬁed according to Body Mass Index
(weight in kg/meters squared). For example, underweight women (BMI < 19.8) are
advised to gain 28-40 1b.; normal weight women (BMI 19.8-26), 25-3 Slbs; overweight
women (BMI 26.1-29), 15-251bs; and obese women (BMI >29), 151bs (IOM, 1990).

Socially, women are pressured to be thin; however, during pregnancy, this pressure
may be relaxed, but returns soon after delivery (F ranko & Walton, 1993). This rigid,
constraining, historical-time layer which surrounds a woman’s self deﬁnition negatively
affects the ability of a woman to develop self knowledge. The social historical time
dimension of women experiencing postpartum diﬁculties can be described at constraining
and constricting, allowing women fewer opportunities for role variation, (Peck, 1986)
which may exaggerate postpartum depressive symptoms, slow return of ﬁrnctional status,
and decrease satisfaction with family ﬁrnctioning as the woman may not be able to adapt
to the role of motherhood as expected.

10

In this study, weight gain was deﬁned as the social-historical piece of a
physiological event which may impact roles and experiences, contributing to postpartum
depressive symptomatology, alterations in functional status, and alterations in family
functioning. The weight gain of pregnancy is a physiological aging process, and a
woman’s social development in a time when emphasis on thinness is so prominent it makes

the social-historical time dimension more constraining and rigid.

themoflnﬂuence

E 'l E . .
The outcome variable of family functioning falls within the sphere of inﬂuence.

The sphere is the sum of the relationships in which a woman is involved. Women with
concerns about their weight have less marital satisfaction (Stunka, 1992) and more
depression (Walker, 1997) in the postpartum period. This leads to a lack of ﬂexibility in
the sphere of inﬂuence, potentially limiting redistribution of emotional investment to
people within the support system that would normally be called upon for the reaﬁrmation
of the self in a time of need. Social support is thought to alleviate some of the diﬂiculties
experienced in the postpartum period (Crnic, Greenberg, Rugozin, Robinson, & Basham,
1983), with support ﬁ'om the spouse being particularity important (W andersman,
Wandersrnan, & Kahn, 1980).

Important areas of maternal adjustment in the postpartum related to family
functioning are: quality of relationship with husband, perception of father’s participation in
child care, delivery experience, satisfaction with life, conﬁdence in roles, or tasks,
satisfaction with maternal role, and support in maternal role (Mercer, 1986; Smilkstein &
Moore, 1988; Tulman et al., 1990). Women exhibiting depressive symptomatology
related to weight gain in pregnancy experience a loss of libido, which aﬁ’ects their intimate
relationships (Garner, 1997). Furthermore, due to the lack of ﬂexibility, the sphere it is
less likely to expand to include or gain new ﬁiendships or deve10p other channels of

support.

11

Lack of elasticity in the sphere of inﬂuence causes a woman to have self doubt, and
possible maladjustment (Peck, 1986). The relationships in a woman’s sphere of inﬂuence
are strained in the postpartum period, and are therefore, not responsive to a woman’s
changing needs, motivations, and self-deﬁnition. A woman’s sphere that is inﬂexible does
not allow for her to have inﬂuence or control over the extent to which others’ needs and
expectations affect her behavior and her ability to diﬂ’erentiate other’s concerns ﬁom her
own (Peck, 1986). The sum of an inﬂexible, non-elastic sphere is an alteration in a
woman’s self deﬁnition.

Family functioning in this study was deﬁned as the sum of relationships in a
woman’s sphere of inﬂuence which are viewed as nurturing and supportive and impact self
deﬁnition after pregtancy. The degree of satisfaction a woman receives ﬁ'om her
interaction with others ultimately determines level of family functioning. Relationships
that are ﬂexible, and elastic in character will have higher levels of functioning, whereas,
those relationships that are inﬂexible and non-elastic will have lower levels of functioning
in the postnatal period.

Selchﬁnitinn

The outcome variables, depressive symptomatology and ﬁmctional status, fall
within the woman’s self deﬁnition, being heavily dependent on the sum of the
social-historical forces and on the elasticity and ﬂexibility of the sphere of inﬂuence. In a
study by Walker (1997), higher depressive symptomatology in the postpartum period was
shown to be present in women who historically gained more than the recommended
weight for their BM] in pregnancy, which would possibly indicate diﬁculty in a woman’s
self deﬁnition.

EostnamrmlleptessirLeSmptnmatology

Postpartum depressive symptomatology ﬁts within the dimension of self deﬁnition.

Self deﬁnition of the childbearing woman may be disrupted in the post partum period as

12

symptoms of depression affect a woman’s ability to bond with the infant and develop the
role of motherhood (Phillips & O’Hara, 1991).

Women’s experiences with mood and emotional changes during childbearing are
frequently reduced to ﬁt an identiﬁable diagrostic category of depression (major or minor
depression, mild moderate, or severe depression). A major depressive episode is
described as an abnormal emotional state characterized by exaggerated feelings of sadness,
melancholy, dejection, worthlessness, emptiness and hopelessness that are inappropriate
and out of proportion to reality (American Psychiatric Association, 1994). Depressive
symptoms for clinical depression are similar to those experienced by women in the
post-partum period. Identiﬁed symptoms that warrant investigation by the professional
are: change in appetite or weight; insomnia or hypersomnia; psychomotor agitation; loss
of interest or pleasure in usual activities; decreased libido; loss of energy or fatigue;
feelings of worthlessness, self-reproach, or excessive or inappropriate guilty feelings;
complains or evidence of diminished ability to concentrate, such as slowed thinking or
indecisiveness; and/or recurrent thoughts of death, suicidal ideation, wishes to be dead or
suicide attempt (Yawn, 1996). The following cluster of symptoms are more likely to be
associated with PPD than with other depressions: feeling worse in the evenings, diﬁculty
falling asleep, irritability, phobias, and anxiety (Horowitz et al., 1995; Jermain, 1992; Pitt,
1968). Postpartum depression is distinguished from major depression by the onset after
childbirth.

Classiﬁcations found in the literature in relation to post partum depressive
symtomatology are most commonly classiﬁed into three separate illnesses. The three
illnesses are: postpartum or maternity blues, postpartum depression, and postpartum
psychosis.

“Postpartum depression” diﬂ’ers from “postpartum blues” in that the postpartum
blues are transient emotional disturbances, typically occurring on or around the 4th or 5th

day postpartum and usually last for a few hours or, at most, 1-2 days (Hansen, 1991;

13

Kumar, 1991). Studies estimate that as many as 75% of all women suffer from the
maternity blues after delivery. By deﬁnition, the blues are dysphoric reactions, although
they may be intermingled with normal feeling of happiness and achievement that follow
birth (Kumar, 1991). Due to the high prevalence of the maternity blues, along with the
mildness and brevity, they are considered “normal” in both the statistical and clinical sense
(Kumar, 1991). Following delivery, a woman may seek support ﬁ'om her primary partner,
or those support persons closest to her for validation. The ﬂexibility and elasticity of the
sphere of inﬂuence generally contract and expand to allow a woman to recover from the
blues.

Postpartum depression is most commonly understood to be an aﬂ'ective
disturbance characterized by dysphoric mood, anxiety, compulsive thoughts, despair,
feeling of inadequacy, inability to cope, fearfulness, loss of libido, fatigue, decreased
appetite, dependency, and irrational fears about the baby’s or one’s own health (Horowitz
et al., 1995). PPD may begin within the ﬁrst weeks after delivery and persist for months
(Martell, 1990). Women feel inadequate and unable to COpe. They do not enjoy life, tend
to withdraw, and may complain of fatigue (Martell, 1990; Yawn, 1996).

Postpartum psychosis is uncommon, and most severe, affecting 1 in 500 to 1 in
1,000 pregrancies. It is more common in primiparous women and may be associated with
a history of previous major psychotic illness. Onset may be as early as the ﬁrst days
postpartum and is almost always within the ﬁrst three months postpartum. Once
recogrized, most postpartum psychoses require hospitalization and medications, such as
major tranquilizers. Treatment may need to extend over years to a lifetime, and
recurrences with future pregrancies may be as high as twenty percent (Yawn, 1996).
Postpartum psychosis is characterized by extremely altered perceptions of reality and is
much more severe than postpartum depression (Martell, 1990).

The self deﬁnition of a woman after childbirth can be disrupted. The ﬂexibility

characteristic of the sphere of inﬂuence contracts to prevent new relationships, preventing

14

a woman from seeking help for depressive symptomatology. A woman experiencing post
partum blues following delivery may seek support from her primary partner, or those
support persons closest to her for validation. She is able to redistribute her emotional
involvement with each relationship in order to receive support and reafﬁrmation of the self
when necessary. In contrast, women experiencing post partum depressive symtomatology
may be unable to redistribute emotional investment, leading to a lack of well-being and a
blurred self deﬁnition (Peck, 1986).

For this study, postpartum depressive symptomatology was deﬁned as an aﬂ‘ective
disturbance after childbirth characterized by feelings of inadequacy, which leads to an
inability to effectively cope in the post partum period. Women may feel worse in the
evenings, have diﬁculties falling asleep, be irritable, and have unrealistic levels of anxiety.
A woman with postpartum depressive symptoms is not able to go through the process of
the spiraling motion characteristic of self deﬁnition, resulting in an inability to
psychologically separate from relationships and see herself as a sole mean to gaining self
knowledge. This results in a blurred self deﬁnition, or depressive symptomatology.
Eunctionalﬁlatus

The process of self-deﬁnition is portrayed as occurring by means of a spiraling
motion, suggesting that a woman is engaged in a consent process of monitoring her own
gowth and change (Peck, 1986). The need to modulate personal gowth against any
possible negative effects is central in a woman’s self deﬁnition, and aﬂ‘ects her ability to
function on a day to day basis. The time following childbirth is crucial to the healthy
development of not only the infant but the mother. This period of profound change
related to the weight gain of pregrancy can be hindered if the weight aﬂ'ects a woman’s
emotional or physical well being by decreasing functional status. Demands such as
housework, infant care, and taking care of the family can seem overwhelming in the
postpartum period for any new mother, and devastating for those with decreased

functional capabilities related to the additional weight gained during pregrancy. The

15

postpartum period is normally a time of adjustment, with the new mother experiencing
fatigue as a common occurrence. However, for most women, fatigue is generally a
temporary problem that disappears with rest. Fatigue is an overwhelming symptom for a
woman with depression (Smith-Hanrahan & Deblois, 1995), and negatively affects her
ability to function. Fatigue may be exacerbated by weight gained over the recommended
guidelines, further decreasing functional capabilities and role attainment.

For this study, ﬁrnctional status was deﬁned as the ability of a woman to function
in the postpartum period related to the psychological and physiological effects of the
weight gain of pregrancy. Functional status is the action component of roles, such as a
woman’s ability to assume infant care responsibilities and resume her normal activities,
and the ability to perform behavior associated with roles. A woman who feels good about
herself, and can ﬁnd within herself a means of gaining self knowledge will attain higher
levels of functioning, whereas a woman with emotional diﬁculties related to the weight
gain of pregnancy will be unable to psychologically separate herself from dependence on
other relationships as a sole means of self knowledge and score lower on the functional
status indices.

Summary

Peck’s model of Women’s Self-Deﬁnition provides an appropriate ﬁ'amework to
allow the APN to assess childbearing women for the prevalence of PPD and alterations in
functional status and family ﬁrnctioning early in the weeks following delivery. By using
this model the APN can comprehensively understand and develop interventions to treat
women experiencing post-partum depressive symptomatology. The Model of Women’s
Adult Self-Deﬁnition can be implemented in practice by the APN as a framework for
assessment, diagnosis, treatment, and intervention. By utilizing this model an
understanding of the childbearing woman’s social-historical time dimension (weight gain in
pregrancy), sphere of inﬂuence (family functioning), and level of self-deﬁnition (ﬁrnctional

status and postpartum depressive symptomatology) is possible in the postpartum period.

16

Review of the Literature

A review of the literature was done in an attempt to identify relationships between
weight gain in pregrancy and postpartum depressive symptomatology, functional status,
and family functioning. Much literature exists in relation to postpartum depression and
post partum functional diﬁculties, however little attention has been given to how women
feel about increased weight after childbirth (Walker, 1998). Postpartum depression was
ﬁrst described in the literature at least 200 years ago (Kumar, 1991). Recent literature
has brieﬂy looked at body image and weight gain in pregrancy as potential areas to focus
on when attempting to describe depressive symptomatology. However, there were no
studies found speciﬁcally attempting to describe the correlation between excessive weight
gain to decreased functional status and/or alterations in family functioning in the postnatal
period. The literature review for this paper begins with empirical studies on weight gain
and its association with postpartum depressive symptomatology; studies about family
functioning and personal functioning in the postpartum period are then discussed, and
ﬁnally, the literature review concludes with a review of empirical studies related to
overweight non-pregrant population and functional status.

Research by Walker (1997) sought to determine whether or not psychosocial
context was related to weight status one year after childbirth. This was one of the few
studies found in the literature that investigated weight gain and postpartum depressive
symptomatology. The survey provided data on life-event stress, social support, and
depressive symptoms and three weight variables: body mass index, weight gain, and
weight related distress. Of the 82 women, 32 (39%) reported gains of geater than 5 kg
and 50 (34%) met the criterion for high depressive symptoms. Higher weight gain was
related to low social support, low income, and high depressive symptoms. Women with
retention of weight geater than 5 kg reported high depressive symptoms (53% vs. 28%)
more often than women with less than 5 kg. Women who reported lowered self-esteem
because of weight also had higher depressive symptoms, body mass indices, and weight

17

gains than women with increased of unaffected self-esteem. Higher pre pregnancy body
mass index, larger gestational weight gain, higher current postpartum body mass index,
less healthy lifestyle, and geater body image dissatisfaction were associated with
signiﬁcantly more dissatisﬁed/distressed feelings about weight. A more recent study by
Walker (1998) determined that higher pre pregnancy body mass index, larger gestational
weight gain, higher current postpartum body mass index, less healthy lifestyle, and geater
body image dissatisfaction were all associated signiﬁcantly with more dissatisﬁed or
distressed feelings about weight.

Aﬂ’onso and Mayberry (1990) and Kline, Martin, and Deyo (1998) identiﬁed body
image related to weight gain in pregnancy as one of the most ﬁequent stressors identiﬁed
in the postpartum period. Women’s body attitudes tend to become more negative during
pregnancy (Drake, Verhulst, Fawcett, & Barger, 1988), and shift to more positive
postpartum (Drake et al., 1988; Strang & Sullivarn, 1985), however, attitudes toward the
body postpartum are still less favorable than before pregnancy (Drake et al., 1988; Strang
& Sullivan, 1985; Walker, 1998).

Jenkin and Tiggemann (1997) did a prospective investigation of the eﬂ’ect of
weight retained after pregnancy to weight satisfaction, self esteem, and depressive eﬂ’ect,
using the framework provided by expeaancy-value-theory. On average, the women were
heavier four weeks after having the baby than they were prior to becoming pregnant, and
were less satisﬁed with their post-natal weight and shape. They were also slightly heavier
than they had anticipated, particularly in the case of younger women. Actual post-natal
weight proved the most importarnt predictor of psychological well-being following birth.

Research revealed a profound and obvious change in the form and appearance of
the woman’s body during pregnancy and the postpartum with a linking to a change in
body image (Fisher, 1973; McConnell & Dastorn, 1961; Walker, 1998). Literature
contains studies suggesting that women may perceive less pressure on them to maintain

and achieve a thin ﬁgure while pregnant (Franko & Walton, 1993). Wiles (1992) found

18

overweight women to have varying changes in their body images while pregnant, although
they felt their obesity was more socially acceptable while they were pregnant.

Women who are overweight before pregnancy are more likely to have a positive
change in body image when they are at more than 30 weeks’ gestation, while women who
are normal weight before pregnancy are more likely to have a negative change (Fox &
Yarnaguchi, 1997). However, overweight women have more negative body shape
concerns than normal weight women (Copper, DuBard, Goldenberg, & Oweis, 1995; Fox
& Yamaguchi 1997). Thinner women tend to have a positive attitude toward gairning
weight, while obese women have a negative attitude. However, a positive attitude about
weight gain does not necessarily predict appropriate weight gain across BM] goups
(Copper et al.,1995). In a similar investigation, Davies and Wardle (1994) evaluated body
image, body satisfaction, and dieting practices in pregnancy, expecting that social
pressures for thinness might be relaxed due to the pregnancy. They found that pregnant
women had lower scores on the drive for thinness subscale of the eating disorder
inventory and, when body mass index was controlled, they had signiﬁcantly lower body
dissatisfaction scale scores than non-pregnant women. They also rated themselves as less
overweight (in terms of body size), used less dietary restraint, and had less frequent
attempts to lose weight than the non pregnant goup (Davies & Wardle, 1994).

Abraham, King, and Llewellyn-J ones (1994) studied the eating behavior and
attitudes to body weight of 100 primiparous women 3 days postpartum and found that
41% reported weight control problems, while 20% considered their weight and eating
problems to be geater during pregnancy than at any previous time in their lives. The
researchers used an “eating behavior” questionnaire which sought out information about
the women’s eating behavior, body image, and concern about weight before and during
pregnancy. Fairbum and Welch (1990) similarly found that out of 50 women they
included in their study attempting to investigate body image and pregnancy that 6% dieted

19

through pregnancy, with 26% overeating; and that 24% felt distressed about weight gain
in pregnancy.

Women who gained more than 35 pounds were more than twice as likely to retain
20 or more pounds postpartum than were those whose weight gains were witlnin the
Institute of Medicine (IOM) guideline of 25-35 pounds (Parker & Abrams, 1992). A
study by Keppel and Taﬂ’el (1993) speciﬁcally examined the relationship between the IOM
prenatal weight-gain guidelines and post partum weight retention for underweight, normal
weight, and overweight mothers. Women who gained more than the BMI-speciﬁc IOM
weight-gain recommendations retained a median of 5.6 pounds postpartunn, and had more
depressive symptomatology (Parker, 1994) whereas those whose gains were within the
recommended range retained only 2.2 pounds and had less depressive symptomatology
(Keppel & Taﬂ’el, 1993 ), indicating that there is some sort of protection against retained
weight after pregnancy if women gain within their BMI speciﬁc guidelines.

Richardson (1996) found a correlation between women with preterm labor and
body image disorganization. She found that women with preterm labor have a geater
diﬁculty assimilating and accommodating to the body changes of pregnancy, with preterm
women being signiﬁcantly worried with or distressed about their body changes. The
tolerance for body adjustments for the ﬁrst 26 weeks of pregnancy was constrained and
women had a less ﬂexible comfort zone related to tolerable alterations of body change
(Richardson, 1996).

In a large survey by Garner (1997), of 3,452 women and 548 men, it was found
that body dissatisfaction is higher among women and men than it ever has been before.
Sixty two percent of women between the ages of 13-19 were unhappy with their weight
and 67% of women over age 30 were unhappy with their weight. Fifteen percent of all
women surveyed would give up 5 years or more of their lives to be at their ideal weight.
Middleman et al. (1988) similarly found that in a study of 3,055 students with a mean age
of 16, 61 .5% of females were trying to lose weight or had a low body image. Likewise,

20

Stevens and Tiggemann (1998) used Fallon and Rozlin’s set of 9 silhouette drawings to
assess body ﬁgure preferences in a non pregnant population. Women of all ages (18 ~59)
rated their current ﬁgure as signiﬁcantly larger than their ideal ﬁgure, indicating the
presence of body dissatisfaction across the life span. Stowers and Durm (1996) found
positive correlations between self concept and body image, with more obese people having
a lower self concept, and women being signiﬁcantly less satisﬁed with their body image as
a whole.

There was linnited research found describing the impact of weight gain in the
postpartum population to alterations in family and/or personal functioning. In general,
mothers ﬁ'equently report the period after giving birth as a time of geat personal and
family stress, however, functional status after childbirth has been investigated only recently
in the literature (McVeigh, 1997), with no studies identiﬁed that speciﬁcally look at
weight gain and how it aﬁ’ects ﬁrnctional status in the postpartum period. Tulman et a1.
(1990) indicate that women are not fully recovered ﬁ'om childbirth until three to six
montlns after delivery. At one month postpartum, mothers are not yet functioning at their
pre-pregnant levels, with as many as 83% sitting most of the day, 38% not getting
dressed, and 65% not accomplishing as much as usual (Fishbein & Burggaf, 1998;
McVeigh, 1998; Tulman et al., 1990). At one month postpartum women participate in
social activities with family (82%), and ﬁiends (66%), but few had resumed community
service involvement (15%), or other professional orgarnizations (7%), religious activities
(27%), and/or social events/clubs (25%) (Fishbein & Burggaf, 1998). Activities most
commornly consuming the time of new mothers were fading, giving baths, changing
diapers and clothes, and playing (Fishbein & Burggaf, 1998; Mcveigh, 1998; Tulman et
al., 1990). Studies in the literature measuring ﬁrnctional status most commonly use the
Inventory of Functional Status After Childbirth (IF SAC). Researchers found that by using
this scale to assess functional status, the subscales of household activities, social activities,

self care activities, and return to work activities increase when measured at 6 weeks, 3

21

months, an 6 months postpartum (Fishbein & Burggaf, 1997; McVeigh, 1997; 1998;
Mercer & Ferketich, 1995; Tulman et al., 1990). The subscale of infant care has been
reported to decrease within the same time ﬁ'ame (McVeigh, 1997).

Smith-Hanrahan and Deblois (1995) found the most common complaint aﬁ’ecting
postpartum functional ability was fatigue (25% at discharge, 31% at 1 week, and 19% at 6
weeks postpartum). In a recent study by Sampselle (1999) new mothers who began
exercising in the postpartum period were found to lose more weight, be more socially
active, experience less fatigue and feel better about themselves than women who did not
exercise after delivery. Women exercising in the postpartum period retained 8.6 pounds
compared to 11.3 pounds retained by non exercising women 6 weeks after delivery.
Exercise, and less weight retention was associated with increased ﬁnnctional status and
psychosocial well being.

Midmer (1995) found that prenatal parenting education signiﬁcantly decreased
anxiety, increased martial satisfactiorn, and facilitated geater postpartum adjustment in 70
prinniparous couples. Prenatal parenting education included information on body image
changes and weight loss expectations in the postpartum period

As evidenced by review of the literature, many variables have been analyzed and
identiﬁed to predict the prevalence of postpartum depression in childbearing women. It is
unlikely that one single variable exists that would deﬁnitively predict postpartum
depressive symptomatology, as human beings are multidimensional in nature. To date, no
studies have speciﬁcally examined the weight gain of pregnancy to depressive
symptomatology, altered functional status, and/or altered family functioning. This weight
gain, although natural and expected, may cause body image changes that can be profound
and unsettling for some women. Therefore, it is imperative to investigate the relationship

between the weight gain of pregnancy and postpartum depression.

22

2.. El 1'

As indicated in the literature review, studies exploring the weight changes of
pregnancy exist, however, there is a lack of literature describing the effect of weight gain
to postpartum depressive symptomatology, functional status and family functioning. The
studies investigating the relationship between various aspects of maternal body change and
weight gain in pregnancy employ a large number of diﬁ’erent instruments, some developed
speciﬁcally by the researcher. The ﬁgure rating scale, and the perceived size of body and
body parts scale (Davies & Wardle, 1994); the eating behavior scale (Abraham et al.,
1994) and the pregnancy and weight gain attitude scale (Copper et al., 1995) are examples
of these single-use measurement tools which may account for variability in ﬁndings
between weight gain and body image to depressive symptoms in the postpartum
population. Studies investigating the relationship between weight gain and postpartum
depressive symptomatology also employ single measurement tools or questionnaires
addressing emotional reactions to weight (Walker, 1997, 1998), making it diﬁcult to
generalize ﬁndings. Studies of body image and depression in the non-pregnant,
non-postpartum population tended to use scales with established validity and reliability
such as the Beck Depression Inventory and the Tennessee Self-Concept Scale (Stowers &
Dunn, 1996). .

Most studies use questionnaires or interviews, however, the authors usually did
not include a copy of the tool used, which prevents the reader from easily duplicating the
study, and there was a general lack of information regarding the questions and the
reliability and validity of the instruments (Abraham et al., 1994; Davies & Wardle, 1994:
Walker, 1997, 1998). Most studies included complete information regarding statistical
analysis in the data analysis sections.

Many studies did not indicate demogaphic makeup of the population that might be
crucial to control for when investigating weight distress to depressive symptomatology .

Variables thought to contribute to postpartum depressive symptomatology commonly not

23

addressed in the studies were marital status (Fox & Yarnaguchi, 1997; Kline et al., 1998;
Walker, 1998), educational level (Copper et al., 1995), socio-economical status (Abraham
et al., 1994), number of previous pregnancies (Abraham et al., 1994), and whether or not
the pregnancy was planned (Davies & Wardle, 1994; Walker, 1997, 1998). Previous
history of eating disorders and/or depression was usually not assessed (Garner, 1997;
Middleman et al., 1988; Richardson, 1996; Walker, 1997, 1988). Studies mostly employed
convenience sampling (Davies & Wardle, 1994; Fox & Yamaguchi, 1997; Richardson,
1996; Walker, 1997, 1998) which lacks ethnic and demogaphic diversity to limit the
generalization of the results to a larger population.

There is also a wide variation to when body image and depressive symptomatology
were assessed. This ranges from prenatal (Davies & Wardle, 1994; Fox & Yamaguchi,
1997) to 3 days postpartum (Abraham et al., 1994), to 6 weeks postpartum (Sampselle,
1999) to 1 year postpartum (Walker, 1997). Inconsistencies in timing of assessment of
body image and depression make it diﬂicult to generalize ﬁndings, as body image changes
drastically throughout the childbearing experience, and some depressive symptomatology
is expected in the postpartum period, manifested as maternity blues which typically occur
4-5 days postpartum, usually last for a few hours or, at most, 1-2 days (Hansen, 1991;
Kumar, 1991), eﬁ’ect as many as 7 5% of all womern, and are considered “normal” irn both
the statistical and clinical sense (Kumar, 1991).

Most studies had an adequate sample size, with a wide range in variability from 30
to 2,245 subjects (Abraham et al., 1994) which were adequate for the variables discussed.
Larger sample size studies tended to use questionnaires and chart review during prenatal
and/or postpartum periods (Aﬂ’onso & Mayberry, 1990), while the smaller studies most
commonly used personal interviews (Richardson, 1996; Walker, 1997). Large studies in
the non pregnant population tended to use questionnaires or surveys (Garner, 1997;
Middleman et al., 1988).

24

Literature addressing functional status in the postpartum period tended to use
measures with established reliability and validity (F ishbein & Burggaf, 1997; McVeigh,
1997, 1998; Mercer & Ferketich, 1995; Tulman et al., 1990), and adequate sample size
(79 to several hundred subjects) (F ishbein & Burggaf, 1997; McVeigh, 1997, 1998;
Smith-Hanrahan & Deblois, 1998). However, most samples were convenience samples
(Fishbein & Burggaf, 1997; McVeigh, 1997, 1998), which lack ethrnic diversity.
Functional status was not viewed speciﬁcally within the realm of postpartum weight gain
in any of the studies found, however one large study of 1,003 women (Sampselle, 1999)
brieﬂy discussed the impact of exercise on postpartum functioning and well being. This
study was a convenience sample, utilizing a questionnaire developed by the researcher
without established reliability or validity, and was not included in the description of the
study.

As evidenced by the literature review further research related to weight gain in
pregnancy is needed to provide women with sound information regarding their journey
tlnrough pregnancy and the effects of weight gain on depressive symptoms, functional
status and family functioning. This study adds to the knowledge about weight gain and its
relationslnip to postpartum depressive symptomatology, functional status and family
functioning in the period following childbirth which may lead to the development of PPD,
and alterations in functional status and family ﬁmctioning.

Methods
Design

This study was a secondary arnalysis and descriptive study of low-income pregnant
women. It was designed to describe how varying degees of weight gain during
pregnancy affect postpartum symptomatology, family functioning and personal functioning
after childbirth. The data were obtained ﬁom a study originally done by Schimnan and
Omar (1994) which examined factors related to the adequacy of prenatal care and

pregnancy outcomes in a not-for-proﬁt center serving low-income women in a

25

southeastern Michigan community (Schiﬂinan & Omar, 1994). The original study utilized
prospective surveys and chart reviews. Instruments were adrrninistered at the ﬁrst or
second prenatal visit and at the six week postpartum checkup.

Samnlﬁ

The sample consisted of 65 pregnant female subjects who completed the
instruments for the original study at the postnatal visit. In the original study there were
172 subjects: 132 ﬁom the Center and 40 from other provider sources in the community
offering pre-natal and post-natal care.

Subjects were very similar in demogaphic characteristics. Generally the subjects
were in their early twenties, single, Caucasian, with very few having geater than a high
school education. Most had one previous pregnancy, with a mean of 2.5.

The variables in this study include weight gain, postpartum depressive
symptomatology, functional status, and family functioning.

Weightsain

Maternal BMI was calculated from information obtained at the ﬁrst prenatal visit
(BMI = weight in kg/meters squared). Body Mass Index calculations were possible for 62
women. Women were classiﬁed into weight gain categories deﬁned by the IOM (1990), as
follows: underweight (<19.8), normal weight (19.8-26), overweight (26.1-29), or obese
(>29). In this population (N = 62), 14 were underweight (22.6%), 24 normal weight
(38.7), 7 overweight (11.3), and 17 obese (27.4).

Once BMI was calculated, women were placed into recommended weight gain
categories, according to guidelines proposed by the IOM (1990): 28—401b, 25-3 51b,
15-251b, and 151b., for each BMI category respectively. Women were then further deﬁned
by adequacy goups as gaining below, withirn, or above the recommended guidelines. Data
describing the adequacy goups was available for 59 women (n = 59). In this sample 7

26

women were below recommended (11.9%), 15 within recommended (25.4%), and 37
above recommended (62.7%).
E . S l . l E E . 1

Depressive symptoms in the postpartum period were operationalized by the
CES-D (Radloﬂ‘, 197 7; Radloﬂ‘ & Locke, 1986) (see Appendix A). Subjects were asked
to identify depressive symptoms at the ﬁrst postpartum visit. Reverse scoring of the four
positive affect questions was done in order to minimize bias tendencies towards response
sets. The range, or possible scores are 0-60 with higher scores reﬂecting geater
depressive symptomatology.

Family ﬁrnctioning was operationalized by the Family APGAR (Smilksteirn, 1978)
(see Appendix B). Respondents were asked to rate their satisfaction with ﬁve items
(adaptation, partnership, gowtln, aﬁ‘ection, and resolve) ranging from 0 to 4. This self
report instrument was admirnistered at the postpartum visit. The total mean score from
these ﬁve items is calculated, and satisfaction with family ﬁrnctioning is determined with
lower scores indicating low satisfaction and higher scores indicating higher satisfaction.
Eunct'nonaLSratusBosrpamnm

Functional status in the period after childbirth was operationalized by the Inventory

of Functional Status after Childbirth (IF SAC) (Fawcett et al., 1988) (see Appendix C).
Respondents were asked to complete the 36-item self report questionnaire regarding
household activities, social and community activities, infant care responsibilities, self-care
activities, and occupational activities at the postnatal visit. The possible range of scores
for each subscale and total IFSAC is 1 to 4 with the higher score demonstrating geater
functioning after childbirth. This study focused on the total mean IF SAC score rather than

the subscale scores.

27

D C I] . I
C ﬁE'l'l'lS 1.1: . $155433}

The Center for Epidemiological Studies Depression Scale (CES-D) is a 20 item
self-report scale used to assess depressive symptomatology in the general population
(Rabkin & Kleirn, 1987). There are sixteen items assessing the following areas of
depressive symptomatology: depressed mood, feelings of guilt and worthlessness, feelings
of helplessness and hopelessness, psychomotor retardation, loss of appetite, and sleep
disturbance. Possible responses range ﬁ'om (0) rarely to (3) mastaithejime and assess
current depression, as well as how often symptoms occurred within the last week prior to
administration . Average scores range ﬁ'om 7.8 to 9.9 (Radloﬂ’ & Locke, 1986), with a
score of 16 or geater generally considered as evidence of possible depression (Horowitz
et al., 1995). Researchers using the CES-D with samples of pregnarnt and postpartum
women have reported means of 8.5 and 8.8 (Horowitz et al., 1995) and 5.3 and 6.3
respectively (W eissmarn, Sholomskas, Pottenger, Prusoﬂ’ & Locke, 197 7).

Evidence of content, concurrent, and discrinninate validity of the tool have been
demonstrated (W eissman et a1, 1977). Internal consistency reliability coeﬁcients have
been reported (alpha >.85) across varying age, sex, and racial goups (Barnes & Prosen,
1984; Hall, Gurley, Sachs, & Kryscio, 1991; Jones-Webb & Snowden, 1993; Radloﬂ‘,
1977; Radloﬂ’ & Locke, 1986). Cronbach’s alpha coeﬁcients for the original study were
.87 prenatally, and .92 postrnatally (Schiﬁinan & Omar, 1994).

E '1 EE [3 ! E U . .

The Family APGAR Questionnaire is a ﬁve item screening measure designed to
reﬂect an individual’s view of the functional state of his or her family. Degee of
ﬁnnctioning is represented by self-report of satisfaction with family relationships.
Respondents rate their satisfaction with family as (5) W (4) mm
(3) mm; (2) hardlijer, or (1) nearer. The total score is the sum ofthe ﬁve
items with higher scores reﬂecting more satisfaction (Snnilksteirn, 1978).

28

The ﬁve dimensions of family ﬁrnctioning measured are: adaptation (satisfaction
with family as a resource), partnership (satisfaction with commurnication style), gowth
(satisfaction with the family’s response to change), affection (satisfaction with the
emotional response), and resolve (satisfaction with the way time is shared) (Snnilkstein &
Moore, 1988).

Construct validity was established by comparison of APGAR to the Family
Function Index (Pless & Satterwhite, 1973). There was a strong correlation of t = .80
between the APGAR and the Family Function Index and a moderate correlation of t = .64
between the APGAR and family evaluation by clinical therapists (Good, Smilksteirn, Good,
Shafer, & Aaron, 1979).

The Family APGAR Questionnaire has been used successfully in general medical
clinics, with children, college students, and psychiatric patient goups and across diﬁ’erent
cultural goups. Reliability testing for internal consistency was reported as a Cronbach’s
alpha coeﬁcient of .86 (Smilkstein, Ashwortln, & Montano 1982). For the original
project the Cronbach’s alpha for the prenatal administration was .88 and for the
postpartum adnninistration was .91 (Schiﬁnan & Omar, 1994). Total adjusted score on
the APGAR can be one to ﬁve, with higher scores indicating higher levels of family
satisfaction.

I [E . 15 !ﬁ Cl'lll'lﬂESEC)

The IFSAC was developed by Fawcett, Tulman, and Meyers (1988) to measure
women’s. functioning level following childbirth and comprises a 36-item self report
questionnaire which includes the following ﬁve subscales: household activities, social and
community activities, infant care responsibilities, self care activities, and occupational
activities. Each item is rated on a four-point scale. For items on self-care activities and
occupational activities, response choices range ﬁ'om (1) nexer to (4) alLthtLtime while
responses to items on the infant care responsibilities, household activities, and social and

community activities subscales are rated from (1) nQLaLall to (4) ﬁrllx Some items are

29

reversed scored to avoid response bias, with answered item responses calculated into a
mean for each subscale and a total score. The possible range of scores for each subscale
and total IFSAC is l to 4 with the higher score demonstrating geater functioning after
childbirth. Several studies of women, ranging ﬁ'om 3 weeks to six months postpartum
have demonstrated the sound psychometric properties of the IFSAC (Fawcett et al., 1988;
Tulman et al., 1990).

Internal consistency was determined by Fawcett et a1. (1988) in a sample of 76
women completing the IF SAC at the six and ten weeks postpartum. Cronbach’s alpha
internal consistency reliability coeﬁicients ranged from .56 to .98. Using a sample of 18
women over a four to seven day interval, test-retest reliability was .86 for the total IFSAC
while the subscales ranged ﬁ'om .48 to .93. Cronbach’s alpha coeﬂicients for the original
project were: .90 for household activities, .76 for social and community activities, .95 for
infant care activities, .67 for self-care activities, .85 for occupational activities, and .88 for
the total scale (Schiﬁnan & Omar, 1994). Scores could be one to ﬁve, with a higher
score indicating higher levels of ﬁnnctioning.

Validity was established by Fawcett et al., (1988) using Popharn’s (1978) average
conguency procedure. A panel of women who were professionally educated and
experienced childbirth within one year prior to questionnaire rating, served as judges in
two rounds. The ﬁrst round achieved 84.4 percent level of ageement. Revision of some
items in the second round achieved 96.7 percent level of ageement for all questionnaire
items.

EtotectionnfﬂumanRights

Approval was obtained ﬁ'om Michigan State University Committee on Research
Involving Human Subjects for the original study and for this secondary analysis (see
Appendix E). Conﬁdentiality was rrnaintained by allowing only the researcher and the
thesis chair to review the data. Subjects were identiﬁed by code numbers ornly, preventing

access to distinguishing information.

30

W
The data was analyzed using the Statistical SPSS Progarn. The sample population
was described demogaphically. Women were placed into three adequacy goups for
weight gain according to BMI goup. Women were described as gaining below

recommended, within recommended, or above recommended, deﬁned by the IOM (1990).
Each of the three research questions were answered using a one way analysis of

the variance (AN OVA) with weight gain as the independent variable to depressive

symptomatology, functional status, and family ﬁnnctioning, as separate dependent
variables.
The following limitations were identiﬁed.

1. The use of previously collected data limits the interpretation of the variables in this
study. Additional data on how women felt about their weight and body image
change in pregnancy in relation to postpartum depressive symptomatology would
add depth to the association between weight gain and postpartum depressive
symptomatology. Also needed would be information about history of previous
eating disorders in the subjects.

2. The use of convenience sampling and lack of ethnic and demogaphic
diversity limits the generalization of the results to a larger population. The
majority of the sample population were young, single mothers with
socio-economical diﬁculties, and limited post high school education.

3. The small size of the sample population limits generalization to the population.

4. Women who did not return for the follow up visit may have different results than
the women who did. Self selected individuals who did not return for follow up
may have exlnibited post partum depressive symptomatology, or an alteration in

functional status, preventing them ﬁom returning for the postpartum visit.

31

Assumptions

1. It is assumed that the answers to the questionnaires are truthful, without input
from others.
2. It is assumed that there were no errors in data recording.
Results
Sample

Thesample consisted of 65 women who returned for their follow up visit.
However, data in relation to BMI categories was only available for 59 subjects. On
average, the subjects (n = 65) were in their early twenties (M=21.67, SD=4.92), were
single, Caucasian with only a few having more than a high school education. About half
of the sample had at least one prior pregnancy, with a mean of approximately 2
pregnancies (SD = 1.35). Most of the women were in the above recommended weight

gain by BMI category (Table 1).

1:5,. 0.1 “10! .t' -:t: .0 i u 01.6w .‘:t :ztt t -gu-u . .tt
nostaartnmﬁeptessivesympromatnlogﬂ

The ﬁrst question was analyzed by using analysis of the variance to determine if
there was any signiﬁcant effect of weight gain by adequacy goup on total score for
depressive symptomatology in the postpartum period. The means and standard deviations
for the three goups are represented in Table 2. The three goups all had mean scores
above 16, which is the cutoﬂ‘ score to indicate depressive symptomatology. The goup
exlnibiting the most depressive symptomatology was the goup within the reconnrnended
weight guidelines. Those gaining below the recommended guidelines exhibited the least
depressive symptomatology. There were no signiﬁcant differences between the goups
(Table 3) indicating that there were moderate levels of depressive symptomatology

regardless of weight gain.

32

Tablel.
E 12 ES I C] . .

 

 

Characteristic Frequency Valid Percernt
Age

<19 22 34.8
20-30 35 55.6
>30 6 9.6
Educational Level

Less Than High School 27 43.5
High School Diploma/GED 28 45.2
Some College 7 11.3
Marital Status

Sirngle 44 69.8
Married/Cohabiting 11 17.5
Separated/Divorce 8 12.7
Race

Caucasian 50 79.4
Aﬁican American 12 19
Hispanic 1 1.6
Parity

One 31 49.2
Two or more 32 50.8
Weight gain by BMI

Below Recommended 7 1 1.9
Withirn Recommended 15 25.4
Over Recomrnernded 37 - 62.7

 

Note. Valid percents were calculated for those goups with missing variables (weight gain
to BMI, n=59; parity, n=63; race, n=64; marital status, n=63; education level, n=62; age,
n=63).

33

Table 2.

“3:. 40.0.“... .rc\.rg‘ e "0‘ . utterrzeefao

 

 

 

 

 

 

Adequacyﬁmuns

Adequacy Group No. M SD Rm:
Below 7 16.08 15.72 349
Within 15 24.14 12.58 3-48
Above 37 18.61 12.18 0-48

Table 3.

st. . e r‘ .uzt ‘ e .ao' . HIOOH.OOf\I O'.O‘1IO.||||.‘~)||OO

Adequacxﬁmuns

Source df M Square E

Between Groups 2 215.82 1.34

Within Groups 56 161.49

Total 58

(ma: 001' or urn: .ouzotoa\.'—.m.'-igt f.ttt'fu:t~n:tc

ﬁrnetinnal status"

The second question was analyzed by analysis of the variance to determine if there
was any signiﬁcarnt effect of weight gain by adequacy goup on mean total score for the
Inventory of Functional Status after Childbirth (IFSAC). The means and standard
deviations for the three goups are represented in Table 4. Overall, women in this sample
had low functional status scores at the postpartum visit. There were no signiﬁcant
diﬂ’erences between the goups in the measurement of functional status after childbirth
(Table 5). All goups scored below 3 (on a 1 to 5 scale) indicating an overall low

functional status across goups, regardless of weight gain.

34

Table 4.

11 51111" IE EE'IS Ill 3

 

 

 

 

 

 

Adequacy No. M SD, Range
Below 7 2.22 0.42 1.86-2.85
Within 15 2.2 0.68 0-2.86
Above 37 2.36 0.28 1.80-2.77
Table 5.

;r._ i e ...r ‘ a Inst. _.1 .r r"e‘1o.uu"ae,tr .‘.c'.,r,:,g to 0
Source df M Square E
Between Groups 2 0.16 0.85
Within Groups 56 0.19

Total 58

{5.1: 1.1323!!! t“.t.,.om.nt-atna'tr‘afuzzttt'guztonzurztt
ﬂ . . 9

The third question was analyzed by analysis of the variance to determine if there
was any signiﬁcant eﬂ’ect of weight gain by adequacy goup on total mean score of the
Family Apgar. The means and standard deviations for the three goups are represented in
Table 6. There were no signiﬁcant differences in the measurement of family ﬁrnctioning
between the goups (Table 7). All goups had a mean score of three or below (on a 0-10
scale), indicating a low satisfaction with family ﬁrnctioning across all goups, regardless of

weight gain.

35

Table 6.

- l -0 C D . O C I -
Us. .00. c U 1- or an an: o -u rurrjn shat I. o

 

 

 

 

 

 

Adequacy Group No. M SD Range
Below 7 2.94 1.1 1 1.4-4
Within 15 3.03 1.11 .40-4
Above 37 2.96 0.95 .4-4
Table 7.
g l . EEC . E E .1 E . . l I 1 G
Source df M Square E
Between Groups 2 2.97 0.29
\Vrthin Groups 56 1.02
Total 58

Discussion

Sample

Sample characteristics from studies in the literature were compared. Studies that
addressed postpartum depressive symptomatology, functional status, and fannily
functioning to weight gain in pregnancy identiﬁed a positive relationship between weight
related distress and PPD, alterations in ﬁrnctional status and alterations in family
ﬁmctioning (Gamer, 1997; Walker, 1997, 1998). However, studies in the literature
consisted of primarily Caucasian, married, middle income women with the majority having
some form of college education, as compared to the young (early twenties), single,
uneducated, Caucasian women in this study. Literature looking speciﬁcally at weight
related distress in the postpartum period were typically done between 6 and 12
months postpartum, while the variables in this study, were assessed at 6 weeks
postpartum. However, the results of this study are inconsistent with other documented

studies evaluating weight related distress to PPD, ﬁnnctional status, and family functioning.

36

In this study there was no identiﬁable association between weight gain for speciﬁc
categories and postpartum depressive symptomatology, ﬁrnctional status, or family
functioning. However, over ﬁfty percent of this population gained over the recommended
weight per BMI category. In this study, women’s depressive scores were, on average,
above the score of 16 for CES-D indicating moderate levels of depressive
symptomatology over all weight categories. The standard deviations and ranges for
CES-D scores for each adequacy goup are large, indicating that women could fall
anywhere along the classiﬁcation for depressive symptomatology, regardless of weight
gain.

Functional status scores were typically about 2.2 for this population over all
weight gain categories indicating lower than average scores for return of functional status
at six weeks postpartum. In the literature, at six weeks postpartum, women average 3.2
when functional status is assessed using the IF SAC (McVeigh, 1998). The standard
deviations and ranges were moderate in each adequacy goup, indicating that there was an
overlap across goups in assessing return of functional status, regardless of weight gain.

Family APGAR scores were generally below 3, indicating low levels of satisfaction
with family functioning across all adequacy goups. However, the standard deviations
and ranges (Table 6) were large for all adequacy goups, indicating a large variability
between goups. The results of the APGAR in this population are signiﬁcantly lower than
average scores for well women (M=8.24) (Snnilkstein & Moore, 1988; Smilkstein et al.,
1982, respectively). .

In order to investigate and explain why this study did not yield statistically
signiﬁcant results, the sample, statistical methods, and conceptual ﬁamework were
examined in relation to each research question.

. -'e. ,t'. z.. as“... .. s-.- '- m. ...; . .3. °. .- um... .. '-...

There was not a statistically signiﬁcant relationship found between weight gain by

category and postpartum depressive symptomatology. In this study, all of the goups had

37

moderately high scores on total CES-D, regardless of amount of weight gained in relation
to BM], which was expected.

Low income, single women were investigated in this study. Studies investigating
low income women identify various independent variables associated with low income
status (Campbell & Cohn 1991; Walker, 1998) that may or may not be related to weight
gain. Social-historical factors, such as low social support and low income, have been
linked to higher than recommended weight gain in pregnancy (Walker, 1997), which
would explain why PPD is more prominent in women with lower social support and low
income (Campbell & Cohrn, 1991). Over ﬁfty percent of this sample population gained
above the recommended weight gain by BMI category, which was not expected. Women
in all adequacy goups had moderate levels of depressive symptomatology, however, the
standard deviation for each adequacy goup was large, indicating that women could have
various scores for depressive symptomatology, regardless of the amount of weight gained.
Literature describing depressive symptomatology in low income women indicates that
depressive symptoms vary geatly in this population, so the moderately high scores in this
sample population can not be attributed to low economical status alone.

Studies that looked primarily at weight gain in relation to postpartum depressive
symptomatology were done primarily on middle income women (Walker, 1997, 1998),
thus decreasing the stressors associated with ﬁnancial concerns. Socioeconomic status is
an important factor to assess while comparing literature in relation to this study focused
primarily on low income women. Comparing this studies sample demogaphics to other
studies may provide indicators of the impact of economical status on the outcome of
depressive symptomatology in the postpartum period.

This study consisted of primarily young, single women. Although single women
may receive support ﬁom other avenues, such as boyﬁ'iends, ﬁiends, or extended family
members, the buffer of having a spouse to protect against postpartum depressive

symptomatology appeared to be lacking with this population. Younger women who

38

encounter pregnancy before self-deﬁnition is achieved may experience negative outcomes,
such as postpartum depression. In unexpected pregnancies, the normal psychosocial
development of the young mother may be disrupted, leading to possible negative
outcomes for both mother and child. Literature examining age and its relation to
depressive symptoms postpartum varies. Studies identify younger women to be more at
risk (O’Hara & Swain, 1996; Troutman & Cutrona, 1990), while others indicate older
women to be more at risk (Kumar & Robson, 1984). Most research, however,
acknowledges that the age of the mother does not have an eﬂ‘ect on the development of
depressive symptomatology (Kemp, Sibley, & Pond, 1990; Stemp, Turner, & Noh, 1986;
Stowe & Numeroﬂ‘, 1994). Regardless of weight gain, this sample population of young,
single mothers had moderate depressive scores.

The conceptual framework for this study provides a framework which emphasizes
the importance of life experiences. Women may experience varying emotions in the
postpartum period, which can be attributed to many factors. The conceptual framework
describes the impact that weight gain in pregnancy would have on a woman’s self
deﬁnition in a time period when physical ﬁtness is emphasized. In this study, it was not
assessed how the women felt about weight gain in general, a woman may experience
emotional difﬁculties depending on how welcomed the weight gained in pregnancy was,
and this was not assessed.

IEZ'lG' IE 'IS '12 E'l

There was not a statistically signiﬁcant relationship found among adequacy gain
categories and assessment of functional status in the postpartum period in this study.
Overall functional status scores were low, however, this was somewhat anticipated, as
women may not have adjusted for the role of motherhood effectively at 6 weeks
postpartum. Likewise, few women return to work by 6 weeks postpartum so it is diﬁcult
to assess the functional status component related to occupational activities. Research

indicates that there is signiﬁcant changes in ﬁrnctional status taking place over the six

39

months following childbirth (McVeigh, 1997; Tulman, et al., 1990), so a one time
assessment at 6 weeks may not indicate what functional status will be at six months to a
year, regardless of the weight gained in pregnancy.

The study population consisted of primarily young, single, women which also may
account for low ﬁnnctional status scores across weight gain categories. Although the
IFSAC is an excellent tool for measuring functional status after childbirth in the general
population, it may be limited in this population, simply due to the deﬁnition of ﬁnnctional
status after childbirth and what it implies. The IFSAC was developed with a sample of
women who were older than this sample population (26-30); were almost equally divided
in number of pregnancies, primiparous (41%), multiparous (59%); and had some college
education (94%) (F awcett et al., 1988). Young, single, women who are attaining ‘
self-deﬁnition and the role of motherhood at the same time may not ﬁt into the rigid
deﬁrnition assigned to ﬁnnctional status. The IFSAC is limited to assessment of the status
of role function and does not measure feelings about roles, role conﬂict, overload, or
ambiguity (Fawcett et al., 1988).

Most women in this study had one previous pregnancy (mean = 2.5), however, few
had more than a high school education, indicating that overall, they were not established in
careers. When viewed through the conceptual model, younger women may have
diﬁculties adapting to the role of motherhood, as they may not have achieved
self-deﬁnition yet. The time frame required to modulate personal gowth against possible
negative effects, which is central to self deﬁnition, my be lacking. This may be
compounded in this sample population, as the majority are multiparous, and may

struggling to return to previous functional status with the demands of having more than

one child in the home.

 

There was not a statistically signiﬁcant relationship found among weight gain

categories and assessment of family functioning in the postpartum period. Scores of the

40

family APGAR were generally low across all weight gain categories, with standard
deviations and ranges being large, indicating that this goup of women was a homogenous
sample, consisting of primarily young, single women. Research indicates that social
support, with support from a spouse being of particular importance (Crrnic, et al., 1983;
Wandersman, et a1. 1980) essential to buffer some of the negativity’s associated with
decreased satisfaction after childbirth. It is not surprising, then, that the women in this
sample had low satisfaction with family functioning after childbirth. Low income, single
womarn, regardless of weight gained in pregnancy may have low satisfaction with family
functioning simply because they have a lack of resources to buffer against the stresses of
childbirth. Literature assessing family ﬁrnctioning in the postpartum period indicates that
married mothers tend to report higher satisfaction with family functioning in the
postpartum period than single mothers (McCain, 1990) when the APGAR is used to
assess satisfaction. The APGAR is useful in assessing satisfaction in families, however, it
may be linnited in assessing the single parent household.
Summary

Literature on the subject of weight gain in pregnancy and how it relates to
depressive symptomatology, functional status, and family functioning is limited. Previous
studies focused primarily on weight gain in relation to postpartum depressive
symptomatology, with most studies indicating higher depressive symptomatology with
more weight gain (Abraham, King, Llewellyn-Jones, 1994; Walker, 1997, 1998). Studies
speciﬁcally analyzing functional status and family functioning in relation to weight gain in
pregnancy were not found in the literature.

The conceptual model used for this study, Women’s Self-deﬁnition in Adulthood
Model (Peck, 1986) provided a ﬂexible ﬁamework to investigate the relationship of
weight gain to postpartum depressive symptomatology, functional status, and family
functioning. Weight gain is an important issue to women (Garner, 1997; Parker; Walker,

1998), and the ﬁamework was suitable because it represented the multiple roles,

41

responsibilities, and relationships of women’s lives in the period following childbirth.
Although the conceptual framework was not supported by the results of the study, it
provided a guide to discuss weight gain in the childbearing woman.

The variable of weight gain, based on the ﬁndings of the study, was not associated
with postpartum depressive symptomatology, ﬁnnctional status and family functioning.
Although the conceptual model was suitable, there was not a ﬁt between the operational
and conceptual deﬁnition of weight gain. Weight gain in pregnancy should be
operationally deﬁned in a manner that would be more reﬂective of the life experiences of
women. Perhaps more subjective data in relation to feelings about weight gain, body
image, and role identity in relation to weight gain in pregnancy and during the postpartum
period are required to evaluate the concept of body image in the childbearing woman.
More subjective information evaluating the concepts of weight gain and feelings about
weight gain, body image, and role identity in relation to weight gain may provide the
missing links in this study.

Implications

In this study, no statistically signiﬁcant relationship was found for depressive
symptoms, decreased functional status, or decreased family functioning for weight gain
categories by BMI. Therefore, it appears as though the variable of weight gain in this
study is limited in its ability to predict postpartum depressive symptomatology, alterations
in ﬁnnctional status and alterations in family functioning. However, while there was not a
signiﬁcant relationship between adequacy goups and the variables measured, the APN
must be aware of the prevalence of moderate postpartum depressive symptomatology,
low ﬁrnctional status scores, and low satisfaction with family ﬁnnctioning scores found in
this study, regardless of weight gain.

When examining the variable of depressive symptomatology to weight gain, it is
important to emphasize that in this populatiorn, about ﬁfty percent gained over the

amounts recommended by the IOM (1990). Although there was no signiﬁcant correlation

42

between adequacy goups and depressive symptomatology, women in this population were
overall, moderately depressed. Furthermore, the large standard deviations and ranges of
the CES-D scores indicate that this was a homogenous goup of women, both in weight
gain and depressive symptomatology.

It is also important to acknowledge that the weight gain guidelines issued by the
IOM in 1990 exceed previous guidelines by ﬁfty percent, in some cases (Johnson &
Yancey, 1996). Guidelines were developed by review of epidenniological data on fetal
death, prematurity, and low birth weight (Johnson & Yancey, 1996) and a determination
was made based on a correlation between low maternal weight gain and adverse
obstetrical outcomes. Guidelines were developed advising women to gain more weight
than what was previously recommended. However, relationships between matennal
weight gain and pregnancy outcome are much more complicated than the IOM suggested
(Johnson & Yancey, 1996). When providing prenatal and postpartum care, it is essential
for the APN to assess each woman individually for appropriate weight gain in pregnancy
and then provide nutritional counseling speciﬁc to each woman’s needs.

Given the large amount of women in this population gaining more than
recommended amounts of weight, the APN must consider maternal and fetal adverse
eﬂ’ects associated with geater maternal weight gains such as predisposition to postpartum
obesity (Smith et al., 1994), and the complications associated with obesity such as
coronary vascular disease, diabetes, hypertension, and cholelitlniasis, diﬁcult labor and
delivery, and postpartum hemorrhage (Johnson & Yancey, 1996). Fetal adverse eﬂ‘ects
associated with excessive weight gain include fetal macrosomia, prolonged labor resulting
in fetal trauma, abnormalities in fetal heart rate, and mecornium staining (Johnson,
Longmate, & Frentzen, 1992; Johnson & Yancey, 1996; Parrish, Holt, Easterling,
Connell, & LoGerfo, 1994).

In all weight gain categories, depressive symptomatology in the postpartum period

was evident, indicating the need for the APN to assess all women, regardless of amount of

43

weight gained, for depressive symptomatology in the postpartum period. Long term
consequences of obesity, as discussed previously, must be addressed in order to provide
women with comprehensive and cost eﬂ‘ective care. Women should be provided with
individualized care upon conception, and individualized care should continue over the 12
months following delivery, as it is essential for the APN to recognize and treat depressive
symptomatology to assist in supporting not only the psychosocial and physical well being
of the childbearing women, but also to establish and maintain functional relationships with
the child, family members, and signiﬁcant others.

Overall functional status across the weight goups was low, and could not be
statistically predicted by individual weight gain categories. Given this information, it is
essential for the APN to assess ﬁnnctional status prior to delivery to evaluate pre-existing
problems with ﬁnnctional capabilities, and to provide counseling in the postpartum period
about expectations and norms of role mastery and functional status in the postpartum
period. Although literature tends to imply that role performance occurs simultaneously
with the physical healing of childbirth, at about six weeks postpartum, studies have found
that resumption of some role activities do not occur until six months postpartum (Tulrnarn,
et. a1, 1990).

When addressing weight gain to ﬁnnctional status, it is important for the APN to
consider the consequences previously mentioned that are associated with weight gain and
obesity when providing care. The APN plays an essential role not only in promoting
optimal ﬁnnctional status by assisting women in preventing complications associated with
obesity, such as hypertension, but also contributes to cost containment by counseling
women about activities that assist in preventing illness resulting in low ﬁnnctional status.

Data shows that women have a marked weight increase between the ages of 18-50
(Lederrnan, 1993 ), regardless of parity. By assessing functional activities prior to and
during pregnancy, the APN can counsel and guide women on healthy lifestyle choices, that

promote optimal functional status, such as exercise progams, which have been shown to

44

increase satisfaction with the role of motherhood, parenting abilities, and increase
socialization after childbirth (Sampselle, 1999). When compared to women who have
sedentary lifestyles, women who exercise regularly report a geater satisfaction with their
lives in. general (Sampselle, 1999). When working with childbearing population, the APN
has the ability to develop a data base of resources for women, such as facilitating
postpartum support goups that assist in socialization by offering women the opportunity
to share experiences and help one another after childbirth. The APN could also identify
resources that would enable women participate in physical activities, such as identifying
gyms that provide daycare. By introducing new mothers to one another and opening
avenues that encourage return of functional activities to women, the APN promotes self
eﬁcacy.

The APN counsels women and their families about expected emotional and
ﬁrnctional changes associated with childbirth, and utilizes problem solving skills to address
the concerns women and their families face throughout prenatal and postpartum periods.
The APN assists in educating women’s primary support systems about postpartum fatigue,
and encourages participation in care, as they can provide the support essential to achieve
Optimal functional status. By educating women’s support systems, the APN facilitates a
strong base of support in which women can rely on to achieve mastery of functional
activities such as household, occupational, social, self-care, and infant care responsibilities.
The resumption of these activities is a process, occurring at six months after childbirth or
longer. A strong support system promotes well being and positive functional adjustment
throughout the childbearing phase. Those resources closest to women may need guidance
on how to support women throughout pregnancy and in the postpartum period when role
mastery is crucial.

Satisfaction with family functioning scores assessed with the family APGAR were
also low across weight gain adequacy goups when compared to APGAR scores in the
literature (Smilkstein, 197 8). It is important for the APN to assess the childbearing

45

woman’s individual support systems, ideally, prior to delivery, and then continue to assess
for alterations in satisfaction with family functioning throughout 12 months postpartum, as
roles and expectations change, especially when women return to work, which may not
take place for several months after delivery. When a relationship of trust is established
with the childbearing family, women are more likely to return for postpartum follow up.

The APGAR serves as a screening test for family functional disability, and provides
the APN with a means to assess overall patterns of functioning. It is crucial to assess
disability prenatally, and to reassess at the postpartum visit. Families with ﬁnnctional
disability can be identiﬁed and the APN can utilize family counseling to promote optimal
satisfaction with family ﬁnnctioning. To some extent, in this population, nonmarnied
mothers might have been less satisﬁed with family relationships owing to the ﬁnancial
strains of single parenthood (McCain, 1990), however, it is important to consider the large
number of women in this population who gained above recommended weight guidelines,
and be cognizant of the possibility that decreased satisfaction may be inﬂuenced by
feelings related to the weight gain of pregnancy, even though this study did not show a
signiﬁcant relationship between these variables. Although not supported by the ﬁndings of
this study, unwelcome weight gain may affect marital satisfaction (Stunka, 1992), leading
to a lack of ﬂexibility in the relationships, potentially limiting redistribution of emotional
investment to people within the support system. Signiﬁcant others need to be counseled
about the impact of weight gain on a woman’s body image, and how to be supportive as
she adjusts to changes in body satisfaction in the postpartum period.

By assessing family satisfaction, the APN identiﬁes families that may be having
difﬁculties, and supports and promotes fnmctional relationships within a woman’s support
system. The transition to parenthood is a stressful time, as various demands are made on
the family to adapt to a new situation (Martell, 1990), whether the transition be beconning

a new mother, or adjusting to life with a second child.

46

Regardless of weight gain in pregnancy, the APN has the opportunity to establish a
positive relationship with women in the childbearing phases of their lives. The APN
establishes a partnership with women, facilitating a working relationship which aids in
understanding the changes that take place in the postpartum period. By gaining subjective
information about depressive symptomatology, functional capabilities, and family
functioning, the APN monitors for difﬁculties women may encounter during the
postpartum period. By developing a relationship with the childbearing woman, the APN
may provide anticipatory guidance speciﬁc to the individual needs of each womarn,
assisting in individualized treatment, and facilitating an understanding of life experiences
and changes that are expected in the childbearing phase of life.

Some women may not have symptoms of depression, alterations in functional
status, or alterations in family ﬁrnctioning, however, by using a clinically based knowledge
of risk factors that may indicate problems in the postpartum period, the APN may irnitiate
interventions geared towards helping women should symptoms of depression, changes in
ﬁrnctional status, or decreased satisfaction of family functioning occur. By establishing a
clinically focused working partnership with women in the postpartum period, the APN in
primary care has opportunities to establish connections that will facilitate access to
appropriate avenues to increase quality of life and well being .in the postpartum period.

The role of the APN working with the childbearing woman begins with
assessment, the APN continually assesses for diﬁculties once a woman presents for
prenatal care. The tools utilized in this study can provide the APN with a base line to
screen for and predict diﬂiculties. The tools should be adnnirnistered at six weeks, three
months, six months, and one year following childbirth to assess for the presence of
depressive symptomatology, alterations in ﬁrnctional status and decreased satisfaction in
family functioning. A data base of subjective and objective information identiﬁes the
needs of women, and their families, and allows the APN to provide individualized care

women and their families.

47

Finally, the APN acts as a case manager who coordinates the identiﬁcation of
speciﬁc health needs of the childbearing woman, and provides information and referrals to
support goups and collaborates with other health care professionals to assist women in

attaining the highest level of ﬁrnctioning possible throughout the childbearing experience.

RecommendationsfoLEutthenResearch

It is important to recognize the limitations of this study. The results of this study
indicate a need to further investigate the impact of weight gain in pregnancy to depressive
symptomatology, functional status, and family ﬁnnctioning because of the inability to
establish statistical signiﬁcance in this sample population. The sample size for this
population was adequate, however sample characteristics such as race, socio-economical
status, and marital status should be more representative of the general population of
women who may present with postpartum difﬁculties (depressive symptomatology,
alterations in ﬁrnctional status, decreased satisfaction with family ﬁnnctioning).

This study was designed to assess how weight gain would effect postpartum
difﬁculties. There was not a statistically signiﬁcant relationship between the variables of
this study and the adequacy goups. However, since ﬁfty percent of this population
gained over the recommended weight per adequacy goup, and depression was moderate,
functional status low, and satisfaction with family functioning low, the next step would be
to conduct a study, more generalizable to the general population, where women could be
asked about subjective feeling related to the weight gain of pregnancy. It would also be
beneﬁcial to screen for prior history of depression, marital problems, psychological
problems including eating disorders, substance abuse, physical/sexual abuse, and
co-existing medical problems to focus more speciﬁcally on feelings related to weight gain
and how these feeling eﬂ’ect postpartum diﬂiculties.

Data were collected at approximately six weeks postpartum in this sample

population. Collection of data from subjects at six weeks, three months, six months, and

48

one year would provide a more descriptive evaluation of the effects of weight gain, loss,
or failure to lose weight over time on depressive symptoms, functional status, and family
functioning. It would be beneﬁcial to assess the variables of this study, and weight
ﬂuctuations over these periods of time as well, to assess incidence of postpartum
difﬁculties related to patterns of weight changes over time.

Weight gain, described as a social-historical time dimension, and operationalized
by categories related to body mass index by adequacy goup did not have the ability to
predict depressive symptomatology, decreased functional status, or decreased satisfaction
with family ﬁrnctioning in the postpartum period. The weight gain of this sample goup is
a reasonable representation of a sample population that may develop weight related
distress. Future research using the variable of weight gain should include subjective
feelings about weight gain, body image, and self concept in pregnancy, as those women
who have more negative feelings about weight gain may present with more weight related
distress in the postpartum period.

Summary

Depressive symptoms, functional status, and family functioning are important
issues for not only the childbearing womarn, but also for the infant and family. Current
literature supports the need for early identiﬁcation, preventative measures, and treatment
of depressive symptoms, alterations in functional status, and alterations in family
functioning. By identifying difﬁculties in the postpartum period, healthy adaptation to the
physiological process of childbearing can take place.

This study focused on weight gain as a variable to determine the occurrence of
postpartum depressive smptomatology, alterations in functional status, and decreased
family functioning. Women in this study, on average, had moderate levels of depressive
symptoms, low functional status scores, and low satisfaction with family ﬁrnctioning,
despite the weight gained in pregnancy. The results of this study indicate the need to

assess for other factors that could contribute to depressive symptomatology, low

49

functional status and decreased satisfaction with family functioning. All women should be
assessed at six weeks, three months, six months, and one year for psychosocial difﬁculties
in the postpartum period, regardless of weight gain category, to facilitate early detection
of problems, and promote well being in this transition of life.

Further research is needed to determine the impact that weight gain in pregnancy
has on the well being of women in the postpartum period. The development of strategies
to assess subjective feelings about weight gain during pregnancy are required to ﬁrrther

investigate the connection between weight gain and distress in the postpartum period.

50

REFERENCES

51

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58

APPENDICES

59

APPENDIX A

60

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88838833

APPENDIX B

62

AUPIHEJQI)I){IB

mm 1: __

INVENTORY OF FUNCT 101W. STATUS AFTER CHILDBIRTH

 

BART I:

Please check all the usual W11; ou had a??? to the In 's birth
y rsspons b I W

and than indicate to what extent you have rssrnsd thsss
uss born.

Prior to the hair 's birth. sly

usual rssponsibt ltlss Included:
N01 Al’ ALL .1051 BEGINNING

1. __Cars of fully snssnbsr 1 2

2. _Clsantng the house 1 2

3. _‘I’Idytng the house (asking

beds. picking up things. etc.) I 2
4. _Laundry 1 2
5. _Dotng dishes I 2
6. _Cooktng 1 z
7. _lIousshold business (paying bills.

banking. etc.) I 2
8. _6roesry shopping 1 2
9. _Slnopp1ng. other than groceries 1 2
10._Dotng errands l 2
"-”l:l£2:2i1i§§a.33“§§liii:.f°l§..i n 2
12._Car1ng for pets 1 2

Cements:

63

I have rssnsssd this activity:
PARTIALLY

3
3

“UH“

““0“

U

ties sign the baby

FULLY

4 (6)
4 (7)

4 (3)
4 (9)
4 (10)
4 (ll)

4“!)
4(13)
4(14)
4(15)

4 (16)
4f")

PART II:
Please check all the usual

bIrth and then Indicate to what extent you have

baby was born.

Prior to the baby's birth. by
usual rosponsIbIlItIss Included:

13.__CowuunIty service organizations
14.__Professtonal organizations
15.__RelIgIous organizations
16.__SocIslIzIng with friends
17.__5ocIalIzIng with relatives
18.__5oeIal clubs

Comments:

PART III:

I have rssuuad thIs activity:
NOT AI ALL JUST BEGINNING

I

”pHHH

you dId

2

NNNNN

PARTIALLY

““000”

to the baby's
resumed those responstb lItIss 313;: the

“FULLY

4(18)
4(19)
4(20)
4(21)
4(22)
can)

Please W that Indicates to what extend you have sssrnod your part of the
bahx;s_cs:s-

fbllowIng aspects of the

19. DaytIns feedings

'20. Night fssdIngs

21. Baths the baby

22. Change dIapors

23. Change the baby's clothes
24. Play with the baby

Consents:

l

HH~HH

NUT AT ALL JUST BEGINNING

NNNNN

RARTIALLY

3

”“00““

FULLY

4(24)
4(25)
4(26)
4(27)
4123)
4(29)

PART IV:

Please respond to the following phases based on how your life has been during the p;§3_uggk

25. Spend much of the day lying
down

26. Sit during much of the day

21. Spend much of the day sleeping

or dozing

28. Stand for only short periods
of time

29. Spend lost of the day in my
nightgown/bathrobe

30. Take walks
31. Go up and down stairs
32. Nalk slowly

Comments:

BART V:

If you are currently employed, please respond to the following items.

NEVER

e—ee—Oe-ee-e

SOMETIMES

NNNN

MOST OF THE TIME

“NU“

ALNAYS

..

(3°)
(31)

(32)
(33)

(34)
(35)
(35)
(37)

Please respond to the following phases based on how your life 31_ug:§ has been during the

out W-

33. Ah accomplishing as much as
usual in my Job

34. Act irritable toward my work
associates (give sharp
.answers, snap at them,
criticize easily. etc.)

35. Am working shorter hours

36. Am doing my Job as carefully
and accurately as usual

Comments:

RS:kJa/2-17-92

NEVER

SONETINES MOST OF THE TIME ALNAYS

65

4

4

4

(33)

(39)
(40)

(41)

APPENDIX C

66

AUPPHETJI)I)((C

PATIO ll __._.

11
Family APGAR (P)

The following questions have been designed to help us better understand you

and your family. You should feel free to ask questions about any item in the
questionnaire.

The space for comments should be used when you wish to give additional
information or if you wish to discuss the way the question is applied to your
family. Please try to answer all questions.

Family is defined as the individual(s) with whom you usually live. If you

live alone. your 'family' consists of persons with whom you now have-the
strongest emotional ties.

For each question. circle only one number:

Almost Always Some of Nardly Never
Always the Time Ever

I am satisfied that I can turn
to my family for help when
something is troubling me 4 3 2 1 0 (12)

Comments:

 

I am satisfied with the way my
family talks over things with me
.and shares problems with me. 4 3 2 1 o (13)

Comments:

 

I am satisfied that my family
accepts and supports my wishes to
take on new activities or direction. 4 3 2 1 o (14)

Comments:

 

I am satisfied with the way my

family expresses affection and

responds to my emotions, such as

anger. sorrow, and love. 4 3 2 1

(15)
Comments:

 

I am satisfied with the way my
family and I share time together. 4 3 2 1 0 (16)

Comments:

 

N0:kJa\famapgar.m92

(37

APPENDD( D

68

APPENDIX D

M ICHIGAN STATE UNIVERSITY

 

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ANDMO'MGIAWATIW

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MildeedOner. PILD.

A230 Life Scienc-
RE: nu: I: 92-115
TITLE: memes WONG PREGNANCY OUTCOME

CATEGORY: l-C

REVISION REQUESTED: Febemery 23. I993
APPROVAL DATE: Mead: 1. 1993

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2. Thebmbuuiﬂeﬁeﬂsnﬂmmdbybmﬁeoudmehwmhhmdy.

3. mmmmwmﬂmbytbenbjeaeaﬂsmdmdbwmimb
My.

4. Thebubmednphhmmmwmmmhﬁabm
HUMWMMWMBMmWyMndW

'I'b'enisemnsimmuoffoureuchempedﬂedremewelepoeeible. WMboomtimmeepeojeotbeyomd
thattimaemeedtomabnititepimiorcompletereview.

UCRIHS m-nvbvuydlngahmimvdvhgbmm-Mpdorbmofhm
Wmmmdﬂumwyofuymoﬂu(w&hmme&)wm
hummebjecudurimgthecouueoftbewk.

lfwecem beefeny mm. pleasedomotbeeitaoetocomtectusetal'l) 355-21300:th ($17) 336-1171.

 

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69

MICHIGAN STATE UNIVERSITY

 

OWICEOPVICEPINDINTMW MW'MMOWM
ANDDEANO'TIIIWTEW

Hatch 19 . 1992

Hildred A. Omar. Ph.D. ,
Rachel F. Schittmen. Ph.D.
A-230 Life Sciences Bldg.

RB: morons memo PREGNANCY ouroona. m {92-115

Dear Dre. Omar end Schiftman:

The above project is exempt from full nouns review. One of the Go-ittee's
members has reviewed the proposed research protocol and finds that the rights and
welfare of huen subjects appear to be protected. You have approval to conduct
the research.

You are reminded that 001118 approval is valid for one calendar year. If you
plan to continue this project beyond one year, please make provisions for
obtaining appropriate ucems approval one month prior to larch 16 . 1993 .

Any changes in procedures involving huen subjects last be reviewed by the ucems
prior to initiation of the change. llCRlIIS mat also be notified promptly of any
problems (unexpected side effects. complaints. etc.) involving lumen subjects
during the course of the work.

Thank you for bringing this project to our attention. If we can be of any future
help. please do not hesitate to let us know.

5 incerely .

 
  

David 3. ilrigh o.
cunt. ucezus

DEV/pi-

IQSU '- em ”ﬁr-slime Mime/ﬂees! My lmsde'lmle'sm

70

APPENDIX E

71

APPENDD( E

 

MICHIGAN STATE
u N l v E a s I T v
April22.1999

TO: Dr.Rad'imI SCHIFFMAN

as leer ease? CATEGORY: 1.5
venom DATﬁzAprII 2. 1m

TlTLEzTHE ASSOCIATION BETWEEN MATE‘RNAL WEIGHT GAIN AND
POSTPARTUM DEPRESSIVE SYMPTOMATOLOGY. FUNCTIONAL STATUS
AND FAMILY FUNCTIONING

The University Corrvnitteeon Research involving Human Sublects‘ (UCRIHS)reviewoi
thisproiectisoompleteandlampleaeodtoadvisethatthorighbmndwiiareufihe
hmnansubiectsappeartobeedequatelypmtectedandnmmodstoobuhhnonned
consent are appropriate. Therefore. the 116le epprovedthia project.

RENEWALS: UCRll-is approvalievalidioronecalendaryemr. bmg'nningwiththe
approvaldateshownabove. Prolemant'lmiingboyondoneyearrmstberonewed
with the green renewal ionn. A mexirnum oi four such expedited'renewels possible.
Investigators wishing to continue a project beyond that time need to submit it again for
a complete rovrew.

REVISIONS: UCRll-ls must review any changes in procedures involving human
subjects. prior to initiation oi the change. If this is done at the time of renewal. please
use the green renewal form. To revise an approved protocol starry other time during
the year. send your written request to the UCRIl-is Chair. requesting revised approval
and referencing the project's IRBN and title. lndude in your request a description of the
change and any revised instruments. consent forms or advertisements that are
applicable.

PROBLEMSICHANGES: Should either of the following arise during the course oi the
work. notify UCRIHS promptly. 1) problems (unexpected side effects. complaints. etc.)
involving human subjects or 2) changes in the research environment or new information
indicating greater risk to the human subjects than existed when the protocol was
previously reviewed and approved.

liwecenbeoihirtherassistance.pleaeeoontactusat517 355-2180orviaemail:

UCRIHSOpilotmsuedu. Please note that all UCRll-is forms are located on the web:
http'leww.msu.edqunitlvprgsIUCRIHSI

m a w - VT:
. ('UL" ”f‘,

David E. Wright. Ph. D.

UCRIHS Chair

DEW? bd

cc: AymeeSchuyier me

72

 

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